Asian Hospital & Healthcare Management - Issue 57

I S S U E 57

2022

w w w.asianhhm.com

LUCIANO BRUSTIA Regional Managing Director Asia Pacific InterSystems

DIGITAL ENGAGEMENT PUTS PATIENTS AT THE CENTRE OF CARE Transformative Radiology Roadmap to the future Role of Telemedicine and Digital Technologies Future of emergency care services in India www.asianhhm.com

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Foreword Emergency Care Services in India Technology as a key enabler Emergency care is all about the quick response,

recently in 2019, WHA 72.16 ‘Emergency care systems

accessibility, and availability of essential services. The

for universal health coverage: ensuring timely care for

quality and accuracy of the information available and

the acutely ill and injured’ placed emergency medicine

relevant data obtained during an emergency incident

as a core specialty within any healthcare system.

are the key factors that determine the outcome and its

Recently, the WHA called on the member states to

success.

prioritise the establishment of integrated emergency

Technology plays a key role in healthcare and, in

and trauma care systems. The Indian government is

fact, a critical element in emergency incidents. From

collaborating with different organisations and setting up

geo-tracking to reach patients in the shortest possible

autonomous bodies like the Centralised Accidents and

time, predictive analytics, telehealth, portable diagnostic

Trauma Services (CATS).

devices, and chatbots to drones aiding transportation of

Development of best-in-class emergency systems

blood bags to remote places and facilitating emergency

revolves around key factors such as governance

medical air delivery, saving lives through virtual reality

and

and simulations, to the ever-rising healthcare apps, we

continuous monitoring and improvement of systems

see technology as an enabler for timely care.

for effective emergency care delivery. Several hospitals

regulation,

technology-aided

infrastructure,

According to the National Crime Records Bureau

in the country have been looking at insights from

(NCRB), more than 3,74,000 people lost their lives due

space technology to upgrade emergency and critical

to accidents in 2020. A July 2021 study by All India

care services. As the country continues to focus on

Institute of Medical Sciences (AIIMS), Delhi, found

technology and digitalisation, a holistic approach to

that the emergency medical care systems in India are

building next-gen emergency care systems emulating

far from adequate. While 91 per cent of hospitals in

practices with learnings from leading nations can help

secondary and tertiary level centres have ambulances,

India embark on its journey to enhance the emergency

less than 35 per cent of these have trained medical staff

care landscape.

and paramedics to provide emergency medical care to the patients.

In a bid to create a strong health system, the World Health Organization (WHO) in its 2007 World Health Assembly (WHA) Resolution 60.22 ‘Health Systems: Emergency Care Systems’ called for all countries to develop effective emergency care systems. More

Prasanthi Sadhu Editor

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CONTENTS HEALTHCARE MANAGEMENT

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06 Space Medicine Challenges and Achievements 12 Keeping Nutrition and Fitness at the Heart of Vascular Health Alex Teo, Director, Research & Development and Scientific Affairs, Asia Pacific, Herbalife Nutrition

18 MD Ph.D Programmes Relevance in emerging economies Krishnan Ganapathy, Member, Board of Directors, Apollo Telemedicine Networking Foundation &, Apollo Tele Health Services

24 Preparing for Patient Surges Amid a Pandemic John Lee-Bartlett, Country Director, Allscripts Canada

30 Exploring Equality, Equity, Diversity and Inclusion in Driving Business Impact Peggy Wu, Vice President, AbbVie, Asia

33 The 3 Ps of Organisational Performance Gurrit K Sethi, Founder, Miindmymiind

Regional Managing Director Asia Pacific InterSystems

DIGITAL ENGAGEMENT PUTS PATIENTS AT THE CENTRE OF CARE

COVER STORY

LUCIANO BRUSTIA

Thais Russomano, InnovaSpace

DIAGNOSTICS 41 Transformative Radiology Roadmap to the future Mai-Lan Ho, Physician-Scientist

TECHNOLOGY, EQUIPMENT & DEVICES 46 Medical Technology Trends and Device Regulation Devasheesh Kamra, Neurosurgeon, All India Institute of Medical Sciences

INFORMATION TECHNOLOGY 49 Role of Telemedicine and Digital Technologies Future of emergency care services in India Vikram Thaploo, CEO, Apollo Telehealth

52 Fundamental Theory for Successful A.I. Adoption by Healthcare Industry Abhishek Dutta and Pankaj Kandhari

60 Robotics for Autism Zheng Li, Caiwei Chen and Pradeep Ray, University of Michigan-Shanghai Jiao Tong University Joint Institute

MEDICAL SCIENCES 35 Redefining Innovation in Orthopaedics For Seamless Patient Care and Improved Operational Efficiency Sureshan Sivananthan, Consultant Orthopaedic and Sports Surgeon, ALTY Orthopaedic Hospital

SURGICAL SPECIALITY 38 Introducing a Novel Surgical Technique for Complete Atrioventricular Septal Defect V-Shaped double-layer patch technique Shanquan Sun, Chief, Cardiac Center of Guangdong Women and Children Hospital

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IS S UE - 57, 2022

Dedicated on radiology and free exemplary educational

Free paramount educational content on latest principles, techniques and applications

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Advisory Board

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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

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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

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SPACE MEDICINE

Challenges and Achievements

Gravity on Earth has shaped the anatomy and physiology of human beings. Exposure to microgravity has been shown to affect the entire body, causing numerous changes, such as a reduction in heart size and blood volume, disturbances of the neurological system, and decreases in bone density and muscle mass. This paper aims to increase the awareness and understanding of humankind’s final frontier.

Thais Russomano, InnovaSpace

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he presence of gravity on Earth has had an integral effect on the development of life over billions of years and shaped the anatomy and physiology of human beings. Exposure to microgravity has been shown to affect the entire body, causing numerous changes, such as a reduction in heart size and blood volume, disturbances of the neurological system, and decreases in bone density and muscle mass.

These physiological changes can lead to undesirable health consequences and to operational difficulties, especially in emergency situations.

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The growth in private space corporations, the imminent increase in numbers of space tourists, and intentions to prolong the duration and distance of space travel necessitates a greater awareness and understanding of humankind’s final frontier and its potential effects on space travellers.

It is vitally important to know more about the characteristics of the space environment and how these affect our health and wellbeing, and anatomy and physiology during spaceflight, including the cardiopulmonary, neuropsychological and muscle-skeleton systems.

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A discussion follows of some of the most notable alterations that take place in the body of astronauts when exposed to the environment of space.

The cardiovascular system in space

The removal of all hydrostatic gradients when entering space (microgravity) causes a headward shift of blood and body fluids, resulting in facial oedema and decreased leg volume. This shift is believed to be the primary stimulus for many of the physiological effects of spaceflight, including a reduction in plasma volume, increase in central fluid volume, enlargement of the heart, and an increase in cardiac output on initial exposure to microgravity. However, this is subsequently followed by a decrease in heart size and cardiac output, with a drop in the circulating blood volume as part of the cardiovascular adaptation to microgravity. More recently, neurovascular changes (Spaceflight Associated NeuroOcular Syndrome - SANS) and decreased venous blood flow in veins in the upper body have been identified.

HEALTHCARE MANAGEMENT

The symptoms of post-flight cardiovascular de-conditioning include low arterial blood pressure, inappropriate increase in resting heart rate and decreased exercise tolerance.

This condition exists when there is either an excessive postural decrease in cardiac filling and stroke volume and/or an inadequate compensatory neurohumoral response, resulting in a failure to maintain adequate brain perfusion in an upright position. Post-flight orthostatic intolerance has been reported widely by astronauts and cosmonauts, especially after long-term space missions.

Lung function in space

The effects of short and long-term microgravity exposure on lung volumes, capacities and function have been studied on the ground, in parabolic fights and during space missions.

Parabolic flights have shown that the sternum bone is displaced in the cranial direction in microgravity and is accompanied by an increase in diameter of the lower rib cage. This change in the

position of the chest wall was predicted to cause the volume-pressure curve to lie between the standing upright and the supine position curves, with a net result of a reduction in lung volumes.

During the 9-day flight of the Space Life Sciences-1 mission, lung volumes were able to be measured in sustained microgravity and showed a reduction in static and dynamic volumes. The

Humans are terrestrial beings. We have been shaped by Earth’s gravity and atmosphere.

Every single cell in our body is affected when exposed to extraterrestrial environments.

gravitational gradient also affects the distribution of ventilation and perfusion in the upright human lung.

This uneven distribution of ventilation and blood flow within the lungs leads to variations in ventilation-perfusion ratios. Microgravity was expected to abolish completely apicobasal differences in perfusion and its persistence is possibly related to other mechanisms not affected by gravity, such as centralperipheral differences in blood flow and interregional differences in conductance.

The diffusion capacity of the lung increased by 62 per cent in a parabolic flight study and by 28 per cent in sustained microgravity, when values were compared with pre-flight standing values.

Neuropsychology in space

The vestibular system, located within the inner ear, is used by the body to give us our spatial orientation and balance.

It is one of the first organs to react to microgravity exposure, with a quick and sometimes intense response to the lack

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of gravity. This is known as space motion sickness.

The psychosocial aspects faced by astronauts during space missions are also considered, addressing the coping mechanisms used to deal with confinement, monotony and isolation from family and friends. This important topic affecting humans and their interactions in space, including psychiatric, interpersonal and cultural aspects, becomes even more relevant with the imminent increase in space tourism and longer-term plans for crewed Moon and Mars missions. Astronauts on the International Space Station (ISS), for example, live in an isolated, confined and extreme environment, initiating natural pathophysiological processes of psychosocial adaptation. Although isolated, crews maintain continuous communication with the ground control Mission Support, who provide in-flight guidance and assistance at any time during the flight.

The human muscle-skeleton system

Our muscle-skeleton system is greatly affected by time spent in space and countermeasures are applied to minimise the changes that occur in bones and muscles. It is well known that the amount of weight that bones must support while in space is reduced to almost zero. At the same time, many bones that aid in movement are no longer under the same stresses that they are subjected to on Earth. Bone loss begins within the first few days in space and astronauts are able to regain most, but not all of their bone mass in the months following their return to Earth.

The lack of gravity also has the same detrimental effect on skeletal muscles, especially those that normally act against the force of gravity, such as the calf and quadricep muscles, which become weaker and atrophic. The best way of decreasing the effects of microgravity on the muscle-skeletal system is through the adoption of a routine of daily exercise during a space mission.

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It is a hard task to keep astronauts healthy in space missions.

Countermeasures for the body and mind are needed, together with the use of digital health.

Exercise countermeasures require the adaptation of exercise devices and the use of restraint systems to keep the astronaut in place when performing exercises. A healthy and balanced diet plus supplementary substances, such as vitamin D, are also important for the maintenance of muscles and bones in space.

The importance of an adequate understanding of these and other physiological responses to microgravity, with a view to assuring the good health and wellbeing of astronauts in space, has grown since the beginning of human space exploration and has motivated a series of biomedical experiments in several space missions, such as the Skylab, Space Shuttle, Mir Space Station and ISS programmes. However, many factors associated with spaceflight activities complicate attempts to delineate the time course of physiological responses to microgravity, including: Sample Size - crew sizes have ranged from 5 to 8 astronauts, with only 2 or 3 of these being allowed to participate in biomedical experiments. Any attempt to extrapolate from this small number to a larger population is unsatisfactory; Limited Capabilities for Scientific Observations - biomedical experiments are restricted by operational limitations

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and the time available during a space mission; Extensive Use of Countermeasures - the prophylactic and therapeutic use of a variety of countermeasures has masked the direct effects attributable to microgravity alone on human adaptation to the space environment; Different Mission Types - frequent changes of mission profiles make direct comparisons between flights difficult.

Therefore, space analogues on Earth, water and air have been developed, ranging from placing a volunteer on a tilt-table, immersion in a pool (neutral buoyancy facility) or studying the effects of gravitational changes in a parabolic flight. Some analogues can be established in Universities or Research Institutes, with the involvement of professors and grad/undergraduate students. The best scenario would be to have academics from different areas, creating a very inter- and multidisciplinary environment in which to study the human body and mind reactions and adaptations to some simulated aspects of a space mission.

Given the current rise in number of commercial spaceflight organisations, such as SpaceX, Virgin Galactic and Blue Origin, and predicted exponential growth in this space sector, it is vital to better understand some aspects regarding Space Tourism, particularly the medical challenges involved, and also contemplating the next steps for this developing area. The profile of the civilian space traveller, for example, is likely to be very different from that of the well selected and trained professional astronauts, which will impose a range of medical and health challenges to doctors and scientists on the ground. In the evolving spaceflight arena that will increasingly consider longer-duration spaceflights and the potential for Moon bases and Mars exploration, the human factor becomes increasingly important to long-term mission success and to the possibility of humankind living in off-Earth communities.

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April 2018, with activities in the areas of aerospace medicine, space physiology and telehealth.

A strong Advisory Board, consisting of world-leading researchers and scientists, provides further support in the space life sciences and related areas, covering a wide diversity of fields, such as space pharmacy, nutrition, psychiatry, physiology, biomechanics, aerospace medicine, human factors, parabolic flights and Space/Earth technology transfer, among others.

InnovaSpace is focused across the spectrum of society, from a governmental level through to universities and the industry, whilst also conducting outreach projects with the general public and the young, using the subject of Space and Space Exploration to inspire interest in the STEAM subjects. InnovaSpace also endeavours to assist nations in harnessing the human side of short- and long-term space program goals, as well as developing access to space knowledge and TeleHealth potential in educational institutions.

InnovaSpace has identified Six Factors that are necessary for Space Leadership and Distinction: (1) the Global Bridging of institutes, experts and talent; (2) the enablement of a Space Identity through initiatives, which form a rate of global participation; (3) the empowerment of Innovation through research that is transferable to other sectors; (4) the Facilitation of New Knowledge; (5) the Cultivation of young minds for aerospace and space science through engagement with schools and the development of aligned curricula For example, our Kids2Mars outreach program, with a model of global participation, has introduced Space and Space Sciences in a motivational manner to children worldwide; (6) Building skilled capacity in highly-complex yet necessary areas for Space Preparedness.

In summary, InnovaSpace is a Think Tank, global and inclusive, multicultural and multidisciplinary in nature, and operating in space, aeronautics

and telehealth. Through its work, InnovaSpace establishes collaborations and partnerships with governments, the business sector, academic world, research institutions, non-profit organizations and society as a whole. Its actions aim to conduct innovative activities in teaching and research, provide technical and scientific consultancy and establish a network of professionals, researchers, entrepreneurs, and students, linked by the common theme of the human presence in extreme environments, such as astronauts on orbital missions/ interplanetary trips and aviators/crew members in aeronautical activities.

AUTHOR BIO

Besides the use of countermeasures in a space mission, a very important way to medically support astronauts and space tourists is the use of digital health, and in particular, telemedicine.

Telemedicine has been applied to space missions since the first manned spaceflight in 1961, when the ECG of Yuri Gagarin was transmitted to the mission control centre on Earth. The continuous development of digital and communication technologies has progressively improved the way these systems can help monitor the wellbeing of astronauts during space missions and treat clinical conditions.

This technology applied at the ISS has provided some inputs for the provision of healthcare in rural and remote areas of the globe. Groundbased telemedicine and digital health studies have also been conducted to evaluate how these systems could provide health assistance in the management of physical and mental issues through the evaluation of medical procedures and care of different health conditions. However, the great distances in planetary exploration, such as a trip to Mars, leads to time delays in communication with medical personnel on Earth, which can range from three minutes to 24 minutes each way, affecting the application of telehealth in space missions. In terms of telesurgery, for example, a useful tool when there is the need to invasively treat patients who are geographically separated from their physicians, it would be impossible to apply it for a medical situation on Mars, however, it is still a viable technique for missions to low-Earth orbit or the Moon.

It is in this context of the current human space exploration era that InnovaSpace, founded by myself and Administrative Director Mary Upritchard, was born!

InnovaSpace believes in a Space Without Borders and this is our driving ethos. It is a limited company, established and registered in England & Wales in

Thais Russomano has 30+ yr of experience in Aerospace Med, Space Phys, Telemed & Digital Health. She is an MD with an MSc in Aerospace Med/USA, a PhD in Space PhysKCL/UK, and was a researcher for 3 yr at DLR/Germany. Founded and coordinated for 18 yr the MicroGPUCRS, BR, is academically linked to many Universities (KCL-UK, Univ of Lisbon-PT, UFCSPA-BR), CEO-InnovaSpace UK, member of IAA Board of Trustees, and was a volunteer Space4Women Mentor-UNOOSA, UN.

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Executive Interview with the Guerbet CEO David Hale on ‘innovation4MRI’ How is Guerbet innovating in MRI contrast media and associated technologies?

How do you see Guerbet’s contribution to the future of medical imaging?

David: Guerbet is a pioneer with a long history – over 100 years in the field of contrast agents, particularly in MRI, having invented the 1st macrocyclic GBCA, which has been on the market for more than 30 years and in more than 70 countries.

This really gives us the opportunity to build very strong relationships with the radiology community and through that better understand their medical needs.

We’re a company with a long-term growth strategy supported by shareholders from the Guerbet family and we invest a significant part of our revenues 10% in R&D (Research & Development). With more than 200 of our employees are dedicated to innovation in 5 R&D centers around the world. They’re actively collaborate with a broad network of academic partners, centers of excellence to strengthen and accelerate our innovation capabilities.

Guerbet’s innovation in MRI is not restricted to the development of contrast agents and injection systems.

We’re also actively exploring new approaches in MRI, including the integration of artificial intelligence (AI), this is a way to the future of clinical imaging.

Guerbet will obviously continue to invest in R&D specifically focused on helping our radiologists, delivering on their expectations in their daily practice and help them improve on patient outcomes.

If you think about it, given the ever-increasing volume of information that radiologists are expected to be aware of, about best practices and new techniques in the field of MRI. For us it seems fairly obvious for us to provide what help we can in this area. Guerbet is committed to staying at the forefront of innovation in MRI and as a leader in the field we believe by sharing information and building new solutions, we can really add value.

What were Guerbet’s guiding principles over the decades to foster relationships with clients and partners?

At the basis our guiding principle (and this is also our purpose) has really been – can we build a lasting relationship to do something together that enables people to live better. At Guerbet we relentless in our commitment to go further and to help build the future of medical imaging.

Collaborating closely with radiological community, observing and listening, sharing knowledge through multiple educational resources – that allows us to better anticipate what their needs are for patients. And I would add that what makes us unique ‘Guerbet touch’ is with nearly a century of passion and dedication to innovation. This is the commitment that drives our R&D teams to create innovations that serve both radiologists and patients.

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About Guerbet At Guerbet, we build lasting relationships so that we enable people to live better. That is our purpose. A world leader in medical imaging, Guerbet is a publicly traded company on the Euronext Paris Stock Exchange, headquartered in France with offices and production facilities in Europe, the Americas and Asia-Pacific. It has a long-standing reputation as a pioneer in the research and development of contrast media for radiology.

Today, Guerbet contributes to progress made in the diagnosis of major disease areas including cancer, cardiovascular, inflammatory and neurodegenerative diseases. The company’s novel and effective imaging solutions help to improve patient management throughout the world. Guerbet offers a comprehensive range of imaging products, solutions, and services for Diagnostic Imaging –MRI, X Ray, Digital Solutions / AI– and Interventional Imaging, to enhance clinical decision-making, from diagnosis to treatment and follow-up, and improve patients’ quality of life.

For more information, please visit www.guerbet.com.

We’re specifically focused on working on innovation that will improve the radiology practice and benefit patients. One area of innovation is ‘how do we find solutions to reduce gadolinium retention in both in patients and in the environment’. The is an emerging unmet need and in this are Guerbet primarily position to help

David Hale was appointed Chief Executive Officer of Guerbet on January 1, 2020. He joined Guerbet Executive Committee as Chief Commercial Officer in February 2018. David has almost twenty years’ experience in the field of radiology. His international career is characterised by strong geographical mobility, particularly in the United States, France, Germany and Switzerland, contributing to his ability to adapt and succeed in different cultures.

About Innovation4mri Innovation4MRI.com has been created to provide a source of relevant news about innovation in MRI. The information published on the site has been selected and reviewed for relevance, interest, and outstanding scientific value. The site provides information about 3 pillars of innovation in MRI: scanners (hardware) and image analysis and digital capabilities (software), image-enhancement approaches (including contrast agents), and sustainability (packaging).

Innovation4MRI.com provides summaries and links to research articles, recent reviews, public presentations, and video or podcast interviews with experts. These include interviews with academics and clinicians with expertise in radiology, as well as experts working in private industry. All the resources on the site have been carefully selected because they are particularly relevant to MRI enthusiasts.

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Keeping Nutrition and Fitness at the Heart of Vascular Health As the world moves to an endemic stage, recent studies have pointed out the rising risks of new heart problems due to the pandemic. With growing uncertainty around heart health data, what can the general public practice to minimise further risks to their vascular wellness?

Against this backdrop, healthcare practitioners must play a more active role in ensuring the public is aware of the importance of nutrition and diet management.

Alex Teo, Director, Research & Development and Scientific Affairs, Asia Pacific, Herbalife Nutrition

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s the world turns a page on the pandemic, much is still unknown on the full implications of the Covid-19 virus and its health impacts in the long term. For example, “long Covid1” is an emerging phenomenon 1 https://www.bbc.com/news/health-57833394

that has brought about anxieties over the pandemic’s largely undiscovered long-term effects. Recent studies show that this virus could increase the risks2 of cardiovascular diseases (CVDs), particularly among people with pre-existing cardiovascular conditions or lifestyles that are not conducive to good vascular health.

In Asia, this is a concerning development given that CVDs were already the leading cause of 10.8 million deaths3 in 2019, or approximately 354 per cent of the total deaths in the region.

Amidst this landscape, how can consumers maintain or boost their vascular wellness? The shift in focus towards preventive care such as choosing a healthy lifestyle with balanced nutrition that promotes heart health, regular check-ups and maintaining a good relationship with a healthcare 2 https://www.nature.com/articles/s41591-022-01689-3 3 https://www.jacc.org/ doi/10.1016/j.jacasi.2021.04.007?_ ga=2.51021292.412519287.1648615111697237784.1648615111#bib2 4 http://ghdx.healthdata.org/gbd-results-tool.

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professional (HCP) are some of the primary measures that can help.

According to the Herbalife Nutrition Myth Survey5, consumers also want and rely on credible and accurate information from HCPs and nutrition companies when it comes to differentiating between nutrition myths and facts. Hence, HCPs can play an influential role in raising awareness on nutrition and lifestyle options for health risk prevention.

Here are some aspects for consumers and HCPs to look into when it comes to maintaining a healthy heart: General nutrition philosophy

When it comes to nutrition for heart health, the ideal calorie consumption should comprise 40 per cent carbohydrates, 30 per cent protein, and 30 per cent healthy fats, coupled with 25 grams of fibre and adequate hydration – around eight glasses of water per day.

While a dietary pattern of fresh fruits, vegetables, lean protein and whole grains 5 https://www.herbalife.com.sg/apacnews/press-release/ nutrition-myth-hcp/

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provide a good daily dose of vitamins and minerals, other natural molecules such as omega-3 fatty acids, nitric oxides, and flavanols have beneficial effects on vascular health.

Nitric Oxide

Although still largely unfamiliar among the general public, the importance of the molecule nitric oxide is critical in supporting good heart health. Nitric oxide is a molecule that helps all the cells in our body to communicate with each other. Despite being a simple molecule, nitric oxide is an important biological regulator and therefore a fundamental component in many fields of physiology and medicine.

A component of our arteries and other organs, the natural molecule restores arterial elasticity and promotes vasodilation, which means the widening of blood vessels resulting from relaxation of the muscular walls of the vessels. With

an intake of 3 grams or more of arginine, which can be found in protein-rich foods such as nuts, fish, meats, dairy, and multigrain, we can increase the amino acid, which gets directly converted into nitric oxide.

Flavanols

Flavanols, which are naturally occurring compounds found in plants, can support cardiovascular health by lowering blood pressure, and improve nitric oxide production and arterial function.

Flavanols are found in foods like berries, cocoa (dark chocolate), kale, and tea to name a few sources of high concentration.

To profit from flavanols found in cocoa, it is recommended6 that cocoa flavanols be consumed daily from sources such as cocoa powder (2.5 g),

dark chocolate (10 g), and/or cocoa extract (200 mg). For health-conscious individuals, selecting chocolate products with less sugar and fat would allow them to reap maximum benefits from cocoa flavanols.

Similarly, studies have shown that drinking green or black tea may have beneficial effects on blood pressure7 in people with pre-and hypertensive ranges. Furthermore, tea consumption can benefit people with type 2 diabetes8, which contributes to a higher risk of heart disease and stroke.

Get your heart active

Identifying people with existing or potential vascular risks should be followed by sharing with them tips on the importance of exercise and 7 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6567086/

6 https://efsa.onlinelibrary.wiley.com/doi/epdf/10.2903/j. efsa.2010.1792

8 https://www.medicalnewstoday.com/articles/tea-anddiabetes#summary

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Omega-3

Omega-3 is helpful in maintaining healthy vascular performance due to its ability to reduce inflammation throughout the body. Inflammation is often responsible for the occurrence of heart diseases and strokes as it tends to restrict blood flow through the vascular system.

Foods like fatty fish (salmon, mackerel, and tuna), flaxseeds, walnuts, pumpkin seeds, and soybeans are high in omega-3 fatty acids. Not only is fish a great substitute for foods like beef, which is high in saturated fat, the omega-3s also help to support a healthy cardiovascular system by helping to lower triglyceride levels.

The consumption of plant-based omega-3 fatty acids supplements is useful for vegetarians, as these are primarily found in fish.

9 https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/ managing-blood-pressure-with-a-heart-healthy-diet 10 https://www.who.int/dietphysicalactivity/global-PArecs-2010.pdf

increase in presence of HDL cholesterol.

Complementing these exercises with adequate nutrition and food intake is also crucial to enable one to keep up with one’s heart health endeavours, by providing the necessary dietary support needed to fuel an active lifestyle.

Role of healthcare professionals

With the added threat of Covid19 related cardiovascular risks, the importance of an active lifestyle becomes even more important. By advocating a lifestyle that is active and focused on the right nutrition, HCPs can bring about

AUTHOR BIO

suggesting the right kind of exercises and duration. For instance, the American Heart Association9 recommends 150 minutes or more of moderate-intensity aerobic workouts or 75 minutes of intense aerobic exercises per week.

Depending on the person, one can also choose a combination of both. The World Health Organization10 (WHO) also recommends aerobic exercise as the ideal form of physical exercise.

The aerobic exercises focus on repetitive and patterned movement of muscle groups such as legs, shoulders, and arms. The most popular aerobic activities11 include swimming, jogging, walking and dancing etc. HCPs can educate patients on the benefits of exercise such as lowering blood pressure, strengthening of muscles leading to superior oxygenation, weight management, lowering of stress and

11 https://www.who.int/dietphysicalactivity/global-PArecs-2010.pdf

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a transformation in the way people approach their vascular health. Medical facts and health resources need to be conveyed to the general public in an easyto-understand manner. Caregivers can also identify people who are at a higher risk by looking at their parameters such as lifestyle, food habits, existence of heart problems, diabetes and the individual as well as family health history.

Multi-sector collaborations can also go hand in hand with ongoing efforts to raise public education. For example, Herbalife Nutrition has formed collaborations with various government bodies and nutrition organisations in the region. In Indonesia, the company’s partnership with GERMAS, a government organisation under the Ministry of Health, has aided the dissemination of information from GERMAS’ many public health campaigns to local consumers, with the help of Herbalife Nutrition’s extensive distributor networks.

Steps forward for vascular wellness

The identification of Covid-19 as a contributor to vascular diseases has raised a new area of concern. However, this risk can be managed and prevented by more meaningful collaborations between HCPs, nutrition companies and other stakeholders. Most often, it starts with enabling wider access to accurate and proper information about the causes of vascular diseases, and encouraging more prevention measures through balanced nutrition and an active lifestyle.

Alex Teo has some 30 years of experience in food and nutritional sciences, having led the research and innovation of new products and processes at several multi-national corporations in the region. Dr. Teo's research works have been extensively cited in peerreviewed journals and he has received numerous patents for these works. He has a doctoral degree in Food Science and Nutrition. He has spoken at major conference proceedings across the US & Asia.

An Agile Response to Pandemic Management Oracle

Throughout the pandemic, Oracle worked closely with the with the US Department of Health and Human Services and Centres for Disease Control on several solutions to help support the COVID-19 recovery efforts. The vaccine management capabilities developed were made available to numerous countries worldwide, including locations in Africa and Australia. As part of a ten-year philanthropic gift from Oracle, the Tasmanian Government has implemented this solution supporting their community through the phases of the vaccine rollout.

Peter Williams, Executive Director, Healthcare Industry, Oracle Japan and Asia Pacific

1) What are the key benefits of the vaccine management system?

The prime purpose of the vaccine management system is to make it as easy as possible for citizens to access and receive the vaccination so we can drive up the level of community uptake.

Through the Oracle Health Management System, individuals can book a vaccination appointment online or through the hotline. They then receive a digital Quick Response (QR) code to confirm their identity, which speeds check-in at their vaccination appointment. From there, healthcare workers use the system to record the type of vaccination administered and create or update a unique electronic health record for every person vaccinated. The system also reminds consumers to schedule a subsequent dose vaccination, if required.

With all data held securely in the Oracle Cloud running in Australia data centers, authorised government personnel can easily see the percentage of the population that has been fully or partially vaccinated and the types administered to help manage inventory and demand. Individuals also have their record of vaccination included in the Australian Immunisation Register as required under national legislation.

Doing all this requires technology that is simple to use and intuitive, and can be readily accessed through your phone, but also work for the digitally disadvantaged. The technology also needs to be able to quickly adapt when things change and operate at scale while maintaining the specified integrity, security and privacy of the information.

2) How would the state and local governments manage their state-wide COVID-19 vaccination program with this system?

Oracle has been working with governments around the world, in the US, in Africa and in Australia, implementing the Oracle Health Management System in support of vaccination programs for both COVID-19 and other diseases, such as Yellow Fever.

For Tasmania, it was essential that any IT solution could support several requirements, including operating a call centre hotline, dealing with some particular cohorts (such as schools), managing “walk-ins” at clinics, as well as enabling all citizens to be able to book appointments online and clinic staff to manage the administration of the vaccine.

Another important aspect for Tasmania was also integrating seamlessly with the national immunisation register so citizens vaccination status is captured and is also included in their ‘My Health Record’, which also uses Oracle technology and helps over 20 million Australians access their key health data.

3) Can you shed some more light on how the Tasmanian Government executed the vaccination program smoothly?

When Tasmania started to work with us in early 2020, there was an urgency for action. We knew from experience elsewhere that we could very quickly stand up the system.

From our initial engagement, it took less than six weeks

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to get to production and go-live with the cloud solution from our secure data centre in Australia. Tasmania worked with us to help achieve that timeline.

Oracle Health Management System is built using Oracle Cloud Infrastructure (OCI) and our low code application development platform, Application Express (APEX). The system is highly configurable and lends itself to supporting agile processes. With the proven successes of the Health Management System in other regions, Tasmania wanted to take the system “out-of-the box” as much as possible in the first instance to avoid delay.

But some features unique to Australia needed to be accommodated. That is where the agility and responsiveness of APEX stood out.

After discussing requirements with users, it was literally configured overnight by our US team and the changes walked through with the Tasmanian team on the following day. This agility is particularly important as policy changes in the way vaccines are to be administered requires system parameters to be quickly reset.

Peter Williams is Oracle’s Executive Director, Healthcare Industry for Asia-Pacific, helping healthcare organisations gain insights to drive business transformation and digital evolution.

Peter has previously held senior health ICT roles for National and State governments in Australia. He currently co-leads the ISO Task Force on Artificial Intelligence in Health Informatics.

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4) How do you think this system would enable governments to scale quickly and support high-demand vaccine programs without any disruptions or failures?

The capability of APEX is just one part of the solution. Some of the most critical features of the system are ‘under the hood’. As noted, the system is deployed on Oracle Cloud Infrastructure (OCI), which is Oracle’s next generation cloud platform, and provides massively scalable performance with stringent, built-in data security which is essential for government.

For individual citizens, the system is designed to help them throughout the entire process – covering right from booking their appointment, to receiving a QR code to streamline processing when they arrive for their vaccination, to sending reminder notifications and confirmation of their vaccination status.

Service providers want people to have the most seamless possible process to check-in, receive their vaccine, and have their treatment recorded. To get that outcome, the workflow of the system must align with the administra-

When Tasmania started to work with us in early 2020, there was an urgency for action. We knew from experience elsewhere that we could very quickly stand up the system.

From our initial engagement, it took less than six weeks to get to production and go-live with the cloud solution from our secure data centre in Australia.

tive and clinical processes. The Oracle Health Management System is deliberately set up to allow changes to workflow to be configured at the local level without necessarily requiring any change to the core system.

It also provides clinics with operational reporting in real time on how many people have been processed, failures to attend, waiting times, etc. These data can be rolled up to provide a view of regional performance. The system also comes with access to Oracle Analytics Cloud. Its capabilities assist management and policy makers to undertake analysis of data in the system to help plan for the future.

5) Although the challenges were unprecedented, what approach do you have for the pandemic management?

As a cloud service provider, it is not our role or remit to manage pandemics and other large-scale disasters, but there is a critical role for technology and data to play, now and in the longer term. We have responded to that need. For example, throughout the pandemic, Oracle provided cloud technology and services to the U.S. government to ensure our public health officials have access to up-to-the-minute data to better understand and combat the virus.

In addition, the University of Oxford and Oracle have collaborat to build the Global Pathogen Analysis System (GPAS), which is now being used by research organisations on nearly every continent to discover and act on potentially harmful new coronavirus mutations.

Researchers are using the system to upload pathogen data and receive comprehensive results within minutes. With user permission, the results may be shared with participating

laboratories around the globe in a secure environment.

Making this data comprehensible and shareable can help public health authorities evaluate and plan their response by giving them invaluable insight into emerging variants even before they are officially designated as Variants of Concern.

Institutions using the platform include: the University of Montreal Hospital Centre Research Centre, the Institute of Public Health Research of Chile, the Oxford University Clinical Research Unit in Vietnam, the Institute of Clinical Pathology and Medical Research – New South Wales Pathology, and Oxford Nanopore Technologies. GPAS is also now part of the Public Health England New Variant Assessment Platform.

6) How will your organisation ensure your employee wellbeing and safety of productive assets in the aftermath of the crisis?

Our employees’ well-being and success are of paramount importance at Oracle. True to these priorities, we continue to invest in our people through ongoing career development, diversity and inclusion initiatives, and health and wellness programs designed to support them throughout the pandemic and beyond.

7) How would this platform enable health officials and providers to manage vaccine distribution, expedite vaccine administration, citizen registrations, inventory management, and simplify monitoring?

Unlike many systems out in the marketplace, the Oracle system is not built to just manage the current global pandemic. It is a full function system designed to be adaptable for use with any vaccine protocol, not just COVID19, and to be a sustainable system for the future. Already, it has been used for HPV and Yellow Fever vaccinations in Africa and influenza in Tasmania. Further, while the Oracle Health Management System is built on an agile and flexible base, it is managed exactly like any of our other global Software as a Service products with regular new releases incorporating innovation and learnings from successful implementations provided as and when available.

8) Any other areas you would like to comment on Oracle is a global organisation with a large number of employees and their families impacted by the global pandemic, including thousands here in Asia. Oracle saw an opportunity to help be part of the solution and didn’t hesitate to lend its people and technology to the fight.

The important lessons we learned, such as the critical importance of being able to obtain fast, real-world data, will continue to impact how we help the healthcare market and the communities where we work and live for years to come.

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MD Ph.D Programmes

Relevance in emerging economies

In 1998 while giving an Institute lecture at IIT Kanpur India, the author had bemoaned that science, engineering and technology institutions were far away from medical colleges, physically and emotionally. It is a sign of the times that autonomous medical colleges will now be part of IIT’s. The recent announcement from the globally renowned Indian Institute of Science, Bengaluru that an integrated 7 year MD Ph.D progammes will be started from 2025, to develop a cadre of fully trained medical scientists, augurs well for India. This overview discusses the relevance of such initiatives.

Krishnan Ganapathy, Member, Board of Directors, Apollo Telemedicine Networking Foundation &, Apollo Tele Health Services

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I

n 1998 while giving an Institute lecture at IIT Kanpur, India the author had bemoaned that science, engineering and technology institutions were far away from medical colleges, physically and emotionally. It is a sign of the times that autonomous medical colleges will now be part of IIT’s. The recent announcement from the

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globally renowned Indian Institute of Science, Bengaluru that an integrated 7 year MD Ph.D progammes will be started from 2025, to develop a cadre of fully trained medical scientists, augurs well for India. This overview discusses the relevance of such initiatives.

The concept of an MD–PhD program as an integrated approach to training clinician –scientists dates back to 1956. A long tradition exists of clinicians also becoming researchers.

However well, integrated MD–PhD programs were established, as the standard medical college curriculum is insufficient to produce proficiency in the lab and the clinic. USA has the longest history of MD-PhD dualdegree training programs producing the largest number of MD-PhD’s in the world. Currently, around 90 MD Ph.D programmes exist in the US. Of 1 million MD physicians in USA, only 14,000 considered research to be their primary focus. The 18,535 physicianscientists in 1983, had fallen to 14,479, a 22% decline by 1998. Heavy debt burden of most MD graduates, extended post-MD research training to 8–10 years, uncertainties for success even after pursuing rigorous research training accounted for this decline.

On the other hand more than half of the individuals awarded Nobel Prizes in Physiology or Medicine (1997–2013) were MD–PhDs. The professional worlds of the scientist and the clinician differ fundamentally.

Clinical care is delivered with strong adherence to standards of practice and respect for individual expert opinion, despite realising possible uncertainties in diagnosis and management. Although the clinician desires to apply scientific knowledge, unequivocal relevant evidence often does not exist. In the real world, medicine, unlike the laboratory, is neither black nor white, it is various shades of grey ! Clinical care is delivered using scientific evidence, clinical experience, and patients’

If we knew what it was we were doing, it would not be called research, would it?

- Albert Einstein

individual desires and circumstances.

Clinical practice values inquiry into what is unknown; however, confirmed diagnosis and management takes precedence. In contrast, the scientist embraces uncertainty as a means to discover what is true; variance and error are integral and informative to scientific practice. Clinicians are educated in the value of established standards of professional practice and protocols and need to adhere to them. In contrast, scientists are rewarded for investigating gaps in knowledge, challenging current hypotheses and questioning accepted truths.

Without the clinician in the scientist, there can be little translation of scientific discoveries to benefit patients.

The gap (cultural and linguistic) between the research scientist in the laboratory and the harried clinician managing demanding patients with multiple complex health problems is getting wider. There are few scientists who truly understand clinical problems.

Double blind, randomised, controlled, cross over, multi institutional studies are easier planned than executed. A clinical situation cannot be broken down to a mathematical quantifiable measurable number of constituent problems which can be replicated in a laboratory setting repeatedly. A clinician’s primary raison d^etre is to deliver what the patient

wants – not necessarily treat the disease alone. Laboratory scientists generally have no idea of the complexities of insurance reimbursement. It is a sad fact but undeniable that choice of therapy is often determined by socio economic factors not by pure science. Although clinicians can work with scientists to great effect, the existence of both competencies in the same individual has conceptual advantages. However this unique individual is becoming an endangered species.

Training of clinician-scientists is long and complex requiring mastery of two challenging independent domains - rigorous medical specialty training coupled with equally rigorous laboratory and research training.

Scientific training requires dedicated time away from the clinic. This results in longer clinical training times.

It is intellectually and emotionally demanding to be trained as a scientist and a clinician simultaneously. It takes 10 years or more to complete residency and become a specialist in a procedural discipline. These individuals need to be convinced that less sleep, relentless amounts of work, longer time to become a specialist, sacrifices in personal lives and perhaps a rather unsupportive environment are still worth it. Clinician-scientists are vital members of the medical research enterprise, as the scientific questions they ask, result from taking care of sick people. They are in an ideal position to communicate and collaborate with PhD scientists and with health-care providers. The clinician–scientist role is critical to the future of health care.

Clinicians generally focus primarily on clinical practice. The clinician–scientist also considers scientific research. This, bridges the gap between discovery and clinical care.

Post MD-PhD, there would be multiple career paths. Healthcare sciences is growing exponentially the emphasis shifting from the current “individual diagnosis and treatment”

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clinical exposure to health care scientists and technologists. The CoE for Telemedicine and Healthcare Robotics will bridge the urban rural health divide using technology. A CoE for AI in Healthcare focusing on diagnosis and disease prevention has been established, planning for a smarter and connected healthcare ecosystem.

IIT Kharagpur and healthcare

to “promoting population wellness the e Way”. There is often an overkill in deploying technological aids even for primary health care. With insurance companies having a say in reimbursing procedures, even the clinician of tomorrow should have better training in science and research methodology to be able to dispassionately evaluate and understand evidence based medicine.

IIT Kanpur and healthcare

Medical Research and Technological Innovation under the same roof is available at IIT Kanpur. Government, healthcare organisations and academia have the single goal to bridge the gap between science, engineering, technology and healthcare The institute has developed knowledge centres during the last few years. The Mehta Family Centre for Engineering in Medicine at IITK is a centre of higher education with its prime focus on research in Regenerative Medicine, Molecular Medicine and Engineering and Digital Medicine. The Indian Council of Medical Research (ICMR) is ensuring the setting up of a Centre of Excellence for Medical Devices. A rapid prototyping facility and a medical device testing facility with funding support by BIRAC and National Biopharma Mission (NBM) has also been set up. This is in addition to the Centre for Nanosciences, National Centre for Flexible Electronics (NFlexE), DBT School for Healthcare Innovations and Entrepreneurship and

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Startup Incubation and Innovation centre (SIIC). IITK has a large pool of academic resources spanning across 18 departments, 25 centres, and 5 Interdisciplinary programmes in all engineering, science, design, humanities, and management disciplines.

The recently started Gangwal School of Medical Science and Technology aims to build academic and research leadership with local, national and global impact. Training next-generation healthcare professionals for India, who will develop cost effective, need based, future ready, appropriate solutions for healthcare needs is the need of the hour.

Several ‘Centres of Excellence (CoEs) are being planned. This will include a superspeciality hospital for hands on

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The School of Medical Science and Technology @ IIT Kharagpur was established as early as 2001. SMST provides a platform of interdisciplinary teaching and research in medical science and technology, resulting in a better integrated healthcare delivery system.

India needs clinicians with a knowledge of, and trained in technology. A medical academic institute with a multispecialty research centre at its core, promoting education and collaboration in biomedical research, leading to better treatment and healthcare delivery to patients is necessary. The School introduced an interdisciplinary 3 years Masters Program in Medical Science and Technology (MMST) for MBBS doctors. The MMST program was the first comprehensive physiciantechnologist training program in India aiming to bridge the gap that has

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Indian Institute of Science (IISc) and healthcare

IISc will set up a postgraduate medical school on its campus in Bengaluru to develop physician scientists. The new 800 bed multi speciality BagchiParthasarathy hospital will provide the training area for these dedicated medical scientists. This new entity will provide an integrated MD-PhD programme. The clinician-scientists, of the future will be trained in the hospital and science and engineering labs of IISc. The hospital will have state-of-the-art facilities for diagnostics, treatment and research.

There will be a number of specialities and super specialities. Advanced digital technologies and solutions, such as integrated EMR systems and a comprehensive telemedicine suite with haptics interfaces will be available.

Those selected for training as clinician scientists will identify their areas of research that combines biotechnology, nanotechnology, or data science and AI with medical diagnosis and research.

Another dual degree in the offing is the MD-MTech programme to develop indigenous med-tech products. This will be a confluence of basic science, engineering, technology and clinical sciences The med-tech incubation system will support this initiate.

Govt. of India through it’s e-Sanjeevani telehealth platform has initiated delivery of remote healthcare. It is just a question of

time before state-of-the-art, pointof-care diagnostics (IOMT enabled POC devices) assessing 100 different physiological parameters ensure better last mile healthcare delivery. Achieving this implies accumulation of colossal patient data. Deployment of block chain technology can ensure health data privacy. This data vault could be a rich repository of health data for AI powered disease prediction leading to precision medicine. To make all this happen from conceptualisation to implementation, maintenance, self sustenance and ultimately to ensure better health care outcome for the individual suburban / rural patient, requires clinicianscientists – technologists who can see the “Big Picture” . Those driving

these initiatives need to have been exposed to clinical sciences, technology, innovation, scientific research and business management during their formative years and training.

Epilogue The author completed a 5 year post graduateM.Ch course in neurosurgery after a 6.5 years MBBS course. Following this he took another 5 years to get a Ph.D in neurosurgery while working as an Asst Professor and having private practice. This was in the nineteen eighties, when the world was totally different. Considerable family support and determination alone made this possible in a government medical college bound by rules and regulations without precedents!

Alas there was no combined M.ChPh.D programme then!!

AUTHOR BIO

historically separated biological sciences from engineering and physical sciences.

A 4 semester M.Tech program in Medical Imaging and Informatics is offered to engineers. Areas identified for teaching and R&D activities include Medical Imaging and Image Analysis, Medical Instrumentation, Tissue Engineering, Biomaterials, Bio-MEMS, Reproductive Biology, Cancer Drug Design, Medical Statistics and Informatics, Nuclear Medicine, Radiation Therapy ,Health Care Management, Herbal medicine and Bio-Engineering

K GANAPATHY 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: https:kganapathy.in Mail: drganapathy@apollohospitals.com

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Bringing Innovative Healthcare Solutions Since 1997 MEDICAL FAIR ASIA, held in Singapore, and co-located with MEDICAL MANUFACTURING ASIA, connects you to 850 exhibitors from 50 countries, and across 22 product categories.

The future of healthcare technology is fast becoming an innovative and life-changing space, where medical devices and equipment are increasingly focusing on affordability, accessibility, and efficiency. Access to affordable and quality medical devices is crucial in addressing healthcare emergencies, advancing healthcare coverage and promoting a healthy population and communities. According to the World Health Organization (WHO), it is estimated that there are 2 million different kinds of medical devices on the global market that are classified into over 7,000 generic devices groups.

With the continuous development of e-commerce, the marketplace is flooded with options and new developments in the healthcare space and MEDICAL

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FAIR ASIA provides an ideal one-stop marketplace and procurement platform for all those involved in the medical and healthcare sector to keep up with industry trends, develop new contacts, compare products and meet suppliers. Held in Singapore – the medical hub of the region, the exhibition will co-locate with MEDICAL MANUFACTURING ASIA once again, and feature 22 product categories covering medical consumables, electromedical equipment, medical technology, and testing equipment to orthopaedic supplies and rehabilitation equipment.

on hospital, Diagnostic, Pharmaceutical, Medical & Rehabilitation Equipment & Supplies, will see the 14th iteration presenting a Phygital Edition that brings together the best of the in-person format and an online extension, so networking and discussions can continue at any time.

Phygital edition for face-to-face networking and online engagement Well-established in the region for over a decade, MEDICAL FAIR ASIA – the International Exhibition

PROGRAMME HIGHLIGHTS COMMUNITY CARE PAVILION Presenting products and solutions addressing the needs of ageing societies and the rise of chronic diseases.

PANDEMIC MANAGEMENT SOLUTIONS ZONE With lessons learnt from the pandemic, here’s where you’ll gain access to relevant solutions and pandemic preparedness.

START-UP PARK See innovative start-up companies showcase their readyto-market innovations, or join the conversation as they share ideas and technologies EXHIBITOR TECHNICAL PRESENTATION WEBINARS July and August Join industry partners and professionals as they share insights into on medical and healthcare innovations.

Taking place online before the actual show, these sessions provide a sneak preview on what you can expect at MEDICAL FAIR ASIA CO-LOCATED EVENTS AND INTERDISCIPLINARY INDUSTRY CONFERENCES: • MEDICAL MANUFACTURING ASIA – 5th Manufacturing Processes for Medical Technology Exhibition and Conference • MEDICAL FESTIVAL ASIA • 3rd MEDICAL FAIR ASIA MEDICINE+SPORTS Conference (MFAMSC) • The 42nd WT | Wearable Technologies Conference 2022 Asia • Paradigm Shifts in Healthcare • Start-Up Podium

Comprehensive showcase of healthcare innovations, medical technology and devices MEDICAL FAIR ASIA 2022 continues to see strong international participation as exhibitors from around the world showcase custom solutions for outpatient and inpatient treatment, digitalisation of the care processes and trending healthcare solutions, as well as service providers and suppliers focused on preventing delivery and supply bottlenecks - oriented around the COVID-19 pandemic.

Visitor registration to MEDICAL FAIR ASIA 2022 is now open online, go to https://www.medicalfair-asia.com/registration.

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W

hile patient and provider experiences vary by country, COVID-19 has illuminated the global nature of healthcare and tested the resilience of organisations. At the beginning of the pandemic, hospitals braced for an incoming wave of COVID19 patients and took proactive steps to preserve hospital capacity and resources.

Many countries directed public hospitals to cancel non-urgent surgeries and to ramp up their intensive care unit (ICU) bed capacity to accommodate any potential surge in pandemic patients.

At the individual level, many patients chose to delay their care and stay home to reduce their risk of contracting COVID-19. On this side of

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PREPARING FOR PATIENT SURGES AMID A PANDEMIC In March 2020, the World Health Organisation (WHO) declared COVID-19 a global pandemic. Since that time, health systems and patients have been challenged to rapidly adapt in the face of capacity surges, unprecedented resource consumption and an array of new safety procedures. As vaccines continue to roll out, a surge of patients needing non-emergent care is likely to put new strains on our healthcare resources.

Solutions and new workflows will be needed to cope with the increased volume of patients seeking care.

John Lee-Bartlett, Country Director, Allscripts Canada

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the world, research showed that fewer Canadians sought medical care for significant concerns like cardiac events and trauma, as well as for common concerns like abdominal pain colds and the flu1. In the Asian region, Malaysia saw an overall surgery cancellation rate of about 71 per cent, which was projected to take 11 months to clear the backlog of surgeries2.

This may be one of the largest indirect consequences of COVID-19: more than 28 million cancelled or postponed operations, which means a significant number of patients are waiting for care3.

For conditions such as cancer, surgery is central to diagnosis and treatment, and a delay in either can significantly worsen outcomes4.

The true impact of the pandemic on our healthcare system — and the global population’s healthcare in general — is so far-reaching we likely do not yet know its full scale. It may likely take years before we can determine the full impact of these care delays, and potentially the same amount of time for the system to recover financially and operationally.

According to a global study3 using data from 359 hospitals across 71 countries, the total number of cancelled elective surgeries in 190 countries across duration of 12 weeks of peak disruption were estimated to be at 2.3 million operations per week. These numbers represent a massive backlog of delayed surgeries and procedures, which are

likely to worsen with additional week of continuing restrictions and lockdowns.

It will also place unprecedented stress on healthcare systems across the globe in the coming months and years, which for some countries, were already routinely filled beyond capacity even before the pandemic with patients experiencing long wait times for specialist referrals, surgeries or diagnostic procedures.

The same study also predicted that it would take at least 45 weeks to clear the surgical backlog and get back on track. However, these projections assume hospitals will be able to operate at 20 per cent above pre-pandemic volumes over the coming years, which remains an existential challenge for already overcrowded healthcare systems.

Rethinking what it means to be digital

While increasing funding is critical to help our hospitals prepare for patient surges, healthcare leaders and decision-makers will also have to find innovative ways to increase volume and capacity above pre-pandemic levels to clear the backlog. Organisations are all at different stages of workflow modernisation, and, from a culture perspective, acceptance of technology is as important, if not more so, than the adoption of new solutions.

We need to explore solutions that enable patients to access the surgeries or procedures they are waiting for,

without compromising quality of care.

To achieve this, we need to get to the root of the problem – inpatient capacity planning — which includes hospital admissions, discharges, and transfers, as well as staffing and operating-room utilisation. For example, a significant step would be to move from electronic versions of analog processes to digitalfirst processes, where healthcare providers can then realise the full potential of digital workflows that are bolstered by artificial intelligence, machine learning and other technologies poised to transform healthcare delivery, operations and more.

Managing surges in patient volume

The backlog of appointments resulting from suspending non-urgent procedures and screenings during COVID-19 waves has become a major side effect of the pandemic. However, the healthcare sector can boost patient access using some creative approaches. There are five opportunities healthcare leaders and decision-makers can consider: 1) Optimise patient access and bed management Adopting bed management technology can enable fast, accurate patient placement. With visibility into transfer and discharge activities, hospitals can rely on the data to match patients to beds under the right service lines more quickly, expediting patient throughput.

1 Canadian Institute for Health Information (CIHI).

Overview: COVID-19’s impact on health care systems.

Available at: https://www.cihi.ca/en/covid-19- resources/ impact-of-covid-19-on-canadas-health-care-systems/overview-covid-19s-impact-on Accessed on: May 25, 2021.

2 British Journey of Surgery, COVIDSurg Collaborative: Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans 3 World Economic Forum: 28 million elective surgeries may be cancelled worldwide: how non-COVID-19 medical care is suffering 4 Eskander et al. Access to Cancer Surgery in a Universal Health Care System During the COVID-19 Pandemic.

JAMA Netw Open. 2021;4(3):e211104. Available at: https://jamanetwork.com/journals/jamanetworkopen/fulla rticle/2777399?resultClick=1#zld210019r1. Accessed on: May 25, 2021.

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3) Effectively manage the porter pool To optimise the porter service and limit delays, many organisations centralise the transport workload.

Streamlining transport processes with a mobile application maximises staff productivity by optimising task allocation with batching and barcodes.

4) Harness the power of predictive analytics for proactive decisionmaking From an operational perspective, organisations can leverage predictive analytics to make actionable staffinglevel decisions based on history and predicted demand and ensure that they have the capacity to effectively manage volumes during any given shift. When staffing decisions are aligned with demand, a foundation for improved patient access is created. Powerful predictive analytics can optimise capacity planning and discharge forecasting.

5) Deploy a single command and control team This provides an integrated patient flow solution that incorporates bed management, portering, environmental services, transfer management, surgical flow and predictive analytics, ensuring communication, efficiency and patient throughput are maximised.

Bringing care to the patient

While optimising in-person care experiences is a worthy endeavour, there is no denying that remote care is on the rise. During the pandemic, telehealth enabled patients with everything from

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behavioural health to post-surgical care needs to engage with clinicians flexibly and comfortably. The possibilities for telecare will only expand as connected device technologies advance, where the smart thermometers and sleep trackers of today suggest that more comprehensive and efficient care is within reach.

Patients can get visibility into their progress and useful information to help improve their health along the way.

Managing the volume of data collected in our personal environments will thus be key to actualising this vision.

John Lee-Bartlett is VP International Solutions Management & Managing Director Canada and Americas (non US). Originally from the UK, John has a 20-year growing passion for healthcare transformation.

Having worked for many years in the NHS and then for various healthcare IT companies, he provides a clear and

passionate approach to improving the ways healthcare IT can enable clinical transformation. For the last several years, John has worked in Canada providing leadership across the Allscripts business for existing clients and growing the business to provide innovative solutions to organizations and patients.

About Allscripts

Allscripts (NASDAQ: MDRX) is a leader in healthcare information technology solutions that advance clinical, financial and operational results. Our innovative solutions connect people, places and data across an Open, Connected Community of HealthTM. Connectivity empowers caregivers and consumers to make better decisions, delivering better care for healthier populations. To learn more, visit www.allscripts.com, Twitter, YouTube and It Takes A Community: The Allscripts Blog.

As of 6 May 2022, the Allscripts Healthcare Solutions’ Hospitals and Large Physician Practices business segment has since been acquired by N. Harris Computer Corporation (“Harris”), a wholly-owned subsidiary of Constellation Software Inc. (TSX:CSU).

The segment is now operating as Altera Digital Health, a business unit of Harris Healthcare. To learn more, visit www. alterahealth.com.

John Lee-Bartlett is VP International Solutions Management & Managing Director Canada and Americas (non US). Originally from the UK, John has a 20-year growing passion for healthcare transformation. Having worked for many years in the NHS and then for various healthcare IT companies, he provides a clear and passionate approach to improving the ways healthcare IT can enable clinical transformation.

For the last several years, John has worked in Canada providing leadership across the Allscripts business for existing clients and growing the business to provide innovative solutions to organizations and patients.

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AUTHOR BIO

2) Eliminate environmental services inefficiencies to prioritise patient safety Eliminating manual processes and ensuring environmental services tasks are completed safely and efficiently will minimise hospital-acquired infections which require lengthened hospital stays.

HEALTHCARE MANAGEMENT

LUCIANO BRUSTIA Regional Managing Director Asia Pacific InterSystems

DIGITAL ENGAGEMENT PUTS PATIENTS AT THE CENTRE OF CARE Asian hospitals have learned the value of data from the pandemic. Delivering world-class care and the best patient experience is now the minimum standard.

The race is on to go fully digital with leading providers moving to digitally engage their patients inside and outside the hospital for the best virtual experience.

C

OVID has given digital health technology a huge boost. It has spurred investments in telehealth, patient engagement via mobiles, and electronic medical record systems.

With fewer hospital visits, healthcare providers are looking to technology to fill the gap. Strategies include empowering patients to take more responsibility for

their care and finding ways to provide care virtually, not just in the hospital or clinic.

We spoke with Luciano Brustia, Regional Managing Director, Asia Pacific at InterSystems1, about the latest developments in digital patient engagement, the challenges that hospitals 1 https://www.intersystems.com/

face, and how the company is working with leading hospitals in the region.

The digital patient engagement trend shouldn’t surprise anyone in the healthcare industry, says Brustia. “Digital engagement is already part of life in almost every other industry. Consumers expect to interact with their trusted suppliers digitally, particularly through their smartphones, and healthcare is now catching up.”

But healthcare is not like every other industry. The “customer” data that providers collect about patients is far

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more complex and difficult to interpret.

This gives rise to many challenges. For example, while hospitals want to move quickly to engage patients digitally, the services they roll out must also do no harm.

“There is a great advantage in encouraging patients to take responsibility for their care,” says Brustia.

“The Value of Engagement Research shows that engaged and activated patients have higher satisfaction levels and use fewer resources. Combined with telehealth, clinicians can see more patients, and providers can maintain closer relationships with their customers.”

Personal Community2 patient engagement solutions from InterSystems, for example, provide a range of capabilities. These include reviewing care records, uploading data from personal medical devices, scheduling appointments, completing forms for care providers, receiving alerts and notifications, and accessing thirdparty SMART on FHIR apps.

Many Asian hospitals have already pressed ahead with digital engagement strategies focused on patient communications. These have already proven valuable in maintaining relationships with patients that were making fewer hospital visits because of the pandemic.

Patients expect clinical data access

Brustia says these initiatives have been a significant first step. Hospital management teams have moved quickly to develop new business strategies and invest in technology to implement them.

But they run the longer term risk of not meeting patient expectations.

“With digital engagement, healthcare providers need to think about their brand. Are they an organisation that promotes medical treatments, or do they provide the best care for each 2 https://www.intersystems.com/interoperability-platform/ personal-community

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patient? If you want to be known for patient-centred care, clinical data has to be part of the equation.”

“We need technology to be a bridge between healthcare providers, patients and clinicians,” says Brustia. “But we also need to do that in a clinically safe and simple way that benefits the patient and the clinicians, and meets the business objectives of healthcare providers.”

Providers that have invested in digital clinical systems have a massive advantage over those that rely on paper-based systems. The need to capture clinical data and make it available for sharing with patients and clinicians makes an electronic medical record (EMR) system a must-have.

With digital engagement, healthcare providers need to think about their brand.

Luciano Brustia InterSystems

While provider organisations want to move quickly, digital patient engagement should be approached like any other new clinical process, says Brustia. “Hospitals should start with some simple use-cases.

You need to try them, test them and prove that they work before releasing them into the world.”

While every hospital will have a different strategy, the most popular use-cases include booking appointments online, reviewing lab results, and checking medication lists. More advanced strategies include medication refills. A mobile app may alert patients when medications need replacing and set up a telehealth consultation with a doctor.

Before implementing these strategies, you need to involve each

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stakeholder group, says Brustia. “You need to meet patients’ expectations, but you also need buy-in from clinicians and a commitment from hospital executives to an ongoing digital engagement program.”

Thinking strategically, healthcare organisations should look at digital engagement as the lens through which patients view and benefit from the digital transformation of hospitals.

Delivering hospitals’ future vision

“While patient engagement is the goal, it is just one part of digital transformation.

We are only at the beginning of a long transformation journey for healthcare.

While we can provide the technology to deliver the hospital’s vision for the future, you cannot achieve everything at once.”

Brustia says that while InterSystems offers a wide range of technologies for the digital transformation of healthcare, the real value lies in how they are used.

That is one reason why InterSystems prefers to work in partnership with healthcare providers. “We want our customers to move as quickly as they can.” But healthcare is not an industry where you can ‘move fast and break things’, as Facebook founder Mark Zuckerberg said.

“Digital patient engagement involves more than technology,” says Brustia.

“You need to consider many issues to develop the best solution. These include clinical safety, social safety, security and privacy. How are you going to verify the identity of the patient? How will you protect against the potential for medical information to be stolen or misused and avoid potential liability for the hospital and the clinicians?”

He says that InterSystems has invested in large clinical safety and information security departments to keep abreast of these issues and advise its customers. “We pour millions of dollars into the things that make up a complete solution. We tell our customers that you should trust us to work together in a true partnership to succeed.”

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InterSystems believes that healthcare providers should win their patients’ trust one step at a time when it comes to digital engagement. The company is currently working with several Asian hospitals on digital engagement. In almost every case, the strategy is to start small, achieve some wins, and build the program from there.

For example, Bumrungrad International Hospital3 in Thailand recently implemented InterSystems TrakCare 4 Personal Community.

Another leading hospital group, Rumah Sakit Pondok Indah5 (RSPI) in Indonesia, is also working with InterSystems to make digital patient engagement a reality.

“We are working to help RSPI achieve HIMSS EMRAM Stage 7 validation, and patient engagement is central to their strategy,” says Brustia. “In particular, they are looking to leverage InterSystems TrakCare’s ability to integrate EMR data with mobile apps.”

Starting small may mean enabling patients to book appointments and access lab results from the TrakCare EMR. But the long-term goal would be to give patients the information they need to manage their health. That might include reminders for vaccinations or regular appointments to manage a chronic health condition.

Both Bumrungrad International Hospital and RSPI are building patient engagement on top of mature EMR systems. But organisations implementing new EMR systems are also building patient engagement into their digital transformation plans.

“One of our customers is implementing InterSystems TrakCare at a new hospital,” says Brustia. “As well as digitising their patient records and providing clinical support from 3 https://www.bumrungrad.com/en/ 4 https://www.intersystems.com/au/products/trakcare/

day one, one of their objectives is to build interoperability for digital patient engagement.”

Patient engagement driving need for interoperability

TrakCare can integrate with mobile apps, Brustia points out, and the new hospital wants to leverage its EMR data for patient engagement. “This organisation already has some home-grown mobile apps for patients, and they are looking to increase the richness of the engagement with clinical data.”

Asian hospitals have long seen EMR systems as desirable in supporting world-class levels of healthcare. Now, digital patient engagement is driving the need for other advanced technologies, including interoperability and data analytics.

This is something that has already happened in other industries, says Brustia. “If you look at the financial or the travel industries, you see the ability to combine multiple sources of information into a single customer service using Internet technologies. When you search for the best airline flight on a booking site, you see information from multiple databases that have been combined in a meaningful way.”

The healthcare industry is also making rapid advances in interoperability, driven by new standards for exchanging healthcare information like FHIR (Fast Healthcare Interoperability Resources).

Another new standard, SMART on FHIR6, builds on FHIR and other 6 https://www.intersystems.com/fhir/

Internet standards to provide secure data interchange with EMR systems like InterSystems TrakCare.

When it comes to digital patient engagement, FHIR offers a standard way to integrate mobile apps, for example, with a hospital’s information systems. Organisations can also take advantage of a healthcare data platform, like InterSystems IRIS for Health™,7 to develop FHIR apps, provide advanced interoperability, and orchestrate digital services.

“Learn to walk before you can run”

Likewise, data analytics, artificial intelligence and machine learning will also be essential capabilities as digital patient engagement evolves.

Healthcare providers could potentially analyse engagement patterns, for example, and correlate them against healthcare outcomes to make informed recommendations to individual patients.

Building the technology capabilities to support future enhancements is essential. Right now, however, Asian hospitals need to develop a digital patient engagement strategy and go after the low-hanging fruit, says Brustia in conclusion.

“How many healthcare providers have a strategy to care for their customers’ whole families, for example. How do we help them become responsible for not only health but also wellness? How can we look after our patients remotely, so they don’t need to visit the hospital?

Many of these strategies are achievable, but you must learn to walk before you can run.”

7 https://www.intersystems.com/intersystems-iris-for-health

AUTHOR BIO

Start small, achieve wins and build one step at a time

LUCIANO BRUSTIA is Regional Managing Director, Asia Pacific at InterSystems, a provider of innovative data solutions, including cloud-first data platforms which solve interoperability, speed and scalability problems, as well as the world’s most proven electronic medical record which supports advanced data management in hospitals.

5 https://www.rspondokindah.co.id/en

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Exploring Equality, Equity, Diversity and Inclusion in Driving Business Impact Studies show that equality, equity, diversity and inclusion (EEDI) initiatives are crucial to business success. In the creation and execution of EEDI initiatives, several critical factors must be considered. How can regional healthcare brands build sustainable EEDI initiatives and what are some ways these initiatives can be enhanced?

Peggy Wu, Vice President, AbbVie, Asia

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I

t is no secret that diversity and inclusion have taken centre stage in company strategies worldwide due to their essential roles in driving business growth. Research has found that companies with the greatest diversity outperform less diverse ones by 36 per cent. In fact, companies with a solid commitment to equality, equity, diversity and inclusion (EEDI) have also been shown to reap a myriad of additional benefits1, such as an increase in innovation, enhanced brand reputation, and the ability to attract and retain talent in an effective manner.

These advantages hold true when viewed through the lens of gender equality. Companies that have more than 1 Workforce Institute D&I Insights Report, 2021, https:// www.achievers.com/sg/resources/white-papers/workforceinstitute-di-insights-report/

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30 percent women on their executive teams are significantly more likely to outdo2 those with fewer or no women executives. In the healthcare industry in particular, developing and delivering innovative life-changing medicines for our diverse patients with unique health challenges requires thoughtfulness and creativity that comes from having a wide range of inputs. Incorporating EEDI into ways of working also result in better clinical outcomes3 for patients, as it enables effective communication which leads to higher employee productivity and, in due course, the provision of higher-quality care.

Despite these proven benefits, however, there should still be much progress in designing and executing lasting and impactful EEDI approaches within the healthcare landscape. A report by McKinsey in 20204 discovered that only one-third of the firms the company tracked since 2014 had achieved real gains in executive team diversity. Additionally, nearly 50 per cent had made little or no progress and, within that, many have seen gender and ethnic minority representation even go backwards. According to a survey carried out by Deloitte and NAHSE5, three out of four respondents did not believe that their leadership was held accountable for meeting diversity and inclusion goals.

Then, how can the perception of diversity and inclusion be transformed in healthcare? This is especially the case in the Asia region which is a melting pot of different cultures, races, languages, backgrounds, identities and more.

In this day and age, individuals are 2 McKinsey & Company, 2020, https://www.mckinsey. com/featured-insights/diversity-and-inclusion/diversitywins-how-inclusion-matters 3 Relias, 2022, https://www.relias.com/blog/how-diversityequity-inclusion-influence-healthcare 4 McKinsey & Company, 2020, https://www.mckinsey. com/~/media/mckinsey/featured%20insights/diversity%20 and%20inclusion/diversity%20wins%20how%20inclusion%20matters/diversity-wins-how-inclusion-matters-vf. pdf 5 Deloitte, 2021, https://www2.deloitte.com/us/en/insights/ industry/health-care/diversity-in-healthcare-workforce.html

becoming increasingly inclined to respect differences, encourage meaningful collaborations, and understand the importance of diverse viewpoints in the workplace. With this comes along opportunities to bridge gaps in gender and generation and culture as well as to break through from traditional assumptions and practices.

Factors to consider for a successful roll-out of diversity and inclusion initiatives

Building a talent pipeline Building an effective diversity and inclusion strategy starts with considering talent management. Building a talent pipeline begins with putting the awareness of EEDI into action.

Hiring managers should learn how to recognise potential unconscious bias that they should avoid when conducting interviews or screening candidates. They need to ensure that they consider the wide range of perspectives and qualities possessed by candidates to attract a diverse and talented workforce.

Inclusive leadership should be regarded as a core competency for people leaders. This begins with establishing an inclusive mindset.

Secondly, while the competition for talents gets fierce, diversity and inclusion become critical factors in attracting and retaining talents. According to Forbes Insights6, a diverse workforce can attract 6 Forbes Insights, 2011, https://images.forbes.com/forbesin-

talents in the market. When companies have good career advancement opportunities, they have a higher chance of securing a diverse workforce. Talent management strategies and development programs can be integral in continuously developing the talent pipeline and helping qualified employees advance their career journeys. We have our annual talent assessment processes in place, running various development programs based on talent development plans, coaching and mentoring programs, and short-term assignments for talents across Asia. We have developed and exported our talents beyond the region, which can strengthen a global diverse workforce.

In terms of career advancement for women, I think steps are being made in the right direction. McKinsey & Company and LeanIn.Org7 found that female leaders are more likely to help employees navigate work-life challenges and spend more time contributing to EEDI efforts. A healthy representation of women leaders is more likely to foster diversity and inclusion.

Strengthening of leadership accountability

Leaders in organisations must play a substantial role in cultivating diversity and inclusion in the workplace, as the extent to which companies respond to matters of EEDI is largely, if not fully, dependent on leadership. In the Heidrick Asia Pacific Diversity and Inclusion Survey 20198, it was found that business-driven EEDI strategies led by CEOs and other C-suite leaders achieve more success. Additionally, around 70 percent of employees in the survey believed that it would be helpful for their leaders to learn to manage sights/StudyPDFs/Innovation_Through_Diversity.pdf 7 McKinsey & Company and LeanIn.Org, 2021, https:// wiw-report.s3.amazonaws.com/Women_in_the_Workplace_2021.pdf 8 Heidrick & Struggles, 2020, https://www.heidrick. com/en/insights/diversity-inclusion/diverse_region_inclusive_workforces_-asia_pacific_diversity_and_inclusion_survey_2019

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diverse groups, recognise unconscious bias, and adopt more inclusive behaviour and thinking.

Inclusive leadership should be regarded as a core competency for people leaders. This begins with establishing an inclusive mindset. It is also important for leaders to model behaviours that help nurture a culture that offers the opportunity for employees to achieve their best.

Once an inclusive mindset is adopted, we can move towards putting EEDI into practice9 by promoting flexible ways of working, conscious inclusion of diverse team members, and creating an environment where open communication is encouraged.

Diverse employee communities for the underrepresented can be fostered throughout the organisation by leadership to promote awareness and appreciation of diversity and support people of all backgrounds. We also 9 General Counsel for Diversity and Inclusion, 2022, https://www.gcdandi.com/app/uploads/2020/12/ practical-step-2-top-ten-tips-e-an-accountable-inclusiveleader-final.pdf

receive valuable input from our employees through biennial employee surveys, which evaluate our leaders’ inclusion behaviours.

As a female leader, I realise how necessary it is to step up to the plate and be a role model both at work and at home. In Asia, we encourage our leaders to attend inclusive leadership programs where we learn how to manage diversity in teams and foster a welcoming culture.

We had also created Women Leaders in Action (WLA) in Asia — a group for women leaders to empower our employees in the region to reach their full potential.

Looking at a long-term holistic approach

For diversity and inclusion initiatives to achieve their maximum impact, it should be made integral to the mission 10 of healthcare companies. Companies should have concrete measures to boost diversity and inclusion, such as 10 National Library of Medicine, 2020, https://www.ncbi. nlm.nih.gov/pmc/articles/PMC7387183/

a roadmap to implement them and a plan to monitor progress over time.

The established strategy should be part of the fabric of the work environment. Leaders should work with their teams to plan a constant stream of applications of EEDI throughout the year.

We should also measure the performance of diverse and inclusive initiatives by celebrating quick wins, highlighting successes, and managing what should be improved. Realistic goals should also be set to best determine the progress of diversity and inclusion in an organisation. They can take the form of a demographic that the company is looking to increase or perhaps boost overall employee engagement. In both cases, employees, including leaders, need to understand their roles in reaching these objectives and how they can contribute to making impactful change together.

For instance, our legal team leaders have specific personal goals to advance our diversity objectives which are continually measured and assessed11.

AUTHOR BIO

Steps forward for building diversity and inclusion in healthcare

The adoption of diversity and inclusion in healthcare has proven crucial in driving business impact and success by securing a talent pipeline and enriching a diverse workforce which sparks innovation to bring sustainable growth to life. To achieve a favourable outcome, a holistic approach needs to be adopted while prioritising leadership accountability and ensuring the right strategy to weave diversity and inclusion into a company. When companies can successfully embed a diverse and inclusive way of working into their culture, they can expect highly engaged employees to unleash their potential and ultimately drive business growth.

Peggy Wu, Vice President of AbbVie Asia, manages fifteen markets in the region including Korea, Taiwan, Southeast Asia, and India.

She leads commercial and product strategy, marketing and P&L. Ms Wu holds an MBA from National Cheng Chi University in Taiwan after earning a bachelor’s degree in Pharmacy from Taipei Medical University.

11 AbbVie, https://www.abbvie.com/our-company/equality-inclusion-diversity/diversity-in-law.html

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THE 3 PS OF ORGANISATIONAL PERFORMANCE The inputs (work) of the people towards the output (profit) for an organisation, is an achievement of process. People and process define profits which reflect in the profit & loss statement. And in between lies the use of various ingredients such as skills, domain knowledge and other resources. This interplay may vary in degree by industry type, but the core remains the same in any business organisation.

Gurrit K Sethi, Founder, Miindmymiind

Y

PEOPLE

PROCESS

- Skill - Knowledge

- Other resources - Product / service construct

es, we do know them all; there is no rocket science to this. Just a balanced interplay of sensitivities, skills and desired outcomes. I am talking of people, process and profit & loss statements — the three Ps of performance. The first P does it in a manner of the second P and the third P is the result of the first two.

I was tickled into penning down this article after an interesting exchange with a few experts who evaluate managerial skills of professionals based on the mathematical concoction of a profit & loss statement. This is an effort to try and throw some light on the making of the mathematical

concoction. This understanding comes through not the managerial degrees and courses one went through, but an output of the tango of roles one played through the years to make profits happen on ground, be they for start-ups or established entities.

The 3 Ps is an amalgamation of on-the-job training, learning through mistakes and of course guidance from various stakeholders including bosses, peers, juniors, and professional outsiders. After all what is a P&L. Yes many would know the definition and the formulae and the layout and the (we all learn this in business school).

However, in the creation of a P&L

PROFIT & LOSS - Performance

on ground, how do we make the mathematics work, who does what part of the work and who ensures it gets done?

While business schools teach us what a P&L is, it is the experience of being on the job that teaches us how to create profits that impress, profits that sustain, month after month, year after year. And the biggest learning that comes from all of these is that it is the people that make it happen, and not just a grand strategy on paper.

Strategy creation is, again, an outcome of the experience, understanding of the landscape and innovative ideas on navigating the

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Peop devel le opme

nt

anaging People m es resourc

s

ces

Pro

Pro fi

le ce op an Pe rm r fo pe

satisfaction indexes. But do we follow an ‘employee satisfaction index’? If so, at what level do we measure it, if at all?

In my experience, if we look at achieving both factors together (customer satisfaction and employee satisfaction) and keep an eye on the performance of each process, the effects on the profits can be quite immense. I don’t just go by the adage that a happy employee ensures happy customers.

Rather, I am pointing to the fact that if each small process in any organisation is tempered with aspects of employee safety, employee satisfaction and ease of performance, a lot of wastage of efforts is negated, bettering throughput and resource usage. The performance of each process can be measured numerically through various methodologies.

A simple theory of ensuring that the tasks allocated to any employee can be performed with the least of obstacles,

AUTHOR BIO

market. The success of this strategy is in the implementation, again defined by who does it and how well it gets done.

And thus, the process gains importance as well as depth. The process of people management needs to ensure that the various elements and dynamics of a business are taken together within an organisation during any strategy rollout.

People are complex beings — yes all of us! Each one comes with a different perspective, different background, different learning. And each also has a different takeaway from the very same session each would have attended.

The stitch up together of each of these perspectives to make it all work towards profitability of the organisation is the key role of a profit & loss manager.

Who does it is equally important as what is it to be done as it dictates how it is finally done! A tongue twister but a more interesting mind twister!

Many feel that an organisation structure is simply a way of a reporting structure. As part of those structures, I ask, how many have felt the constrictions of policy, methodology, and even people? We often hear the words ‘bureaucratic’ and ‘red tape’.

Have we wondered what the P&L statement of an organisation lost or gained through these and how and why? An organisation structure needs to be designed to ensure that the people work together for to ensure a coherent interplay of various business activities.

And this work together has to be designed to deliver. And this simply is the process.

All strategy, all people management skills come to a nought without a methodology towards performance.

And this methodology can be tweaked to enhance profits. In fact, given the dynamism of business, it is necessary to tweak it.

Incidentally, products and the services are also an output of people and process. We often hear ‘customer satisfaction’ and deftly follow the net promoter score (NPS) and customer

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ergonomically or otherwise, simply speeds up the time taken, leaving room for more work to be done. Also, because the task was done hassle-free, it leaves the employees with better energy levels.

Do we not find ourselves tired out after even a short time of enduring a task that has many hassles?

This ease of performance comes through design, through practice and through a keen eye on every minute performance metrics and the employees.

The old adage — keeping an ear to the ground —serves very well for process design as well! Thus, every manager should deign to have a numerical value as an output for every small process.

This finally adds up to the profits in a P&L statement at the end of each period.

If you look at any issue / hurdle within an organisation, these mostly are people (skills), people (attitude) or process issues. Ensuring people skills and ensuring the right person in the right place are also in turn process issues!

Summing up, a profit & loss statement is the simple outcome of the performance of people resulting from the use of various resources, how efficiently these have been used and how well the task was performed. Each of these is measurable and we can create those measurable structures. Thus, it is the process of people management that leads to the delivery of a good P&L. I rest my case!!

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.

MEDICAL SCIENCES

Redefining Innovation in Orthopaedics For Seamless Patient Care and Improved Operational Efficiency With new technology being introduced to the market ever so often, the future of orthopaedics care in the region has never looked more promising.

Sureshan Sivananthan, Consultant Orthopaedic and Sports Surgeon, ALTY Orthopaedic Hospital

D

igital transformation has presented incredible opportunities for change, especially within the field of healthcare. Technologies such as big data, artificial intelligence (AI), machine-learning (ML) and analytics have gained popularity in recent years and promise greater business impact and industry disruption.

Big data provides the raw material (data sets) for AI and ML to make better data analysis such as personalised risk prediction, improved decision-making process, detecting implant specifics from imaging that will assist to monitor patient movement and recovery process.

Some possible innovations in orthopaedic surgery predicted by experts also include the use of robotics and augmented reality (AR) for greater precision1 in the operating room.

This makes remote procedures and minimally invasive surgeries a reality, further minimising patient recovery timelines.

1 https://www.alcimed.com/en/alcim-articles/3-applications-oftechnological-innovations-in-orthopedics-and-orthopedic-surgery/

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With these technological and innovative approaches in place, we can foresee the orthopaedics industry moving to a spectrum of providing minimally invasive treatments with maximum results.

This is more so needed in emerging markets within the Asian region where healthcare models are already fragmented. A seamless and more efficient approach to healthcare delivery can also improve operational efficiency and patient experience for electives such as cardiovascular conditions, orthopaedics, oncology etc.

Let us take orthopaedics into consideration. Chronic pain is one of the most critical healthcare problems in the Asia-Pacific region2, and twenty per cent of chronic pain worldwide3 is related to osteoarthritis (OA). In fact, a recent study showed that in some countries like Malaysia, one in three people over the age of 55 suffer pain from OA. Apart from OA, musculoskeletal discomfort (MSD) typically related to our shoulders, neck and lower back region has also increased in recent years.

A study published by the International Journal of Health Sciences and Research reported that 70.5 per cent4 of participants between 18-65 years who were working from home reported discomfort and pain, especially in the lower back and neck region.

With a growing ageing population and a sedentary lifestyle, the burden of orthopaedic conditions in this region is only expected to rise.

In order to effectively manage the surge in orthopaedic related conditions and to offer patients the highest level of care and efficiency, industry leaders need to start developing approaches that are efficient across all levels — from diagnosis, treatments, post-operative care and follow ups.

As compared to conventional X-ray systems, EOS imaging offers 50 per cent to 85 per cent less radiation and up to 95 per cent less dose than basic computed tomography (CT) scans, in accordance with the ALARA (As Low As Reasonably Achievable) principle for minimising a patient’s exposure to radiation.

Improving operational efficiency via ERAS A shift to remote patient care via telemedicine

The pandemic has accelerated digital adoption in the healthcare industry, and one such prominent example is telemedicine. Although telemedicine has been available pre-pandemic, the urgency to digitalise increased during the pandemic.

Telemedicine in orthopaedics allowed healthcare professionals to connect with their patients remotely when movement was restricted. This shift to remote patient care has made consultations and post-surgery followups more convenient, cost-effective and well-received5 especially by younger patients who are early adopters of technology.

The use of telemedicine in an orthopaedic setting further allows surgeons to consult and tailor best treatment options to their patients via

2 https://www.masp.org.my/index.cfm?menuid=14 3 https://apsoc.org.au/PDF/GYAP/2016_GYAP/Fact_ Sheet_13_Osteoarthritis_Pain.pdf 4 https://www.ijhsr.org/IJHSR_Vol.11_Issue.2_Feb2021/ IJHSR05.pdf

5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC75949 65/#:~:text=Telemedicine per cent20for per cent20orthopedics per cent20has per cent20safely,outpatient per cent20basis per cent20in per cent20many per cent20countries

Figure 1: xooixo ixo ixoxi oxixo ixoxi oxio ix 36

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secure video conferencing platform.

Though remote care for conditions such as fracture may seem unconventional, healthcare professionals who are quick to embrace technologies have found ways to do much of it virtually6.

For example, by delivering X-ray imaging to doctors for diagnosis virtually, they may be able to perform preliminary examinations without the hassle of walk-in appointments.

Telemedicine may also facilitate with post-operative care such as follow-ups, consultation on diet and lifestyle habits, movement observations post-surgery, and rehabilitation. Patients who require more advanced care can stay connected to their consultants remotely while seeking for home care and therapy, making the overall journey for patients more seamless, convenient and costeffective.

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Enhanced Recovery after Surgery (ERAS) is all about improving patient outcomes and speeding up recovery after a surgery.

An enhanced recovery pathway focuses on optimising every aspect of a patient’s journey and promoting the patient as an active participant in their recovery process and rehabilitation. Successful pathways aim to optimise every step of a patient’s journey in order to accelerate post-operative recovery, reduce complications and general morbidity.

For instance, an ERAS Pathway could potentially be as follows: PREOPERATIVE: Minimise fasting to reduce anxiety and pain perception, and improve diet recovery INTRA-OPERATIVE: Optimise anaesthesia and pain relief protocols and promotion of normal blood circulation, temperature and oxygenation during surgery POST-OPERATIVE: Patient assessment, early physiotherapy, 6 https://www.verywellhealth.com/telehealth-for-fractures-5115438

MEDICAL SCIENCES

Adapting technological advancements in imaging and diagnosis

In the past, orthopaedic practices addressed musculoskeletal deformities through exercise and splints. Moving into the 19th century, doctors practicing orthopaedic techniques and treatments used intramedullary rods to help with broken femur and tibia bones8. Today, effective and non-invasive health screenings and procedures are widely available as multi and single specialty hospitals have been investing in stateof-the-art technologies operated by experienced healthcare professionals to provide seamless patients and quality healthcare.

This boom in imaging technology can provide a new dimension for Asia’s healthcare framework, especially combined with the rise of super specialty 7 https://ortoday.com/the-2-25-million-financial-impactof-an-enhanced-recovery-after-surgery-program-andpriceless-improvements-in-patient-safety/

hospitals in the region that focus on niche areas.

For example, at ALTY Orthopaedic Hospital we are focused on managing orthopaedics and related musculoskeletal conditions.

ALTY Orthopaedics Hospital is equipped with facilities that aid in the functional recovery of patients with advanced imaging technologies that help transform patient’s journey to wellness.

The hospital recently acquired the first ever EOS imaging system in Malaysia, an advanced 2D/3D imaging system dedicated to adult and paediatric patients with orthopaedic and osteoarticular pathologies.

As compared to conventional X-ray systems, EOS imaging offers 50 per cent9 to 85 per cent10 less radiation and up to 95 per cent11 less dose than basic computed tomography (CT) scans, in accordance with the ALARA (As Low As Reasonably Achievable) principle for minimising a patient’s exposure to radiation. As such, reducing radiation 9 Diagnostic imaging of spinal deformities: reducing patient’s radiation dose with a new slot-scanning x-ray imager. Deschenes S et al. Spine. 2010 10 Comparison of radiation dose, patient comfort and financial break-even of standard digital radiography and a novel biplanar low-dose x-ray system for upright full-length lower limb and whole spine radiography. Dietrich TJ et al.

Skeletal Radiol. 2013 11 Ionizing radiation doses during lower limb torsion and anteversion measurements by EOS stereoradiography and computed tomography. Delin C, et al. Eur J Radiol. 2013

AUTHOR BIO

promotion of a wellness model of care and team approach to perioperative management, utilising medical hospitalist and cardiologist to optimise medical care during early recovery DISCHARGE: Patients improve faster and are therefore discharged home earlier and have clear instructions on how to progress with their rehabilitation at home and have home visits from the physiotherapist to ensure that they are progressing well.

Overall, ERAS is a paradigm shift in perioperative care. The use of enhanced recovery pathways within elective orthopaedic surgery can help reduce patient discomfort and pain, allow early mobilisation and improve patient outcomes. This multidisciplinary approach has improved outcomes in nearly all surgical specialties, including shortening length of stay (LOS) by 30 per cent to 50 per cent7, making it more cost effective.

dose is particularly beneficial for children requiring frequent imaging, such as children with spinal deformities like scoliosis.

In addition, the hospital also invested in Malaysia’s first-ever weightbearing Magnetic Resonance Imaging (MRI), also known as the tilting MRI. The machine allows a patient to be positioned in a supine (lying down) or weight-bearing (standing up) position, as the device can rotate a patient from 0 to almost 90 degrees.

This enables doctors to study all joints and the spine with more precision and produce more detailed diagnosis.

For example, when a patient is suffering from joint pain, a traditional MRI imaging (usually when a patient lay downs) could not detect the pressure on the joints as is significantly decreased in that position. However, when a patient is in a natural stand-up position, the compression and pressure cause by the force of the body weight reveals the symptoms and disorders more clearly.

Not only do advanced imaging provide visual aid that aid the consultant’s accurate diagnosis but also improves the overall patient experience via a safer delivery method.

As healthcare evolves with an increased focus on patient care, investing in advanced imaging technologies will not only develop a reputation for providing niche care, but also further strengthen access to quality care for patients. Advancements in imaging will provide great potential for shorter reporting times, fulfilling urgent patient needs and improving overall healthcare outcomes.

Sureshan Sivananthan is a Consultant Orthopaedic, Arthritis & Sports Surgeon at ALTY Orthopaedic Hospital. He is Board Certified by the UK General Medical Council and is on the National Specialist Register. For the past 15 years, he has performed over 5,000 procedures on the hip, knee and shoulder joints.

8 https://aica.com/the-history-of-orthopedics/

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SURGICAL SPECIALITY

Introducing a Novel Surgical Technique for Complete Atrioventricular Septal Defect V-Shaped double-layer patch technique This article recommends a novel surgical technique for the treatment of complete atrioventricular septal defect (CAVSD): V-shaped double-layer patch technique. Since 2011, V-shaped double-layer patch technique applied for all CAVSD in our centre which had a satisfactory survival rate and reoperation-free rate during follow-up.

Shanquan Sun, Chief, Cardiac Center of Guangdong Women and Children Hospital

C

urrently popular surgical techniques for complete atrioventricular septal defect (CAVSD) are mainly ‘two-patch technique’ and ‘modified single-patch technique’. The discussion on which surgical strategy to use (two-patch versus modified single-patch technique) has continued for more than 20 years. As pointed out by Prof. Carl L. Backer, an internationally renowned authoritative expert in congenital heart surgery, cardiac surgeons have always been troubled by reoperation due to postoperative left atrioventricular valve regurgitation. Here in our centre, we applied a novel surgical technique ‘V-shaped double-layer patch technique’.

It is a functional surgical technique, in which the left atrioventricular valve (LAVV) was protected by maintaining its original shape and position, avoiding being pulled by the patch tension. The

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follow-up (the longest 10 years, and the median 5.1 years) results have exhibited excellent performance of this technique.

Designing of the V-shaped doublelayer patch technique

The surgical technique for CAVSD should be designed to have anatomic advantages and to be more consistent with the principle of haemodynamic, so as to reduce the postoperative complications and improve prognosis.

The V-shaped double-layer patch technique procedures proved to reduce the reoperation rate. Moreover, it is simple and takes no more operating time than other techniques.

We noticed some something interesting: (1) severe AV regurgitation and LV outflow tract stenosis were less common in partial atrioventricular septal defect (PAVSD), and the long-term prognosis was much better than CAVSD.

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(2) Some CAVSD cases had no or only mild AV regurgitation before operation, and the common atrioventricular valve (AV) regurgitation may be characterised by progressive aggravation. (3) We consecutively observed 111 cases of fetal CAVSD echocardiography and found that 94 per cent had no or mild AV valve regurgitation (56 cases without and 48 cases with mild), and only 1 case (0.9 per cent) had severe AV valve regurgitation.

Therefore, we consider that in spite of the congenital defects of the AV valve and subvalvular structure of CAVSD, most of them still have a certain haemodynamic structural rationality, and their insufficiency is the result of long-term volume overload. Therefore, it is critical to maintain the original shape and position of the AV and its subvalvular structures for CAVSD patients.

Both the classical single-patch and two-patch techniques change the

SURGICAL S PECIALITY

shape and the position of the AV and subvalvular structures. Due to the higher pressure in the left heart than in the right, the patch separating the left and the right created a continuous tension to the right ventricle, and the AV sutured on the patch would transmit the tension to the LAVV, making the patch concave on the left side, which may lead to the possibility of dehiscence at that suture line and the LAVV regurgitation.

The operation of CAVSD has two purposes: (1) to repair the atrial and ventricular septal defect and prevent blood shunting from left to right; (2) to repair and restore the function of the AV valve, which is the key to the success of the operation and affects the long-term outcome. We think that the haemodynamics of the AV valve is similar to the aerodynamics of a parachute, and that changing the original state of the AV valve and subvalvular structure is as bad as changing the parachute's canopy shape and cord length. If the ventricular septal defect under the AV valve is regarded as defect of the root part of the LAVV, the left patch can also compensate for the loss of suture and increase the area of the AV valve. Then the AV valve and the subvalvular structure can maintain their original shape and position and keep their function of opening and closing unchanged as before the operation. The right patch is sutured on the anterior portion of interventricular defect and the edge of the atrial septal defect. It reduces the repaired margin of ventricular septal defect by 50 per cent and decreased the incidence of ventricular septal defect residual. The right ventricle is a low-pressure heart chamber, and the right AV valve is under less pressure.

The right AV valve is fixed in the proper position of the patch to achieve the purpose of repairing the right AV valve.

In other words, the "V-shaped doublelayer patch technique" is formed by the patch for repairing the root of the LAVV and the patch for repairing the atrial and ventricular septal defect (Figure 1).

Figure 1

Operative technique

The operation is performed by conventional median sternotomy under continuous CPB through aortic and bicaval cannulae with cooling to 25-28°C. Cold histidine-tryptophanketoglutarate cardioplegia solution (Custodiol; Dr F Kohler Chemie GmbH, Alsbach, Germany) was given for myocardial protection.

1. Extracting and folding method of untreated autologous pericardium patch: Remove the fibrous tissue on the autologous pericardium. Keep the smooth surface of the pericardium inward, sew 6 stitches for traction and the folding of the patch is completed.

The length of the patch is a plus b, and the width of the patch is c (Figure 2). When extracting the autologous pericardium, its length and width should

be 20 per cent larger than the measured value, so that it can be trimmed to an appropriate size for suture.

2. Observe the depth and the deepest position of the ventricular septal defect under the AV valve. Observe the edges of the left superior leaflet (LSL) and the left inferior leaflet (LIL) during saline injection. Suture interruptedly with the first needle for traction (Figure 2).

3. For Rastelli type-A and type–B CAVSD patients, the incision of the bridging leaflets is not necessary.

Only for Rastelli type-C and very few type-B patients, the incision is required. The bridging leaflets across the interventricular septal crest was cut at the corresponding position to facilitate the placement of the patch (Figure 2).

When the anterior bridge valve and the posterior bridge valve are incised, pay attention that the incision should be in the middle of the boundary between the left and right ventricular chordae tendineae to avoid damage to the subvalvular structure. (Figure 2) 4. The folded edge of the patch was sutured with the right ventricular side of the interventricular septum by interrupt mattress suture. The first stitch is sutured at the anterior point of the interventricular septum. The other end is sutured at an appropriate distance to the interventricular septal crest, and

Figure 2

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SURGICAL SPECIALITY

Figure 3

5. Push down the pericardial patch and tie the knot, retract the right pericardial patch or push it into the right ventricle to expose the left pericardial patch and LAVV. Pull the traction thread of the left AV valve to keep the LAVV and the chordae tendineae flat and extended, avoiding the cardiac conduction bundles. Observe the size of the defect between the LAVV and the left interventricular septal crest. Trim the left pericardium patch to an appropriate shape and size. Suture the left pericardial patch and the free edge of the LAVV intermittently or continuously with 7-0 sutures to repair the root defect of the LAVV (Figure 4).

6. Saline solution is injected through the LAVV to test its closure competence.

If the LAVV still has central regurgitation and the annular diameter is large (comparing with mitral valve annulus diameters matched to patient’s age and weight), an annuloplasty could be added in the region of the commissure between the LSL and left lateral leaflet and/or in the region of the commissure between the LIL and left lateral leaflet to eliminate LAVV regurgitation.

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Figure 4

Figure 5

7. The right patch is also trimmed to an appropriate size and sutured continuously to close the right atrial and ventricular septal defect, separating the coronary sinus into the left atrium.

If combined with persistent left superior vena cava, it is necessary to go away from the coronary sinus. The suture method and the method of avoiding the cardiac conduction bundle are the same as the two-piece method.

8. Saline solution is injected again to confirm the right AV valve competence after suturing the right superior and inferior leaflets to the appropriate location on the right pericardial patch (Figure 5).

The V-shaped double-layer patch technique is less difficult, eliminating the trouble of accurate measure during the operation. There is no need for special training. The difficulty of the operation is similar to that of the PAVSD technique.

The operation time is short, similar to the modified single-patch technique.

The V-shaped double-layer patch method is a functional repair surgical technique. The left AV annulus and the right AV annulus are separated to avoid the mutual influence on each other. This technique has maintained the original position, shape and function of the AV valve and subvalvular structure which may reduce the need for reoperation.

Shanquan Sun is the chief of the Cardiac Center of Guangdong Women and Children Hospital, China. He specializes in the surgical treatment of complex congenital heart disease, congenital vascular rings, and congenital tracheal stenosis.

AUTHOR BIO

passes through the folded autologous pericardium. The appropriate sutured distance is 3-5mm (Figure 3). The stitches are mattress-sutured sequentially until the posterior point of the interventricular septum and transferred to the root of the right AV valve, avoiding the AV node. The suture position should be carefully laid out. The suture method and the method of avoiding the cardiac conduction bundle are consistent with the two-piece method (Figure 3).

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DIAGNOSTICS

Transformative Radiology

Roadmap to the future Academic medicine is founded on the tripartite principles of clinical care, education, and research. Radiology—the study of medical images—exemplifies the “bench-to-bedside” translation crucial for advancement in the field. In this article, we summarise foundational concepts, drivers, and implications for the future of health care.

Mai-Lan Ho, Physician-Scientist

A

cademic health centres follow the tripartite mission of advancing clinical care, education, and research. Academic physicians have the opportunity to pursue focused excellence in clinical and translational research, medical education, safety and quality, global health, health care informatics, and public advocacy. (Figure 1) A key step in information flow involves the conduction of research ideas into practice, moving scientific concepts from “bench-to-bedside.”

Using the RDI (research-developmentinnovation) model, fundamental knowledge discovery is utilised to improve processes and advance patient care. This process requires continual communication and feedback among basic scientists, engineers, and physicians. (Figure 2) In radiology, stepwise development and implementation of novel technologies is an important aspect of evidence-based care. Continual innovation pressures and the advent

CLINICAL Vare of complex and underserved patients

Academic Medicine EDUCATION

RESERCH

Training next generation of physicians

Translating new scientific discoveries

Figure1

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DIAGNOSTICS

Science

Engineering

Medicine

Figure 2

Novel Technology

Phantom Testing

Animal Research

Human Research

Clinical Application

Hardware Softare Drug

Feasibility Quality Reliability

Safety Accuracy Validity

Utility Applicability FDA review

Generalizability Practicality Value

Figure 3

Figure 4

of disruptive technologies such as automation, cloud computing, and blockchain are transforming the modern marketplace. Ongoing advances in radiology include innovations in hardware (scanner platforms), software (acquisition techniques and post-processing), and pharmaceuticals (contrast agents and radiotracers). Most imaging technologies are initially tested on phantoms and animal models, then move to human subjects pilot

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evaluation for FDA review. Ultimately, product practicality, generalisability, and added value are key determinants of whether the product will be effectively integrated into clinical practice. (Figure 3) The notion of the “adjacent possible” represents society’s next great discovery, arising from the confluence of current knowledge and state-of-theart advances. (Figure 4) However, public sentiment for new technologies varies over time, following

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the Gartner hype cycle: initial peak of inflated expectations, subsequent trough of disillusionment, gradual slope of enlightenment, and eventual plateau of productivity. In order to facilitate steady progress and forward thinking in medicine, physicians need to actively “challenge the dogma” by building multidisciplinary networks to promote collision science. (Figure 5) In radiology, process improvement strategies follow the imaging care cycle.

Patients are referred to radiology for a specific health question, prompting a specific imaging examination and protocol. Using a “lean” approach, departments can continuously optimise and streamline each stage of the imaging life cycle. (Figure 6) The translational imaging (I3) model helps to conceptualize data flow through the radiology department via three core pillars of imaging acquisition, imaging analysis, and imaging informatics. (Figure 7) The grand vision of precision (P4) health integrates multiscale biological information extracted from various disciplines of medicine, including radiology, pathology, genomics, clinical examination, and laboratory values. The ultimate goal of P4 health is to achieve better risk screening and disease prevention, earlier and more accurate patient diagnosis, personalised care and treatment regimens, and fully participatory decision making among patients and clinicians. (Figure 8) Implementing Innovation

Being a highly data and technologydriven specialty, radiology is a major driver of health care. A radiologist serves as the “doctor’s doctor,” providing important advice and insights to referring clinicians to guide patient diagnosis and management. However, radiologists are not directly patientfacing; as consultants to multiple stakeholders, their contributions can be overlooked by patients and the public.

Opportunities for radiologists to engage

DIAGNOSTICS

Visibility Peak of Inflated Expectations

Plateau of Productivity

Slope of Enlightenment

Trough of Disillusionment

Time

TechnologyTrigger

Figure 5

Knowledge & Action

Health Question

Patient Preparation

Analysis & Synthesis

Radiology Interpretation

Examination Planning

Image Processing

Image Acquisition

Figure 6

Imaging Informatics

Imaging acquisition Figure 7

Imaging analysis

with referring clinical teams include multidisciplinary care conferences, integrated clinics, inpatient radiology rounds, and consult services. Major pillars of excellence at leading hospitals centre on oncology, neuroscience, cardiovascular, immunity, women’s and children’s care—all areas in which imaging plays a critical role. (Figure 9) During the COVID-19 pandemic, agile management and disaster response have inspired transformational changes in health care operations and delivery, particularly in the arena of digital health. Developing reliable systems infrastructure is particularly important in ensuring sustainable growth and development. Academic medical centers can continue fostering innovation through interdisciplinary programs with other hospital and university departments, as well as strategic publicprivate partnerships. Entrepreneurial incubators and accelerators can help provide startup funding and commercial sponsorship for new companies.

Radiology is poised to lead the field of telemedicine, having already developed international DICOM standards (Digital Imaging and Communications in Medicine) and interoperable PACS (picture archiving and communication system) for medical image display, interpretation, storage, and transmission. Much like the Six Million Dollar Man, medical imaging technology continues to become “better, faster, and stronger.”

Magnetic resonance imaging (MRI), the crown jewel of diagnostic imaging, is undergoing a paradigm shift from the conventional (1.5 Tesla) and highfield (3 Tesla) platforms seen in most hospitals. Ultrahigh-field (7 Tesla) MRI is now Food and Drug Administration (FDA)-approved for all major MRI vendors.

Ultrahigh-field imaging enables interrogation of microscopic and mesoscopic biological processes, extending our understanding beyond traditional macroscopic anatomy.

(Figure 10)

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DIAGNOSTICS

Future of healthcare

Figure 8

Genomics & Gene Therapy

Oncology & Hematology

Translational Neuroscience

Women & Children

Immunity & Inflammation

Vascular & Interventional

Figure 9

Meanwhile, low-field MRI units are leveraging lower cost and smaller footprints to enable broader accessibility to rural areas and underserved populations. (Figure 11) Finally, software advances including artificial intelligence (AI) are enabling radiologists to “do more with less” by optimising workflow processes; minimising imaging time, patient radiation, and contrast doses; and extracting high-quality, reliable, and accurate diagnostic information. 3D visualisation (virtual, augmented, and mixed reality) facilitate patient counselling, medical education, surgical planning and guidance.

Conventiona (1.5T)

High-field (3 T)

Low-field (0.2 - 1 T)

Very low-field

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Ultrahigh-field (?7T) T)

(10-100 mT)

Ultralow-field (< io mT)

Extreme-field (20 T)

Figure 10

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The nature of work has changed over time, as humans evolved from a huntergatherer society and underwent the 1st through 4th industrial revolutions of mechanisation, electrification, automation, and digitalisation. The ongoing COVID-19 pandemic has accelerated global development of big data and the internet of things, with machines replacing much of traditional human work. We are rapidly entering the 5th industrial revolution, with personalised human-machine collaborations that maximise creativity and collective intelligence. (Figure 12) Modern health care parallels society’s increasing focus on technology and big data, accelerated by the global pandemic. As data and technology stewards, radiologists have an incredible opportunity to influence the future of medicine.

Artificial intelligence is empowering faster, better, and safer imaging with end-to-end workflow optimisation and performance augmentation, freeing up radiologists’ time to maximise cognitive potential and serve as valuable consultants on difficult cases.

Important future AI tools will include study triage, error minimisation,

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DIAGNOSTICS

SOCIETY 5.0 Imagination

SOCIETY 4.0 Information

INDUSTRY 5.0 Personalization

SOCIETY 3.0

INDUSTRY 4.0 Digitalization

Industrial

INDUSTRY 3.0 Automation

SOCIETY 2.0 Agrarian

INDUSTRY 2.0 Electrification INDUSTRY 1.0 Mechanization

SOCIETY 1.0 Hunting

Figure 12

COST

SIZE

SAFETY

Purchase Installation Maintenance

Siting Shielding Bore

Projectiles Noise Heating

TECHNOLOGY

PERFORMANCE

CONTRAST

Field Coils Gradient

SNR Resolution Sensitivity

Relaxation Susceptibility Artifacts

AUTHOR BIO

Figure 11

clinical decision support, structured reporting and communication, and business analytics. Big data informatics is guiding precision education with standardised and tailored curricula that address the shifting global workforce.

International 5G connectivity is enabling democratisation of care with multicentre expert consultations, remote-control imaging, and robotic surgeries. Smart devices and wearable sensors are realising the potential of preventive care with real-time

monitoring, point-of-care-diagnostics, biofeedback, and telemedicine consults.

As we move toward precision theranostics (therapeutics + diagnostics), integrated patient datasets will guide the selection of targeted therapies to achieve best outcomes. In this exciting future, radiologists will serve as central consultants for enterprise imaging and continued drivers of technology and innovation. Together, we can build the ultimate “imagination” society and realise humanity’s greatest potential.

Mai-Lan Ho is a radiology physician-scientist who specializes in translational advanced MRI, head & neck imaging, and neurogenomics. She trained at Stanford, UCSF, MIT, Washington University, and Harvard. Ho is author of Neuroradiology Signs and editor of The AAWR Pocket Mentor and Pediatric Neuroimaging: State-of-the-Art.

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TECHNOLOGY, EQUIPMENT & DEVICES

MEDICAL TECHNOLOGY TRENDS AND DEVICE REGULATION Medical Technology is making progress at an ever increasing pace.

This article uncovers the innovations which have helped mankind achieve better health. Newer medical devices have eased this process remarkably. Stringent regulatory standards ensure that the devices are safe, well studied and have least adverse reactions. Device regulation is therefore necessary to safeguard us against possible adverse effects.

Devasheesh Kamra, Neurosurgeon, All India Institute of Medical Sciences

GUIDLINE

STANDARDS

REGULATION

RUILES

COMPLIANCE PROCEDURE

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LAW

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M

edical technology has brought us here and technological advancements have fuelled it to reach amazing heights. New innovations have been coming at an ever increasing rate.

Artificial intelligence (AI) has enabled machines with humanlike thinking behaviour with reasoning and problem solving skills. Since newer technologies are coming so fast, it becomes our moral responsibility to use them to shape our future in the right direction and that is where the regulatory part comes in.

We have seen innovations in almost each and every aspect of medical sciences. COVID-19 has tested healthcare standards

TECHNOLOGY, EQUIPMENT & DEVICES

throughout the world and taught us valuable life lessons. Although we have lost a lot to it, the rate at which we have responded to the situation is also exemplary and has been never seen before in the history of mankind. Never before, vaccines have been released on such short notice and been administered on such a large scale1. Healthcare infrastructure and practices have been tailored to meet the demand. Research has been upscaled like never before.

Telehealth is now routinely being used to take care of the health of patients using different video conferencing platforms when a formal physical visit is strenuous for the patient. Though it is suboptimal compared to formal history taking and physical examination, it still helps in addressing the major clinical concerns.

The advent of ECG in the early 20th century paved a way for the future and has its potential further explored by the new trends in healthcare. Cardiac holter has been used for more than 20 years.

Mobile cardiac telemetry is able to record and transmit abnormal cardiac rhythms upto 30 days and implantable Cardiac monitors for upto 3 years altogether.2 We have a bluetooth-enabled patient status engine3 to provide more comfort to patients recording valuable data from patient monitoring even with remote transmission. Though it's not widely available, it will certainly be in the years to come and will shape our future.

There has been a significant role of extended reality using simulation to create an environment for training doctors, surgeons in an environment without risking the safety of patients.

The trainees are able to practice and master their microsuturing skills, 1 “COVID-19 Vaccines.” WHO | World Health Organization, https://www.who.int/emergencies/diseases/novelcoronavirus-2019/covid-19-vaccines.

2 Medtronic. Heart Monitoring. https://www.medtronic. com/us-en/patients/treatments-therapies/heart-monitors/ monitoring.html.

3 Isansys PSE. https://www.isansys.com/en/Patient-StatusEngine.

During the last fiscal year 2021 as per US FDA data, 2607 medical products were recalled by the manufacturers.

endoscopy skills and anastomosing skills. It is also used to treat childhood disorders like autism to improve social skills. It is also being used to facilitate Cognitive behaviour therapy for various psychiatric disorders.

We have seen growth in almost every clinical specialty and creation of new superspecialities. Had we been born with epilepsy before the eighteenth century, we would have found ourselves in an asylum or in isolation. The scenario has now changed dramatically. The growing knowledge of neurosciences have helped treat this disease in a comprehensive manner. We have advanced from EEG and StereoEEG and Magnetoencephalogram have become the standard of care at tertiary centres. What was incurable years ago is now curable with favourable odds.

The newer drugs are being discovered and indications of use of already in use drugs are ever increasing.

We are fighting hard against the deadly diseases and have successfully found a cure for Hepatitis-C which was once considered incurable. The latest endoscopy equipment can view the whole gut from inside out and still be able to find a needle in a haystack.

When did we ever think that we can have quality images of the inside of the

gut using equipment as small as a pill.

With Wireless Capsular endoscopy, it's now possible.

There has been an increase in survival for almost all cancers over the timespan of the last 20 years owing to newly developed chemotherapy, immune mediated therapies, better screening tools leading to early detection, rising awareness and research enabling us to increase longevity. Immunotherapies have been on the rise and leading to better outcomes. Radiopharmaceuticals are increasing their spectrum and are being used in neuroendocrine tumors of digestive tract and prostate cancer.

With increased longevity and prevalence of diabetes and lifestyle diseases, the demand for dialysis has also been increasing. The need for better outcomes and ease of use has led to questioning ourselves even more. The concept of dialysis is not new and has been in use for centuries, now having given birth to newer modalities like Continuous renal replacement therapy4 (CRRT) and Wearable artificial kidney5.

However, we have a long journey ahead to attain perfection in better toxin excretion and functional outcomes.

It is difficult for any individual to live with a thought that they have a brain tumour and there is sometimes a social stigma also associated. Newer technologies and awareness has led to its early detection and good functional outcomes. Brain surgery has made big progress with awake painless surgeries, robotic assisted, navigation guided and neuromonitoring assisted surgeries becoming a new standard of care. The survival rate has considerably increased.

Some common myths about spine surgery include that the patient will have to spend more than a month in bed. That the surgery will cause more 4 Tandukar S, Palevsky PM. Continuous renal replacement therapy: who, when, why, and how. Chest. 2019 Mar 1;155(3):626-38.

5 Topfer LA. Wearable artificial kidneys for end-stage kidney disease. CADTH Issues in Emerging Health Technologies. 2017 Jan 30.

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6 Sedlakova V, McTiernan C, Cortes D, Suuronen EJ, Alarcon EI. 3D bioprinted cardiac tissues and devices for tissue maturation. Cells Tissues Organs. 2021 Mar 5:1-4.

Success is not final; Failure is not fatal: It is the courage to continue that counts.

- Winston Churchill

substantial at present and research is still ongoing.

Medical reforms and newer technology have put mankind in the driving seat. Though moving still at a steady pace, we need both brakes and accelerators to keep moving further without any untoward accident.

Medical device regulation is one such measure to keep balance and checks and ensure the technology is moving in the correct direction to prevent any harm to mankind.

The US FDA is the regulatory authority in the US for controlling drugs and medical devices. CDSCO is its Indian counterpart that regulates the approval of new drugs and devices, import registration and licensing, banning of drugs, devices and cosmetics, testing of new drugs and ensures the devices which are available in the market have adequate

AUTHOR BIO

pain.Or that if one undergoes spinal surgery they will never be able to walk again.

Most of these myths do not hold true. These are just less common or very rare problems being generalised to the whole lot just like driving a car will lead to an accident and likewise. We have robots and O-arm assisted navigation systems that assist in placing the implants in the spine at very difficult trajectories leading to very satisfying outcomes with a very less margin of error. The results of fusion surgeries have improved significantly with newer concepts of sagittal balance, better fusion materials like Bone Morphogenetic proteins and demineralised bone matrix.

Newer technologies like 3D printing have revolutionised the concept of custom made implants and prosthetics with impressive outcomes. These implants outperform the traditional implant methods. The cranial vault reconstruction, bony fractures, and prosthesis are in regular use. In future, developments might lead to invention of 3D printed cardiac valves6 and even as minute as retina.

3D models are used in difficult spine surgeries and difficult intubation that simulate patients anatomy and help safely practice the difficult steps in a controlled environment without concerns of patient safety.

The deficits after brain injury or neuronal loss are severely disabling and affect the quality of life drastically.

Though due to some neuronal plasticity7, there is some functional recovery. However, the recovery is never complete and is different depending upon the modality. By developing a brain-computer interface, we might be able to restore functional independence with patients of paralysis or blindness in years to come. We have nothing

7 Bernhardi RV, Bernhardi LE, Eugenín J. What is neural plasticity?. The plastic brain. 2017:1-5.

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standards. The devices that come under its purview have been defined in Drugs and Cosmetics Act,1940 Section 3(b) (iv). Medical devices are defined as devices intended for internal and external use in diagnosis, treatment, mitigation or prevention of disease or disorder in human beings or animals.

Just a few more than 100,000 devices have been approved for use by CDSCO in India till date8. The medical devices have been classified into four classes based on risk stratification: class A - low risk, class B - low moderate risk, class C - moderate - high risk and class D High risk. The high risk devices such as implantable defibrillator, heart valves have to go through more stringent checks and regulations in comparison to low risk devices like thermometers and tongue depressors. The device may also be reclassified into other categories by the authorities if deemed necessary by the authority. Any devices which are deemed unfit for use are recalled. Failure is not the opposite of success, rather it is a part of success. During the last fiscal year 2021 as per US FDA data, 2607 medical products were recalled by the manufacturers9. These failures actually represent all the sincere human efforts which were meant for upliftment of healthcare. We have come so far in technology, but nothing can still replace the clinician’s skill to diagnose and treat the patients.

8 MD - Medical Devices. https://www.cdscomdonline.gov. in/NewMedDev/Homepage.

9 Health, Center for Devices and Radiological. “2021 Medical Device Recalls.” FDA, Dec. 2021. www.fda. gov, https://www.fda.gov/medical-devices/medical-devicerecalls/2021-medical-device-recalls.

Devasheesh Kamra is a Neurosurgeon and has done his training from prestigious All India Institute of Medical Sciences, Delhi. He has held the position of Associate Consultant Neurosurgery at Max Super Speciality Hospital, Saket, Delhi and is at present pursuing fellowship in Neurovascular intervention.

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Role of Telemedicine and Digital Technologies Future of emergency care services in India India is the second most populous country and the largest democracy in the world. Despite that, emergency care in India is still fragmented with emergency medical services (EMS) not accessible in different parts of the country.

According to the Ministry of Road Transport & Highways data of 2016, nearly four hundred deaths occur on Indian roads every day. Additionally, it is being reported that out of every 1 million people, 42,800 suffer from sudden cardiac arrest every year. These figures clearly indicate the need for efficient emergency care services in the country that should be accessible at all places. While the government has been playing its part to improve the condition of EMS in India by collaborating with different organisations and setting up autonomous like the Centralised Accidents and Trauma Services (CATS), the existing emergency care in India fails to meet the public demand. However, with the disruptions caused by the COVID-19 pandemic, digital solutions have come to the fore to enable easy and timely access to care without the need to be physically present at the doctor’s office. Telemedicine services are transforming the approach to care by not only preventing overcrowding at EMSs, but also ensuring proper safety and wellbeing of medical professionals in emergency care settings.

Vikram Thaploo, CEO, Apollo Telehealth

Telemedicine to the aid of emergency care

Emergency care services have been designed to provide timely and immediate care to time-sensitive conditions. In any sort of medical emergency, EMS act as the sole point of contact for patients suffering from stroke, trauma and other emergency medical conditions. However, due to the shortage of staff, overcrowding and lack of necessary resources, emergency medical services in the country often fail to meet up to the needs and expectations of the public. That’s where the power of technology comes into play. Patients can be pre-screened from the comfort of their homes, during hospital transport or after arrival in the emergency department with the help of telemedicine services.

This can significantly reduce the time required to provide immediate care to emergency patients.

In the case of rural emergency medicine, the role of telehealth can never be undermined. With the help of a single specialist, telemedicine is allowing care to be provided to different sites simultaneously. Different patient-care

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sites may also connect with a centralised hub using telemedicine services while helping to foster more regionalised care.

Telemedicine services are already making a difference in the remote, mountainous regions of Himachal Pradesh. Apollo Telehealth has established the world’s highest telemedicine centre at an elevation of 14,000 feet above sea level.

The health services provided at this telemedicine include medical assistance in case of emergencies as well as primary and specialist tele-consultations, saving lives by using technology.

One of the significant challenges of rural emergency sites in India is the lack of trained, skilled professionals.

Also, with high variability of staffing, there comes the issue of variation in skills, experience and education.

Through provider-to-provider models, telemedicine can facilitate experience sharing and fill education gaps by giving cognitive support to non-emergency clinicians who lack the experience and/ or training in an emergency department.

It is being estimated that every year almost 1.8 million people in the country suffer from stroke and early treatment is the only way through which the incidences of morbidity and mortality cam be reduced.When a person suffers a stroke, he/she loses almost 2 million brain cells every minute when a blood blockage or rupture prevents oxygen from reaching the brain. It is nearly impossible to know whether the patient has a block or bleed, and giving the wrong treatment can prove fatal.With telestroke programmes, it is increasingly possible to connect hospitals with a neurologist so as to evaluate a CT scan image and discuss with the on-site doctor about the best course of action. Telestroke programmes decrease the door-to-treatment time helping improve patient outcomes.

Game changing technological advancements for EMS

For an ageing and rapidly increasing population, technology can be the best answer to some of the prevalent and

complex problems in EMS. The digital revolution in recent years has completely changed the way information is stored, processed and communicated. On top of that, the inception of robust wireless broadband networks, powerful mobile computing and deep data analytics can play an important role in defining how emergency medical services will be conceptualised and provided to the citizens of India in the future.

Here are some of the ways technology is making a difference: Connected ambulance service Though this is not a new technology but its adoption in India has been very slow. The connected ambulance service allows a new way of connecting patients, remote medical experts and ambulance workers in real-time.Connected with GPS and cameras along with portable ECG machines, these ambulances are able to relay critical information to physicians and emergency departments before the patient reaches the hospital.

Studies reveal that every minute of delay in starting emergency treatment lessens the chances of survival by 7 per cent-10 per cent.

An integrated and connected system for health records A connected database management system provides the opportunity for emergency medical services to share a patient’s medical record with the ED which can significantly improve the chances of saving someone’s life in times of emergency. With the shared information, ED personnel can make informed decisions and attain good health outcomes. Presently, paramedics and ambulance crew have no access to patient medical data which limits their understanding about the health conditions of a patient. In India especially, where paramedic care training is not yet standardised, scarcity of information can detrimentally affect the way any diagnosis is carried out. In some

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Predictive analytics Predictive analytics can be utilised to enhance the pace and manage patient flows effectively. This data-driven solution allows the monitoring of admission and discharges in hospitals, notifying on-site paramedics regarding the availability of beds and connecting to emergency medical services systems as emergency department staff, doctors and healthcare organisations can reduce delay rates and enhance health outcomes.

By using predictive analytics, healthcare providers can also learn about potential areas to place ambulances based on past data. This can reduce ambulance dispatch time and response time and allows hospitals or healthcare providers to manage their resources efficiently, smartly and reduce the admission and wait time.

A government-led push towards digitisation in healthcare The Indian government has been actively promoting digitisation in the healthcare sector. With the introduction of the Ayushman Bharat Scheme, the government has come up with the Information and Communication Technology (ICT) scheme, which focused on the development of the health sector. The said scheme includes telehealth development ideology to make it effective, safe, efficient and patient-centric. The National Digital Health Mission (NDHM) launched by the government is another step to building the foundation for digital healthcare infrastructure in the country.

The primary aim of the initiative is to make India self-reliant by providing universal health coverage to all the citizens in the country.Similar to an Aadhar ID, the introduction of a unique health ID aims to recognise and

authenticate a person depending on previous health records.

In the recent Union Budget 202223, the finance minister of India declared that the government will launch an open platform to connect India's digital health ecosystem under the Ayushman Bharat Digital Health Mission (ABDM).

Way forward Over the coming years, technological advancements will lead to increased acceptance by both patients and doctors and telemedicine usage will witness unprecedented growth. The increased acceptance will also allow the growth of other fields like Tele-ICU, TeleOphthalmology, Tele-Dermatology and Tele-radiology.

Technological innovations remain the key to navigating the challenging EMS landscape in India. As telemedicine

becomes more responsive and innovative, enhancing the adoption rate among patients and providers, para-medicine services will become critical and undergo massive change and emergency treatments will be offered at much lower costs than the emergency department.

The latest technologies are capable of doing numerous things we want them to do and assure to improve accessibility to emergency healthcare services and reduce the huge amount of money lost in unnecessary patient transports and emergency department visits. When done the right way, technology can be the golden thread uniting patients and providers and catering to the needs of patients even from the comfort of their homes.

References are available at www.asianhhm.com

AUTHOR BIO

cases where the emergency staff arrives in advanced life support (ALS) ambulances and are aware of how to take action, plenty depends on the patient’s medical history.

VIKRAM THAPLOO is the CEO - Telehealth at Apollo Hospitals Group. After completing his Healthcare Management Programme from the Indian School of Business (ISB) and PGDBM from Symbiosis, Pune, he briefly worked for the hospitality industry before moving on to retail, crowing his eventful journey with his current stint in healthcare. A proactive leader, his mandate as the CEO of Apollo TeleHealth include a larger-than-life duty that comes with the express goal of turning healthcare affordable using the convergence of Technology, Telecom, Medtech ecosystem, and Healthcare.

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Fundamental Theory for Successful A.I. Adoption

by Healthcare Industry Artificial Intelligence (AI) has seen an unprecedented interest and growth, both in terms of academic research and rapid industry adoption. As per numerous academic researchers and industry leaders, in 2020, no one had imagined the progress and development that this field has experienced. They are still in awe at how this technology, still in its nascence, is aiding with ground-breaking abilities to perform critical tasks which until recently were considered not feasible! However, most people in general still corroborate AI to ‘Terminator Movies’ of the yesteryears. This is further relevant in the healthcare industry where ‘healthcare data of any patient or product’ is extremely sensitive and thereby exceptionally challenging to acquire. This human perception needs to change and it is only possible through education, explainability and fabrication of fundamental principles, that shall guide in AI Adoption by Industry in a safe, secure and regulated fashion, reducing the risk of conflict and fatalities. The authors’ of this article deliberate on the progress, maturity, applications, challenges of AI and thereby positions a construct of such fundamental principles, derived through extensive research, industry experience, excerpts from industry leaders and journal literature survey.

Abhishek Dutta and Pankaj Kandhari

W

hile Amazon’s Alexa and Google’s Home internet of things (IoTs) are the most popular IoT devices available widely in the market, they are still impaired in their ability to perform advanced activities described in the above quote from a popular movie franchise. Concurrently, the industry is severely stinted in being able to a) formalise data requirement, b) setup databases, c) tackle inherent bias, d) setup security measures, e) manage patient safety issues that may arise and f) introduce timely regulatory legislation to aid in effective governance and thereby adoption of AI. The world is at the edge of global transformation, heralding the advent of global digitalisation! It is different from

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the prior era of digital globalisation where few enterprises concocted some maturedand standardised digital platforms to connect people across the world, whereas now in the age of global digitalisation it has become a quintessential necessity to synergise and deploy digital platforms. All this, while the industry and patients grapple with the reality of witnessing the commercial deployment of iteratively learning algorithms, in every facet of life.

It is no different in the field of healthcare. Until very recently, there existed an acute lack of standardisationsand regularisation in software as medical devices (SaMDs) and the internet of medical things (IoMTs). This culminated in dearth of

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Tony Stark: "Check the heart, check the, check the, is it the brain?"

J.A.R.V.I.S (AI): "My diagnosis is that you've experienced a severe anxiety attack."]

-Iron Man and J.A.R.V.I.S, Iron Man 3, Marvel Cinematic Universe, 2013

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interoperable, secure and synchronous ‘capture’ and ‘processing’ of enhanced medical meta data supporting in healthcare manufacturing, healthcare services as well as clinical diagnostics.

The same was true for even the United States Food and Drug Administration (FDA), who though proactive since 2014 in attempting the regulatory constructs, were still overdue considering the accelerated development of digital technologies. This deficit was especially felt in aiding adoption, application and incubation of machine learning (ML) and AI in SaMD. Hence, the patient community was often forced to adopt conventional healthcare technologies for survival, despite the incumbent technology advantage.

Defining AI:

AI is defined by 2020 editorial in Nature as ‘intelligence demonstrated by machines’. The article discusses and deliberates on a myriad of approaches taken by researchers since the mid 90’s to effectively define AI but concludes with “We can expect that what is generally considered as intelligence and ‘artificial intelligence’ will remain in flux.

By integrating advances from different disciplines, there is an opportunity to create intelligent machines with ever greater complexity.” This article will hence not deliberate further on definition but consider ANY machine of any form factor, physical (hardware) or ethereal (software) demonstrating ability to provide deduction using data provided as input or self-assimilation and demonstrating the capability of differential decisions as AI. Therefore, both supervised (forecast or predict outcomes based on the use of labeled data provided to an algorithm) and unsupervised (predict outcomes based on unlabelled data sets through hidden patter recognition in data) techniques used by ML and deep learning (DL) algorithms, can classified as AI. However, based on recent observations, it is the iterative or self-learning DL

As per Allied Market Research, ‘The global AI in healthcare market was valued at US$ 8.23 billion in 2020, and is projected to reach US$ 194.4 billion by 2030, growing at a CAGR of 38.1 per cent from 2021 to 2030.’

algorithms and architectures that will essentially mould the future for AI. Presently, AI is of the form of artificial narrow intelligence (ANI). These algorithms drive most AI applications across industries but is primarily useful in predicting, classifying or clustering outcomes at a local or singular task level and cannot be expected to generalise the ‘level’ of outcome, across multiple tasks or applications. For example, ANI can be trained and validated to play chess but will NOT be able to apply the same learning as playing chess to playing dominoes, unless specifically trained on the same data. However, the developers of AI algorithms currently strive to provide a level of general intelligence termed currently as Artificial General Intelligence or AGI which aims to rely of current learnings in one task and develop rules that may be applied across multiple intellectual tasks.

The holy grail, as per researchers would be the artificial super intelligence (ASI), which would mimic human ability to perform cognitive tasks. However, that concept is a conjecture at this time.

Accelerated adoption of AI during Covid 19

It is often said that war is the harbinger of innovation. Like the birth of radars,

computers and penicillin during the WWII, affliction inflicted by COVID19 has provided an unprecedented impetus, resulting in paradigm shifts in the traditional way of designing, planning, execution and deployment of healthcare using AI/ML enabled SaMD. The impact has been especially evident in the field of vaccine development when the world united to develop and license ‘emergency use’ of the anti-Covid vaccine, within a year since COVID-19’s inception. And almost like a medical marvel, the vaccine has inherently been successful across the globe, irrespective of the type of populace.

Thus, what typically takes 10-15 years for commercialisation was built within a year. This success would not be remotely possible without the extensive application and adoption of virtual ‘in-silico’ (in simulation) screening using neural networks (Net.) like long short term memory net (LSTM), recurrent neural net (RNN) or convolution neural net (CNN), to name a few popular algorithms.

Applications and USP of AI

Fast forward to 2022 and the healthcare industry has begun adoption of ANI in their intrinsic operational and tactical workload to alleviate cost and human effort, especially in their business-critical operations. The adoption is widespread and covers a plethora of healthcare industries and their respective functions.

The industries can be classified into the following – 1. Healthcare (Devices and Pharma Manufacturing), 2. Pharma Drug Designing and Biotechnology (Gene therapy, in-silico Virtual Screening,Clustered regularly interspaced short palindromic repeats or CRISPR based gene manipulation), 3. Clinical Diagnostics, 4. Hospital Management - Medical and Operational Records Management and Analysis to drive better patient outcomes, 5.

Advanced Telemetry based Home Health-Care for effective Rehabilitation, 6. Proactive and Pre-active Care measures

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TOP USE CASES OF AI IN MEDICAL DEVICE MANUFACTURING

Better Patient Outcomes

Improved Regulatory Control

Faster and Safer Diagnosis

Proactively Identifying Safety Signals

Figure 1.1: Top Use Cases of AI in Medical Device Manufacturing (Source: BirlaSoft)

Figure 1.2: AI in Drug Discovery and Development (Source: Medium.com)

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to drive preventive patient outcomes.

Figure 1.1 depicts the most prominent use cases for applied ANI in medical device manufacturing where application of Defect Detection (images processing in a CNN algorithm) and Anomaly Detection (based on data provided by sensors in the manufacturing line), have enabled the Medical Device industry to take action on a device or a manufacturing conveyor line to eradicate the presence of defects, thereby improving regulatory control and delivering on faster, safer and better patient outcomes with minimal product recalls. The above use cases are also applicable for the Pharma manufacturing processes as well.

Figure 1.1 depicts the most prominent use cases for applied AI in Drug Discovery, Design and Development where LSTMs and RNNs

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have been applied to predict inhibitor molecules using the lock and key hypothesis to generate protective drugs or vaccines against pathogenic protein sheath. In parallel, similar algorithms have also been used in variation to identify biomarkers for pathogens, physiological processes and diseases in a faster and cost-effective manner.

Understanding the disease mechanisms and biomarkers help in essential root cause analysis of the disease itself, which when synergised with patient clinical trial information and aggregated in a database, helps in allaying multiple challenges.

While these ANI ‘applications’ are immeasurable, researchers and developers revel in the fact that the extrinsic architecture of these algorithms are robust and are mostly perpetual, thereby remaining akin to the base architecture regardless of any specific application. Only the hyperparameters intrinsic to each DL technique (such as weights, biases, learning rate etc.) changes to train and validate an ANI for a specific task.

With regards to recent applications in healthcare manufacturing, an analytics services company was recently chartered by a Fortune 500 healthcare client to design, build and deploy a ‘multi-defect detection’ ANI model for a particular line of medical device, while its still in the manufacturing line. The analytics company was able to successfully deliver on such an ANI, with an ‘F1 score’ (maintains both sensitivity and specificity of task done by a model) governed 95 per cent accuracy. This alleviated the client problems of cyclical variation in quality management process, thereby minimizing product recalls, enabling the client to abolish the yesteryears process of quality management through human intervention and thus bringing in considerable reduction in cost.

In a discussion with Velbiom Probiotics, India’s first and exclusive probiotics company, Saikat Ray, CEO at Velbiom highlighted regarding the

dire need of AI/ML derived applications required in their field. “Probiotics is looking at the root causes of how a healthy microbiome can alleviate variegated critical diseased conditions that might afflict patients in their future, thereby is focusing on pre-biotics, i.e., chemicals which enable maintenance of a healthy microbiome in any body, thus a healthy balance of good bacteria in the body”. This aims at revolutionising conventional healthcare by transforming Reactive Care to not only Preventive care but inculcating Pro-active Care as a behaviour / hygiene in the next generation, from an early age. Currently, data in this field which is at its nascence is scarce and Saikat believes that AI is set to play a key role in identifying the all the different types and proportion of good bacteria, comprising a healthy microbiome.

Abhishek Narsipur, CEO of Thingstel, a leading provider of end-toend IoT solutions for Manufacturing Industry, discusses on how every healthcare manufacturer is looking to optimize their process by adopting AI based predictive maintenance capabilities in their plants. Abhishek further explains “A simple definition of optimization in manufacturing is to get the highest productivity with lower cost, resulting in maximum profitability with least amount of energy consumption.

This needs to be achieved with a finite

set of resources (machinery and people).

Often companies go for this to stay competitive but in recent times, its seen as a foundation for long term sustainable growth and the industry looks to AI to deliver on advanced self-learning predictive maintenance and anomaly detection to aid and support on the same”.

Market size and challenges

As per Allied Market Research, ‘The global AI in healthcare market was valued at US$ 8.23 billion in 2020, and is projected to reach US$ 194.4 billion by 2030, growing at a CAGR of 38.1 per cent from 2021 to 2030’ as illustrated in Figure 1.3. The Asia Pacific applied AI healthcare market on the other hand was just at an estimate of $274 million of the US$ 8,230 million global market back in 2020, as per Pure Storage. Thus, the Asia-Pacific market was just 3.3 per cent in terms of Market Share in 2020, though it is set to grow at a faster pace of 48 per cent from202027. Despite the burgeoning interest and growth expected in the market, AI as a technology is still incredibly young.

To make matters worse, the industry is ridden with challenges in terms of 1> lack of capture of actionable data, 2> unavailability of machine driven meta data, in a structured database3> lack of regulatory legislation and oversight in terms of security and safety of SaMD

Figure 1.3: AI in Healthcare Market (Source: Allied Market Research)

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AI/ML-based SaMD with approved SPS and ACP Approved SPS + ACP

FDA premarket review for reasonable assurance of safety and effectiveness

Software modifications decision tree requires new 510(k)?

Modification outside of "agreed SPS+ ACP"?

Documents

Modification lead to a new intended use?

Focused FDA review of SPS and ACP

Establish SPS+ACP Approved SPS + ACP

Premarket submission cleared or approved FDA premarket review

New approved SPS + ACP

Legend Proposed regulatory pathway for new AI/ML-based SaMD

Proposed regulatory pathway for modifications for AI/ML-based SaMD

Endpoint for AI/ ML modification

Figure 1.4: SPS and ACP based SaMD Review and Governance Framework (Source: FDA.gov)

and 4>unwanted inherent bias in the data which is used to train SaMD and aid in its maturity.

Finally, the FDA between 2021 and 2022 have published its review and governance framework illustrated in Figure 1.4, for regulating AI/ML enabled SaMD. The complexity that FDA had to consider prior to setting up this framework was multifold starting from ‘defining and classifying an AI/ ML enabled SaMD as a device’ to the implications on ‘patient safety, data security, clinical responsibility, socioethical consideration and potential IP conflicts’ that may arise out of a selflearning and iteratively transforming AI algorithm. The FDA governance framework displayed in Figure 1.4, tackled this incumbent problem by asking SaMD manufacturers to declare and abide by a ‘Predetermined Change Control Plan’ comprising of the belowmentioned two sub-parts: 1>‘SaMD Pre-Specifications (SPS): This will describe "what" aspects the manufacturer intends to change through learning’ 2>‘Algorithm Change Protocol (ACP): This will explain "how" the

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algorithm will learn and change while remaining safe and effective’ Further to the above, the FDA has deliberated at length on potential Intellectual Property (IP) issues that may arise out of multiple self-learning algorithms of standard and robust architecture, converging on similar hyperparameter values as each other, while being potentially exposed to patient data of similar demography

or ailment. To mitigate this intrinsic problem that may exist in the current ANI driven SaMD, the FDA urges the manufacturers to submit periodic addendums to their existing IP as the primary protective measure safeguarding interests of the manufacturer.

Though this seems to be a stop-gap solution, is also the best bet that any SaMD manufacturer would have against potential IP infringement which may get realized owing to the modus-operandi of any SaMD. The above FDA framework depicts a forward-looking iterative solution to a self-learning SaMD and only future will determine how this impacts the potential issues with regards to legislature.

In addition, the FDA has also etched ten guiding principles as best practices to be adopted for medical device development, as shown in Figure 1.5.

These principles are aimed at but at the same time limited to bringing forth, safer and secure regulatory control towards SaMD development.

Hence, there is a GAP in terms of relevance and advocacy for the multitude of functions within the healthcare industry and thereby the Market which seeks to benefit through adoption on ANI models.Establishing broad and comprehensive fundamental principles

Good Machine Learning Practice for Medical Device Development: Guiding Principles Multi-Disciplinary Expertise is Leveraged Throughout the Total Product Life Cycle

Good Software Engineering and Security Practices Are Implemented

Clinical Study Participants and Data Sets Are Representative of the intended Patient Population

Training Data Sets Are Independent of Test Sets

Selected Reference Datasets Are Based Upon Best Available Methods

Model Design Is Tailored to the Available Data and Reflects the Intended Use of the Device

Focus is placed on the Performance of the Human-Al Team

Testing Demonstrates Device Performance During Clinically Relevant Conditions

Users Are Provided Clear, Essential Information

Deployed Models Are Monitored for Performance and Re-training Risks are Managed

Figure 1.5: Good Machine Learning Practice for Medical Device Development (Source: FDA.gov)

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to enable successful ANI adoption, within multi-faceted Healthcare Industry has therefore become a quintessential necessity. The authors seek to empirically derive these fundamental principles, through an experimental literature survey on adoption guidelines highlighted by many industry experts, academicians, researchers and AI developers, as showcased in the next section.

Experimentation - Studying Journal and Web Literature on AI Adoption guidelines, using Natural Language Processing (NLP): NLP Technique - Latent Dirichlet Analysis also known as LDA has been used for Topic Modelling Data Used – From Journals in Google Scholar and Open-Source Articles published online on the topic and keyword:“AI Adoption Guidelines in Healthcare Industry”. The list of same are provided in the references section at the end. Total all text from 25 articles

were used. All the articles and Journals were between the years 2014 and 2022.

Web Crawling Tool – Data was captured using My80Legs tool (Source: 80legs.com) Results: Figure 1.6 and Figure 1.7 depicting the key topics. Coherence Score (c_v): 0.4, optimum alpha value was selected as 0.1 Inference From Topic 0 as shown in Figure 1.7, we can infer that AI or in this case ANI technology adoption require ‘discussions’, ‘guidance’, ‘human support’ and ‘Intervention’ at all levels to formalise ‘guidelines’. The ‘design’ of AI system needs to be ‘inclusive’ and ‘Bias’ in ‘data’ needs to be managed through inclusion and diversity in terms of both legislation and data availability as input to the models. The ANI model ‘output’ needs to be ‘explainable’.

From Topic 1 as shown in Figure 1.7, we can infer that ‘development’ AI or ANI systems fuelling the SaMD

adoption need ‘interoperability’ and ‘synergy’. AI ‘system’ ‘development’ require ‘study’ and ‘trials’ through ‘labeled’ data. The ‘labelling’ of data will result in the boundary conditions we create to localise and bind patient outcome to curtail any related fatality.

From Topic 2 as shown in Figure 1.7, we infer that ‘SaMD’ ‘software’ ‘model’ should be able to utilise ‘medical’ ‘datum’ and ‘report’ the outcome effectively.

‘SaMD’ based on AI / ML tech is still at its nascent stage and require ‘guidance.’

Excerpts from industry discussion with Thingstel CEO on AI adoption guidelines: 1. Check hygiene of the data and source before deployment 2. Diversity and variation of data is a requirement to get desired accuracy with AI 3. Deploy only where necessary and avoid overkill as it may affect the overall feasibility

Figure 1.6: pyLDA Visualization (Source: Jupyter Notebook by Author)

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TOPIC - 01

TOPIC - 02

TOPIC - 03

Figure 1.7: 3 Topic Word Cloud Visualization (Source: Jupyter Notebook by Author)

Excerpts from industry discussion with Velbiom Probiotics CEO on AI adoption guidelines: 1. Centralised database of Microbiome data 2. Govt/DBT Funding to encourage more Startups to do deep dive 3. Microbiome testing is very expensive currently and if we can price control, it will be better and more patients will go for it. As a result, more data set will be

available from all parts of the world.

Summarising the learnings as fundamental principles: In this article, assessment of AI tech for Healthcare industry usage,has been performed using the following methodology – a) Extensive Research, b) Decades of professional experience, in analytics and AI/ML services, c) SaMD development and deployment

Figure 1.8: Possible futuristic development of AGI and ASI (Source: Author)

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experience andc) Discussions with numerous business leaders, attempting to adopt AI practices in their tradecraft.

Through research, surveys, discussions and collective experience in attempting to adopt AI, it is deduced that the following five Fundamental principles, will govern successful adoption of AI, in the near future– 1. AI/ML enabled SaMD systems Interoperability

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2. The ‘design’ of AI system needs to be ‘inclusive’ and ‘bias’ in ‘data’ needs to be managed through inclusion and diversity in terms of both legislation and data availability as input to the models.

3. The ANI model ‘output’ needs to be ‘explainable’. AI/ ML enabled SaMD adoption require ‘discussions’, ‘guidance’, ‘human support’ and ‘Intervention’ to formalise ‘guidelines’.

‘SaMD’ based on AI / ‘ML’ tech is still at its nascent stage and require ‘guidance.’

4. SaMD adoption need ‘interoperability’ and ‘synergy’. AI ‘system’ ‘development’ require ‘study’ and ‘trials’ through ‘labeled’ data.

5. The ‘labelling’ of data will result in the boundary conditions we create to localise and bind patient outcome to curtail any related fatality.

Nonetheless, the authors are also mindful of the fact that the industry, developers and users are still witnessing the youth of ANI and corresponding nuances. With time many new learnings will become known. Therefore, as a protective best practice, the authors recommend the age-old law applied in the field of Industrial Robotics (derived from Isaac Asimov's "Three Laws of Robotics”) since decades, as the sixth and final fundamental principle, which states: A robot may not injure a human being or, through inaction, allow a human being to come to harm. A robot must obey the orders given it by human beings except where such orders would conflict with the First Law (source: Wikipedia) These fundamental principles will be relevant for all functions within the industry, starting from healthcare manufacturing to drug designing to clinical diagnostics to hospitals and home-care, enabling doctors and hospitals to drive better, safer and secure patient outcomes.

In conclusion, adoption of ANIin healthcare is becoming inevitable, but the aforementioned 6 fundamental

principles, will ensure fewer collective failures and thereby pave the path for a true, successful and easy adoption.

Future

Human beings have always built the basic functioning layer of any device first and built the futuristic views on top of it in layers, in logical integrated steps.

- For example, we built a cart with round wheels and today we build smart and connected cars by building layers of complexity on top of it. However, the basic structure remained the same.

- Development of DL in AI has been no different, starting from the base perceptron architecture biomimicking a single neuronal ganglion to the complex Neural Nets of the world built

via addition of numerous layers in the architecture with Hyperparameters of weights and biases.

Based on the same human philosophy and human creative trend, we hypothesise the probable design / architecture which might ease the rise of ASI soon, as illustrated in the Figure 1.8 below – Acknowledgements

Sindhu Ramesh, Principal Data Scientist at Affine, Saikat Ray, CEO at Velbiom Probiotics, Abhishek Narsipur, CEO at Thingstel, Sujan Deb, Critical Care Unit physician at Fortis Hospital and Nivedita Roy, Analytics Manager, Accenture Consulting.

References are available at www.asianhhm.com

AUTHOR BIO Abhishek is a seasoned Data Science and AI Leader, with 16+ years of rich and extensive experience in delivering strong controllership, decision support and leading functions like applications of AI and Machine Learning in Manufacturing Process, Marketing Automation and Campaign Management,Revenue and Pipeline Management,Thought-Leadership and Business Consulting. He has numerous IEEE and IEE conference publications in varied fields of Medical Device Technology, Drug Discovery, Nanotechnology and Data Science. He holds publication in the Journal of Environmental Toxicology which has received over ~100 citations in research by eminent scientists. He has authored chapters on business outlook in several academic textbooks and worked in various labs across India, including the likes of Indian Institute of Chemical Biology-Kolkata and Analog Devices Lab - IIT Madras to name a few. He has also been quoted by multiple business magazines, including the likes of LIVEMINT (Wall Street Journal) and Business Standard. Abhishek is academically trained in Biomedical Engineering, Machine Learning and Artificial Intelligence. He also is an alumnus of IIIT – Bangalore, majoring in Machine Learning and AI. Pankaj Kandhari is an entrepreneur with 18+ years of rich experience, primarily, in the field of analytics, setting up/managing large teams and serving clients across the globe. He has mainly worked with CXO / senior executives of Fortune 100 companies across Delivery, Project and Account Management roles. He has worked for several companies in Fortune 100 list, the notable ones include working with one of the world's largest retailers, managing a team of over 100 analytical professionals for them. He has done 2 startups in his career, first in the field of IP and Analytics, and then a datadriven, tech-enabled product for offline marketing. He has done his Bachelor’s and Masters from IIT Mumbai, specializing in Process System Design and Engineering.

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ROBOTICS FOR AUTISM Autism is a complex, lifelong developmental condition that typically appears during early childhood and can impact a person’s social skills, communication and relationships.

Various technologies, such as robots, VR/AR and eye tracking are being investigated for the diagnosis and treatment of autism. This article presents a summary of recent research on the use of robots for autism.

Zheng Li, Caiwei Chen and Pradeep Ray, University of Michigan-Shanghai Jiao Tong University Joint Institute

A

utism Spectrum Disorder (ASD), hereafter referred to as Autism (which includes Asperger’s Disorder and Pervasive Developmental Disorder – Not Otherwise Specified [PDD-NOS]), is a complex, lifelong developmental condition that typically appears during early childhood and can impact a person’s social skills, communication, relationships, and self-regulation. The autism experience is different for different ASD affected people. It is defined by a certain set of behaviours and is often referred to as a “spectrum condition” that affects people differently and to varying degrees.

While there is currently no known single cause of Autism, early diagnosis helps a person receive resources that can support the choices and opportunities needed to live fully.1 The prevalence of ASD has been increasing steadily over the past two decades. Luckily, with the advance of information technology, human society can tackle ASD much more maturely than in the past. Today, information technologies such as robotic technologies offer some promises in the treatment of ASD patients as discussed in this article.

This article presents a classification criteria for robotic technologies for ASD management based on the criteria, the real-world applications of these robotic technologies are discussed from the aspects of joint-attention, imitation, turn-taking and emotion recognition.

1 Autism Society, see https://autismsociety.org/the-autismexperience/, accessed Jan 2022

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Finally, the article presents some evolving low-cost technologies for the management of ASD at homes and schools.

Robotic technologies for ASD treatment

The development of robotic technologies brings new possibilities to both ASD diagnosis and treatment. Previous literature shows that the use of robotic technologies in ASD treatment is quite beneficial since ASD patients have challenges in interacting with real people while showing interest in interacting with robots.2 Robotic technologies have been applied to ASD treatment in many studies from several different aspects including training joint attention, improving imitation ability, teaching turn-taking activities and strengthening emotion recognition skills. These ASD treatments based on robotic technologies need knowledge from diverse disciplines, including psychology, computer science and robotics, which makes it hard for researchers to see the relationships between different robotic technologies 2 Alabdulkareem, Amal, Noura Alhakbani, and Abeer Al-Nafjan. "A Systematic Review of Research on RobotAssisted Therapy for Children with Autism." Sensors 22.3 (2022): 944.

for ASD treatment. To provide an overview of the robotic technologies for ASD treatment, the following sections discusses several classification criteria for robotic technologies in ASD treatments.

Classification of robotic technologies in ASD treatment

There are many classifications of robotic technologies for ASD treatment.

As shown in Figure 1, some studies classified these technologies based on the characteristics of ASD patients while other studies used robotic features as the criteria to classify these robotic technologies.

Considering the characteristics of ASD patients, many studies classified robotic technologies for ASD treatment based on the major deficiencies of ASD patients. The criteria provided in the DSM-5 for diagnosing ASD includes three deficiencies in social communication and interaction, which are “difficulties in social emotional reciprocity”, “difficulties in non-verbal communication used for social interaction” and “deficiencies in developing and maintaining relationships with other people”. Since many robotic technologies for ASD treatment are designed to treat one of

Classification of Robotic Technologies in ASD Treatment

these three specific deficiencies, they can be classified based on the deficits that they aim to treat.

Another widely used classification is based on the positive behaviours that the robotic technologies aim to achieve.

Since it is relatively hard to solve the three deficiencies of ASD patients directly, many therapies solve the deficiencies by decomposing the treatment into teaching ASD patients positive behaviours. These behaviours include joint-attention, imitation, turn-taking, emotion recognition etc. By learning these positive behaviours and applying these social skills in their daily life, ASD patients will face fewer problems in social communication and interaction.

Therefore, as many robotic technologies are designed to teach the ASD patients specific positive behaviours they can be classified by the positive behaviours that they want to achieve.

While the two classifications mentioned above are mainly based on the deficiencies and behaviours of ASD patients, there are also classifications based on the features of robotic technology itself. For example, based on appearance, robots used in ASD treatment can be classified as human-like, animal-like and toy robots. The robotic technologies can also be classified as home-based, play-based and educationbased robotic technologies considering the treatment environment.

Realistic applications of robotic technology in ASD treatment

Based on Patients' Characteristics

Based on ASD Deficits

Based Positive Behaviors

Based on Robotic Features

Based on Appearance

Figure 1. Classification of Robotic Technologies in ASD Treatment

Based on Treatment Environment

In this section, several real-world applications are analysed to give an overview of the current robotic technologies used in ASD treatment. As shown in Figure 2, using the classification that is based on positive behaviour, this section will mainly analyse the application of robotic technology in joint-attention, imitation, turn-taking and emotion recognition, which are the most popular research focuses nowadays.

The definitions of these positive behaviours is shown in Table 1.

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Joint Attention

Imitation

Positive Behaviours Emotion Recognition

Turn-taking

feedback based on the recognition of patients’ gestures. In some studies, the instructions are not limited to gestures and higher-level human behaviours such as facial expressions can also be used for imitation training. The application of robots in imitation training improves the efficiency of imitation intervention, since ASD patients will have less difficulties in interacting with robots compared with human therapists. Moreover, the mobility and programmable features of the robots also contribute to the training efficiency.

Figure 2. Four Major Positive Behaviors in ASD Treatment

Positive Behaviour

Definition

Joint attention

Joint attention refers to the ability of sharing focus on the same object with other people. It is realized when a person can draw another person’s attention to a specific object through physical instructions like pointing. ASD patients have a high possibility of lacking the ability of joint attention.

Imitation

Imitation refers to the ability of imitating others’ physical movement. Many ASD patients lack the ability of imitating body movements, which could further lead to difficulties in social interaction.

Turn-taking

Turn-taking refers to the ability of taking appropriate turns during the conversations. To achieve successful turn-taking, people need to maintain their turns while considering the views from listeners, which is difficult for most ASD patients.

Emotion recognition

Emotion recognition refers to the ability of recognising other people’s emotions through their facial expression. The deficiencies in emotion recognition of ASD patients prevent them from developing more complex social skills.

Table 1. Definition of the Positive Behaviors

Joint attention In joint attention therapies, the robots give instructions to ASD patients and ask them to focus on a specific object or location. After giving the instructions, the robot measures the attention of the ASD patients and give the corresponding feedback based on the measurement data to reinforce the ASD patients’ ability of joint attention. Since ASD patients have difficulties in direct communication and interaction with other people, using robots in joint attention training can

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greatly improve the training efficiency by eliminating the communication barriers.

In addition, the robots have a stronger ability to measure patients’ attention than humans with the aid of eye-tracking technologies.

Imitation Imitation intervention mainly uses robots to replace human therapists in imitation training. During the training, robots present specific gestures for the patients to imitate and provide corresponding

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Turn-taking The application of robotic technologies in training turn-taking ability also uses robots to replace therapists in treatment. In the treatment, ASD patients need to complete the turntaking tasks with their robot partners and the robots will provide feedback based on their performance. Although human intervention can also achieve similar result of improving turn-taking ability, robot-enhanced treatment still has advantages in attracting ASD children due to the nature of ASD patients, which makes the robotenhanced treatment more efficient than traditional human intervention therapy.

Emotion recognition Emotion recognition training commonly uses robots to imitate human beings’ facial expressions. During the treatment, the robots will perform several specific facial expressions and the participants need to identify the emotion behind the corresponding facial expressions.

Since ASD patients have less difficulties in interacting with robots and the facial expressions imitated by robots are less complex compared with facial expressions of human faces, it is much easier for ASD patients to recognise the emotions behind facial expressions. The practice of recognising robots’ facial expressions can act as an intermediate step of learning recognising humans’ facial expressions for ASD patients.

INFORMATION TECHNOLOGY

Building portable technologies for low-cost management of ASD

Worldwide, roughly 6 per cent of the population suffer from ASD. More cases are seen in developing countries.

India has the largest number of autistic children (approximately 1 million), followed by China (approximately 0.5 million). Imbalanced medical resources and the COVID-19 pandemic situation necessitate remote ASD management.

Different kinds of equipment are required to quantitatively assess the performance of ASD patients. However, traditional devices for research labs and hospitals like eye trackers are too expensive for individuals to afford at home or in schools. Recent advances in webcam based eye-tracking, virtual reality (VR) and augmented reality (AR) technologies make it possible to screen, diagnose and track behaviours of ASD patients during treatment with portable, low-cost devices.

Eye-tracking is a significant technology to assess the joint attention and thus diagnose ASD patients as mentioned. Researchers have developed webcam eye-tracking platforms such as RealEye. The technology captures eye movement of users based on video stream, analyses the gaze patterns, saccades etc., and predicts possibility of having ASD or seriousness of condition through a trained deep learning network.

High accuracy in eye movement based ASD diagnosis and little requirement on devices show great promise in the development of this technology.

VR/AR further improves the treatment effect and cuts down the cost.

Lacking the ability of joint attention, it is hard to conduct treatment remotely through a screen. VR/AR create a 360-degree virtual space to animate reallife scenarios, which keep the attention of ASD patients on the interactive video stimuli without being affected by

the movement of ASD patients. It also eliminates the need for building humanlike robots and thus increases portability.

Besides, many VR helmets are equipped with eye-tracking module, so it is possible to track reactions of patients during treatment.

Home-based and education-based diagnosis and treatment solutions for ASD patients are necessary, and also feasible with state-of-the-art technologies. The research will aid development of ASD patients and ease the burden on their families.

Conclusion

In this paper, the applications of robotic technologies in ASD treatment are introduced and several classification criteria for these robotic technologies are

AUTHOR BIO

In some studies, emotion recognition training is combined with imitation training to achieve a better outcome.

discussed. Based on the classification, several realistic applications of robotic technologies for ASD treatment are analysed. The common classifications used are mainly based on the characteristics of ASD patients or the features of the robotics used.

From the analysis of the realistic robotic technologies for ASD treatment, it can be concluded that the applications of robotic technologies in ASD management mainly make use of the characteristics of ASD patients.

Since ASD patients face difficulties in interacting and communicating with other people and ASD patients show a higher interest in interacting with robots, using robots to replace human therapists in ASD treatment can greatly improve the efficiency of ASD management.

Zheng Li is a member of the University of Michigan (UM)-Shanghai Jiao Tong University (SJTU) Joint Institute (JI) Center For Entrepreneurship (CFE) and member of the IEEE Technology and Engineering Management Society (TEMS) student branch in JI. He is interested in interdisciplinary research in engineering and entrepreneurship.

Caiwei Chen is a member of the University of Michigan (UM)-Shanghai Jiao Tong University (SJTU) Joint Institute (JI) Center For Entrepreneurship (CFE) and chairs the IEEE Technology and Engineering Management Society (TEMS) student branch in JI. She is interested in interdisciplinary development in business field, with major interest in entrepreneurship and business analytics.

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).

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