Asian Hospital & Healthcare Management - Issue 21

Issue 21

2009

ÂŁ12 â‚Ź18 $25 Rs.300

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Cancer Nanomedicine Emerging opportunities

Diagnostics in APAC Changing dynamics

Quality and Safety

Creating a supportive cultur

Foreword

IT in Healthcare The evolution continues

I

nformation Technology, perhaps the most important addition to the healthcare continuum over the last couple of decades, is still at various stages of adoption. Its incorporation into the healthcare system across countries and, at time within a country, varies depending on various factors such as cost and willingness to change.

Its role in reducing costs and improving workflows has been the major drivers for its adoption. And at a time when the global economy is facing a downturn, this particular aspect could prove to be a great catalyst in IT adoption. That said, expectations from the industry have gone up as well given the bigger cost constraints.

These rising expectations will be coupled with long-existing challenges such as interoperability. Given the complexity of the healthcare landscape and the varied approaches taken by providers, this is perhaps the largest hurdle facing IT in healthcare. It could also have a bearing on the success of online Personal Health Records (PHRs), which have shown great potential to reduce costs and improve the quality of patient care.

A lot, in this regard, will depend on the willingness of the respective governments. In Asia, countries like Singapore and Japan have taken a lead in standardising EMRs, whereas India, for example, is a far cry comparatively.

The cover story of this issue, an interview with Pawel Suwinski of Frost & Sullivan, Singapore, brings forth the key trends affecting healthcare IT and the challenges that it faces with respect to Asia.

I hope you enjoy reading this issue. Kindly get back to me with your feedback.

Akhil Tandulwadikar Editor

Contents 17

IT in Healthcare Targeting better patient care Prasanthi Sadhu Editor, Lifesciences

IT in Healthcare

About quality, costs and convergence Pawel Suwinski, Frost & sullivan, Singapore

Healthcare Management 06 Emergency Care Experience from a community-based centre Joe Djemal, Terem, Israel

Medical Sciences

Technology, Equipment & Devices 40 Medical Devices Going the generic way

Richard Kuntz, Generic Medical Devices Inc., USA

Matthew Dennis, Espicom Business Intelligence, UK

Facilities & Operations Management

Surgical Speciality

45 Quality and Safety Creating a supportive culture

22 Cancer Nanomedicine Emerging opportunities

28 Quality Assurance Programmes for Surgery How and why in Asia?

Malcolm J Underwood,CA van Hasselt and Hong Fung Cluster Prince of Wales Hospital, Hong Kong SAR

Diagnostics 31 Diagnostics in APAC Changing dynamics Nitin Naik, Frost & Sullivan, Singapore

32 Strengthening Radiology Education Generational Challenges and Electronic Publishing Basri JJ Abdullah, University of Malaya, Malaysia

Philip Hoyle, Northern Sydney Central Coast Area Health Service, Australia

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Advisory Board

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

Sandy Lutz Director Health Research Institute PricewaterhouseCoopers, USA

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

Harald Becher Professor Cardiac Ultrasound Oxford University, UK

Peter Gross Chairman Internal Medicine Hackensack University Medical Center, USA

John R Hawkins Director Information and Technology Services Abu Dhabi Health Service Company (SEHA), UAE Malcom J Underwood Chief Division of Cardiothoracic Surgery Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

Gabe Rijpma Health and Social Services Industry Director Public Sector Group Microsoft Asia Pacific, Singapore Basri JJ Abdullah Professor Department of Biomedical Imaging Faculty of Medicine University of Malaya, Malaysia

Beverly A Jensen Associate Professor Communications UAE University, UAE

Steven Yeo Vice President and Executive Director HIMSS Asia Pacific, Singapore

Editors Akhil Tandulwadikar Prasanthi Sadhu Art Director M A Hannan Sales Manager Rajkiran Boda Sales Associates Murali Manohar Srujana Potluri Mark Twain Leanne Reeves Assistant Manager – Compliance P Bhavani Prasad COMPLIANCE A.N.Rani Vatsala Sharma CRM Yahiya Sultan Sindhura Abburi Subscriptions incharge Vijay Kumar Gaddam IT Team Ifthakhar Mohammed Azeemuddin Mohammed Sankar Kodali Thirupathi Botla Thodeti Krishna Deepak Yada Mohan Pendilv Chief Executive Officer Vijay Chintamaneni Managing Director Ashok Nair

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

Vivek Desai Managing Director HOSMAC INDIA PVT. LTD., India

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Healthcare Management

Emergency Care

Experience from a community-based centre An ability to manage patients in a communitybased Emergency Care Centre without referral to hospital translates into major cost savings for the health system, whilst reducing the burden on the Hospital Emergency Rooms.

Joe Djemal CEO Terem Israel

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he challenge of filling the gap between primary healthcare and the hospital emergency rooms has been recognised by healthcare policy makers world wide. Yet the methods and facilities introduced to meet this challenge vary wildly. From minor injury clinics, walk-in clinics, out of hours doctors, urgent care to ‘polyclinics’ and ‘front ends’ to emergency rooms, many approaches have been taken, but what these approaches have in common is: • To try to keep patients away from hospitals and emergency rooms with the associated high costs and health risks • To try to improve patient care by

providing increased levels of service with better response and treatment times.

Dr David Applebaum, an American physician boarded in both Internal and Emergency Medicine, was frustrated with seeing patients with less than critical medical problems wait hours to be treated in a hospital setting. He believed that there was a need for an intermediate medical service that would fit between the primary care physicians and the hospital-based Emergency departments.

The purpose of this service would be to manage all cases apart from those that require the specific and unique resources of a hospital.

Key Facts • Terem’s five Emergency Care Centres (ECC) will manage over 200,000 patient visits in 2009.

• Terem centres are located within the community and are open 24/7 or extended hours.

• 93 per cent of all Terem cases are discharged home.

• 95 per cent of all Terem cases are discharged within 2 hours.

• Terem centres and staff deal with high levels of acuity including chest pain, fractures, facial lacerations and advanced infections requiring repeat IV antibiotics.

• Statistics show that where Terem provides coverage, the number of hospital emergency room visits has remained constant or decreased whereas elsewhere numbers have increased.

• Physicians preferentially refer to Terem rather than the emergency room since Terem saves the healthcare system money whilst providing the highest level of patient care.

• Terem makes extensive use of technology to provide remote real-time consultation, digital documentation and full reporting to the primary care physician in the community.

• Terem’s success is due to a rigourous staff training program, clinical and administrative procedures and a comprehensive technological solution.

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Healthcare Management

referred to the hospital, Terem still significantly contributes by identifying the problem and stabilising the patient until the ambulance arrives.

Of course, there are many cases that present to Terem that are not life threatening yet still would crowd the emergency rooms during the evenings and nights as well as on weekends and holidays. In some cases, earlier identification of these “simpler” cases definitely prevents deterioration until the patient would otherwise have access to their primary care doctor.

These cases include infections of the tonsils that can progress to difficulty in swallowing, urinary infections that, left untreated, can extend up to the kidneys and then require IV antibiotics and young children with a high fever who are not drinking and may become dehydrated.

Principles of urgent and emergency care

Only patients who require the unique resources of a hospital should go to the hospital. This includes those requiring moderate to extreme surgical interventions, advanced radiological procedures, extended admissions and intensive medical support.

In Terem’s emergency care centres, physicians with specific experience and training in urgent and emergency care can safely and effectively manage appropriate cases. Over 93 per cent of patient attendances are successfully managed at Terem, without the need for referral to hospital.

Amongst patients who are treated within Terem, there are many cases that would most likely be admitted if they were to go directly to the hospital.

However this does NOT mean that they HAVE to be admitted. For example, due to hospital specific protocols as well as Health Maintenance Organisation (HMO) related issues, certain patients (children with head injuries, croup, patients medicated for fracture reduction etc.) are often automatically admitted

if they arrive at the hospital Emergency rooms.

An ability to manage these patients in a community-based Emergency Care Centre without referral to hospital translates into major cost savings for the health system, whilst reducing the burden on the Hospital Emergency Rooms. Furthermore, by locating these centres in the community rather than within or adjacent to the hospitals, patient access is improved.

Acuity of patients

The level of acuity manageable within a Terem Centre is relatively high. Even for those patients not discharged home, they will have been identified, stabilised and have begun treatment, all within a very short time, before transfer to hospital.

It has also been noted that over time, as the community has come to trust the resources of Terem, that there is a measurable rise in the acuity of illness that presents to all Terem branches.

While cases such as life threatening heart rhythm abnormalities, severe diabetic complications, seizures or severely displaced fractures must be

Patient Flow The Importance of Time

Waiting times (from registration to first encounter with medical personnel) and total treatment time (from registration to discharge) are critical factors in ensuring patient safety as well as creating satisfaction amongst patients. It has been shown that patients return to Terem not just due to the high quality of care but also due to the short total treatment times.

On a regular weekday, an average of 250 patients are seen in Terem’s main centre. Over a typical 2 day weekend over 800 patients are seen and during peak periods, patient registrations can be as frequent as one every 1.5 minutes.

Even at these busiest of times, waiting times are kept to a minimum via a two-tiered triage approach. Overall, 95 per cent of all Terem patients are discharged within 2 hours of arrival.

At the busiest of times, still over 90 per cent of all arrivals are discharged within 2 hours. Given the great emphasis placed on shortening waiting and treatment times, both in the medical and policy literature, Terem sees these

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Healthcare Management

Electronic medical record and Clinic management system A custom designed integrated system for managing patient data allows doctors to digitally enter a description of the patient encounter as well as the diagnoses, discharge instructions and tests performed. Furthermore, it allows the physician to review previous clinical data and incorporates a wide range of tools for storing, distributing and archiving all X-rays done throughout Terem. All hand-written and printed materials related to the patient’s care are scanned and recorded, demographic data is captured and billing codes are automated.

accomplishments as fundamental to the proper practice of urgent care.

Staffing of doctors and nurses is a critical part of the equation for maintaining quick patient flow. Staffing needs are calculated based on historical records and experience and can significantly change from day to day. Staffing is increased for flu seasons, holiday periods, weekends, evenings and other key events.

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The Importance of Design

The system includes inventory ordering and distribution, recording and tracking of bacteriological cultures and a centralised data warehouse allowing for the quick retrieval of patient information, both for chart review by senior physicians as well as clinical research.

The use of smart phones and PDAs has also allowed Terem to manage patients more efficiently by allowing consultants to remotely review data and images and provide remote diagnostic services.

Key to the successful management of patient flow and the positive patient experience is the design of the facility itself. With 20 years of experience in designing and building Emergency Care centres, Terem has, through a process of continuous improvement, established design principles which result in facilities which are able to manage high volumes

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of patients in a comfortable environment for both patients and staff. Examples of elements of the design include: • Waiting area flooded with natural light and incorporating calming colours where refreshments are available and a children’s play area is provided • Internal waiting rooms between ‘stages’ of the patients journey (triage, x-ray, casting)

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Healthcare Management

• Central lab and observation room for staff to monitor patients, run lab tests and oversee patient flow • Portable and fixed computer stations for doctors to access and update patient records • Multi-purpose rooms which are used differently depending at peak periods • Lecture / case review room.

Training the Team

A Terem doctor is only one part of the team, which includes nurses, Xray technicians and secretaries. It is the Terem “team” that takes care of the patient, rather than any particular staff member. An experienced nurse is critical to maintaining patient flow and patient satisfaction and even a receptionist must be trained to identify signs of patients who need to be fast-tracked through triage.

Key to the successful running of a high-volume Emergency Care centre is the continuous training of staff: • All Terem doctors must be certified in: o Advanced Cardiac Life Support to handle even the occasional unconscious patient in need of full scale resuscitation o Advanced Paediatric Life Support, an American standard course for managing acutely ill children.

• Doctors are strongly encouraged to consult in real time (either with on-site staff or with senior physicians remotely using advanced technology) • Mentoring—new doctors are always assigned to shifts with more experienced doctors.

• Over 40 per cent of all charts are reviewed by a second physician, every x-ray performed is reviewed within 24 hours by a certified radiologist and higher acuity cases are reviewed as standard • X-rays with significant findings become part of a teaching library for all staff to view • Physicians regularly receive follow

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Managing emergencies cases requiring ambulatory IV antibiotics fractures requiring casting dislocated finger and limbs the advanced elderly (> 80 years old) the very young (< 3 months). evaluations for chest pain and dyspnoea mild to moderate heart failure severe allergic reactions severe asthma attacks certain heart arrhythmias patients with facial lacerations up comments on their charts via email within 1 to 2 days following the case • As an active member of the Urgent Care Association of America, Terem and its staff regularly contribute teaching materials to the association’s Journal of Urgent Care Medicine..

All of these elements together produce a physician who is capable of handling a very wide array of clinically urgent problems, as well as a well rounded team member.

Integration with Primary Care

One nearly universal problem in emergency care is that documentation, along with results of studies such as labs and x-rays, does not readily reach the primary care physician. Terem’s solution, as an extension of its in-house developed elec-

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tronic health record system, allows secure web access to the complete copy patient’s digital medical file by the primary care physician. Such communication is not only a convenience but is fundamental to the proper care of all patients with urgent medical problems.

Upon arrival at a Terem centre, a patient can specify the name of his or her physician and an email will be sent to the community physician, with the alert that the patient was treated in Terem, and providing him the ability to securely access the patient’s chart.

Marketing

A critical factor to the success of Community-based emergency care is the marketing of the facilities and the service. A significant reduction in inappropriate attendances at the Hospital Emergency room can only be achieved if patients know about the availability of a viable alternative.

It has been seen that in the same way that patients in the UK automatically go to the hospital Emergency Room resulting in long wait times and high costs to the Hospitals, patients in Terem’s catchment area automatically go to Terem centres.

This is achieved by: - Word of Mouth - GP Referrals - Street Advertising (Posters and directions) - Sponsorship - Terem Urgent Care Conferences - Through and with HMOs Benefits of the community-based emergency care centre model Benefits to the Patient

The role of the community Emergency Care Centre is to act as an intermediate model of care standing between the primary care physician and the Hospital Emergency Department. The key benefits to the patient are: Convenience: Patients can simply arrive and be seen without an appointment.

Unlike the patient’s primary care physi-

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Healthcare Management

Convenience: Each Emergency Care Centres is located in the community and provides laboratory and radiology services offering efficient and high quality service. Since Terem also operates “out of hours”, it allows the HMOs to use Terem as their “preferred provider” of healthcare.

Conclusion

Benefits to the health system

Since Terem acts as a real alternative to the Emergency Department, many of the

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190,000 visits to Terem in 2008 saved hospital attendances and admissions.

Cost Saving: The availability of Terem’s Urgent Health Care service saves the HMOs, and the health system in general, millions of dollars every year.

Safety: The Terem model cuts down on the numbers of patients admitted to hospitals, and reduces the likelihood of hospital-acquired infections for those patients not requiring admission.

A u t h o r

cian, the Centre offers a 24/7 one-stop shop approach where lab tests and Xrays can be performed in one location during a single visit, with the results available within minutes.

Speed: 95 per cent of all patients are discharged within 2 hours of arrival. Just the initial waiting times at the hospital Emergency departments are most often more than this.

Quality: Quality of care in Terem is the sum total of on-site physicians and nurses, all specially trained in urgent care, plus ready access to remote consultants, plus a streamlined set of technologies to expedite patient care.

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The community-based one-stop shop model of emergency care provides quality, efficient and fast service to healthcare as an alternative to hospital Emergency Rooms. Through a combination of its procedures, technology and training, Terem is able to treat and discharge the vast majority of patients within 2 hours of arrival. As such, many national standards for treatment times can be met or exceeded, whilst releasing valuable resources within Hospitals for the benefit of the more acute patients.

The automatic notification of a patient’s doctor of their care in Terem guarantees continuity of care and ensures that the patient will not get lost between treatments provided at different location. HMOs recognise that by funding a visit to a private community-based emergency care centre such as Terem, they will be realising a significant cost saving compared to the patient attending the Hospital’s Emergency Room.

Emergency Care centres do not compete with family doctors or hospitals; rather, this approach to continuity of care (both in philosophy and technology) complements these other medical services. And the 24/7 nature of the Emergency Care Centre means that patients always have access to timely care, even when their personal doctor is unavailable.

Joe Djemal was born in Beirut, grew up in Bangkok, educated in the UK and lives in Israel. He is the CEO of Terem and a General Practioner. Joe has overseen 10 per cent year on year growth in patient visits to Terem while managing the company’s international expansion.

w w w . a s i a n h h m . c oAdvertorial m 15

Anesthesia EMR

Moving ahead with the future of healthcare Ashok Kumar, CEO, Binary Spectrum

A

nesthesiology, an important component in the overall wellbeing of the patient in pre and post surgery instances has often been ignored by software solution providers. With the advent of ambulatory surgery centers which provide a surgery focused infrastructure, it is compelling enough to spruce up and prove better solutions to simplify processes, enhance patient care and increase facility throughput. Anesthesia EMR has therefore become talk of the town, as it helps the anesthesiologist and anesthetist to focus on accurate clinical documentation and improving the patient care/ surgery throughput.

Although believed anonymously, that anesthesiologists are indeed slow to adopt the method of monitoring the drug administration electronically, based on a research by Frost and Sullivan, it is estimated that the anesthesia EMR would have a growth rate of about 30 percent annually over the next three years.

I am very excited about the future of Specialty EMR’s in the healthcare system. The evolving nature of the U.S. health care marketplace has given room to such a need; nonetheless, the Asian and Gulf regions too provide scope to necessitate treading the modernization path of the healthcare industry.

Using an EMR surely helps the organization. Compare spending about 3 hours in recording an appointment in paper for 10 patients (assuming it takes 20 minutes to

record the details for each patient) versus using the automated EMR that would help take 30 minutes only (about 2-3 minutes each for the same 10 patients). One would surely save valuable time and increase operational efficiency this way.

At Binary Spectrum, we aim at addressing to similar specific practice needs wherein the anesthesiologist firstly finds it easier and stimulating to enter this electronic process, of being able to enjoy the flexibility to manage the notes made at the surgery center in a Tablet PC and thereby increasing the revenues. Thus, maintaining the standards of anesthesiology and helping the patient experience the surgery without pain.

Maintaining the Anesthesia Records The entire process of Anesthesia comprises of a Pre Anesthetic assessment that would take place prior to the surgery. Details like patient demographics, current medications, allergies, review of systems and past surgical history are recorded. The problem list and anesthesia plan is then structured out. Based on these, the anesthetic drugs are then administered.

Care is taken for any irregularities that may occur during the loss of consciousness. Once this is done, during the surgery, the anesthesiologist accesses the application through his / her Tablet PC. This would involve an offline mode of entering data. Here the Anesthesia Flowsheet is feeded in with details like Medications,

Monitors, Antibiotic Details, PACU details and any Equipments used for the surgery. Post which all the records maintained are then just plugged in to the main system, thereby collaborating the entire set of records.

Post Surgery, the application focuses on Procedures and Diagnosis notes, with the respective ICD and CPT codes alongwith the billing process. The Anesthesia Procedure Notes includes Arterial Catherization, Central Venous Catheter / Shiley Catherter Placement and Pulmonary Artery Catherterrization. The workflow Benefits of Anesthesia EMR The entire process enables an ease of use with charts and intuitive designs. Other such benefits include: • 24/ 7 real time data • Electronically document the entire patient experience • Accessible in the Surgery Center through Tablet PC • Go paperless to improve patient care • Quick charge capture • Efficient Claim generation and submission to Clearing House and Insurance Payers No doubt, there are challenges to be faced. To take full advantage of such a system could require anesthsiologists to redesign the way they practice medicine to a certain extent. However, I also believe the benefits could be ten-fold too. In any case, bridging the gap between technology and healthcare has been and is demanding.

Advertorial

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IT in Healthcare

Targeting better patient care

Prasanthi Sadhu Editor, Lifesciences

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n the era of growing Information Technology (IT) involvement, the healthcare industry is trying its maximum in utilising the opportunities presented by Healthcare IT (HIT) in reducing cost, providing better patient care, secured healthcare information exchange etc. Though the healthcare industry is using IT in delivering its services in a much better way, there is always room for betterment considering the issues and challenges faced by HIT. The main trend in HIT is increasing patientsâ&#x20AC;&#x2122; involvement in managing their health information / full medical report.

Electronic Medical Records (EMRs) are helping doctors and patients in storing and maintaining patient records. But, they serve only doctors. With regards to increasing patient satisfaction with better outcomes and lower medical costs, Patient Health Records (PHRs) are going online. The concept of PHRs is evolving. Though it is in the beginning stage in Asia Pacific, it has a start.

Though the concept is not new, the convergence of information technology with medical devices is the challenge IT professionals are facing. Since the IT-intensive medical devices are growing in number, hospitals need to be ready with the IT infrastructure to support IT-based medical devices for improved patient safety and better outcomes. This can be done by a proper collaboration of clinical engineering (CE) and information technology (IT) departments.

For this, it is important that the healthcare infrastructure be in place. Spending on healthcare infrastructure is increasing with the increasing technology but, this is different in India.

Sources say that the Indian healthcare industry is growing rapidly and is expected to reach US$ 75 billion by 2012 and US$ 150 billion by 2017. However, the country has poor standards of healthcare infrastructure. In order to maintain level with global healthcare industry, India has to increase its investments in healthcare infrastructure.

Key challenges identified in HIT are interoperability and integration, meeting user demand, security and best practices.

Vendors and hospitals need work on these challenges for providing better patient care.

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IT in Healthcare About quality, costs and convergence

What are the major drivers and opportunities in healthcare IT today?

DRIVERS Patient Safety – correct and relevant medication, investigations and procedures.

Demands for Quality – patients more often do not accept forces of nature as an explanation for substandard care and poor outcomes.

High Costs - innovation, ageing, chronic diseases are all winding up the cost spiral by increased demand for healthcare services.

Convergence of Life Sciences coming together of many life sciences domains: biotechnology, information technology, genetics and bio-physics requires close collaboration and information exchange that only IT applications and infrastructure can provide.

R&D - Innovation incurs high costs in the form of R&D that need to be recovered.

Opportunities Mobility – mobile and portable devices have become very popular in ambulatory, home and bed care. The use of wireless networks helps to access the information anywhere and anytime—at the point of care.

Clinical applications – the dusk of the first decade of 21st century is the time of clinical applications. By this time most healthcare providers would have acquired back office and administrative modules and now are expanding into clinical care.

Business intelligence – the same like clinical applications, business intelligence

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is picking up in popularity. The economic survival requires that the available information is well processed and analysed to detect any trends and patterns that can be utilised for management and corporate decision making.

Virtualisation – it is a very important concept allowing organisations to save money by outsourcing some of the hardware components. As such, the users are running applications directly from remote serves and other infrastructure components.

Miniaturisation – the progress of modern medical technologies and biosciences would not be possible without miniaturization. IT plays a very important role in providing controls and monitoring capabilities. Using these advances, we are able to launch miniature devices (or even cells) into blood stream to combat the pathogens and cancer receptors.

Robotics – using artificial intelligence for procedures is becoming essential in specialties such as neurosurgery. Robotics also play role in replacing humans in hazardous environments e.g. radiation and medical waste management. Some routine tasks can be outsourced to robotics: reception, distribution of medication and patient documents.

Simulation – as in pilot and military training, simulation is gaining more popularity in preparing new physicians for work. From emergency procedures, to surgical interventions as well as mimicking rare diseases, the simulation has become one of the most important training tools.

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Pawel Suwinski

Senior Consultant Healthcare Practice Frost & Sullivan, Asia Pacific Singapore AUTHOR BIO Prior to joining Frost & Sullivan, Dr Pawel served as a healthcare consultant to Malaysian companies such as HS Consulting, DSAV Proheacs, Planet Connection, FTG Horizon and as physician to Klinik Kita (Malaysia) and district hospital (Poland). He did seven years of clinical practice, both in Poland and Malaysia and worked eleven years as a consultant specialising in healthcare: informatics, economics and management.

Interoperability (EHR, PHR) – perhaps the most pressing issues to address is the integration and interoperability. Without them the networking of EMRs into HER would not be possible.

Furthermore, these technologies are very often required to glue all the modules and applications into one cohesive EMR. How are new innovations like PHRs helping the healthcare industry in delivering patient care?

The main benefit is continuity of care.

With Patient Health Records, care givers are able to access historical medical information about a patient that originated from other providers. We could expect that the care would become more relevant with: Reduction of duplications - diagnostic tests and therapeutic interventions Increased patient safety due to decrease in medical errors – historical

data will provide information such as known allergies and past medications resulting in less adverse reactions and complications from wrong medications, which constitute around 70 per cent of all medical errors.

Better disease management - knowing past therapies and outcomes would help in managing of presenting clinical conditions Decreased of medical costs – from reduced duplications (as above) and number of therapeutics - adjustment of therapies that will use more of personalized medication rather than broad spectrum and many types of therapeutics.

Better clinical outcomes – more accurate treatments will result in shorter hospitalisation times and faster recuperation.

Increased patient satisfaction better outcomes, lower medical costs will result in higher patient satisfaction and loyalty.

Speaking PHRs, where do you think Asia Pacific stands with respect to its adoption?

Asia is just at the beginning of PHR journey – infancy stage. We need to remember that the concept might be 15 years old (in terms of HIT) but the real implementation started just a few years ago and mostly in North America with products like Microsoft’s Health Vault and Google Health and MyPHR (AHIMA).

Before the industry can move into PHR, the basic HIT infrastructure needs to be in place in terms of Electronic Medical Record (EMR) and Electronic Health Record (EHR). EMR is a local IT healthcare platform that is confided to single facility (Hospital, clinic, Day Care) whereas EHR is the collation of all EMRs at the organisational, regional, or national level. Most of APAC countries are still at the EMR level, and it is advisable to progress to EHR before implementing PHR as the latter is simply an extension of EHR. The most HIT advanced countries in

APAC are: Singapore, Japan, Australia, and Hong Kong. Besides having implemented EMRs, these countries also established localised terminology for healthcare data (for storage and exchange) in terms of medical data standards including ICD 9, ICD 10, DRGs, and others.

In terms of current usage, according to CNN the number of active PHRs in 2008 in US amounted to 7 million—a far cry from the objective of having all healthcare facilities and physicians to participate to the PHR framework.

In this downturn, how has Healthcare IT helped hospitals in reducing costs?

HIT is often underappreciated in terms of tangible benefits to the healthcare organisations. In economic downturn, having HIT is a crucial competitive advantage because of the following: Reduced costs - Increased revenues • Higher efficiency and lower redundancy by better utilisation of resources • Lower wastage: better management of drugs, elimination of fraud • Higher turn-around of patients because of shorter treatments, higher volumes, and patient loyalty (brand attachment) • Faster processing of insurance claims – faster funds recovery from Accounts Receivable Better Brand Exposure – Increased Patient Loyalty: • Higher patient satisfaction because of lower waiting times, better outcomes, and lower costs • Improved Patient Safety: better clinical outcomes due to lower incidents of medical errors and more effective treatments Increased patients’ volumes—Medical tourism Apart from saving money, HIT is the main driver for medical tourism as foreign patients trust hospitals with EMR expecting better standard of care (quality and safety) and possibility of remote follow ups. In an economy where local patients are switching to public

healthcare system to save money, the loss can be recovered by attracting foreign patients.

How helpful is the convergence of information technology and medical devices?

By the collaboration of the two industries it is possible to create innovations based on: • Miniaturisation • Robotics • Mobility Such innovations are later used to design new therapeutics and medicines.

The main objective of this collaboration is to personalised treatments to suit specific needs of particular patient.

How has this convergence impacted hospitals?

• Extension of care beyond hospital borders—remote monitoring • Shortened treatments—possibility of day care procedures • Delivery of care at the point of care— outcomes, patient satisfaction • Remote directed procedures—telemedicine • Effective treatments—Personalised medicine What are the challenges and opportunities found in managing IT-based medical technologies?

The main challenges will always revolve around privacy, confidentiality and integration. Another challenge represents user compliance and acceptance, which requires the solutions to be very ergonomic and user friendly.

Legal aspects are just being explored and in US it is becoming already a hot topic. Implementing applications with faulty design can be the source of medical litigations as well as wrong or underusage by the care givers.

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Cancer Nanomedicine Emerging opportunities Nanotechnology has many advantages when applied to medicine.

However, continued research into disease processes at the molecular level is essential for its development.

Matthew Dennis Cancer Market Specialist Espicom Business Intelligence, UK

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D

iagnosing, treating and tracking the progress of therapies for each type of cancer that exists has long been a dream of oncologists, and one that has grown recently alongside developments in genomics, proteomics and cell biology. Now, a revolution in nanotechnology is pushing personalised cancer treatment closer than ever before.

Future techniques in medical diagnosis and treatment have often been the subject of science fiction and fantasy.

What was once the stuff of fiction is now closer to becoming reality. Nature already operates at the nanoscale and we are acquiring an increasingly profound understanding of natural processes at this scale, enabled by a new generation of scientific instruments. Armed with this knowledge, we are able to design devices that can either directly interact with, or

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influence, the behaviour of living cells. As with any nascent and rapidly developing field, there are research, technological and ethical challenges to be considered, and the approaches to these constitute an integral part of this field.

Nanotechnology has many advantages when applied to medicine. At the nanometre scale, materials often exhibit surprisingly different physical, chemical and biological properties, compared to the very same material in bulk form.

The properties of nanoparticles, such as increased chemical activity and the ability to cross tissue barriers, are leading to new drug targeting and delivery techniques.

In the future, a nanoparticle or a set of nanoparticles may be designed to search for, find and destroy a single diseased cell, driving us ever closer to realising the ultimate goal of disease prevention.

Medical Sciences

In the foreseeable future, nanotechnology as applied to medicine, will lead to advancement in remote monitoring and care, where a patient may be treated at home, a less expensive option, and one that is more conducive to a successful medical outcome than treatment at a hospital.

Continued research into disease processes at the molecular level is essential for the development of nanomedicine, and involves teams of scientists from across conventional disciplines, such as physics, chemistry, surgery and mathematics, as well as those from the relatively new fields of genomics, proteomics, metabolomics, pharmacokinetic modelling and microscope design.

Highlighted below are the six main areas under which progress in nanomedicine is expected to advance over the next five to ten years. These areas were identified by the National Cancer Institute (NCI) in its 2004 Cancer Nanotechnology Plan1, which set out to describe how to accelerate the application of nanotechnology to cancer research and clinical care, emphasising the need for cross-disciplinary and cross-sector collaboration to develop and deliver the public health benefits. After each potential area for development, there is an analysis of the specific section, with three predicted development scenarios over the five to ten year time course: optimistic, realistic and pessimistic.

These six sections are:

• Molecular imaging and early detection • In vivo imaging • Reporters of efficacy • Multi-functional therapeutics • Prevention and control and • Research enablers As the field of nanotechnology continues to grow, an increasing number of countries are developing research agendas with particular focus on specific areas of nanomedicine. This has led to some identifiable research trends and initiatives. There are however, many research

programmes with broad initiatives that are not specific to cancer. Some trends are highlighted below that have been identified from national and international reports.

At the CancerNano 2006 Symposium, held from 7th to 11th May, in Boston, MA, researchers from around the world gathered to discuss the next steps for taking promising cancer-fighting nanoresearch from the laboratory to clinical trials. The Symposium was co-produced by the Nano Science and Technology Institute, the National Cancer Institute (NCI) and the National Institutes of Health. “We have a lot of exciting nanotechnology research going on throughout the country, and our main goal now is to expand the connections between the nanotech and cancer communities, and help get today’s cancer-focused nano research out of the labs and into clinical trials,” stated Dr Mansoor Amiji, co-chair of the Symposium from the Department of Pharmaceutical Sciences at Northeastern University in Boston.

The Symposium highlighted many promising nano-driven research projects: 1. An in-body detection system based on quantum dots that can safely be inserted into the human body to find, detect and make images of cancer cells as early as possible (even before symptoms appear) 2. In-body gene and drug-delivery systems that can be safely inserted into the human body to target cancer cells directly (with time-release delivery of treatment drugs or gene therapy) 3. In-body monitoring and surveillance systems that detect cancer mutations (via triggers or genetic markers) 4. New nanoscale tools, protocols and methodologies for designing drugs for more efficient, targeted release into the system and 5. New nano-driven diagnostics that will enable cancer investigators to more quickly identify submolecular targets for research, clinical development and/or predict drug resistance

Examples of public funding for R&D in nanoscience and nanotechnology Country

Expenditure on nanoscience and nanotechnologies

US

st The US’ 21 Century Nanotechnology Research and Development Act (passed in 2003) allocated nearly US$ 3.7 billion to nanotechnology from 2005 to 2008 (which excludes a substantial defence-related expenditure). This compares with US$ 750 million in 2003.

Europe

Current funding for nanotechnology R&D is approximately EUR 1 billion, two-thirds of which comes from national and regional programmes.

UK

With the launch of its nanotechnology strategy in 2003, the UK Government pledged £45 million per year from 2003 to 2009.

Japan

Funding rose from US$400 million in 2001 to US$800 million in 2003, and was expected to rise by a further 20 per cent in 2004.

India

India’s Department of Science and Technology will invest US$ 20 million from 2004 to 2009 in their Nanomaterials Science and Technology Initiative.

Brazil

The projected budget for nanoscience during the 2004 to 2007 period is approximately US$ 25 million.

Table 1 www.asianhhm.com

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Medical Sciences

At the present stage, it is not possible to determine the amount of funding that has been allocated to nanomedicine with respect to oncology. This is partly due to the emerging nature of the technology, but primarily because much nanotechnology R&D at this stage is not disease-specific, being at a much more basic and therefore general level.

There is however, information relating to nanotechnology funding as a whole.

Nanotechnology R&D spending is distributed among governments (including national, regional, State and local), universities, corporations and venture capital investors. The availability and consistency of accurate figures varies for the different categories. When comparing the available data for various countries, Product

The majority of products in development for the treatment of cancer are still in preclinical development, though a few are nearing approval and possible market launch. Of the products identified by Espicom Business Intelligence: • 3 (6%) are either in Phase III or have filed for approval • 9 (17%) are currently in Phase II development • 11 (20%) are currently in Phase I development and • 31 (57%) are currently in preclinical development • Further analysis can reveal that, of the products identified: • 32 (59%) are nanotechnology reformulations of currently approved anticancer drugs • 15 (28%) use nanotechnology to deliver new or unapproved drugs or are treating cancer in another way • 4 (7%) are nanotechnology imaging agents • 1 (2%) is using nanotechnology to detect cancer; and • 2 (4%) are using nanotechnology for other cancer applications • Products currently on the market with oncology applications

Type of nanomaterial

Indication

Company

Abraxane

Nanoparticle albumin

Non-small cell lung cancer, breast cancer, others

Abraxis BioScience

DaunoXome

Liposomal formulation of daunorubicin

Kaposi’s sarcoma

Gilead Sciences

CellSearch Circulating Tumor Cell Kit

Magnetic nanoparticles (ferrofluids)

Metastatic breast cancer

Immunicon

Verigene platform and Bio-barcode Technology

DNA-functionalised gold nanoparticles

Diagnostics

Nanosphere

Caelyx/Doxil

Doxorubicin liposome injection

Ovarian cancer, AIDS-related Kaposi’s sarcoma and recurrent breast cancer

Ortho Biotech (Johnson & Johnson)

Myocet

Liposome encapsulated doxorubicin citrate complex

Recurrent breast cancer

Zeneus Pharma

Source: Company websites, www.espicom.com

difficulties can arise due to differences in the definition of nanotechnology, the inclusion of private contributions or other variations in the calculation of government funding, difficulty in getting some private, especially venture capital, investment data, mismatch in investment periods, and the various exchange rates employed.

In its report “Emerging Opportunities in Cancer Nanomedicine” (published August 2006), Espicom iden-

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tified six products that are employing nanotechnology in relation to cancer treatments which are currently on the market. Four drugs that have already been launched are all reformulations of currently approved anticancer drugs that aim to reduce the side effects associated with the original forms. This seems to be a common trend for many of the companies that are developing nanomedicines: trying to improve the safety profiles of drugs that are already approved. This

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offers many advantages over developing novel therapeutics and is showing that nanotechnology can be used safely. Once these drugs have been on the market for a period of time then it may give other companies the confidence to develop therapies incorporating nanotechnology from the drug discovery stage. However, it will be some time before these start to make their way through into companies’ development pipelines.

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Research Insights Thomas Group healthcare survey shows direct relationship between hospital-physician alignment, revenue growth and cost savings

T

he latest survey ‘HospitalPhysician Alignment: A Model for Success’ by Thomas Group, Inc. shows the positive impacts of alignment. The survey says that the close alignment between physicians and healthcare leaders could help them in better understanding of mission and vision and they come to an agreement on key goals and objectives. Positive alignment could help doctors and patients to come to an agreement on critical priorities, an adaptive culture and a willingness to focus energy on these priorities. The survey also revealed that the physician involvement in strategic decision making is the important aspect to revenue growth.

The survey has three sections covering (i) alignment assessment, talking about how each participating hospital or health system scored in eight indicators

of alignment based on size, (ii) financial impact talking about relationship between alignment, revenue growth and savings and (iii) focus areas covered by institutions in pursuing enhanced physician alignment.

There exists a direct relationship between a hospital’s alignment score, and its reported revenue growth and cost savings, a study proves. The alignment scores are ranged from 13 to 38 with a mean of 26 and a standard deviation of five and the highest possible alignment score was 40 points. The survey also noted that every change of one point in the alignment score corresponds to a positive change of 0.8% revenue growth.

Other top findings include: • Hospitals and health networks with above average alignment claimed

13% positive impact on annual revenue growth year over year • Sixty percent of respondents felt their physicians were not sufficiently aligned with the institution regarding clinical quality • The top three priorities for hospitals and health systems as focus areas for improved alignment are: clinical quality, utilisation management and service line excellence • The most common strategy used to enhance alignment with physicians is the use of employment arrangements (82%) • The establishment of clinical institutes is the highest correlated strategy element to both positive alignment and revenue growth • The most common compensation method for alignment is establishing medical directorships (74%).

Combination of PEM and MRI improves breast cancer detection

W

omen and their physicians now have a better tool to help cure cancer. Positron emission mammography (PEM) scanners improve breast cancer detection and improve ability to differentiate between benign and cancerous lesions.

The combination of this scanner with Magnetic Resonance Imaging (MRI) represents a significant advance in the detection and treatment of breast cancer.

PEM scanners are high-resolution breast PET systems that can show the

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location as well as the metabolic phase of a lesion, information which is critical in determining whether a lesion is malignant and influences the course of treatment. Other imaging systems, such as mammography and ultrasound, only show the location, not the metabolic phase. Understanding the presence of additional tumors is critical to understanding if a lumpectomy or mastectomy is the right surgery.

The study also found that the most reliable way to identify lesions was to combine the two technologies.

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PEM and MRI scanning together saw an additional 31 (out of 116 total) lesions producing a 20 per cent absolute increase in what researchers call ‘sensitivity’ when compared to using MRI alone.

PEM is proved to be an integral imaging tool in the surgical management of breast cancer, and as an alternative for the large number of patients who cannot tolerate breast MRI exams due to claustrophobia, patient comfort, pacemaker, metal implants, or other factors.

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Surgical speciality

A

quality assurance programme in surgical practice is quite simply a mechanism to ensure that the patient (consumer) is subjected to the least threatening journey through the hospital during a period of treatment, with an outcome that is deemed acceptable by international standards. This process inherently incorporates data collection and outcome analysis, but is in fact conceptually broader and includes assessment not only of patient outcomes, but institutional processes, appropriateness of care and patient and healthcare provider satisfaction. All of these variables inherently, but not exclusively, affect the patient journey.

Historical perspectives and importance

The concept of developing â&#x20AC;&#x2DC;quality assessmentâ&#x20AC;&#x2122; in surgery is historically

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Surgical speciality

Quality Assurance Programmes for Surgery How and why in Asia?

It is inevitable that the concept of quality assurance in surgery will expand worldwide and encompass other surgical disciplines; the process will be driven by patients, professionals and healthcare providers alike.

Malcolm J Underwood, Professor, Department of Surgery CA van Hasselt, Professor, Department of Surgery Hong Fung Cluster, Chief Executive New Territories, East Chinese University of Hong Kong, Prince of Wales Hospital Hong Kong SAR

attributed to the American surgeon Ernest Codman.1 In the 1900s, he suggested that hospitals in general, and surgeons in particular, should collect their results sequentially over time, in order to provide comparative data on ‘end-results’. His suggestion was that these outcomes be made public, allowing patients to use the information and ‘choose’ their place of treatment and individual surgeon. It was his lifelong pursuit to establish an “end results system” to track the outcome of treatments, as an opportunity to identify and resolve clinical misadventures thus providing the foundation for improving the care of future patients.1 It was a recognition that both institutional and individual measures of ‘performance’ need to be recorded, aspects which are now widely recognised as being an important part of the provision of qual-

ity assurance in surgery. But, for surgical specialties in Asia, why do we need this process and how can it be achieved?

Quality assurance programmes in surgery are essential for patients, doctors, hospitals and healthcare providers (financiers) worldwide for a variety of reasons.

Patients need to be reassured that the process of surgical treatment to which they have agreed is appropriate, will be administered effectively, and results in an outcome acceptable by international standards. In order to achieve this, individual surgeons and individual hospitals should be able to provide information regarding outcomes after surgical treatment which is based upon validated data and also ‘risk-adjusted’ for casemix. For example, in cardiac surgery in the UK, a speciality which has led the way in providing outcome data and

analyses, each centre providing cardiac surgical treatments submits data regarding patient risk profiles and outcomes to the UK Society of Cardiothoracic Surgeons. These are subsequently collated by the National body, published and made available to the public.2This process has evolved more recently and in collaboration with the Healthcare Commission in the UK, institutional and individual surgeons’ results are now published on the Internet.3The quality assurance process is important for individual surgeons globally.

Advances in risk-stratification allow them to compare their case-loads and outcomes with other practitioners both locally and internationally, and ensure that the facility within their institution is enabling them to perform to an appropriate level. It is important for hospitals to be able to look at

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Surgical speciality

individual and group surgical outcomes, ensuring that their overall institutional process meets published standards. It is important that healthcare providers are reassured that their financial support of surgical programmes within institutions is being used effectively, not only in terms of patient outcome, but also in resource utilisation.

All of the above issues are pertinent and relevant to the provision of surgical care in Asia in view of the rapid rise of treatment availability, and importantly, the associated financial burden.

Whilst it is perceived that all of the above processes can by default lead to consequential quality ‘improvement’, there are still many areas which require investigation and resolution.

It seems obvious that, despite apparent difficulties in defining surgical outcomes and applying risk-stratification, embracing the concept of quality assurance in Asia would be of benefit to all parties involved in the patient journey.

Stratification and data collection

Presenting information regarding outcome to the public (patients) requires an ongoing ‘educational’ aspect as there needs to be general understanding of the important differences between ‘crude’ and ‘risk-adjusted’ outcomes. A surgeon or institute with a comparatively high mortality for a given procedure may actually be performing exceptionally well when case-mix is considered. This represents a challenge in Asia.

The ‘risk-stratification’ process is well developed in cardiac surgery, but has accepted limitations and is more complicated to establish and consequently less developed in other surgical disciplines. Despite this, the Veterans Affairs Medical Centers in the US has produced risk-adjustment models for 30-day mortality and morbidity rates for both non-cardiac and associated surgical specialities.4The ability of this model to detect variations in the quality of care has also been shown in a validation study.5There are still, however, complexities to be resolved when defining ‘outcome’.

In cardiac surgery, mortality is routinely used as a measured ‘outcome’.

For surgical specialities where this is unlikely to be a useful marker—e.g.

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plastic surgery—clinical indices which reflect quality in that particular service need to be identified. Mortality alone may not be sensitive enough as a ‘quality’ outcome tool and recently, the concept of recording and analysing ‘near-miss’ episodes rather than death has been suggested as being a more useful mechanism to identify rectifiable performance problems at an early stage2. It seems obvious that, despite apparent difficulties in defining surgical outcomes and applying riskstratification, embracing the concept of quality assurance in Asia would be of benefit to all parties involved in the patient journey. But how could it be achieved?

ISSUe - 21 2009

The essential element for a successful quality assurance programme is without question, the determination and commitment of healthcare professionals (providers of direct clinical care as well as financiers) to embrace the concept. The most important practical aspect is the provision of an appropriate institutional infrastructure (system) which allows collection of relevant, validated data.

Without this, any attempt to provide information regarding patient outcome is doomed to fail. Computerised systems and information technology are globally available, which provide the facility for clinical data storage and complex outcome analysis. It is essential that along with these systems, data validation procedures are undertaken. This will allow confidence in the accuracy of outcome reporting. The provision for these facilities should be given priority by healthcare providers. The natural progression of having these resources in place would be the development of national databases for different surgical specialties within the region, enabling institutional comparisons and ‘benchmarking’ exercises appropriate to the local population. The concept of quality assurance within surgery is not new.

The process will continue to be driven by patients, professionals and healthcare providers alike. The provision of comparative systems in Asia, facilitating quality assurance, is a moral obligation of the whole healthcare community involved in the surgical treatment of patients and represents an ongoing challenge within the region.

References

1) Spiegelhalter DJ. Surgical audit:statistical lessons from Nightingale and Codman. J.R.Stat.Soc A 1999;162:4558.

2) Keogh BE, Kinsman R. Fifth National Adult Cardiac Surgical Database Report 2003. London: The Society of Cardiothoracic Surgeona of Great Britain and Ireland 2003.

3) Available from URL: www.healthcarecommission. org.uk 4) Participants in the National VA Surgical Quality Improvement Program. The Department of Veterans Affairs’ NSQIP. Annals of Surgery 1998;228:491-507.

5) Khuri SF, Daley J, Henderson W et al. The National Veterans Administration Surgicla Risk Study: risk adjustment for the comparitive assessment of the quality of surgical care. J Am Coll Surg 1995;180:519-531.

Diagnostics

Diagnostics in APAC Changing dynamics

There is a need for educating the patient and primary care physician to adopt the preventative regime. This mindset change will lead to higher penetration and costs can come down

How is the business model for diagnostics changing in the APAC region?

Business model / revenues rely no longer on just hospital / clinical segment but increasingly on R&D / CROs segment.

The demand for diagnostics is largely expected to grow in the coming years.

Will this be matched by a drop in costs as well?

Not necessarily in the short run. The growth comes from developing new applications for infectious diseases.

However in the long run as these tests come under re-imbursement regime the costs will come down

Nitin Naik Vice President Healthcare Delivery Frost & Sullivan Asia Pacific, Singapore AUTHOR BIO As Vice President of the Healthcare Consulting Practice, Nitin Naik leads the Asia Pacific consulting team for Frost & Sullivan providing business consulting services to a variety of healthcare clients. Nitin’s industry focus includes Medical Technologies, Healthcare Delivery and Healthcare Informatics with special emphasis on government and Trade Regulatory Maps and Healthcare Risk Assessment Models. He has advised leading Healthcare players across Corporate & Market entry strategy, Business Planning, New Product

What needs to be done to keep costs of new diagnostics down?

Educating the patient and primary care physician to adopt the preventative regime. This mind set change will lead to higher penetration / larger volumes and costs can come down.

As diagnostic services become more accessible there is chance that the number of unnecessary tests will raise, how can this are controlled?

There should be transparency in terms of usage and appropriateness of these tests. Government, Academia and Manufacturers need to play an equal role and prevent a ‘mass profit’ situation

Are there any systems in place to avoid unnecessary tests?

Countries like Singapore have DRG which specify what tests to be done under what suspected condition. Many developing countries like Thailand, Indonesia etc would need to adopt something similar to avoid unnecessary tests How do you see genomics impacting diagnostics in the near future?

By 2020 definitely in a big way. Currently it is yet to be truly commercialised and accepted..Most of the impact will come if applications similar to POCT are developed on this platform.

In Frost’s diagnostics briefing, ‘360 Degree Outlook and Growth - Strategies in the APAC in-Vitro Diagnostics Industry - October 9, 2009’, there is mention of an integrated approach towards competition. Could you shed some light on this?

What we mean is that to fulfill the opportunities in a) Sample preparation b) Detection & Quatification Analysis c) Validation and d) Functional analysis there is a need for a supplier to have an integrated perspective as usually each of these opportunities are currently being served by suppliers who ‘only compete in 1 opportunity rather than all’. There is significant competitive advantage by being present in all 4

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Diagnostics

Strengthening Radiology Education Generational Challenges and Electronic Publishing

Medical publishing has been around for more than a century and has contributed towards disseminating new knowledge and raised the standards in the practice of healthcare. The advent of electronic journals was a leap in the evolution of the medical journal.

Despite this, medical publishing continues to face many challenges from various factors. We would like to explore the generational issues in medical publishing, that is Generation Y and their impact on the future role, as well as the form of medical publishing.

Basri JJ Abdullah Professor, Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Malaysia

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Introduction

Today’s student

Many sociologists and demographers have studied generational differences but despite this readily available information, individuals and organisations tend not to see their own lives as part of a different era. Just as fish do not discover water, a person tends to be unaware of the characteristics of his or her generation (Bickel & Brown 2005).

Generational differences (Table 22.1) have real implications on how employers and employees, doctors and patients, teachers and students as well as journals and their readers interact.

Each new generation brings a unique set of attitudes to the interactions, which often do not fit the expectations of today’s leaders. For today’s organisations to fully benefit from the diversity of skills and perspectives of the Gen Y, they must incorporate the Gen Y outlook into their cultures, organisation and management styles. Gen Y desire long–term relationships with employers, but on their own terms with worklife balance, better engagement with management, opportunities, responsibility and recognition of good work (Manpower Services Australia 2007).

Most college students today are part of Generation Y. This generation is referred to as the first human natives of the digital landscape (Prensky 2005/6). Digital natives are characterised by s: o operating at twitch speed (not conventional speed) o employing random access (not step-by-step) o parallel processing (not linear processing) o graphics first (not text) o play-oriented (not work) o connected (not stand alone) Generation Y has several unique characteristics: they are more ambitious and optimistic than Generation X, are the most ethnically diverse (35 per cent are non-white), and favour different values and learning styles from their predecessors (Howe & Strauss 2000). They are the largest child generation in American history, currently making up 34 per cent of the country’s population, and they are the most technologically savvy (Merritt 2002). Also, Generation Y students face parental and self-pressure to study hard and excel, and they have proven to be up to the challenge. Further, they no longer consider the physical library to be

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As is the generation of leaves, so is that of humanity. The wind scatters the leaves on the ground, but the live timber Burgeons with leaves again in the season of spring returning.

So one generation of men will grow while another dies.

~Homer, Iliad Traditionalists/ Veterans 1925-1945

Baby Boomers 1946-1964

Generation X 1965-1980

Generation Y/ Millenials “Nexters” 1980 to 2002

Slogans

“Keepers of the Grail”

Invented “Thank God, it’s Monday”

“Work to live, don’t live to work

“Upcoming optimists”

Values

Logic and Discipline

Participation/Equity

Balance between life and work

Diversity/Morals

Provide

Stable environment

Personal Challenges

Feedback

Structure

Authority

Respectful of authority

Nonauthoritarian

Dislikes Close Supervision

Respectful of Traditionalists

Characteristics

Conformers

Optimistic

Highly Motivated

Can-Do Attitude

Work Priorities

#1 Priority – Work

To Be a Star

Fun and Flexible

Money

Train

Don’t rush things

Skill practice

Visual Stimulation

Mentor Programs

Technology

Unsure and Resistant

Willing to Learn

Technologically Savvy

Technological Superior

Career Goal

Build a Legacy

Build a Stellar Career

Build a Portable Career

Build Parallel Careers

Table 22.1 Today’s workforce: Veterans or Pre-Boomers, Baby Boomers, Generation X and Generation Y (Manpower Services Australia 2007)

essential to their educational experience since these students increasingly rely on the Internet and technology for their learning and communication (Shill & Tonner 2003).

Today’s students have also came of age during the “mass customisation movement,” which essentially translated into being “absolute rulers of their own digital universe”. They now expect to control “when, where, how and how fast they learn.” These students “feel their learning environments as boundless,” with most having laptops with the same

functions as the computers in the library (Barone 2003). As a result, personalised learning, or adaptive learning, is increasing its presence, influence and need. This is happening in a background where individuals not only work alone or in collaborative environments but are increasingly isolated in distance secondary to inadequate physical training places.

Individuals must also learn on-the-job within a tight schedule (Burgos 2007).

In such an environment, the student is able to personalise the different skills, aptitudes, knowledge and interests in his

or her life as they each aim for different objectives. Further the individual personal and professional environment also shapes his or her learning. Therefore, personalised learning becomes a direct answer for specific needs where everything can be adapted: content, style, methodology, itinerary, evaluation and so on.

Generation Y is also responsible for the term “Prosumer” (a portmanteau formed by contracting either the word professional or producer with the word consumer) (A Toffler. The Third

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Diagnostics

Wave, Bantam Books, New York, 1981).

Unlike the typical consumer who plays a passive role in the purchase, the prosumer becomes an active players in the process, changing the product, process or both.

The implication to the economy of the prosumer has been far-reaching. This is most visible in the Internet where content by itself is no longer enough. This is a response to the growth of the “Wiki” concept and there has been a growing interest in the latest generation of Webbased collaboration ware (also known as Web 2.0 tools), namely wikis, blogs and podcasts (Boulos MNK, Maramba I, Wheeler S. Wikis, blogs and podcasts: a new generation of Web-based tools for virtual collaborative clinical practice and education. BMC Medical Education 2006, 6:41doi:10.1186/1472-6920-641). The Open Innovation (OI), which is defined as “…the purposive inflows and outflows of knowledge to acceler-

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ate internal innovation, and expand the markets for external use of innovation, respectively” (Chesbrough et. al. 2005:1), is another paradigm encapsulating this concept. The power of the informed user drives innovation in new product design. It enables users to build new products that suit them, as opposed to manufacturers who develop new products for profit.

This shift to user-driven innovation leads to explosive growth in products and features in various disciplines. OI democratises the innovation processes shifting enormous control to the user.

OI therefore has explosive power when combined with digital communications networks in each area where it is observed. The access principle, as applied in the network, fostered innovation as it shifted power from the owners to the network users. There are groups of prosumers who have created their own

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blogs, electronic journals, and discussion groups outside mainstream media, where they openly exchange their ideas that allow others to build on them. In contrast, the majority of electronic medical and scientific journals today are still very much top-down with a hierarchical structure. This may not appeal to the Generation Y academics, scholars and students.

The Next Generation (The Next Generation 2009) is an example of an online journal created in response to the failure of current journals to provide easily accessible and permanent information about the systems of discovery, policy and care delivery issues perceived to be relevant to the current generation of premedical students, medical students and general interest readers. It encourages the next generation of clinicians and health-conscious citizens to develop a broader perspective on medicine, better

Diagnostics

understand pathways and careers in medicine, explore current events and controversies (e.g. sustainability, access to healthcare, etc), present new discoveries in research (e.g. minimally invasive therapies, flu pandemics, blogging medicine, etc.), clinical trials along with issues of financial independence and starting a family. And, of course, it is open access.

Technology of today’s students

Generation Y are technology veterans as they grew up surrounded by technology. They can hardly recall a time when their music was not available on compact disks or when they could not get any information they needed off the Net that is the Internet, cellular phones and immediately available parallel communications. All who came before Generation Y are no more than digital tourists, but Generation Y is as comfortable and capable in the digital world as in the physical world (Ramirez 2009). When it comes to technology, these students are so comfortable using it that they often feel superior to their teachers and not impressed by its use in a classroom setting (Oblinger 2003).

Besides, as Merritt notes, Generation Y students “don’t see the Internet and technology as tools; they see them as integral parts of their lives” (Merritt 2002).

The natural progression of all these digital technology is the concept of “Edutainment” (also educational entertainment or entertainment-education) where entertainment is designed to educate as well as to amuse. Learning thud becomes fun and teachers or speakers educate their audience in a manner which is both engaging and amusing.

Further it typically seeks to instruct or socialize its audience by embedding lessons in some familiar form of entertainment that is multimedia software, computer and video games, television programs, etc.

Generation Y has evolved the very concepts of networking, collaboration and community. Parents, adults or

teacher often marvel at how a Generation Y teenager can be on the mobile phone communicating with several friends, while simultaneously sending SMS text messages and emailing directly while at the time playing an on-line role-playing game (RPG) that combines video, audio, and text conferencing. Any RPG player must learn and master no fewer than 70 new rules or skills which are the bare minimum to negotiate the first level of the game. To advance through the game requires monitoring of no fewer than 100 individual incoming streams of data from 360 degrees in all three planes of three-dimensional space (X, Y, and Z axis). In addition, the most recent generations of game systems allow players to collaborate in real-time with individuals not only within their country but across the internet in other countries.

But despite their love of technology, for Generation Y, role-playing games are not technology but a tool, while for those who provide education, RPG systems were once considered a “super computer”. This is a chasm almost too wide to bridge (Ramirez 2009), which has serious implications on formulating curriculum and their delivery. Another consequence is that postgraduate training may be just another ‘business’ competing for entertainment dollars from the public, rather than as an institution that serves the public welfare through education or historical preservation (Stoll 1999).

Generation Y’s conditions for engagement presents further challenges. o Real Both we and our communication styles must be credible. Gen Y are seeking understanding and respect, and don’t expect us to understand their lifestyle, or to embrace their culture. o Raw: Gen Y is not comfortable with a rehearsed talk or a manufactured spiel since they are themselves more spontaneous and interactive. Using a similar style will making teaching the less intimidating and they will respond more openly o Relevant The style, content and message in communicating must fall within areas of interest of the target cohort as they are visually educated and entertained.

To be better equipped to reach them we will need more relevant and appropriate research o Relational Communicating to this generation requires openness, vulnerability, and genuine interest in those we are trying to teach, and above all else, understanding. The more relaxed the and socially conducive the environment to discussions; the better will be the quality of the learning. “They don’t care how much you know until they know how much you care!”

Generational differences

As Generation Y moves from their current position as medical students to become doctors, then on to specialists and leaders, they will bring with them these networking skills. Collaboration is based on the principle where knowledge is shared with all the users. These young professionals have truly tapped a globalised market by using Internet and social networking services. The younger generation is willing to collaborate with a larger professional audience especially over the Internet Generation Y members use services such as MySpace and Facebook to serve

The traditional talk and chalk will not work with this generation (McCrindle 2006). While our communication style is structured, they want freedom, while we stress learning, they prefer experiencing, while we react, they favour relationships and while we focus preferentially on the individual, they are socially driven. Such fundamental differences must be recognised by the educators, leaders, managers and editors to ensure they stay relevant or else they face becoming the most recent addition to the heaps of dinosaurs from all the eras before us.

Effects of technology on tomorrow’s doctors

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Seven Core Traits of the Millennial Generation The following are the seven Core Traits typifying the Millennial Generation along with their implications on learning (Table 22.2) (Howe & Strauss 2000): 1. Special— Y Geners, as a consequence of their digital capabilities, regard themselves as special. Their parents also consider them special as they typically have fewer siblings in smaller families.

2. Sheltered—they are often protected by parents and within a wider community policy (for example bike helmets, seat belts, stranger danger, etc). As a generation, they are also particularly concerned with security issues for example crime and terrorism and school violence.

3. Confident—confidence and optimism prevails as they accept uncertainty with a sound economic base.

4. Team oriented— are more predisposed to team activities when compared with other generations. This maybe attributable to experiences in their early years, examples; organised sports, volunteerism, experiencing formal childcare, etc.

5. Conventional—despite all the other difference, they are still regarded as having fairly conventional aspirations centred on career, work-life balance and citizenship.

6. Pressured—regardless of their socio-economic profile, they experience higher pressure, with formalised activities filling many hours of their waking hours with busy social and school calendars 7. Achieving—they form the most education-minded generation ever.

7 Core Traits of MilGen

Strategies for school reform and school curriculum

Special

• Encourage parental involvement • Seek media support

Sheltered

• Stress school safety and accountability • Reconsider class sizes - smaller is perceived as better; learning communities are favoured

Confident

• Stress positive outcomes for everyone • Use contextual and project-based environments • Craft personal progress plans to guide students’ learning and growth

Team-oriented

• Teach team skills • Build community service into the classroom • Provide opportunities for students to help other students

Hold conventional hopes and dreams

• Create curricula that every student is expected to master • Celebrate progress • Continually check, assess and redirect learning

Pressured

• Stress long-term planning • Structure learning around goal mastery • Reverse engineer curricula - start with where you want students to be at the end of the year

Achieving

• Build challenging curricula • Emphasize achievement over aptitude and effort • Incorporate cutting-edge computer technology into the curriculum • Encourage teachers to set themselves as an example of professional achievement and lifelong learning

Table 22.2 Specific strategies recommended for educators to adopt strengthening their practises, based around the seven core traits of the MilGen (Howe & Strauss 2000).

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Diagnostics

as their digital homes. Similarly they use professional networking services such as Xing, LinkedIn and Konnect as their digital offices. LinkedIn being their North American office (LinkedIn 2009), Xing (Figure 1) (XING 2009) being their European branch office and Konnect being their Asian branch office.

For a member of Generation Y, Facebook is a home in their personal neighbourhood, while MySpace is their bedroom.

It is not unusual for Generation Y individuals who initially met in a professional environment to exchange Facebook and even MySpace contact information to facilitate a larger social interaction.

It is not unusual for a Generation Y professional to have over 10,000 direct first person contacts developed through Web 2.0 and Web 3.0 networks. It must be borne in mind that this network is not a random collection of business cards, but rather individuals with whom they have developed business and personal relationships, even friendships. These professionals not only discuss business ventures, successes, and failures, but seek each other’s advice in open mentoring opportunities and even share personal feelings in these virtual spaces. Another such site is Radiolopolis (Radiolopolis 2009) which is a community platform for Radiology. People from all over the world are able to connect with peers, find information from colleagues and, more importantly, share their knowledge. The needs of most radiologists, residents, medical students, technologists and industry could be melted within one central virtual portal Journals have also not been spared the growing global collaboration and communities resulting in more and more recent journals being “born Global” (Rennie 1993) for example Biomedical Imaging and Interventional Journal (www.biij.org). Such journals embrace the concept that it is no longer the case that a community must establish itself in its home market before venturing overseas, and then only through tentative steps in neighbouring countries. Such ‘born

global’ journals actively seek and publish international authors who would be right for their inception. These born global journals with their increased international exposure partly account for phenomenal the rate of growth rate of medical science from China now exceeds both Europe and North America. . This was not the case with the ‘old-world journals’ for example the British Medical journal (BMJ) or the New England Journal of Medicine (NEJM) which took a longtime to go international.

For Gen Y, globalisation and e-health are not issues to be debated on their merits but rather on how their technologies can be fully exploited to gain maximum benefit. Further Gen Y no longer see parents, teachers and adults as being the competent leaders of the changing society. They are often seen as the uncomfortable facilitators trying to keep abreast of the rapidity of technological and other consequential changes, including the all-encompassing effects of globalisation.

Generational differences in medicine

There is a marked gap in the perspectives and priorities between senior doctors and those new to medicine. Many older doctors and academics think young students and residents are lazy, selfinterested and pampered because they don’t want work to interfere with other parts of their life (Merritt Hawkins & Associates 2007, Dorsey et al 2005). On the other hand, the young doctors and students consider their mentors to be harsh, uncompromising and unaware of how the world has changed since they themselves were medical students. The result is a festering hostility in hospitals, medical practices and training programmes.

For Generation Y, feeling comfortable with their colleagues is the most important issue in a job or residency.

While the academic medical faculty receives more than 70 per cent of new information from printed journals the

younger doctors are increasingly turning to the electronic page. One of the most important, and defining, characteristics of young doctors and students is that they don’t adhere to gender roles, as boomers often did. More than half of incoming medical students today are women, when they used to be mostly men with homemaker wives. Students and residents of both sexes now often have a working spouse, and that person is more likely than ever to be a doctor. Younger doctors today generally prefer and expect fixed hours, a good call schedule with reliable coverage, and regular vacation time.

A much higher percentage of young doctors today are female than was the case in the past, and female doctors work 18 per cent fewer hours per week than male doctors. For these reasons, it may take two younger doctors to replace a more senior doctor. This is another reason the retirement or absence from medicine of senior doctors could have a major impact on doctor supply. Often, these are ‘workhorse’ doctors whose departure from the medical staffs are keenly felt (Merritt Hawkins & Associates 2007). These have significant implications for providing enough training positions to make up for the increasing needs from the growth of medicine in general.

Electronic publishing

Publishing is a hallmark of good scientific research. The aim of publishing is to disseminate new research knowledge and findings as widely as possible in a timely and efficient manner (Hersh & Rindfleisch 2000; Clapham 2005; CESTMJP 2009). However, scientific publishing today is still less than ideal. Publications, be they electronic or otherwise, must grapple with issues such as the declining readerships, changing generation of readers with a more interactive mind-set, changing concepts in knowledge dissemination, increased competition for ranking, publishing for publishing’s sake, ISI indexing, escalating costs and many more.

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When we look at learning, it is a concept with much broader connotations and applicability than education.

Education immediately conjures up a particular set of structures and functions that are the serendipitous outcome of history, culture, political power, geography, economics, and sociology. Learning is a fundamental aspect of human life throughout our days on Earth and provides a point of linkage among our lives as citizens, employees, business

owners, and social creatures. (Cheek 2009). There is much that we still do not understand about how people learn, whether it is at the fundamental physiological level of perception, attention and memory, or in the more cognitive dimensions of goal orientation, problem solving, information processing, organising and decision making.

What do journals do? Do we facilitate learning or are we still very much into disseminating information, information

Advantages • Speed and efficiency: Faster dissemination of scientific information by expediting entire publishing and management processes (submission; communication between authors, reviewers and editors; production process, including layout and galley proof).

• Hypertext and hypermedia links: linking to other electronic information.

• Innovative use of multimedia: To present research findings and other forms of data and information using sound, movies and simulation.

• Improved access: Ready access to information through electronic search engines.

• More efficient dissemination of research findings: Services such as abstract alert, advanced notification of publications, and matching articles of interest with readers’ profiles.

• Interactivity: With applications such as Java and common gateway interface (cgi) programs and forms, CME credits can be offered through on-line tests or images can be presented that can be manipulated by users.

• Public peer review: Linking readers’ comments, authors’ responses and evaluations.

• Improved discourse: Enables expanded and facilitated scientific discourse about research, on-line letters to the editor and discussions.

Disadvantages • Readers without laptops do not have access to articles on the go, for example on a commuter train.

• Readers who have access to a journal over a modem may be hindered by the slow acquisition of large images or movie files.

• Electronic journals and articles are considered as non-permanent, perishable citations that could change their URLs or disappear from cyberspace.

Table 22.3 List of advantages and disadvantages of electronic publishing (Ng 2009)

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which is often not integrated into one’s daily practice? How should journals structure their content to facilitate learning and not information dissemination? With time we have moved from ‘publishing information’ to disseminating information in forms that are both interesting and exploit the full potential of the Internet. However, we are finding that we are very much chasing a moving target as our understanding of what ‘business’ we are in keeps evolving as the capabilities of the IT and the Internet escalate along with the increased expectations of the users.

What about the increasing number of institutions which are producing an evergrowing number of papers? Publishing this increased number of papers requires new outlets, so yet more journals are created until there is not enough room in the library. There are 25,000 peerreviewed academic and or scholarly journals, whereby 16,875 (67.5%) of these have on-line full-text or on-line full-content, and the number is increasing rapidly (Ulrich’s periodicals directory 2009).

So we then move on to electronic publishing on the Internet, which supposedly has room for everything where we don’t have to worry about the number of pages, the number of illustrations, etc. Is all that, or even most of it, really adding to scientific knowledge in any meaningful way? Or are such attempts just creating congestion in the pipelines of knowledge? If this is so, then e-publishing has become a liability which gets in the way of true scientific advance. This has been the result of the increasing pressure on universities to go up the rankings for example THES. The term ‘Electronic Publishing’ is primarily used today to refer to the current practice of on-line and webbased publishing. However, it is also used to describe the development of new forms of production, distribution, and user interaction with regard to computer-based production of text and other interactive media. Electronic publishing

Diagnostics

also includes the publication of e-books and electronic articles, as well as the development of digital libraries and catalogues (Lancaster 1995; Lambert 2003). Electronic journals can potentially offer several advantages and a few disadvantages over traditional print journals (summarised in Table 22.3).

Lambert reported on the developments in biomedical electronic publishing since the mid1990s. These include the HighWire, PubMed Central, BioOne, the Public Library of Science, E-BioSci and BioMed Central services. The issues raised by these developments include the need to attract good quality papers, the ownership of copyright, how developments are funded, the question of whether a distributed or centralised system is adopted and preservation of content (Lambert 2003).

The online medium has opened up many possibilities that have increased the accessibility, visibility, interactivity and usability of research (Digital Scholarship 2009; Kadri et al 2009; Ginsparg 2008). Several innovations in electronic publishing that have been developed and refined are: • Personal websites (editors, reviewers, authors, readers) • Blogs: personal entries in diary style • List servers and discussion forums • Wikis: on-line reference works (encyclopaedias) with contributions by anyone in the on-line community • RSS feeds (or really simple syndication feeds) deliver summaries of web content together with links to the full versions of the content • Bibliometrics: automatic statistics on downloads, citation count to quantify the impact of an article.

Open discourse is a relatively new feature in electronic publishing for enhancing communication (Dayton 2006). Most journals, such as BioMed Central publications, encourage open review and discussion that invite interested participants to submit comments using the “Post a Comment” function,

as well as rate or rank the paper.

How often do we face a situation where we don’t have enough images of that specific entity to show for a lecture, talk or to write a paper about specific entities? Collaboration is further enhanced by a website which allows for sharing of cases between researchers and colleagues. Users may find interesting or needed cases or images for different types of projects (studies, books, publications, presentations etc.) at much greater speed and at minimal cost while assuring the owner’s credentials and recognising copyright of the case. Direct contact between the searcher and the owner of the case also provides a good opportunity to get to know new, potential partners for future projects [Dare to Share. http://www.radiolopolis.com/ index.php/my-profile/my-blog/DareTo-Share-Radiology-case-and-imageexchange-released-.html].

One such example is JournalReview. org (JournalReview.org 2009), a website forum for open peer review and discussion and comments of medical literature.

It is essentially a free-membership, on-line journal club which provides a venue to improve communication among doctors and scientists, and foster comment and criticism about published scientific research. The goal is better understanding and interpretation of the medical literature.

Another journal on the forefront of electronic publishing is the journal, Medical Physics. It uses the electronic physics auxiliary publication service, EPAPS (American Institute of Physics 2008). It is an electronic depository for material that is supplementary to papers appearing in journals published by or through the American Institute of Physics (AIP). Appropriate items for deposit include multimedia (for example movie files, audio files, animated gifs, 3D rendering files), colour figures, data tables, and text (for example appendices) that are too lengthy or of too limited interest for inclusion in the printed journal. The Journal of Visualized Experiments, JoVE

(Journal of Visualized Experiments 2009) is the first video journal for biological research. JoVE publishes ideo demonstrations of biological techniques and methods, as applied in the laboratories of leading academic institutions, including Harvard, MIT, Stanford, Berkeley and others. Hundreds of peer-reviewed videoprotocols, demonstrating experimental techniques in neuroscience, cellular biology, developmental biology, immunology, bioengineering, microbiology and plant biology are available, free, on the JoVE website.

Conclusions

There is an unbelievable tension between older and younger doctors who have very differing views in most areas of life, not just in medicine. Electronic publishing and education are not spared from this friction. It will be interesting to watch how it plays out when the current group comes through residency and gets hired into practices with older doctors or when the young doctors from Generation Y become the decision makers.

Human progress depends on new ideas and the ability to implement them.

Innovation is now seen as the basis of economic growth and social reform. There is a multifaceted, worldwide movement to encourage and support innovation in nearly every field of endeavour in basic education, business strategy, science and technology, public policy, and it will be no different in electronic publishing.

The internet and information technology are sure to have an impact on clinical practice, the research landscape, scholarly publishing, research policy and funding, dissemination of knowledge and the progress of science as a whole.

Therefore, there is a need to devise a system of incentives that will promote self-selection and specialisation, so that those with a comparative advantage in knowledge creation will not be crowded out by those with a comparative advantage in knowledge preservation and transmission (including, but not limited to, teaching), and vice versa.

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Technology, Equipment & Devices

Medical Devices Going the generic way

With the application of the generic pharmaceutical model to off-patent devices, the availability of generic alternatives to branded medical devices presents an opportunity for a drastic reduction in healthcare costs.

Richard Kuntz President & CEO, Generic Medical Devices Inc., USA

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O

ver the last two decades, technical improvements in the development of medical devices have helped create a thriving US$ 100 billion-a-year global industry.1 The expansion of innovative and original medical device manufacturing techniques has yielded remarkable biotechnological progress that has prolonged the life expectancy for patients and provided access to new life-saving procedures; but throughout this growth, standard-of-care devices have largely been ignored given their maturity in the product life cycle.

As a result, the price of these devices has risen on pace with the rest of the healthcare industry, but without acquiring any new features or improvements. Now, with the application of the generic pharmaceutical model to off-patent devices, the availability of generic alternatives to branded medical devices presents an opportunity for a drastic reduction in healthcare costs in Asia and internationally.

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Generic pharmaceuticalsâ&#x20AC;&#x201D;Laying the groundwork for generic devices

For years, consumers have widely used generic drugs offered by the pharmaceutical industry. The idea is simple: once the patent on a brand name drug expires (usually after approximately 17 years), competitors are allowed to develop, market and sell generic alternatives as long as they offer the same safety and efficacy as their branded counterparts.

By introducing these lower cost alternatives, drug manufacturers gravitate towards innovation in healthcare for newer, cutting edge pharmaceuticals.

Surprisingly, and despite the success of generic pharmaceuticals across the globe, the generic pharmaceuticals model has never been applied to the burgeoning medical device market, where large manufacturers continue to benefit from price increases on patentprotected surgical devices. These patents create barriers to entry for new competitors, enabling prices to continue to rise

Technology, Equipment & Devices

with little regulatory control and often with few, if any, additional innovations or improvements on those devices. This, in turn, creates financial problems for hospitals, ambulatory surgical centers and independent physicians seeking to provide their patients with the best in medical care; rising costs for devices mean either a direct rise in costs to healthcare systems, insurance providers and patients in a privatised system, or else a reduction in the number of patients who can gain access to care in socialized systems.

However, as patents expire, competitors are allowed to enter markets originally dominated by brand names.

Generic Medical Devices (GMD), Inc. is the first such company to capitalize on these allowances by developing generic versions of standard-of-care surgical products no longer under patent protection. The first generic medical devices are already available: the GMD Universal Surgical Mesh, a Class II, non-active implantable

medical device intended to support tissue growth in open or laparoscopic procedures (common for hernia repair), which has received 510(k) clearance for use in the United States and been submitted for CE-Marketing in Europe; and the GMD Universal Circumcision Clamp, which has been granted both FDA 510(k) clearance and CE Marking.

Several additional generic devices focused on pelvic health are in the product pipeline. Each generic medical device will be offered at approximately two-thirds the cost of brand name devices, providing enormous cost savings to purchasersâ&#x20AC;&#x201D;which can translate into direct savings for patients and healthcare systems.

To be clear, GMD is not setting its sights on devices that are considered life-critical, highly complex from a technology stand point, consistently being improved upon or regularly replaced by new iterations. New medical devices that require years of engineering and development are not products for

which generics should be manufactured. Instead, GMD is focused on devices considered standard-of-care in their respective categories, devices that have undergone little, if any, innovation since first being introduced to the market, and devices which are easily replicated and for which the company can dramatically reduce costs. By some estimates, the first GMD products could save the healthcare system in excess of US$ 360 million per year in the United States alone.

A new era of medical device manufacturing

As more generic alternatives become available in 2007, the impact on Original Equipment Manufacturers (OEMs)â&#x20AC;&#x201D;and consequently, the healthcare systemâ&#x20AC;&#x201D;is likely to be immediate and encompassing. By offering efficacious products costing significantly less than brand name counterparts, the market for generic surgical devices is likely to grow quickly and steadily.

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Hospitals, surgical centres, and thirdparty payers are limited in procurement based on strict fiscal budgets. However, with generic device prices estimated at approximately two-thirds of the current market price, these organisations will now have access to high-quality, lower cost alternatives and benefit from an escalation in purchasing power, allowing them greater access to devices and the ability to provide services to a wider number of patients—whether through lowered direct costs or, in a socialized environment, through the ability to purchase more devices within the same fixed budget.

As a result of the increased purchasing power of hospitals, surgical centres, and third-party payers, it is predicted that OEMs will experience greater demand for surgical devices and increasing production quantity—in short, opening the door to a new “generic”

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revenue stream influenced and created by the demand from the healthcare system itself. Brand name companies will face the greatest challenge in choosing how to contend with this new competition. To protect their market share, brand name, manufacturers will need to respond by introducing lower cost alternatives of their own or adjusting to the new market prices. Either way, the healthcare industry will win as brand name companies compete to match their generic counterparts and overall prices on expensive, standardof-care surgical devices drop.

Ideally, this will benefit Asian countries in several ways; Asian countries are already emerging as prime arenas for manufacturing low-cost medical devices, so, not only will hospitals and patients gain access to quality devices at lowered costs, but OEMs and materials manufacturers based in China, Singapore,

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Korea and elsewhere will experience a rise in the ability to partner with American and international companies to produce the devices.

The market for generic devices in Asia

A 2001 United Nations population study predicted that Asia’s over-65 population will increase by 314% by 2050.2 With one quarter of Asia’s population now over the age of 55,3 the demand for lower cost medical devices is ever-increasing. The increase in elderly patients will necessarily create a higher burden on the various healthcare systems—many of which have already ceased to provide sufficient governmental support for the general population.

As a result of such conditions as widespread deregulation in the healthcare sector in Japan and the fact that much of the cost for healthcare falls to the

Technology, Equipment & Devices

individual in privatised environments like China and Taiwan, generic pharmaceuticals have been widely accepted in Asia.

According to The Asia Generic Pharmaceuticals Forecast Report published in 2006, Japan will be Asia’s biggest branded generics market by the end of the decade as the government continues to cut drug costs and make hospitals and consumers more priceaware, and China’s generics market will continue to expand strongly, although success will depend on brand strength as the population remains reliant on basic drugs 4. This trend demonstrates a willingness among consumers and the healthcare industry to accept products that do not carry a brand name—it is expected that generic medical devices will follow suit.

This prediction is further supported by the fact that many Asian countries, including Taiwan, South Korea and Singapore, import more than twice as much in medical devices as they export—in many cases, Asian countries are importing more than US$ 0.5 Billion in foreign medical devices each year in order to serve their ageing and expanding populations 5. With governmental programmes in place urging reduction in healthcare costs in several Southeast Asian countries and a program directed at raising the standards of medical devices and equipment used in government-owned hospitals in Malaysia 6, there is clearly a place for high-quality generic medical devices in the Asian market.

GMD: A market of one

Currently, GMD occupies an industry of one, but with thousands of surgical devices in production for which generic models could be developed, there is considerable room for emerging generic manufacturers that could similarly benefit Asia and the world.

Ideally, each company would focus on a unique device segment in order to best meet increasing demand and maintain

the highest levels of safety and efficacy.

Supported by deregulation programs in countries such as Japan intended to increased focus on innovation and thus on partnerships with foreign companies, GMD is beginning to establish partnerships with manufacturers and hospital customers throughout Asia; the potential for widespread systemic change and savings is immense.

Generic products will drive down the cost of standard-of-care devices, make room in a burdened global healthcare system for innovation, and, most importantly, give more patients access to cutting-edge treatments by correcting decades of unregulated price inflation worldwide. GMD’s entry into the device industry has opened the doors to a whole new market opportunity for OEMs and new generic device manufactures—and the potential impact on the market is just now being defined.

Ultimately, hospitals, third-party payers and patients will drive the industry shift by choosing brand name quality at generic prices.

BOOK Shelf

Evidence-Based Cardiology Author : RSalim Yusuf, John Cairns, John Camm, Ernest L. Fallen, Bernard J. Gersh Year of Publication : 2009 Pages : 1240 Published by : BMJ Books

References: 1. http://www.medicalplasticsindia.com/ mpds/2002/may/markets.htm 2. http://www.eastwestcenter.org/stored/ misc/FuturePop08Aging.pdf 3. http://www.terrapinn.com/2007/ agmc_sg/Custom_12458.stm 4. The Asia Generic Pharmaceuticals Forecast Report, July 2006,

http://www.piribo.com/publications/ generic_drugs/asia_generic_pharmaceuticals_forecast_report.html

5. http://faculty.fuqua.duke.edu/~willm/ Classes/Pharma_BG/MHMG/ MHMG2005/RCS2088_SEAsia. pdf 6. http://faculty.fuqua.duke.edu/~willm/ Classes/Pharma_BG/MHMG/ MHMG2005/RCS2088_SEAsia. pdf

Description Evidence based Cardiology was first published in 1998 to universal acclaim.

Now, with the move towards more patient focused health care and at the same time increased emphasis on health economics, evidence-based practice is a more important force in health care delivery than ever. This new third edition, written by the world’s leading cardiologists, provides graded evidence-based reviews of the major trials together with recommendations for optimum management, and now includes new grading and recommendation methodology.

For more books, visit Knowledge Bank section of www.asianhhm.com

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Technology, Equipment & Devices

CARDIOMATIC It is a specialised cardiothoracic table, with all world class features to make surgeries more precise, convenient and time saving.

Some special features are: a) Extra low height of 25” compared to standard height of 32” b) Steep Reverse Trendelenberg tilt for near sit up position c) Specialised attachments for easy patient positioning d) Table top slide with remote control e) Zero Auto Leveling f) Dual Control Console g) Non Hydraulic leak proof maintenance free construction h) Affordable Indian prices The wide side arm table attachment helps in radial artery harvesting of the hand. It is a very rigid attachment which does not require any support or stand (which generally comes in the way of surgeons and disturbs their concentration).

‘The Cardiomatic’ from Magnatek CE ISO13485 Quality accreditations Advertorial

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Facilities & Operations Management

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

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

C

onsider a typical senior management meeting, and how care– which is, after all, the core business–is talked about. Care is typically talked about as delays, costs, issues, liabilities and perhaps, revenue or market share.

Its beneficial purpose generally remains implicit. Conversely, consider a typical clinical meeting. Here, the ‘system’ is seen as a block to good ideas and a waste, with its positive role in coordination, resource allocation and system improvement unremarked. Similar fault lines can be observed in quality improvement. Official quality and safety strategies often boil down to exhorting clinicians to “please try to not harm people”, rather than a positive view of doing things well. Conversely, clinicians can be reluctant to buy into broad system issues beyond their own immediate sphere of influence or even their own profession.

This divergence matters because, given the link between resource and clinical outcomes, the clinical and managerial cultures must come together if real progress is to be made. The challenge is therefore to recruit the organisation–not just its

formal structures, but also its culture and practices–to continuously improve care. Given that one must start with the culture one has, rather than the desired one, the practical problem is how to link subcultures in a common, positive project of improving care.

Where are we now?

The quality of healthcare remains highly variable. While excellent results are the norm, the reliability of healthcare processes generally remains low, with unreliability being estimated by the Institute for Health Care Improvement1 (IHI) at 1:10. That is, healthcare processes generally deliver the intended result only nine times out of ten. This estimate is corroborated by the thousands of avoidable deaths and injuries that happen each year, as well as by structured record audits. While there are major exceptions (consider the safety improvements in anaesthesia) even the best health systems perform well below what might be expected.

Technical complexity is necessarily a factor, but as Gaba had noted2, reliability in healthcare is also limited by

So, what can be done?

Given the polarisation of values, three broad options are: 1. Find a value that all share. This only works to a limited extent. For example, while in most healthcare systems everyone is committed to patient care, consensus falls apart when it comes to “which patient” and “what care”, especially if resources are scarce.

2. Impose an “official” value set. Prominent examples are “doctor knows best”, and “financial reality”. This approach can briefly optimise one element, but to an extent alienate those who don’t agree, to the extent that they may not participate at all or only emerge from the cave to throw rocks.

3. Harness the diverse sub-cultures. Recognising and harnessing diversity can positively link the various sub-cultures. While this is an attractive option and works well in some individual units, it is not easy to achieve at a broad organisational level

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Facilities & Operations Management

cultural factors such as lack of accountability, structural secrecy, cultures that blame and, tellingly, the ‘normalisation of deviance’ –the acceptance of poor quality as normal. AHRQ’s description of a high reliability organisation–safety as a top-level priority, recognition that activities are error prone, blame-free reporting, development of solutions through collaboration and resources directed to safety concerns3–gives further insights into why reliability remains low.

Improving our capacity for quality and safety is not just a matter of going out and setting up new quality systems.

First, there is little evidence that quality interventions as such make a material difference4. While this may reflect the difficulty of demonstrating cause and effect in complex evolving systems, it should give policy-makers a pause before making further large investments. Second, safety culture is a facet of the broader culture, and quality will be best improved by addressing broader cultural issues, in particular, how all participants in the health system, whether clinician, consumer, manager, funding agency or regulator, can collaborate to ensure the right care is delivered reliably in the right way.

Cultural limits to quality and safety improvement

While there are exceptions, health services generally remain organised around professional relationships, resource inputs, external reporting lines and historical arrangements. A discourse centred on effective, integrated, efficiently resourced care does not arise naturally in these conditions.

As Degeling and his colleagues have shown5, the major sub-cultures often have conflicting values about important things. For example, most medical clinicians are deeply sceptical of teamwork (unless they happen to lead the team), while nurses generally see teamwork as essential. Similarly, clinical doctors and nurses see quality as a private professional matter rather than belonging in the public domain while managers see (clinicians’)

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A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment

A positive vision Once the conceptual breakthrough of a positive, as opposed to an antinegative vision, is made, it is relatively a simple task to reorient formal quality improvement. A typical set of positive quality goals, suitable to inform business planning might be: Quality outcomes are recognised as a high level objective Best practice care is delivered Staff have the skills to deliver or support high quality care The organisation is a learning organisation Quality improvement is a valued activity Quality and Safety is integrated into operational systems and methods Policies support quality and safety Explicit care processes are systematically improved Risks are identified, assessed, communicated and managed Consumer expectations and needs are understood and our operational activities are informed There is internal accountability There is external accountability Quality & safety problems are found and understood Adverse events are identified, investigated and prevented There is positive engagement with the broader system

quality as a proper matter for the public record. Clinical doctors and clinical nurses generally reject resource constraints as the basis for an individual care decision, while managers are more willing to base decisions on available resources. The key point is that very powerful groups have polarised views on the very issues that must be dealt with if quality and safety are to be improved, namely, teamwork, quality, evidence and the basis of resource allocation.

This dissonance is not theoretical.

Middle managers, whether clinical or general, are subjected to pressures from above to avoid patient harm, to conserve money and to retain the workforce. They also experience pressure from below to protect their unit from outside pressure and to procure new resources and opportunities. This can create great personal stress and even alienation amongst the

ISSUe - 21 2009

very people whose support is needed to ensure a safe, reliable system. A nurse manager’s comment reported in a recent study of a major hospital is revealing: “. I know a lot of the systems could work a lot better, but they’re playing their little party and they’ve got their little set-up nice so, stepping on toes is not my thing because you know you’re not going to get support further up, so why do it? It’s just too difficult and it’s real shame.” said a Nurse Manager6.

The implications for clinical leaders are profound. Unless middle managers are ‘authorised’ to lead by both the followership and those ‘above’, and unless senior management gives consistent support through difficult times, energy is diverted into survival rather than taking the system forward7. The challenge is to engage and recruit divergent cultures in a common task of improving care.

Facilities & Operations Management

Official strategies aimed at improving quality and safety tend to be couched in what might be called ‘anti-negative’ terms-for example ‘please stop killing / infecting / poisoning / tripping people’. While such approaches play well in senior management and political circles, and indeed close loops on much ‘guilty’ knowledge (falls reduction, anyone?), they tend to be less than inspiring to clinicians, who soon tire of straining against system limits and topdown mandates. While increased vigilance and error trapping can make safety gains, these are tiny compared to the gains from optimised care systems.

The challenge is, therefore, to move from the ‘anti-negative’, to the ‘positive’, from ‘don’t harm’ to ‘let’s do the right thing’. This is more than a rhetorical gesture-to make the transition, it requires a rethinking of who ‘we’ are, what we manage, and how.

Healthcare nearly can be described in terms of processes-a sequence of actions and events that tend to be repeated in similar circumstances. Typical examples are treatment of community acquired pneumonia, an elective surgical admission or normal childbirth. While such processes have a technical dimension, namely what is done in what order, they also have a social and cultural dimensionthe values, expectations and interactions of those involved, whether nurse, doctor, consumer or manager.

It follows that if operations are based on care processes, the various sub-cultures can be linked because it is clear who is involved, in what capacity, using what resources, to what effect, with what variation. Furthermore, a process-based system promotes organisation around the care produced rather than history, profession and resource inputs. Even more fundamentally, the values around which the system is built resonate with those involved: quality discourse can move from a post hoc source of guilt to a prospective responsibility, from ‘what went wrong’, to ‘what must we do right’. This re-orientation is more

than sleight of hand. As Quinn points out8, purpose-centred thinking-that is, what must be done to achieve the desired result-can greatly enhance leadership.

A goal of quality and safety

While it is simple to state, ‘quality and safety are our highest goal’, as Marais points out, there is usually conflict between safety and performance goals, and in practice, a choice must be made between optimising performance and optimising safety9. Furthermore, a wide range of external factors affect that choice as also internal influences, ranging from overt politics to mandated targets to the personal ambition of decision makers.

In health services, there are interesting and complex ethical issues surrounding such choices. First, while the careers and reputations of decision makers may be at risk, the lives that are most affected are not usually involved in the discussion, at least at a policy level. Second, at a societal level, the tensions between access to services, quality and funding usually remain undiscussed: unrealistic expectations abound, and quality / performance trade-offs remain implicit. Third, in the absence of a societal consensus and overt policy, the burden of decision-making is typically passed down to clinicians and patients, whose marginal resource decisions are constrained by a system that neither the clinician nor patient feels able to influence.

As Marais points out, the challenge is not to proclaim one goal to the exclusion of others, but to assess the risks and to know how much risk is acceptable.

A simple example from my own organisation is our approach to improving inpatient nutrition. Earlier in-house

A u t h o r

Harnessing diversity - The centrality of process

research had shown avoidable problems with inpatient nutrition, with a significant impact on vulnerable patients. The typical approach in the past has been the ‘anti-negative’-one of developing a set of detailed policies and procedures designed to avoid the problem (in this case, malnutrition), with the hope that the staff would have the time, inclination and resources to follow.

The positive approach is subtly, but crucially different. Rather than being a set of error-trapping procedures, the policy comprises a set of positive evidence-based standards, developed in consultation with consumers, clinicians, food service providers, managers and funders. Each standard is a positive statement, such as ‘the ward environment will be conducive to eating’, with a set of subsidiary statements. Of course, extensive subsystems are now being developed (e.g. risk screening) but once again these are couched in terms of positives, rather than negatives.

The approach does not ‘wish away’ constraints on achievement, such as resources. Rather, it allows them to be effectively risk managed. If, for example, a ‘standard’ in the nutrition policy cannot be met, then the risk, which is now known as opposed to be buried, can be formally and accountably managed by acceptance, elimination or control.

Conclusion

Quality, Safety and Improvement requires a supportive culture, but we must get started. We can start with the culture we have to create the one we want. This requires an understanding of our cultures and a practical way to engage them in a positive vision of where we need to be.

Philip Hoyle is a Director of Clinical Governance for Northern Sydney & Central Coast Area Health Service. Responsibilities within that role include quality, safety, risk management, policy systems and accreditation, as well as executive responsibility for research and disaster management. Philip’s obsession is the prospective design of health systems, so that clinical staff, consumers, managers and funders can combine to ensure the right care is delivered, first time.

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