Healthcare Management Medical Sciences Diagnostics Information Technology Surgical Speciality

Issue 17 2008 £12 €18 $25 Rs.300 www.asianhhm.com

In association with

Advanced Colorectal Cancer Care Pathways Devices for the Failing Heart
Improving the survival rate The basics The future is here
w w w. a s i a n h h m . c o m 
w w w. a s i a n h h m . c o m 

The adaptation continues
For healthcare providers it is important to remember
that globalisation is here to stay.
T
he global market place continues to be a
test for healthcare providers. The technology
boom, combined with trends such as rising
costs, shortage of healthcare professionals, growing
consumerism and a greater than ever focus on patient
safety have meant that providers are in a seemingly
endless cycle of adaptation.
Like in other industries, globalisation brought with
it opportunities and challenges for healthcare. The
opportunity came in the form of a global market place
to tap into, and the challenge involved reaching standards
acceptable at the global level. As simple as it sounds,
this has been anything but easy. In other words, the
global opportunity came with global competition—and
a need for level playing field.
However, if the disparities that exist in global
healthcare are anything to go by, globalisation of
healthcare has a long way to go before it achieves
its goal of healthcare for all. This is especially true for
countries like India that are essentially playing catch-up
with their western counterparts. While they have done
a good job of attracting foreign patients to its shores,
Indian hospitals and government face the challenge
of bringing healthcare to the remote and poor parts
of the country.
The developed countries have their own set of
worries. Ever changing technology, while enabling better
care, has also resulted in growing operating costs. The
Internet has made huge amounts of information to the
Foreword
consumers, thereby making them aware of their options
and more demanding of quality services. They are also
more global in their outlook and don’t mind travelling a
few thousand miles for getting similar—if not better—care
at considerably lower costs.
Standardising exchange of information across the
globe is the need of the hour. The existing standards
present varying levels of complexity depending on which
part of the world you come from. Interoperability at a
global level may not be easy to achieve, but without it
a truly global healthcare may never take shape.
The blurring international borders are a boon for
the consumer and a challenge for the governments and
healthcare providers around the world. In this issue's
cover story we presnt these and other challenges facing
the world of healthcare.
Whether globalisation should be blamed for
complicating the healthcare scenario or credited with
standardisation of various elements of healthcare is
debatable, but the truth that remains is this: it is here
to say and in the years to come will continue to present
challenges and opportunities for care providers around
the world.
Akhil Tandulwadikar
Editor
w w w. a s i a n h h m . c o m 
 50
Basri JJ Abdullah, Professor
Ranjit Kaur, Lecturer
Department of Biomedical Imaging,
Faculty of Medicine University of Malaya,
Malaysia

Management Medical Tourism in India 26

Seeking a differentiator
Vandana Wadhawan, Member, Editorial Team
Global Health Tourism with 06 Asian Hospital & Healthcare Management
Qualified Rehabilitation
Sangita Reddy, Executive Director
Hartmut Hain, CEO Apollo Hospitals Group, India
Jasmin Porter, Key Account Manager
Ganesh Subramaniam, Co-Promoter
Medical Park AG, Germany AyurVAID Hospitals, India

Care Pathways 09 MEDICAL SCIENCES

The basics
Ricard Rosique, Senior Consultant, Diomedes and
Head, Medical Department, B. Braun Group, Spain Heart Failure 29
Care Pathway for Total Hip Replacement 14
Management
Monitoring with
An innovative approach implantable devices
Yosef D Dlugacz, Senior Vice President and
Michael Gold, Professor
Chief, Clinical Quality Education and Research
Medical University of South Carolina, USA
Carolyn Sweetapple, Vice President for Finance and Business Operations
Yong Cho, Tom Bennett, Douglas Hettrick
Krasnoff Quality Management Institute, USA Medtronic Inc. USA

Treatment of Stroke 34
Acting on the symptoms
Managing End-of-Life 18
Caroline Watkins, Proffessor
Services
Stroke and Older People's Care
Experience from England
Michael Leathley, Senior Research Fellow
Candy Cooley, Manager
National Genetics Education and Development Stephanie Jones, Research Fellow
Centre, England Clinical Practice Research Unit,
Department of Nursing,
University of Central Lancashire, UK

Medical Tourism 22 Advanced Colorectal Cancer 36

Role of telemedicine Improving the survival rate
Suman Bhusan Bhattacharyya, Vice-President (Clinical Services) Graeme Poston, Surgeon
Karishma Software Limited Vivek Upasani, Specialist Registrar
Secretary, IAMI, India Aintree University Hospital, UK

 Asian Hospital & Healthcare Management ISSUE - 17 2008

 Contents
surgical speciality Nano-Healthcare 68
Biotechnology & biomedical
Transection of the Liver 41 perspective of disruptive potential
Overview of techniques Abhishek Dutta
Alun Jones, Specialty Registrar Senior Research Analyst, Technical Insights, Frost & Sullivan, Singapore
Marv Rees, Surgeon
Department of Hepatobiliary Surgery, Basingstoke and North Hampshire facilities & operations
Hospital, NHS Foundation Trust, UK
management

Treatment of Gastric 44 Patient Safety and 72

Cancer Risk Management
Role of radiotherapy A look at the basics
Marcel Verheij, Professor and Chair
Department of Radiation, Oncology
The Netherlands Cancer Institute, Sarah Williamson, Consultant
The Netherlands Patient Safety and Risk Management, SalSafe, UK

Improving Reliability 75
for Safer Care
Trends in Surgery of Kidney Tumors 47 A proactive approach
Shift to less invasive and Peter Lachman, Consultant Paediatrician
nephron-sparing techniques Great Ormond Street Hospital for Children NHS Trust, UK
Milan Hora, Head, Department of Urology
Charles University Hospital Plzeň, Czech Republic State of Sustainable 78
Design in Healthcare
A commentary
diagnostics Robin Guenther, Architect
Echocardiography 55 Douglas D Pierce, Architect
New and evolving roles Perkins+Will, USA
Michael H Picard, Director, Echocardiography
Massachusetts General Hospital, USA

Diagnostics for the Developing World 69 information technology

Challenges and constraints
Natarajan Sriram, Director, Tulip Group, Orchid Biomedical Systems, India
Asian Diagnostics Market 62
Emerging opportunities
Suresh Vazirani, Chairman & Managing Director
Transasia Bio-Medicals Ltd., India
technology, equipment & devices
Devices for the 64
Failing Heart
The future is here
Diego Delgado, Professor
Division of Cardiology and Transplantation
University Health Network, Canada
Understanding SOA 84
Caring about IT architecture
Ken Rubin, Healthcare Architect
Martin Holzworth, Enterprise Architect
EDS, USA
Telehealth in Asia 90
Healthcare for the
communities
Gabe Rijpma
Health and Social Services Industry Director
Public Sector Group
Microsoft Asia Pacific, Singapore
Leveraging Authentic Health Information 93
Key to patient empowerment
Amir Hannan
Lead, Information Management & Technology, Tameside & Glossop Primary
Care Trust, Primary Care Lead North West Strategic Health Authority, UK

w w w. a s i a n h h m . c o m 

 Asian Hospital & Healthcare Management
Issue 17 2008
Editors : Akhil Tandulwadikar
Prasanthi Potluri
Editorial Team : Sridevi Prekke
Vandana Wadhawan
Consulting Editor : P Sudhir
Language Editor : G Srinivas Reddy
Art Director : M A Hannan
Visualiser : Sk Mastan Sharief
Graphic Designers : K Ravi Kanth
Ayodhya Pendem
Copy Editor : Omer Ahmed Siddiqui
Prity Jaiswal
Production : Suresh Giriraj
Sales Manager : Rajkiran Boda
Sales Associates : Sylas Makam
Murali Manohar
J B Narsing Rao
Savitha Devi
Compliance : P Bhavani Prasad
CRM : Yahiya Sultan
Vijay Kumar Gaddem
Subscriptions Head : Sasidhar Kasina
IT Team : Ifthakhar Mohammed
Azeemuddin Mohammed
Sankar Kodali
Thirupathi Botla
N Saritha
Advisory Board
John E Adler, Professor, Neurosurgery and Director Radiosurgery and
Stereotactic Suregery, Stanford University School of Medicine,USA
Sandy Lutz, Director, PricewaterhouseCoopers, Health Reseach Institute, USA
Malcom J Underwood, Chief, Division of Cardiothoracic Surgery, Department of
Surgery, The Chinees University of Hong Kong, Prince of Wales Hospital, Hong Kong
Peter Gross, Charman, Internal Medicine, Hackensack University Medical Center, USA
Pradeep Chowbey, Chairman, Minimal Access, Metabolic and Bariatric Surgery
Centre, Sir Ganga Ram Hospital, New Delhi, India
Vivek Desai, Managing Director, HOSMAC INDIA PVT. LTD., Maharastra, India
Asian Hospital & Healthcare Management
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ISSUE - 17 2008
w w w. a s i a n h h m . c o m 
 The international health tourism
has increased in the last few
years. Rehabilitation can play
a significant role in improving
healthcare tourism prospects.
German experience in providing
rehabilitation services illustrates
the huge potential this sector
holds in developing
health tourism.

Global Health Tourism with

Qualified Rehabilitation

Hartmut Hain
CEO
Jasmin Porter
Key Account Manager
Medical Park AG, Germany

R
ehabilitation refers to the most
comprehensive restoration of
health and abilities, following
sickness, accident or injury in a clinic that
has been especially conceived, qualified
and assessed for the rehabilitation.
In Germany, prevention and reha-
bilitation have been regular features of
a modern and overall medicine. With
their vast experience in healthcare sector
and in managing the multitude of quali-
fied hospitals / clinics and because of
great socio-political support they enjoy,
Rehabilition-Clinics (medical park) offer
high quality services in constitutional and
rehabilitative measures.

 Asian Hospital & Healthcare Management ISSUE - 17 2008


In Germany, rehabilitation after an
illness, an operation or an injury is an
inherent part of the treatment. However,
in most countries of the world, such a
complex treatment after operations, inju-
ries or accidents fine-tuned to the patients’
needs is not available. There are two kinds
of rehabilitation: inpatient and outpatient
treatment. The most common type is the
inpatient rehabilitation.
Whether after a stroke, an accident,
a heart attack or a hip or knee replace-
ment—there are several medical proce-
dures that need a systematic and compre-
hensive rehabilitation. Rehabilitation in
Germany is an inherent part of the chain
of treatment and guarantees for the ideal
maintenance.
Scientific studies have clearly shown
that inpatient rehabilitation—a stay in
so-called rehabilitation clinics for several
weeks—almost always has positive effect
on the health of the patient. In other
words, without rehabilitation lasting
damage often remains because patient
is often unable to train his skeletal muscle
system as thoroughly as he could. A merely
outpatient-based therapy is often insuf-
ficiently tuned to the individual diagnosis,
especially if the patient is not following a
individual therapy plan and is only look-
ing for sporadic training or massages.
The patient needs to learn how to
handle his disease and his responses to
specific conditions so that further acute
medical conditions are prevented and
chronic disorders are controlled as far
as possible.
Further, the patient should also be
aware of his daily activities that need
to be performed for the restoration of
health based on his recent medical condi-
tion. This forms a basis for his complete
rehabilitation and healthcare.
Medical tourism in Germany
Historically, patients travelled to Germany
for medical treatment. Russian patients
knew several cities like Berlin or Baden-
Baden from the tourist or political point of
view. They knew about the quality of the
treatment. In past, international patients
H ealthcare management
German medical pathways
1. Consultation at the physician’s office;
2. Operation at a specialised hospital (stay in hospital for about 4 to 12 days, depending
on indication)
3. Inpatient rehabilitation for at least three weeks (depending on indication); and
4. Control of operation / treatment at hospital or physician’s office. All the involved
parties correspond with each other to maintain the status quo.
came to know about Rehabilitation Clinics contact point for medical treatment of
in Germany through their acquaintances international patients. So, the interest for
in Germany or somebody who had studied the German hospitals in this field went
in a German university. higher and the pressure on the political
But it took quite a while for most of level rose.
the hospitals to recognise that there is a Bavaria was the first German federal
potential in this field. There are different state to invest in large advertisement
kinds of patients: so called self-payers, programmes to attract international
people who are sent by their home country patients. The Bavarian ministries, with
and those for whom the treatment is paid its headquarters in Munich, published
by a health ministry or some other sponsor brochures in different languages (English,
and health insured patients. About ten Russian, Arabic, Turkish and much more),
years ago, the first agent showed up in the showed the public benefit during their
German market and initiated marketing international political appointments with
of German hospitals in foreign countries. foreign countries and started sponsoring
The focus was on self-paying patients. It programmes for Bavarian hospitals and
was difficult for the agents because most medical companies to get them to attend
of the German hospitals never needed international exhibitions. Success came
marketing to receive patients. and other German federal states followed.
German hospitals received their local Until today, Bavaria is still the number
patients through physician’s office, either one choice for the patients seeking medi-
by self-hospitalisation or, by emergency cal treatment.
medical services in case of an accident. So,
the German hospitals were very doubtful Risks and opportunities
about spending money on marketing and There are risks and challenges involved in
also did not have the budget. On the the treatment of international patients:
other hand, the hospitals in Germany different mentalities, religions, nutrition
could see how more and more patients habits, barrier of language. Further, the
from Arabic countries were advised to patients have to lay their lives in the
come to Germany for medical treatment hands of someone they have never seen
after September 11 by their sponsors or before, and in a country they haven’t been
the health ministries. Since last 20 years to. They need to trust people without
and more, the US and UK were the first the chance to build up mutual trust
w w w. a s i a n h h m . c o m 
H ealthcare management
in advance. Every hospital or clinic world-
wide has to look into this subject, get
prepared and establish necessary stand-
ards / procedures to be followed in the
treatment of international patients. For
example, it is essential to make a profes-
sional native language speaker or trans-
lator available to the patient during his
examinations and therapies. Further, the
hospitals need to advise the patients on
all aspects starting from hospitalisation
to routine problems.
Experiences have shown that some
patients sponsored for treatment by health
ministries or insurance agencies often
exploit the sponsorers. For instance, a
patient has the approval from his sponsors
to get operated, maybe for a hip replace-
ment. It happened that the patients took a
chance and asked for more medical treat-
ment, like whole check-up programme,
examination of eyes, dental work and so
on. This results in rise of costs and can
end up in refusal of payment from the
10 Asian Hospital & Healthcare Management
particular sponsor. So, it is very important world is getting global and by welcoming
to clarify all the points of treatment in international patients, there is opportu-
advance; and it is even better to inform nity for each side to study the different
the sponsers about the approximate costs mentalities, learn much more about people
to the sponsor and get his approval for and their countries at social levels and to
all the possibilities before the treatment get and stay open-minded about people,
starts. These efforts ensure that there is no matter where they come from.
clarity among all the involved parties. In Bavaria, the basis for all this is
There is a huge scope for the growth of provided and everything is done to keep
medical tourism. The countries around the it this way. The hospitals and clinics are
world have the opportunity to prove their prepared to welcome anyone to help them
quality in healthcare and treatment. The stay healthy.
Hartmut Hain has vast experience in the field of rehabilitation as
well as medicine. Before he took up his role as CEO of Medical Park,
A uthors
Hain was on the board of managers of the Rhön-Klinikum AG. He
studied hospital and social management and is presently respon-
sible for strategy, quality management, corporate communication,
marketing and sales at Medical Park AG
Jasmin Porter has been working with Medical Park since 2004 as
Key Account Manager for both national and international divisions.
Earlier, she worked with the first German professional international
health tourism organisation.
ISSUE - 17 2008
 H ealthcare management

Care Pathways
The basics
Care pathways are considered to be one of the best tools hospitals can use to manage the
quality in healthcare concerning the standardisation of care processes, since they promote
organised and efficient patient care based on evidence. It has been proven that their
implementation reduces the variability in clinical practice and improves outcomes.

The care pathway concept appeared
Ricard Rosique for the first time in 1985 inspired by
Senior Consultant, Diomedes and Karen Zander and Kathleen Bower at the
Head, Medical Department
B. Braun Group, Spain
New England Medical Center in Boston
(Massachusetts, USA). Care pathways
are usually represented as a Gantt chart
(Figure 1).
the purpose of pathways is the enhance-
ment of care processes in three areas:
quality, safety and efficiency.
Care pathways are a powerful tool
for care process management, since
they permit to check the compliance
of all the interventions included in the

C
are pathways are also known as So far, different systematisation tools healthcare plan, fix care standards and
Clinical or Critical pathways. A were being used for clinical processes. introduce clinical audits as a part of the
care pathway is a multidiscipli- The oldest and most known are medical process. Likewise, pathways are very
nary healthcare management tool based and nursing protocols. Over the last years useful to identify improvement areas
on healthcare plans for a specific group of other tools were introduced, such as clini- in these standardised care processes,
patients with a predictable clinical course, cal practice guidelines and standardised under the umbrella of the culture of
in which the different tasks or inter- nursing care maps. Care pathways are Continuous Quality Improvement
ventions by the professionals involved care protocols that embrace all of these (CQI).
in the patient care (physicians, nurses, tools (Figure 2). The development and implementation
pharmacists, physical therapists, social The main goal of care pathways is of a care pathway involves a change in
workers etc.) are defined, optimised and based on the improvement of the follow- the organisational culture at any setting.
sequenced either by hour (ED) or day ing areas: quality in healthcare, coordina- This process may involve overcoming of
(acute care). Outcomes are tied to specific tion / cooperation among professionals, some hurdles in its way of implementa-
interventions. efficiency and patient satisfaction. Thus, tion. Following are some of the activities
to be done to develop and implement
a care pathway:
Gantt chart
• Preparing multidisciplinary docu-
Chronology / Location ments
• Reviewing the process by all the
Day 0 / Admission Day 1 / Ward Day 2 / Ward
concerned staff
Consults • Holding care pathway meetings to
Tests facilitate the exchange of opinions
Assessment about patient care by different profes-
Groups of Meds sionals
Multidisciplinary • Conducting periodic reviews to
Nutrition
activities monitor some defined indicators
Activity
• Analysing variances or deviations
Patient Information • Preparing common record documents
Expected Outcomes for all the staff
Figure 1

w w w. a s i a n h h m . c o m 11
H ealthcare management
Some barriers in developing and
implementing a pathway are identi-
fied: the heterogeneity of patients and
diagnosis, the common reluctance
among organisations and profession-
als to change. These barriers must
be considered by hospital managers
since they may threaten a successful
implementation of care pathways.
Methodology
The methodology of any project for care
pathways implementation is divided in
four phases: selection, development,
implementation and evaluation. In this
article all the steps will be comprehen-
sively explained and some key points will
be clarified in each one of these phases
in order to help anyone who may be
involved in such projects.
Selection
This is a phase in which the consensus is
reached on care procedure to be followed
in care pathway. Pathways should be
designed for frequent and important
(high risk / high cost) care procedures
with an expected clinical course.
What should be the selection crite-
ria? In order to standardise the process,
following recommendations need to be
considered:
• Multidisciplinary implementation
• Non-explained variability
• Outcomes far from standard
• Motivation by professionals to work
on a specific condition
• Evidence-based Medicine, recommen-
dations of good professional practices
and professional references
• Possibility to reach a professional
agreement at the hospital
At the start of the project, there are
some tips to be kept in mind in order
to build strong basis to prepare a good
project. First of all, you need commit-
ment and leadership from top managers
(CEO, Medical and Nursing Managers)
and a good communication from top
to bottom This apart, project planning
(please do not forget project management
tools) and adequate resources (staff, time
and material), which means a planned
12 Asian Hospital & Healthcare Management
Scope of clinical pathways
Clinical Pathways
Medical Protocals
Nursing Protocols
Systematisation tools for clinical processes
financial investment, are required for
the success of the project. Concerning
the hospital staff, you should trans-
fer the ownership of care pathways to
them and give them good training and
education right from the beginning.
Above all, do not forget the economic
incentives for staff to start a new organi-
sational culture.
When all the key points for success
(vision, skill, incentives, resources and
an action plan) are assured, one is very
likely to get the key for changing the
organisational culture (Figure 3). If not,
this could result either in confusion,
anxiety, frustration or a false start.
Development
This is the phase in which the care path-
way is designed and the consensus is
reached. The goals of this phase are the
constitution of a multidisciplinary team
as a ‘Care Pathway Committee’ (with
motivation and ability of agreement)
and the design of all the documents for
a specific care pathway.
Requirements for developing a care
pathway
1. Formation of the Care Pathway
Committee by the Project
Committee
2. Initial risk assessment by hospital
managers
3. Examine the previous clinical audit
of the process with retrospective data
collected form medical histories
4. Evaluation of existing evidence and
Key points for success
Vision Skill Incentives ResouRces
ISSUE - 17 2008
StandardisedCare Maps
Clinical practice guidelines
Figure 2
external practices (considering clinical
practice guidelines)
5. Definition of the starting and ending
point
6. Define objectives for each care path-
way
7. Description of inclusion and exclusion
criteria
8. Agenda of meetings with the Care
Pathway Committee
The formation of the care pathway
multidisciplinary teamwork (‘Care
Pathway Committee’) is essential and
the members should be very involved
with the care pathway development. It is
important to stress the need of consensus
meetings. Professionals of the multidis-
ciplinary team should reach agreements
through the critical analysis of the differ-
ent activities of the care process and the
improvements to be introduced.
Implementation
This is the phase in which pathway is
implemented. The procedures required
for a right implementation are as
follows:
1. Final approval to the pathway matrix
and the rest of accompanying docu-
mentation by the multidisciplinary
team
2. Approval by medical and nursing
managers
3. Education and training for all the rest
of professionals involved in the care
pathway who did not participate in
the Care Pathway Committee
Action Plan Change
Figure 3
w w w. a s i a n h h m . c o m 13
H ealthcare management
Pathways vs ePathways
Pathways
4. Development of the ‘Implementation
Plan’:
a. Decision of the start date for the
care pathway new documents
b. Availability of the new record
documentation
c. Appointment of a responsible
person for each care pathway
d.New pre-implementation risk
assessment
e. Internal communication
f. Training and education
5. Initial testing phase (usually two
months is sufficient)
6. Review of the new documentation
after this pilot phase
7. Official start of the care pathway
implementation after this first review
of the documentation
Although until now most care
pathways at hospitals worldwide are
managed on paper, the introduction
of electronic pathways (‘ePathways’) at
some hospitals has opened a new field
for the improvement of care processes
management. EIRA© is the software
for care pathways management that is
currently being used at two Spanish
hospitals. Electronic pathways are the
driving force to succeed in the imple-
mentation of care pathways.
And now let’s look at some lessons
learnt during our projects for success-
fully implementing care pathways.
The new record documents should be
adapted to the existing ones in order to
avoid too many changes for the staff,
14 Asian Hospital & Healthcare Management
ePathways
Figure 4
and always avoiding the duplication
of any medical or nursing recording.
In case of electronic Pathways, this
specific software must be integrated
with the common hospital informa-
tion system.
Hospital top managers (CEO, medi-
cal and nursing managers) should ensure
that each of these care pathways project
is included in the hospital strategy plan-
ning and demonstrate their leadership
from the beginning to the end. I always
suggest them to attend the first care
pathway committee meetings to show
their personal commitment and inter-
est in the project. At the same time,
managers should promote the clini-
cian management of care pathways to
enhance the commitment of clinicians
with pathways from the start.
Of course, there should be a hospital
coordinator for managing all the care
pathways implemented in the hospital.
The coordinator should be a dedicated
person having relevant experience of
coordinating care pathways, and should
posses leadership and communication
skills. And he should be able to use
a project management software (i.e.
Microsoft Project), defining milestones
and resources for each project phase.
Together with the hospital managers, the
care pathways coordinator must plan a
strategy for communication, education
and training.
A usual question is what to do
with process management projects.
ISSUE - 17 2008
Does process management interfere
with care pathways projects? Must
they start before or after care pathway
projects? Process management means the
upper dimension in the management of
hospital processes. From my point-
of-view, it’s more convenient to first
define the core processes of the hospital
with the respective process maps. If
not, bottlenecks would be created
when designing care pathways for
concrete care processes and it could
be already too late to solve them.
‘Evidence-based care pathways’ is
the ambitious term used for any care
pathway, but in fact you do not always
find evidence for any procedure.
Therefore we must search the best
practice as a reference to design a care
pathway.
In healthcare literature one can find
some articles about how to measure
the quality of a care pathway. One
of the best tools recommended is the
Integrated Care Pathway Assessment
Tool (ICPAT). Developed by Claire
Whittle (University of Birmingham,
England, UK) and sponsored by the
Strategic Health Authority of West
Midlands (England, UK), it is a very
practical questionnaire that allows you
to evaluate the process of design, devel-
opment, implementation and follow-up
of care pathways.
A matter to be considered in the
future is the involvement of patients in
the process of designing care pathways.
Since the main goal is enhancing their
satisfaction during the care process, I
think that we should face the patient
needs together with the goals of the
different professionals caring patients.
The way to do it is an unknown factor,
considering the problems sometimes to
reach the consensus among the staff.
Evaluation / Follow-up
In this phase, the care pathway should
be controlled, analysed and updated.
Pathways are dynamic tools to be peri-
odically reviewed and adapted, not
documents to be left in the drawer.
 H ealthcare management

Follow-up report for vaginal delivery pathway

Indicator formula Outcome %

Number of cases with CP delivery
Coverage X 100 100
Number of cases with complete record
Number of cases with complete record
Record follow-up X 100 See the record follow-up
Number of cases with CP delivery

Mean of US performed Number of US performed

X 100 3.10
pre-delivery Number of cases with CP delivery
Number of NST pre-delevery
Mean of NST pre-delivery X 100 2.60
Number of cases with CP delivery

Record of the doctor who Number of cases with record of the doctor who decides inclusion
X 100 12.50
decides inclusion in CP Number of cases with CP delivery

Epidural catheter withdrawal Number of cases with record of catheter withdrawal 6h post-delevery
X 100 67.31
at six hours post-delivery Number of cases with CP delivery

Fluids tolerance starts Number of cases with record of fluids tolerajce start 4h post-delevery
X 100 87.50
four hours post-delevery Number of cases with CP delivery
Figure 5

In this last phase, the first activ-
ity should be the appointment of a
responsible person for the care pathway
follow-up. Who is suited for the job,
a doctor or a nurse? Involvement of
professionals from both medical and
nursing fields are recommended in
order to not discontinue the pathway
compliance by all concerned physicians
and nurses.
The next steps should be:
1. Establish dates for periodic reviews
(recommended the first review after 6
months post-official implementation
and then every 12 months)
2. A systematic and ongoing audit
3. Follow-up of the completion of the
new record documentation (very
useful in the first 12 months as a
reminder for all the professionals)
4. Monitoring of variances with a fixed
periodicity
5. A ssessment and evaluation of the
7. Feedback to managers and staff
regarding the follow-up of indicators
/ outcomes and variances (essential to
incentive staff to continue working
on care pathways)
Updating the care pathway and
documentation of its records is manda-
tory and should be done based on the
publication of new scientific evidence,
the information collected about the most
frequent variances and considering the
achieved objectives.
Regarding the analysis and evaluation
of the care pathway, one of the most
specific features of this methodology is
the ‘variance report’—the information
gathered from the analysis of the vari-
ance sheets. Variances (or deviations)
may include activities that were carried
out but not defined in the care pathway
and activities defined in the care path-
A uthor
way but not carried out and medical
complications. Different reasons may
cause variances: patient and / or family,
staff and organisation.
Another essential document for
the evaluation of care pathways is the
‘follow-up report’, which includes the
follow-up of the completion of the new
record documentation, the variance
report, as well as the assessment of the
outcomes through the predefined indi-
cators, which are related to the agreed
objectives of the pathway. You can see
an extract of a follow-up report from the
vaginal delivery pathway in figure 5.
In conclusion, the methodology
applied to care pathways projects is based
on the continuous quality improve-
ment (CQI), the P-D-C-A Cycle by
Deming—Plan, Do, Check, Act. And
start again.

outcomes from the information Ricard Rosique is Senior Consultant at Diomedes and Head of
recorded in the care pathway docu- Medical Department of B. Braun Group, Spain. He has contributed in
mentation developing methodology for the development of 120 Care Pathways
(both surgical and medical pathways) in different Spanish hospitals.
6. A nalysis of the impact of the care He shared his project experience at various conferences, seminars,
pathway implementation on the care congresses and courses in Spain, the UK, France and Portugal.
process

w w w. a s i a n h h m . c o m 15
H ealthcare management

Care Pathway for

Total Hip Replacement
An innovative approach

Using clinical pathways to standardise care across the continuum—from the physicians’
office to the O.R., recovery post operation—improves communication among the care-giving
team. The pathways are also a tool to educate and involve patients in their care, as they
identify variation from expected outcomes and goals. Pathways improve the delivery of care
to patients through encouraging early ambulation for those patients who undergo total hip
replacement surgery while increasing clinical and organisational efficiency and revenue.

consumer information have been inter-
Yosef D Dlugacz preted by some clinicians as an infringe-
Senior Vice President and ment on their autonomy. Healthcare
Chief, Clinical Quality Education and
Research
organisations need to develop processes to
Carolyn Sweetapple bridge the physicians’ need for independ-
Vice President for Finance and Business ence and the government’s and public’s
Operations pressure to deliver improved care. One
Krasnoff Quality Management Institute of the most successful ways to build this
USA
bridge is through involving physicians in
creating and implementing a valid and
reliable methodology for communication
resolve the conflict and promote trust
between the healthcare organisation and
the clinical staff.
Ensuring continuum of care
To improve the delivery of care for
patients who required total hip replace-
ment, a partnership was established
among a quality management method-
ologist, a nurse who understands clinical
operations and an orthopaedic surgeon.

N
ew advances in promoting
patient safety, such as requir-
ing physicians to comply with
evidence-based medicine, pay-for-
performance initiatives supported by
the government and transparency for
about and accountability for evidence-
based care. Clinical pathways, which are
algorithms for care based on evidence
that detail specific interventions and
expected outcomes along a timeline, is
such a method and successfully help to
The goal was to enable the surgeon to
operate on as many patients as possi-
ble while maintaining excellent clinical
excellent results. Because this increasingly
popular surgery is performed to improve
quality of life and pain-free mobility,

The Krauss1 Method

Pre-surgical
Office Surgery Post-op care Rehab Office
Evaluation

TJR Physiatrist Medical

PST Acute Subacute Home
Class consult Clearance

1Eugene S. Krauss, M.D. Director of Department of Orthopedics, Director of Orthopedic & Rehabilitation Institute,
Chief of Total Joint Replacement Program, Glen Cove Hospital and Southside Hospital of the North Shore-LIJ Health System
Copyright©2008, Krasnoff Quality Management Institute

Figure 1

16 Asian Hospital & Healthcare Management ISSUE - 17 2008

w w w. a s i a n h h m . c o m 17
H ealthcare management

they perceive them as a nursing tool

rather than a detailed method to coor-
dinate and monitor the delivery of care.
This surgeon recognised the benefit of
following the pathway.
The goal of the innovative
programme was to focus attention
on appropriate patient management.
Appropriate management includes
processes that reduce length of stay,
unplanned returns to the operating
You may receive antibiotics through your intravenous line (I.V) and you may receive room, unplanned return to the hospi-
Medications medication to prevent blood clots. Your pain medication will be based on your needs, tal, surgical wound infection rates,
how it is given will be ordered by your doctor. avoidance of blood clots and results
in high patient satisfaction and level of
Your dier will be ordered by your doctor. A Registered Dietician is available to speak functioning. The team—from surgeon
DIET
to you about your diet needs.
through physiatrist—is educated and
trained in the same way. The patient
Your activity will be ordered by your doctor and will be increased as tolerated.
Activity You will be instructed not to cross your legs, to prevent dislocating your new hip. and family attend multidisciplinary
You will be seen by a Physical Therapist and participate in therapy. educational sessions where they learn
what to expect as regards mobility and
pain management and meet with the
team. Operating rooms and surgical
trays are set up the same way. Pre- and
postoperative care is managed in the
same way. All patients are placed under
a dedicated surgical unit.
Patient-friendly clinical pathways
were developed, which inform patients
regarding what to expect from the
Copyright©2008, Krasnoff Quality Management Institute Figure 2 surgery and recovery in lay language
(Figure 2). Using these pathways to
treatment must be more comprehensive among the care-giving team, the collabo- educate patients about the details of
than the surgical procedure itself and rative initiative focussed on mapping the their episode of hospitalisation and
must include the entire continuum of process of care from the physician’s office post-surgical care, helped them to
care, from the pre-surgical physician to the operating room to recovery and become active participants in their own
office visit to effective postoperative rehabilitation (Figure 1). The ‘mapping’ healthcare. The pathways also help to
rehabilitation. Technological advances was done in a multidisciplinary group reduce patient anxiety by effectively
have provided procedures and materials of healthcare providers involved in the communicating information about
that can result in excellent outcomes for care. pain management, the importance of
patients. In addition, these surgeries are A clinical pathway was developed nutrition and mobility and expectations
among the most lucrative for hospitals. that would permit the entire team to for recovery.
Therefore, healthcare organisations that be on the ‘same page’. Expectations By standardising every aspect of
strive to deliver excellent and efficient were established for daily therapeutic the delivery of care, outcomes are
care, protecting patient safety while interventions and appropriate outcomes. predictable. Moreover, any variation
managing resources and costs benefit The orthopaedic surgeon, with a back- from expected outcomes is immediately
from improving the management of ground in engineering, demanded that documented on the pathway and there-
joint replacement surgeries. each member of his team follow the fore quickly recognised and addressed.
detailed algorithm of care with the goal Noting variation in real time helps the
Developing a clinical pathway of standardising the process of care. It staff focus on patient needs and real-time
To maximise efficiency and standard- should be noted that many physicians evaluation becomes integral to the care
ise the effective transfer of information avoid using clinical pathways because process. Physicians and nurses have an

18 Asian Hospital & Healthcare Management ISSUE - 17 2008


explicit focus for communicating about
the patient’s progress and treatment.
Delivering efficient healthcare
The team is trained to work together.
Every member of the team gets to know
each patient. Each member of the team
assesses the patient before surgery; every
member of the team is involved in post-
operative care. Anaesthesia manages
postoperative pain; physical therapy
begins the first day after surgery, the
physiatrist manages postoperative reha-
bilitation exercise and a case manager
sets up discharge planning. Importantly,
each member knows not only his or her
own responsibility but understands the
responsibility of the other team members
as well (Figure 3).
Compliance with the key interven-
tions of the care pathway for total hip
replacement surgery, for instance, is
100 per cent. Therefore, each patient
who has undergone a physical therapy
evaluation, is moved from the bed to
a chair in a specified time frame, has
appropriate pain management, receives
anticoagulants and antibiotics prior to
surgery, and discontinues antibiotics
24 hours after the end of surgery as
the pathway specifies. These standard-
ised interventions lead to predictable
outcomes. For example, 100 per cent
of patients tolerate getting out of bed
to a chair and express an understanding
of their pain management. Of course,
not every outcome can be predicted, but
most patients (over 90 per cent) have
laboratory values within a therapeutic
range and almost all patients (97 per
cent) have incisions without redness,
swelling or drainage. The ongoing
monitoring by the surgeon reinforces
appropriate behaviour of the team.
The standardisation and predict-
ability of the delivery of care has an
impact on the organisational efficiency
and financial integrity of the hospital.
Operating rooms are booked and used
productively. Materials, staff and supplies
are efficiently allocated. Throughput,
from the operating room to the
H ealthcare management
Execution tactics team approach
Pre-surgical Post-op
Office Surgery Rehab Office
Evaluation care
Surgeon
Physician Extender
Nurse Educator
Anaesthesiologist
Primary Care Physician
Physiatrist
Copyright©2008, Krasnoff Quality Management Institute Table 1
post-surgical care to discharge is seamless has increased, with a ten-fold increase
and predictable. Patients are housed at over an eight-year period. During the
the appropriate level of care. Because same period, complications have been
the patient’s initial history and exami- reduced. The rate of infection has
nation is so thorough, those patients decreased to almost zero. The rate of
who are at risk for complications are blood clots has also decreased. Patient
targeted early and carefully monitored perception of their physical and mental
by the surgeon and appropriate medi- well-being (using SF-36 v2) is assessed
cal consultants. High-risk patients are at the preoperative visit, six weeks post-
moved to the ICU postoperatively if operatively and one year postoperatively.
necessary, and encouraged to move to (Results are not available yet.)
a lower level of care as soon as medi- The pathway improved communi-
cally allowed. The successful programme cation. The patient became a partner,
has drawn patients to the hospital and which helped in their recovery; expec-
the programme has been replicated in tations were established and efficiency
other hospitals. became an explicit part of the process.
Medical responsibility for the ‘total
Results of the programme continuum of care’ in combination with
Results of the programme have been evidence-based methodology leads to
successful. The volume of surgeries positive results.
Yosef Dlugacz is an internationally recognised expert in the field
of quality management in healthcare. His research focuses on
developing models for improved patient safety and clinical outcomes.
Dlugacz has educated clinicians and administrators throughout the
A uthors
United States and internationally, with academic appointments at
New York University Medical Center, New York Medical College,
Hofstra University, Baruch College, CUNY and Beijing University.
Carolyn Sweetapple is responsible for the day-to-day business
and financial operations of the institute as well as the develop-
ment and success of the institute’s consulting. Sweetapple was the
Administrative Director of Special Projects at Southside Hospital, of
the NS-LIJHS. She is licensed as a certified public accountant and
registered professional nurse in New York State. Ms Sweetapple is
certified as a Six Sigma Master Black Belt and is currently complet-
ing a Master’s of Business Administration in Quality Management.
w w w. a s i a n h h m . c o m 19
H ealthcare management

Managing End-of-Life
Experience from England
Candy Cooley, Manager, National Genetics Education and Development Centre, England

For years, charities, hospices and small teams of specialist

nurses and doctors held the monopoly of responsibility for
end-of-life care. Recently, Primary Care (Community) services
across England began to realise the importance of a coordination
point for the development and management of services.

A
round half a million people in
England die each year from many
differing conditions, the majority
of whom are over 75. The personal and
social care given to these patients and
families forms a major part of the day-
to-day work for many health, social and
voluntary staff. However, it has been iden-
tified that too often care for this vulner-
able group, is not coordinated effectively
across the different service providers and
is not designed around people’s wishes
and preferences about the place of care
and care delivery.
A recent review of healthcare by
English National Health Service has
clearly identified a number of areas where
the lack of coordination and management
of end-of-life care services led to a poor
service for the patient and their families.
It was observed that the current channels
of communication within and among
health, social and voluntary organisa-
tions are not swift enough to respond to
the situation and ensure best care to the
patients during the emergency situations
which demand quick response.
of end-of-life services. These included
education programmes on health and
social care to increase the percentage of
patients who received healthcare at home
(DH 2001). The patients who are in their
final stages of life are often placed in acute
hospital setting, which is not only very
expensive but also not conducive to the
situation they are in. This is due to the
lack of confidence in community teams
to keep patients home, lack of support in
an emergency in terms of primary medi-
cation, lack of ambulance services which
help them in resuscitation and moving
them to treatment centres and failure to
provide rapid response service to deal
with the needs of a dying patient.
The NHS in England: The operating
framework for 2007/08 published in
December 2006, set out local plan of
action for Primary Care (Community)

Identifying the need

From the early part of the 21st century
there have been a number of projects
looking to improve the current provision
Services

w w w. a s i a n h h m . c o m 21
H ealthcare management

Trusts (PCTs) for future improvements
in the provision of care for all. This
included undertaking a local end-of-life
care service baseline review in preparation
for the development of an End-of-life
Care Strategy. The strategy was part of
its commitment to help all the end-of-
life patients, whatever clinical condition
they are in, to have their personal choice
regarding the place of care and death.
The purpose of the review was to
provide PCTs and local authorities
with information that would enable
them to:
• Assess the population need for end-of-
life care services
• Identify current provision including
an evaluation of quality
• Contrast the current provision with
the identified population need
• Decide where service improvements
are needed
• Be ready to respond to the end-of-
life care strategy when published
(DH2006)
Lord Darzi was asked by the Prime
Minister and Secretary of State for Health
to lead the NHS Next Stage Review
(2008). Seventy-four clinical working
groups including over 2000 clinicians
were set up within individual SHA
localities. The aim of each group was to
consider both clinical evidence and the
needs of the local community. The groups
identified models of care for their areas to
ensure that the NHS is up-to-date both
clinically and to meet changing needs
and expectations.
The review looked at primary areas
within the health service to identify if
new ways of working might improve
patient outcomes and service provision.
The End-of-life Care was considered as
one of its key pathways, and the End of
life Care strategy was to follow on from
the review ensuring that the commitment
became a reality.
End-of-life Care Strategy
Health Secretary Alan Johnson launched
the End of Life Care Strategy with an
allocation of funds worth £ 286 million
in July 2008. The strategy aims to ensure
that all adults with advanced, progres-
sive illness receive care at a place of their
own choice.The strategy was developed
by an advisory board chaired by Professor
Mike Richards, National Cancer Director,
with stakeholders from health, social care,
voluntary organisations and professional
and academic organisations.
The stated goal of the strategy is for
better quality care for patients by making
it easier for individuals to voice their
choice with regards to the place of care;
promoting dignity and respect, ensuring
well coordinated services and support-
ing carers.The new ten-year strategy, the
first of its kind, continues and develops
the progress made in end-of-life care
services since 2000. Areas it focusses
on include:
Improved community services - Asking
PCTs working with Local Authorities to
ensure that rapid response community
nursing services are available in all areas
24/7. This will enable more people to be
cared for and die at home if they wish
Workforce training and development - To
train health and social care professionals
in assessing the needs of patients and
carers and providing the best possible
quality care
Development of specialist palliative care
outreach services - To encourage PCTs
and hospices to work together to develop
specialist services in the community,
which will support all adults regardless
of their condition
Setting up a national End-of-life Research
initiative - To further understand how
best to care for those at the end of their
lives.
Quality Standards - To work with SHA
Next Stage Review End-of-life Care to
develop quality standards against which
PCTs and providers can assess themselves
and be assessed by regulators.
Care Pathways - Ensuring that there
is documented evidence of the choices
patients and their families make and the
care that is given. (DH 2008)

Key objectives Care pathways

Integrated care pathways have been
Key objectives to deliver these improvements in end-of-life care have been identified: utilised within care settings from the
• To increase public awareness and discussion of death and dying: this discussion 1990s as a way of ensuring locally agreed,
around end-of-life care improves choice and should also act as a lever to improve multi-professional care based on guide-
service quality lines and the clinical evidence (Overill
• To ensure that all people are treated with dignity and respect at the end of their lives 1998). The completed pathway forms all
• To ensure that clinical symptoms and psychological distress amongst people or part of the clinical record and docu-
approaching the end of their lives are kept to an absolute minimum ments the care given. It also supports the
• To ensure that all discussions around choices for end-of-life care are identified, docu- evaluation of outcomes for continuous
mented, evaluated, respected and acted upon service improvements.
• To ensure that the services people need are coordinated, and deliver seamless care There are key common elements that
constitute a care pathway:
• To ensure that carers and families who take care of patient are supported both during
a patient’s life and are offered bereavement support • Organising the process
• Tracing the timeline
• To ensure that health and social care professionals at all levels receive the education
and training that enables them to provide high quality care.
• Gathering supportive evidence of
practice

22 Asian Hospital & Healthcare Management ISSUE - 17 2008

• Ensuring multidisciplinary collabora-
tion
• Care identified usually within an agreed
time frame
• Continuous review of practice
• Assessment of variance
• Ensuring definite outcome
• Constituting all or part of the clinical
record
• Providing complete information
regarding risks and benefits (Overill
1998).
The Liverpool Care Pathway for the
Dying Patient (LCP) (Ellershaw, Murphy
2005) was developed by staff working
at Marie Curie services within an acute
hospital and provides a research-based
framework for the delivery of best prac-
tice care. The LCP encourages a multi-
disciplinary (MDT) approach to care
delivery which focusses on the physical,
psychological and spiritual comfort as
this has been shown to empower generic
staff in the delivery of care.
The LCP ensures that patient choices
and care are documented and that the
information is shared within the MDT. It
also allows good evidenced / researched-
based care to be identified if completed
correctly. Research with patients at the
end of their lives has been fraught with
moral issues making it difficult to ensure
not only best-evidenced practice but also
a cost-effective management of resources
to improve services.
The Gold Standards Framework (GSF
2001) is a systematic approach to improve
the care for the end-of-life patients in
the community. Originally developed for
primary care by Keri Thomas (a General
Practitioner with a Special Interest in
Palliative Care and NHS National
Clinical lead for Generalist Palliative
Care), and supported by a multidisci-
plinary reference group of specialists
and generalists, it aims to improve the
being admitted to hospital. This includes
provision of other services such as equip-
ment provision and ambulance response.
GSF can evaluate the requirements and
help them in better commissioning of
local services.
• It is aimed at care for patients living
at home and in Care Homes where
they are supported by primary care
teams
• It aims to educate and support
community generalists (GPs, District/
Community nurses, Care Home and
other staff), to improve the interface
with specialists and hospices
• GSF is for patients in the final stages of
their lives and is applicable to patients
with any advanced disease (heart fail-
ure, COPD, neurological disorders,
renal failure etc.).
Once GSF is in place across a
community, it enables developments
in end-of-life services including special-
ised palliative care services which lead
to improved outcomes for patients and
cost-efficient advice for health commis-
sioners.
Conclusion
The End-of-life Care Strategy for England
has the potential to ensure equitable serv-
ices for people dying from all conditions,
including old age. However, to ensure
A uthor
the recommendations are implemented
there needs to be a clear management
strategy within the individual NHS
Hospital and Community Trusts and
Voluntary sector services that enables
quick and effective communication to
take place. It is imperative to ensure
that a pathway of care is implemented
properly and choices are documented.
Each service needs to acknowledge that
patient forms key to the care pathway
and information regarding patient and
family preferences and treatment deci-
sions should be documented, shared and
used accordingly.
According to this Strategy, the days
are gone when decisions were made by
health professionals or based on the avail-
ability of services. This will mean some
radical changes to both the culture and
provision of services for the dying and
their families which need to be both well
managed and receive adequate financing.
These changing expectations by individu-
als, their families and health and social
care practitioners are being seen as key
aspect of healthcare in many ‘western’
countries where ‘care’ is emerging as an
important indicator of clinical excellence
along with ‘cure’.
References are available at
http://www.asianhhm.com/magazine

care provided in the community by the
patient’s usual community care team.
One of the key aims of the GSF is
to develop community teams and serv-
ice provision so that more patients are
able to choose where they die, and avoid
Candy Cooley worked for over 14 years in an academic capac-
ity teaching cancer and palliative care at undergraduate and post
graduate level. She was the Consultant Editor of the International
Journal of Palliative Care from 2004 until 2008. She also has a wide
publication and conference presentation profile.

w w w. a s i a n h h m . c o m 23
H ealthcare management
Medical Tourism
Role of telemedicine
Medical tourism has become an important alternative for patients to get timely treatment
and to seek desired medical care in foreign countries. Telemedicine can play a vital role
in medical tourism through an evaluation of the involved business processes.
Suman Bhusan Bhattacharyya
Vice-President (Clinical Services)
Karishma Software Limited and
Secretary, IAMI, India
A
lthough it may easily be dismissed
as another BPO-like fad, medi-
cal tourism is nothing short of a
serious business that has the potential to
revolutionise the global healthcare indus-
try. It is worth US$ 300–375 million,
and growing at a rate of 30 per cent
annually (2004 figures). Today, patients
are combining vacation with care because
either the local treatment is too expen-
sive or involves long waiting periods
or both.
Telemedicine is a serious attempt at
bridging the gap between the care receiv-
ers and providers by making physical
distances irrelevant and cutting down
on travel. An essential cog in the wheel of
medical tourism, it facilitates the patient
and the care providers to “know each
other” before they meet each other for the
first time. It allows all the remote and local
care providers to exchange health-related
notes on an on-demand basis throughout
the duration of the clinical care process
beginning from the first encounter, to
follow-up sessions until the patient is
relieved. Consequently, it increases the
efficiency, productivity and attractive-
ness of medical treatment as a whole and
medical tourism in particular.
24 Asian Hospital & Healthcare Management
Telemedicine
The word Telemedicine is a combination
of the Greek word ‘Tελε’ (tele) meaning
‘distance’ and the Latin word ‘��������
���������
mederi��’�
meaning ‘to heal’ and therefore liter-
ally means, ‘�����������������������������
������������������������������
distance healing�������������
’������������
. It is not
one specific technology but a means of
providing health services from a distance
using telecommunications and computer
science. It spans every level of healthcare
from the first responder or emergency
medical systems to tertiary medical speci-
ality consultations to performing invasive
and / or surgical procedures delivering
home care.
The technology makes it possible
to have the ‘right’ information (clini-
cal information) available to the ‘right’
people (patients, care providers, family
and friends) at the ‘right’ time (on-
demand, during and after the treatment
process).
In short, telemedicine is a high-tech
solution to the universal problem of access
to healthcare irrespective of physical loca-
tion of the various stakeholders of the
clinical care process.
Medical tourism
Medical tourism is a term applied to the
process where people from all around the
world travel to foreign countries to obtain
medical, dental and surgical care. At the
same time, it is a tour, a vacation and an
experience of visiting them.
Medical tourism companies help
organise patients’ treatment, travel
ISSUE - 17 2008
arrangements and tours. The modus
operandi is to couple the medical treat-
ment with travel and tourism at a frac-
tion of cost incurred in the patient’s own
country. This is a great value addition
to all concerned. The patient gets relief
quickly without compromising on the
quality and quantity of care. The health-
care industry earns valuable revenues. The
healthcare industry gets invaluable busi-
ness. The countries where medical tourism
is being actively promoted include Greece,
South Africa, Jordan, India, Malaysia,
Philippines and Singapore.
Medical tourism definitely adds
itself to the top-line of the various
healthcare institutions. Even though
the revenue model is volume-depend-
ent, the capacity and quality of care is
enough to ensure healthy profit margins at
reduced rates.
Medical tourism business process
In medical tourism, the basic business
process is as follows:
1. A patient residing in an area where he
is unable to get relief from his problems
due to high treatment costs, long delays
in getting the treatment or both, looks
for ways and means to get relief as soon
as possible at equal or lower cost
2. Patient decides to travel to a place
where the cost of comparable quality
and quantity treatment is same or less
and is readily available
3. A competent care provider at an insti-
tution of patient’s choice located in

a foreign country reviews patient’s case
records and gives an appointment.
4. The patient then travels to the country
where the institution is located and
receives the treatment
5. Pre- or post-treatment, patient conducts
some sightseeing according to his
choice (and budget), and then at the
termination of his visit travels back
to his country with all his treatment
records and post-treatment advice to
his primary care physician
6. For follow-ups required at his place
of residence, patient is provided with
instructions regarding how these actions
need to be undertaken
The most important decision point
being both the quality and quantity of
care ensure patient safety while providing
the best of care available anywhere.
The prime area of concern however is
that the patient visits and gets treated by a
set of care providers who have never ever
seen him before and will probably never
see him again. This leaves only non-physi-
cal contact methods to interact when the
need arises. If and when he requires any
follow-up evaluation and advice for the
actual treatment received, he will have to
rely on those care providers who did not
provide the treatment and most possibly
have only limited information regarding
the same. Consequently, he is left to rely
on telecommunication to help him bridge
this gap, perceived or otherwise.
Has time / money
constraints? Choose a
medical tourist
agent
Patient has
a problem
and requires
immedaite relief
No
End of Process
The patient is thus left with several
options such as letters, faxes, expensive
long-distance telephone calls, instant
messenger chatting, video conferencing
(low grade: inexpensive and informal; high
grade: expensive and formal requiring prior
appointments) etc. Added to this cauldron
is the inevitable mayhem of information
lost in transmission and faulty instruc-
tions percolated through —all due to the
existence of non-integrated information
exchange mechanisms causing serious inef-
ficiencies to creep in to the healthcare
delivery system. Thus, records are neither
correctly interpreted nor received on time
in many instances. These invariably lead
to a great deal of stress, which is extremely
undesirable especially in a sector where
stress-free environment should be the
first requirement of both the provider
and receiver.
Telemedicine-enabled scenario
Let us now consider what would happen
in telemedicine technology environment.
Here, the patient would have a single
medium through which a ‘virtual’ clinical
encounter can take place where clinical
data exchange—both textual and visual—
can be done electronically on-demand
at the speed of light. The entire medical
record is available to all the stakeholders
right from the beginning as the patient
continues to receive his treatment irrespec-
tive of his physical location. Once he is
Medical tourism process
Make contact
Exchange
with doctors
information take
in the medical
appointment
tourist spot
Yes
Yes
H ealthcare management
back in his country of residence, he can
continue to receive follow-ups remotely
with his care providers who treated him
and are consequently in the best position
to monitor his progress. His primary care
physician or any other care provider based
locally would have physical access to the
patient and can use the technology to hold
consultations with the foreign care provid-
ers either as a conference in the presence
of patient or by direct interaction.
The business process points that would
get impacted through telemedicine would
be as follows:
1. First encounter or a series of pre-proce-
dural evaluation encounters—where the
patient would interact with his foreign
care providers. Telemedicine will allow
a comprehensive remote-consultation
face-to-face and one-on-one. If needed,
medical records can be exchanged and
reviewed. The primary care or the refer-
ral physician can actively participate to
help clarify health issues and in devising
a care plan
2. Procedural encounters—where the
primary care physician can actively
participate in all encounters, includ-
ing surgeries as observers, and be an
integral part of the care process
3. Follow-up encounters—where the
patient gets in touch with his foreign
care providers whenever he requires.
Telemedicine allows a face-to-face
interaction where the local primary
Travel to the
Travel back
country, get
home, follow-up
treated, take a
care locally
vacation
Have a problem / query
Can be tackled locally?
No
Contact foreign-based
doctor; Get advice
Problem alleviated/ query addressed
w w w. a s i a n h h m . c o m 25
H ealthcare management

care physician can actively participate
to ensure better level of post-procedural
and follow-up care to be delivered
There are inevitable downsides of tele-
medicine technology ranging from issues
related to patient privacy and secrecy due
to electronic transmission of Protected
Health Information (PHI) to differences
in time zones leading to encounters taking
place at odd hours to faulty connectivity.
Since nothing comes without a price, the
stakeholders need to be aware of the costs
involved in it and concentrate more on
its benefits. Then, the entire experience
will truly be a fascinating one.
Conclusion
Both telemedicine and medical tourism
There is a great synergy between
telemedicine and BPO in healthcare in
general and medical tourism in particular.
For any healthcare process, there has to be
a follow-up and it does not make much
sense either to ask the patient to return
or to forget about him once discharged.
Therefore, follow-up advice and re-evalua-
tion is imperative. Also, patient’s local care
provider needs to be instructed regarding
what all needs to be done further and
what not. And, this is currently possible
only through telemedicine.
It may justifiably be stated that with-
out telemedicine, medical part of medi-
cal tourism is incomplete. Telemedicine
A uthor
allows for exchange of the patient’s medi-
cal record. Once the treatment cycle is
over and the patient is fit for discharge,
telemedicine becomes the medium-of-
choice to follow-up remote monitoring
and consultation. Since the patient is
always a tourist in medical tourism, he
is expected to be at a physical distance
that cannot be easily bridged. His local
care provider may frequently be unable
to provide adequate help in many clinical
situations that has a direct causal relation-
ship with the care received in a foreign
land. Telemedicine accomplishes this and
therefore needs to be an integral part of
medical tourism.

are here to stay. Both of them are bound
to increase in acceptance and practicality
to a point where it would be considered
not a ‘nice to have’, i.e. want or premium
requirement, but a ‘must have’, i.e. need
Suman Bhusan Bhattacharyya is a healthcare domain expert with
over two decades of experience. He is a business solutions architect
for healthcare provider applications and has worked for several IT
MNCs in India. Currently, he is working as Vice-President, Clinical
Services, Karishma Software Limited and is the National Secretary
to the Indian Association for Medical Informatics.

or basic necessity.

26 Asian Hospital & Healthcare Management ISSUE - 17 2008

Srishti Software
Riding the Hospital Management
Information Systems (HMIS) wave
T
he growth in medical tourism has forced the
hospitals today to comply with some standards
in their administration and the way they run their
operations. Thus, they are implementing Information
Technology in a big way.
Following its success in HMIS, Srishti Software is
today announcing its change to Channel Sales from
the direct sales model it had been following so far.
The healthcare industry in India is estimated to
be worth US$ 20 billion, growing at a steady pace
of about 20 per cent year-on-year, according to
Mckinsey.
According to Ajay Sharma, CEO, Srishti Software,
“In the next few years implementation of high-end IT
for operational and clinical integration, will be a key
differentiator, and hospitals that do not do this will
actually die.”
This is mainly because to attract international
patients, the criteria is being either JCI or NABH
(National Accreditation Board for Hospital)
compliant. Interestingly enough, NABH, which is
an Indian accreditation, is more stringent than JCI.
Today, only 20 hospitals across the country are
NABH accredited.
Advantage
In addition to automation of day-to-day admin and
logistical processes, Srishti brings to the table high-
end clinical integration and analysis.
Christened PARAS, Srishti’s range of HMIS
products offer a robust centralised, well-integrated,
real-time solution that plays a key role in the everyday
workings of hospitals and plays a key role in clinical
integration and decision-making.
PARAS, has in the process been successfully
implemented in more than 40 hospitals in India
including:
• Vinayaka Mission Medical College and Hospital,
Salem
• KG Hospital, Coimbatore
• Rashtrapati Bhawan, New Delhi
• Narayana Nethralaya, Bangalore
• TATA Chemicals Hospital (Babrala), UP
• TATA Chemicals Hospital (Mithapur), Gujarat
• Sri Jayadeva Institute of Cardiology, Bangalore
• Mahavir Cancer Sansthan, Patna
• Seventh Day Adventist Medical Centre, Bangalore
• Shija Hospital, Imphal
• Karnataka Government
• Prashant Hospital, Muzaffarpur.
Channel Sales Model
• Srishti today has regional master partners spread
across the domestic market and one for North
Africa and one for all six countries of the GCC.
• The international regional partners have their own
channels and value-added resellers and local
distributors.
• In the domestic market Srishti has 6 Value-Added
Resellers (VARs) and around 20 resellers below
them who are spread across the country.
• The VARs, who are trained by Srishti do basic
customisation, training and provide the first line of
support. While the local resellers’ responsibilities
are restricted to pure selling.
• Srishti provides back-up support and handholding
and steps in on a need basis whenever there is an
AMC.
Financial Picture
Srishti Software is confident of clocking US$ 5
million from sales in the current year, a big jump from
the US$ 1.2 million in the same period last year.
A growth of more than 4 times year-on-year is
expected.
Ajay Shankar Sharma
CEO
Srishti Software Applications Pvt.Ltd.
Advertorial
w w w. a s i a n h h m . c o m 27
H ealthcare management
Medical Tourism in India
Seeking a differentiator
Incorporating Ayurveda into mainstream medicine could be an advantage
to Indian hospitals in the medical tourism market.
Vandana Wadhawan
Member, Editorial Team
Asian Hospital & Healthcare Management
T
he rise of medical tourism in
Asia over the last few years has
been phenomenal. Along with
the huge opportunity for growth, it also
brought along a need for Asian healthcare
providers to meet world-class standards
of patient care in order to attract patients
from the developed nations, especially
USA. This change has been particularly
visible in the Indian healthcare sector,
which has grown with the steady influx
of foreign patients. Coupled with the
rise of the private sector, medical tour-
ism has put India firmly on the global
healthcare destinations map. With the
best infrastructure, the best possible medi-
cal facilities, and the most competitive
prices, India continues to attract patients.
While this happens, however, remain-
ing competitive over the long run will
require them to develop core competen-
cies unique to India.
The core competence
India has been able to keep pace with the
latest in technology and its applications,
has been widely felt in the healthcare
industry. That is to say, Indian hospi-
tals offer the modern medical treatments
available in other parts of the developing
world as well. In such a scenario, the
biggest differentiator could be the cost
28 Asian Hospital & Healthcare Management
of treatment. But costs are bound to
rise and as that happens its value as a
key differentiator comes down. In the
long run a value add-on unique to India
could be the best differnetator. In this
case, considering the knowledge base
that has its roots in the country since
past several centuries, Ayurveda is an
emerging option.
Renowned for ancient alterna-
tive therapies such as Ayurveda, Yoga
and Meditation, India has historically
proved to be an oasis in the modern
world, providing complete health and
well being.
Dr RV Karanjekar, former Medical
Director at the Fortis Heart Institute,
observed at a medical tourism conference
in 2005* and said, “India will have to
project itself as being a holistic medical
destination to get an edge over other
countries”.
A small beginning seems to have been
made in this regard with Apollo Hospitals
announcing plans to start an Ayurveda-
centred healthcare city. Sangita Reddy,
Executive Director, Apollo Hospitals
Group says regarding Apollo’s plans, “In
keeping with our view to provide holistic
care for improved quality of life, we have
set up an Ayurveda centre that provides
outpatient consultation and treatment
therapies for a range of conditions.”
Besides Apollo, AyurVAID Hospitals,
a Kerala-based chain of hospitals
  Medical Tourism: Opportunities and Challenges
for India
ISSUE - 17 2008
offering exclusive Ayurvedic medical
services opened its centre recently. Ganesh
Subramaniam, one of the promoters says,
“There is a void in mainstream healthcare
which is being effectively complemented
by Ayurveda. To that extent, appropriately
integrating the two will enable delivery
of comprehensive healthcare services to
the market.”
There already seems to be a precedent
existing in the West where Ayurveda is
gaining popularity and research taking
place to study this domain of care. At
Apollo hospital, Ayurveda will be a part
of the centre’s outpatient department.
“We view India’s indigenous systems of
medicine as complementary to allopathic
practices”, says Sangita Reddy.
A need to explore synergies
The greatest hurdle to the integration
of Ayurveda into mainstream healthcare
could come from the fact that the two
are inherently different.
While today’s medicine is driven by
published evidence, little or no evidence
exists in regard to the treatments offered
by Ayurveda. Further, research in this
direction is little or non-existent. This
is the key deterrent to integration of
Ayurveda into mainstream healthcare.
And till it is sorted out, Ayurveda might
continue to be used only on the periphery
of mainstream healthcare, like, in case of
Apollo, its outpatient department.
The entry of private players in the
Ayurveda sector, however, could be the
much needed initiative for bridging the

Sangita Reddy
Executive Director
Apollo Hospitals Group
India
What made Apollo Hospitals take the initiative of opening a 100 %
Ayurveda Treatment Centre? What are Apollo’s future plans with
regard to this new foray?
Apollo views India’s indigenous systems of medicine as comple-
mentary to allopathic practices. In keeping with this view, we have
pioneered Rehabilitation and Rejuvenation Centres, besides advocat-
ing the concept of ‘wellness’ as an absolute pre-requisite to prevent-
ing disease and promoting health.
Also in keeping with our view to provide holistic care for improved
quality of life, we set up an Ayurveda centre that provides outpatient
consultation and treatment therapies for a range of conditions. The
centre offers treatment therapies for rejuvenation, stress manage-
ment, obesity etc.
Can holistic medicine be incorporated in mainstream healthcare?
Indigenous systems of healthcare have always had an important role
to play in our country. The government too has openly acknowledged
this, and talked about their integration with mainstream medicine as
envisaged in the National Health Policy of 2002 and the National Rural
Health Mission of 2005.
Do you think that incorporation of Ayurveda into the mainstream
science would give an edge to India over other Asian countries in the
Medical Tourism sector?
India has always healed the world, right from the days of Charaka and
Sushruta. India’s traditional medicine methods are popular abroad,
and Ayurveda, in particular, is a huge draw for tourists travelling to
Ganesh Subramaniam,
Co-Promoter
AyurVAID Hospitals
India
Can holistic medicine be incorporated in the mainstream health-
care?
There is a void in mainstream healthcare which is being effectively
complemented by Ayurveda. To that extent, appropriately integrating
the two will enable delivery of comprehensive healthcare services to
the market. In fact, our USP of working with mainstream doctors for
specific conditions is a step in this direction.
What synergies do you see between Ayurveda and mainstream
medicine?
The few conditions in which there are demonstrated synergies
include stroke rehabilitation, epilepsy management, multiple sclero-
sis, parkinsonism, low back ache etc.
Do you think that incorporation of Ayurveda into the mainstream
would give an edge to India over other Asian countries in the Medical
H ealthcare management
India. The Medical Tourism industry, which initially operated on similar
lines, catered to the demand for the holistic treatment of the mind and
the body.
Today, as the Indian healthcare industry is coming into its own on
the strength of its value proposition in terms of the global quality of
care at about a fraction of the cost, we have begun to attract a sizeable
number of foreigners who seek our healthcare services for elective
surgeries. But the concept of providing uniquely Indian value addition,
in the form of the rejuvenation and therapeutic power of Ayurveda,
remains valid yet small.
What synergies do you see between Ayurveda and mainstream
medicine?
There has been very little work dedicated to research in this area.
Apollo has plans to use the auspices of its AHERF (Apollo Hospitals
Education and Research Foundation) to look into the possibilities
of some groundwork in this area, especially in the realm of chronic
conditions.
Also, Medvarsity, Apollo’s distance education platform, already
runs a one year online programme in Holistic Healthcare as a fellow-
ship for graduates in any discipline of medicine, including MBBS. The
emphasis of the programme is on eliminating the cause of disease,
rather than treating its symptoms alone. The doctor-students taking the
course are presented a wide array of therapies for treating disease and
creating optimal health. They learn the scope of holistic medicine, in
making it an essential part of the medicine of the new millennium.
Tourism sector? How and why?
It definitely will. Exporting our knowledge base should be one of the
objectives of any tourism policy.
What patients (domestic/ International) do you expect to come for
the Ayurveda treatment?
Our target market is the domestic sector. There is a huge demand
supply gap as on date. Moving forward, it is possible that we may
look at medical tourism.
What is taking the Indian Hospitals so long to merge Ayurveda with
the modern treatment?
There are several reasons for this including lack of initiative on the
part of the Ayurveda sector to bridge the gap and engage in dialogue
with other stakeholders, absence of corporate hospitals in the
Ayurveda sector and a lack of market awareness
w w w. a s i a n h h m . c o m 29
H ealthcare management
A brief history of medical tourism
The concept of medical tourism is as old as medicine itself. In olden
times, Asian countries had their own alternative / herbal medicine
long before modern medicine came in.
Some examples include:
• People from France, Britain, Ireland and
Italy travelled to Germany for spa treat-
ment
• Europeans went to Egyptian Nile River
to experience hot mineral water baths
• In China, traditional herbal preparations
accounted for 30 per cent - 50 per cent
of the total medical consumption
• In Ghana, Mali and Nigeria, the first line
of treatment for 60 per cent of children
with high fever is use of herbal medi-
cine
• In India, yoga and ayurveda attracted
a constant influx of medical scholars
and travellers from all over Europe
and Middle East hoping to master and
benefit from these revered branches of
alternative medicine.
In the modern times it has acquired a
new dimension. Low cost of the diagnos-
tic procedures and the efficiency of the
medical treatments is a guiding force that
brings the patients from all over the world
into the Asian hospital premises.
With the underinsured and uninsured
population growing in the US, the need to
lower the medical costs increased. That
was not easy and thus started the outflow
of the patients. Asia seemed to be right
destination with low cost and high quality
gap that exists between Ayurveda and
allopathic medicine. As Sangita Reddy
points out, Apollo plans to carry out
research through the Apollo Hospitals
Education and Research Foundation
(AHERF) and look into the possibilities
of some groundwork in this area with a
focus on chronic conditions.
This change in approach of India’s
private sector towards Ayurveda is a sign
of the Indian healthcare sector, “coming
into its own on the strength of its value
proposition in terms of the global quality
30 Asian Hospital & Healthcare Management
services. Asian hospitals had to achieve
tough international patient safety stand-
ards, like the ones promoted by the Joint
Commission International (JCI).
Asia’s rendezvous with accreditation
took the competition for medical tour-
ists to a new level. Indraprastha Apollo
Hospital became the first Indian hospital
to get accredited by the JCI
Today, more than nine hospitals in
India have got the JCI accreditation, and
more are in line. However, as the compe-
tition heats up—both at the national and
the regional level—hospitals will need to
come up with new differentiators.
India is one of the preferred destina-
tions in the world for Medical Tourism.
Most familiar treatments include heart
surgery, knee transplant, cosmetic
surgery and dental care. In the year
2007, around 272,000 medical tourists
visited India and brought revenue of US
$ 656 Million. India has also come up
with its own accreditation system through
the National Accreditation Board for
Hospitals & Healthcare Providers under
the Government of India.
Today’s medical tourists primarily
come from US, Canada, Great Britain,
Western Europe and Australia to receive
medical treatments ranging from heart
surgery to hip replacement.
of care at about a fraction of the cost”,
adds Sangita Reddy.
There’s a long way to go before
Ayurveda gets it rightful position in the
world of mainstream healthcare that is
changing at a rapid pace. But this trend is
a positive one and has the backing of the
entrepreneurs shaping Indian healthcare’s
future. With their focus on Ayurveda
they could create for India a niche in
the medical tourism market. And this
augurs well for India’s ancient healing
system.
ISSUE - 17 2008
 M edical sciences

Michael Gold
Professor
Medical University of South Carolina, USA
Yong Cho, Tom Bennett
Douglas Hettrick
Medtronic Inc., USA

L
ong-term management of patients
with Congestive Heart Failure
(CHF) is a growing burden on
healthcare systems throughout the world
today. Management of patients with CHF
is confounded by the observation that
signs and symptoms in many of these
patients are not well-correlated with
actual disease status.

Hemodynamic monitoring
Current methods for routine hemody-
namic evaluation (e.g. Swan-Ganz cath-
eterisation and echocardiography) are
costly and not well-suited for repeated
serial measurement in the ambulatory
Representation of intrathoracic impedance measurement:
setting. Recently, considerable investiga- A low amplitude constant current pulse is transmitted from the
tion has focussed on the development of right ventricular therapy lead to the device case and the resultant Figure 2
alternative methods of assessing patient’s voltage and impedance is determined.
disease status. Implantable hemodynamic
sensors may enable frequent monitor-
ing of hemodynamic changes in CHF
patients and be used as a surrogate
for serial invasive catheterisations in
tailoring and titrating medical therapy.
Furthermore, continuous monitoring
of hemodynamic measurements might
provide unique insight regarding patho-
physiological mechanisms and chronic
responses to treatment regimens.
Pressure monitoring system
A totally Implantable Hemodynamic
Monitor (IHM) has been developed for Monitoring with
outpatient HF management. The IHM
system consists of a pacemaker-like device implantable devices
that processes and stores information
and a transvenous lead incorporating a Implantable devices, including pacemakers,
high fidelity pressure sensor near its tip.
The implantation procedure is similar defibrillators and cardiac resynchronisation systems,
to that of a single chamber pacemaker may play a role in helping monitor the progress of
system with the lead positioned in the heart failure in an individual patient.
right ventricular outflow tract or high
right ventricular septum in an area of

w w w. a s i a n h h m . c o m 31
M edical sciences
high blood flow. The IHM measures and
stores heart rate, patient activity, right
ventricular systolic and diastolic pressure,
estimated pulmonary arterial diastolic
pressure (ePAD), positive and negative
dP / dt, right ventricular pre-ejection and
systolic time intervals, and body tempera-
ture. A strong correlation (r=0.84) was
demonstrated between actual pulmo-
nary artery pressures and ePAD under
a variety of physiologic conditions. The
IHM system continuously measures and
stores hemodynamic information that can
be reviewed remotely via the Internet.
The website automatically processes and
concatenates new data received from the
device with data from previous transmis-
sions and provides visual representation
of the data in the form of trends over
time (Figure 1).
Clinical trials
Several studies demonstrated safety
and accuracy of the implantable
hemodynamic monitoring system.
The COMPASS-HF (Chronicle Offers
Management to Patients with Advanced
Signs and Symptoms of Heart Failure)
study randomised 274 NYHA Class III-
IV patients, all of whom received an
IHM, to the Chronicle-guided manage-
ment group (n=134) or control group
(n=140) over a 6-month follow-up
period. The study demonstrated the IHM
was safe and able to reduce the rate of
heart failure-related events. However,
this 21 per cent reduction in events
did not reach statistical significance
(p=NS) . Retrospective analyses from
COMPASS-HF provided new insights
to the pathophysiology of the transi-
tion from stable, compensated HF to
the decompensated state in HF patient
with reduced left ventricular ejection
fraction (LVEF) and among HF patients
with preserved LVEF (i.e. diastolic heart
failure). These data suggest that chronic
management of HF by the IHM may also
be comparable in these two groups of
HF patients. Another currently on-going
trial (Reducing Events in Patients with
Chronic Heart Failure; REDUCEhf )
will prospectively test the hypothesis that
32 Asian Hospital & Healthcare Management
the ambulatory hemodynamic monitor-
ing can indeed reduce the rate of heart
failure-related hospitalisation.
Intrathoracic Impedance
Monitoring
The correlation between changes in
biological impedance and physiologic
parameters, such as respiration rate and
cardiac hemodynamics has been studied
for decades. For example, the estima-
tion of left ventricular volume using the
impedance catheter technique is the gold
standard of physiological research quanti-
fying left ventricular pump function since
the 1980s. Likewise, many implantable
devices employ impedance as a method
of monitoring therapy system perform-
ance. Also, some devices use changes in
impedance associated with the respiratory
cycle to help automatically adjust the
pacing rate. More recently, the association
between acute decreases in intrathoracic
impedance and acute decompensation
of CHF was investigated.
Early clinical trials
The MidHeft trial provided the first
clinical evidence that daily monitoring
of intrathoracic impedance measured
between the right ventricular defibril-
lation coil and the devise case could
provide a clinically useful tool for
Visual representation of device data
ISSUE - 17 2008
monitoring the onset of acute heart fail-
ure decompensation (Figure 2). Device
recorded daily impedance data from this
non-randomised double blinded prospec-
tive trial (n=33) was used to develop and
validate an algorithm to detect acute
pulmonary fluid accumulation based
on day-to-day changes in the actual
recorded daily intrathoracic impedance.
The algorithm calculates dynamic refer-
ence impedance based upon trends in the
measured daily intrathoracic impedance.
Differences between the measured daily
impedance and the calculated reference
impedance are used, in turn, to incre-
ment or reset a ‘fluid index’ (Figure 3).
According to the reported results of the
study, the fluid index for patients who
were hospitalised for acutely decompen-
sated heart failure crossed a predeter-
mined fluid index threshold (60 ohm
days) prior to hospitalisation in over 77
per cent of the events. The changes in the
calculated fluid index occurred on average
15 days prior to symptom onset. The trial
also observed that the rate of fluid index
threshold crossings not associated with
imminent heart failure hospitalisation
was about 1.5 events per patient per
year. Initial results from the FAST trial,
a follow-on prospective clinical trial in
ICD and CRT patients, further validated
Note
1. Pressure increase noted. Patient
contacted by phone, states she
feels OK.
2. Reinitiated phone contact with
patient. Patient admits deitary non-
compliance.
Weight increace 4kg
Matalazone 205mg/dayinitiated
3. Carvedilol inditeated
The trends show the daily median
(black line) and the daily ranges
(pink lines) over one month when the
patient was non-compliant to dietary
restrictions and ate salted popcorns.
Clinical notes corroborate the pressure
changes.
Figure 1

Fluid index
>200
OptiVol fluld index
OptiVol thre shold 160
120
80
40
Fluid
0
May 2005 Jul 2005 Sep 2005 Nov 2005
Thorocic impedance >100
(ohms)
90
Daily
80
Reference
70
60
50
40
May 2005 Jul 2005 Sep 2005 Nov 2005
Sample implantable device patient diagnostic report including intrathoracic impedance fluid
index and programmable threshold as well as the raw recorded daily and calculated reference
impedance. Decreases in the trend of the measured daily impedance are reflected by consistent
increases in the calculated fluid index. Fluid index values greater than the pre-programmed
threshold indicate potentially worsening heart failure due to thoracic fluid accumulation.
Figure 3
the potential clinical utility of chronic colleagues followed 115 CRT-D patients
intrathoracic impedance monitoring to with intrathoracic impedance monitor-
manage heart failure. ing for an average of nine months. They
reported that the sensitivity and specifi-
Recent clinical findings city of the fluid index depended strongly
Since the MidHeft and FAST trials, a on the programmed detection threshold.
number of other published investigations They concluded that optimal algorithm
further validated the clinical utility of performance may require tailoring the
chronic heart failure monitoring using threshold value to fit the needs of the
device recorded intrathoracic impedance. particular patient. Small and colleagues
Vollmann and colleagues performed a also performed an analogous investiga-
multi-centre non-randomised investiga- tion in 326 US CRT-D patients with
tion of 372 patients with CRT-D devices intrathoracic impedance monitoring
that included intrathoracic impedance but no audible alert, which are not yet
monitoring. Many patients in this trial approved for use in the US. That analy-
were automatically alerted to fluid index sis included univariate and multivariate
threshold crossings by an audible alert linear regression of changes in the fluid
tone transmitted by the device. The index as well as other device diagnostic
authors reported an adjusted sensi- parameters. The results indicated that
tivity and positive predictive value of each intrathoracic impedance fluid index
the alerts to various clinically relevant threshold crossing was associated with
events associated with heart failure of a 51 per cent increased probability of a
60 per cent respectively. Ypenburg and heart failure hospitalisation within the
M edical sciences
same year as the crossing (Figure 4).
In addition, changes in intrathoracic
impedance also showed good correlations
with both weight and BNP levels. All of
these trials confirmed the fundamental
hypothesis that intrathoracic imped-
ance monitoring can provide a useful
clinical tool to help manage patients
with congestive heart failure. However,
two current randomised multi-centre
clinical trials including PRECEDE
HF and DOT are independently test-
ing the hypothesis that in-office and
remote monitoring of device diagnostic
data, including intrathoracic impedance
monitoring, will improve a combined
primary endpoint of death and heart
failure hospitalisation.
Integrated diagnostics
Estimated filling pressure with intrathoracic
impedance monitoring
Chronic monitoring of both estimated
left ventricular filling pressure and
Intrathoracic impedance represents the
potential for further improvements and
refinements to device-based remote clini-
cal monitoring. The relationship between
changes in these two parameters was
investigated in a few small-scale clinical
studies. These pilot data indicate good
correlations between right ventricular
pressure and intrathoracic impedance-
derived parameters of worsening heart
failure. Therefore, chronic monitoring of
both estimated filling pressures as well as
intrathoracic impedance may substan-
tially improve both the sensitivity and
specificity of each respective parameter
to predict acutely worsening heart failure
as well as other clinically relevant events
prior to manifestation of clinical symp-
toms. Clinical trials currently underway,
such as the REDUCEhf trial, should
help to elucidate these complex relation-
ships in the heart failure population.
Eventually, sophisticated computational
algorithms that simultaneously consider
multiple parametric changes determined
separately from multiple independent
sensors may be developed from such
clinical data.
w w w. a s i a n h h m . c o m 33
M edical sciences
AF / CHF
The complex relationship between CHF
and both atrial and ventricular arrhyth-
mias is well described. However, hemo-
dynamic and electrocardiographic data
recorded by implantable devices have
helped to further elucidate this complex
interrelationship. Recent investigations
have reported intriguing correlations
between changes in intrathoracic imped-
ance and the onset of both atrial and
ventricular tachyarrhythmias. These results
demonstrate that reductions in intratho-
racic impedance often precede individual
occurrences or ‘storms’ of arrhythmias.
Likewise, the onset of a persistent atrial
tachyarrhythmia often portends acute
decompensation for congested heart
failure. The nature of this interrelation-
ship may vary from patient to patient
or perhaps even within an individual
patient. Thus, implantable device diag-
nostics that reveal intricate temporal
relationship between arrhythmia onset
and acute decompensation may play a
key role in tailoring therapies for both
co-morbidities.
Heart rate variability
The longstanding ability of implantable
devices to monitor both paced and intrin-
sic ventricular cycle lengths has fostered
interest in leveraging that capability to
monitor changes in heart rate variability
and day and night heart rates. Such diag-
nostic data may provide relative insight
into the condition of the autonomic nerv-
ous system. Several implantable devices
now provide long-term diagnostic trends
for such parameters. Recently, Adamson
and colleagues demonstrated that reduc-
tions in device measured indices of heart
rate variability often precede episodes
of acute heart failure decompensation.
Similarly, results of the OFISSER trial
showed that increases in night heart rate
were associated with acute heart failure
decompensation in patients with CRT-
D therapy. These diagnostic parameters
are somewhat limited by other factors.
For example, if the patient is experi-
encing a persistent atrial arrhythmia,
34 Asian Hospital & Healthcare Management
Kaplan Meier survival analysis
Proportion
wirhout
heart failure
hospitalisation Intrathoracic inpedance
fluid index threshod
crossings(yr-1)
Months
Kaplan Meier survival analysis of time to first HF hospitalisation for groups of patients with similar
frequency of thoracic impedance fluid index threshold crossings: Patients with more frequent
crossings were significantly associated with Heart Failure hospitalisations over the same time period
Figure 4
or if the device is controlling the atrial tant diagnostic applications. For exam-
rate by frequent pacing, then heart rate ple, it has been shown that symptoms
parameters such as heart rate variability are a relatively poor indicator of atrial
are not calculated and the diagnostic tachyarrhythmia occurrence. That is,
information is hence unavailable. This most atrial arrhythmia episodes are
scenario can represent the majority of asymptomatic. Likewise many reported
time for some patients with implant- arrhythmia symptoms are not associated
able devices, especially those who are with an actual arrhythmia. Therefore,
pacemaker dependent. device monitoring capabilities repre-
sent a reliable and diligent method of
Arrhythmia monitoring monitoring arrhythmias that may bay
The ability of implantable devices to used to help manage pharmacologic
detect and discriminate various atrial and and non-pharmacological rate and
ventricular tachyarrhythmias accurately rhythm control strategies. The recent
has been exhaustively documented. These TRENDS clinical trial examined the
capabilities are required in order to apply potential of these implantable device
automatic therapies safely and appropri- atrial arrhythmia diagnostics to help
ately for both ventricular and, in some monitor the risk of thromboembolic
devices, atrial tachyarrhythmias. Many events. This study was underpowered to
devices augment these automated detec- achieve the primary endpoint. However,
tion capabilities by storing ventricular a posthoc analysis of this multi-centre
and atrial bipolar electrograms recorded non-randomised trial (n=2486) showed
prior to and during tachyarrhythmias. that the thromboembolic event risk
However, besides augmenting device may be a quantitative function of atrial
therapy, the ability to record and report tachyarrhythmia burden. That is, atrial
the precise date, time duration, cycle tachyarrhythmia AT / AF burden greater
length and example electrograms of than 5.5 hours on any of 30 days prior
such arrhythmias can also have impor- to the event approximately doubled the
ISSUE - 17 2008
 M edical sciences

thromboembolic risk. Hence, device- remote monitoring rather than intermit-

detected AT / AF burden may help
identify subgroups at higher risk for
thromboembolic events. The ASSERT
study is an even larger study with much
longer follow-up and should answer many
further questions regarding the predictive
value of AF burden for strokes in high
risk patients.
Clinical adoption and remote monitoring
The rapid advances in device monitor-
ing capabilities have, to some extent,
outstripped the ability of many clinics to
leverage the plethora of available diagnos-
tic information. However, many implant-
able devices now also contain telemetric
capability that allows the device to trans-
mit all sensor derived parameter trends
from the patient’s home directly to the
clinic. This is typically achieved through
a bedside monitoring / telemetry device
that can be programmed by the clinic to
transmit automatically based on preset
schedule. Alternatively, a transmission
of device stored monitoring and diag-
nostic data can also be triggered based
on detected clinical events. For example,
some devices can be programmed to alert
the clinic directly if the patient experi-
ences the onset of atrial tachyarrhyth-
mias or if the ventricular rate during a
sustained atrial tachyarrhythmia exceeds
a pre-programmed threshold. Such
remote monitoring ‘care alerts’ may be
quite useful to monitor rate and rhythm
control strategies. These remote monitor-
ing capabilities also foster the potential
to transmit non-device recorded infor-
mation automatically, such as weight,
blood pressure and associated symptoms
back to the managing clinic. Thus, the
stage is set for a new paradigm of heart
disease management based on continuous
tent clinic visits.
The future
The number and variety of physiologic
sensors and the useful clinical param-
eters derived from those sensors is
likely to continue to increase rapidly.
For example, in addition to the capa-
bilities described above, future devices
may include additional sensors to track
respiration parameters (including rate,
minute ventilation and perhaps apnea and
dyspnea detection), tissue perfusion (via
optical sensors), cardiac output and stroke
volume (via impedance acute ischemia or
myocardial infarction via S-T segment
monitoring), electrical alternans and heart
rate turbulence. Indeed some recently
released devices already contain some
of these fascinating capabilities.
The development of practical chemi-
cal sensors to monitor parameters,
although less mature, is also feasible.
However, some external glucose pumps
for the chronic management of diabetes
also contain chronic intermediate-term
(i.e. several days) subcutaneous glucose
monitoring capability. The ability of such
Undiluted Industry
chemical sensors to augment other device Knowledge
monitoring capabilities for heart failure or
other risks will require investigation.
Now also online!
References
Bourge RC, Abraham WT, Adamson PB,
Aaron MF, Aranda Jr JM, Magalski A, Zile
MR, Smith AL, Smart FW, O’Shaughnessy
MA, Jessup ML, Sparks B, Naftel DL,
Stevenson LW. Randomised Controlled Trial
of an Implantable Continuous Hemodynamic
Monitor in Patients With Advanced Heart
Failure: The COMPASS-HF Study. Journal www.asianhhm.com
of the American College of Cardiology.
2008;51:1073-1079.

Healthcare Management | Medical Sciences

Michael Gold is the Michael E Assey Professor of medicine, as well Surgical Speciality | Diagnostics | Technology,
A uthor

as the Director of the Division of Cardiology and Associate Dean of Equipment & Devices | Facilities & Operations
Interdisciplinary Clinical Programs at the Medical University of South Management | Information Technology
Carolina in Charleston. He has authored over 125 articles in peer-re-
viewed journals, in addition to over 30 book chapters. He sits on the
Editorial Board of several peer-reviewed journals, including American
Journal of Cardiology, PACE, Heart Rhythm, and Journal of Cardiac
Electrophysiology.

w w w. a s i a n h h m . c o m 35
M edical sciences

A
stroke has been defined as “a focal,
or at times global, neurological
impairment of sudden onset, last-
ing more than 24 hours or leading to
death, and of presumed vascular origin”.
However, this definition has, as a result of
time-dependent treatment and manage-
ment, become redundant.
Stroke is the third most common
cause of mortality in the developed world
and is also the leading cause of adult
neurological disability. Due to ageing
populations worldwide, it has been esti-
mated that by 2020, stroke will be the
leading cause of lost healthy life-years.
Not only does stroke have a devastating
impact on both patients and their fami-
lies, there are also financial implications
for society as a whole. Stroke costs the
National Health Service (NHS) in the
UK approximately £ 2.8 billion a year in
direct costs. Moreover, an additional cost
of £ 1.8 billion is incurred in terms of
loss of productivity and disability. Annual

Treatment
informal care costs of home nursing are
estimated to be at £ 2.4 billion.

of Stroke
Considering Transient Ischaemic
Attack
A Transient Ischaemic Attack (TIA) is
often, mistakenly, described as a mini-

Acting on the symptoms
Prompt recognition of suspected stroke symptoms and
immediate activation of Emergency Medical Services (EMS)
are crucial to effective pre-hospital stroke care, early access
to stroke specialist services and successful management.
Caroline Watkins
Professor, Stroke and Older People's Care
Michael Leathley
Senior Research Fellow
Stephanie Jones
Research Fellow
Clinical Practice Research Unit
Department of Nursing
University of Central Lancashire, UK
stroke and has until recently been defined
as “a neurological deficit caused by focal
brain ischaemia that completely resolves
within 24 hours”. According to a newly
proposed definition by the TIA Working
Party Group, TIA is “a brief episode of
neurologic dysfunction caused by neuro-
logic dysfunction or retinal ischaemia,
with clinical symptoms lasting less than
one hour, and with no evidence of acute
infarction”.
During the vascular event, of stroke
or TIA, the symptoms would be the
same. Unfortunately, as TIA symptoms
resolve quickly, TIA is often perceived
by the public as unimportant, and does
not warrant any treatment. However, the
evaluation and diagnosis of TIA should
mirror that of stroke and so suspected
stroke (regardless of whether the even-
tual diagnosis turns out to TIA or stroke)

36 Asian Hospital & Healthcare Management ISSUE - 17 2008

 M edical sciences

should result in immediate access to EMS
and be treated as a medical emergency.
The variation in signs and symptoms
from person to person depending on the
areas of the brain affected often creates
problems in recognising stroke. Stroke
classically presents with sudden onset of
neurological loss and can include one or
more of: limb weakness, speaking diffi-
culty or understanding speech, loss of
vision, clumsiness or numbness of the
arms or legs. Symptoms most commonly
described by stroke patients include weak-
ness, numbness or paralysis.
Treatments for TIA and stroke
The recommended assessments and
treatment for TIA patients include brain
imaging, carotid imaging, antiplatelet and
antihypertensive therapy and statins. For
stroke, effective and cost-effective inves-
tigation and treatment options include
immediate brain scanning, thrombolysis
and organised care in a specialist unit,
as well as secondary prevention therapies
as for TIA.
Rapid access is the key to maximise
the benefits from these investigations and
treatments. To provide rapid access, the
time from the onset of stroke symptoms
to hospital arrival must be kept to a mini-
mum. Studies have shown that activation
of the EMS is the single most important
factor in the rapid triage and treatment
of acute stroke patients. Individuals who
activate EMS arrive at Accident and
Emergency Departments (A&E) earlier
and are evaluated faster—particularly
when EMS is the first point of medical
contact—and hence it is the provider of
awareness of stroke symptoms, reluctance
to seek medical help and stroke not being
viewed as a medical emergency. Of these
factors, the principle ones are believed
to be lack of public knowledge regard-
ing stroke symptoms and the need for a
rapid response. A recent campaign by the
Stroke Association in the UK promoted
the use of the Face Arm Speech Test
(FAST) to inform symptom recognition
and facilitate the rapid access for people
with suspected stroke to the appropriate
services. However, the effectiveness of this
campaign has not yet been evaluated.
Stroke screening, educational programmes
and first aid training are some of the
effective ways to increase knowledge
about stroke.
Educational tools have also been
shown to increase stroke awareness
across diverse populations. While it is
appreciated that increasing knowledge
does not necessarily lead to a change in
behaviour, it could facilitate behavioural
change. When people were asked about
what action they would take if they
suspected that they or one of their rela-
tives was experiencing a stroke, approxi-
mately 50 per cent said that they would
call the EMS or would visit a hospital
emergency department. However, when
stroke patients were asked about what
they had actually done at the onset of
Caroline Watkins, the only nursing professor of stroke care in the
UK, has worked with the Department of Health Vascular Team on
developing, and now in implementing, the National Stroke Strategy.
A uthors
symptoms, only 18 per cent said that
they had called EMS immediately.
Those with lower levels of education
have consistently shown poor levels of
stroke knowledge. Participants who had
higher levels of education are more likely
to name at least one symptom of stroke or
risk factor or to provide a correct expla-
nation of the physiological processes of
stroke. Higher levels of education and
upper socio-economic status have also
been associated with the increased ability
to identify the brain as the organ affected
by stroke. Other factors that affected
knowledge are age and ethnicity. It is
observed that older age groups and several
ethnic groups have poor knowledge of the
risks factors and symptoms of stroke.
With ageing populations and a
predicted rise in the incidence of stroke,
the immediate recognition and reaction
to symptoms is of increasing importance.
Currently, the inability of the general
public to recognise the symptoms of stroke
and failure to contact the EMS results in
delays in arrival at hospital. Increasing
public awareness about stroke symptoms,
the required emergency responses and
the available treatment options must be
a priority.
References are available at
http://www.asianhhm.com/magazine

fast transportation to hospital. For exam-

ple, one study showed that for patients
who contacted the EMS first, the mean
time from stroke onset to arrival was 2.7
hours compared to 6.3 hours for patients
who contacted their community physician
in the first instance. Similar delays were
also found for patients who contacted
EMS (3.8 hours) and for those who did
not (7.5 hours).
Many factors contribute to delays
in seeking treatment including poor
Michael Leathley is a Post-Doctoral Research Fellow at the
University of Central Lancashire. His research interests include the
long term follow-up of stroke patients, from admission to hospital
with an acute stroke, to discharge and beyond, measuring provision
of service, support, utilization of resources and charting mortality.
Stephanie Jones is a Research Fellow at the University of Central
Lancashire. She co-ordinated the National Pre-Hospital guide-
lines Group and currently manages a National Institute for Health
Research Stroke Programme Grant. She has worked collaboratively
with the Royal College of Physicians.

w w w. a s i a n h h m . c o m 37
M edical sciences

Advanced Colorectal Cancer

Improving the survival rate
The management of Colorectal Cancer liver metastases has evolved over the past decade
as a result of using more sophisticated imaging technology, effective systemic therapies
including multi-drug treatment regimes with advanced surgical techniques. This has greatly
improved response rates, resectability rates and in turn survival.

Options for treatment ard treatment has helped in improving

Graeme Poston
The management of Colorectal Liver
Surgeon
Metastases (CRLM) has evolved over
Vivek Upasani
Specialist Registrar the past decade as reflected by the inte-
Aintree University Hospital, UK
gration of effective systemic therapies
with advanced surgical techniques. Five-
year survival rates after resection have
response rates, resectability rates and
survival considerably.
Up to 20 per cent of patients with
‘liver only’ disease are candidates for
potentially curable surgery. The criteria
for undertaking surgery include: control

L
ife expectancy has increased increased from 20 per cent to almost of the primary tumour, no extra hepatic
dramatically over the last hundred 60 per cent in recent series. Although disease and resection technically feasi-
years. In the western society it is the dramatic improvements may be due ble with tumour free margins. A small
75-77 years for men and 80-81 years to the adoption of more sophisticated number of patients with completely
for women. The demographics of these imaging technology, the introduc- resectable extra hepatic disease may
changes have important consequences for tion of multi-drug regimens including survive for a long term. Chemotherapy
healthcare professionals in oncology. irinotecan, oxaliplatin, cetuximab, and alone remains palliative but it can
bevacizumab as components of stand- double the survival time for patients
Magnitude of the problem
Colorectal Cancer (CRC) is one of the top CT scan of colorectal liver metastases initially deemed unresectable before (a) and after
three causes of cancer deaths, accounting chemotherapy (b), by which time these tumours are easily resectable.
for over one million new cases annually
and over 500,000 deaths worldwide.
The liver is frequently the only site of
metastases in the patients diagnosed with
advanced disease; only 20 per cent of
patients with liver metastases are possibly
amenable to surgical resection with cura-
tive intent. Synchronous liver metastases
are present in about 20 per cent of patients
with CRC, and metachronous liver metas-
tases will subsequently appear in approxi-
mately 20–50 per cent of patients.
Generally, the median survival time
of untreated advanced CRC is between
6-8 months. Those with solitary liver
metastases have a better prognosis than
those with more extensive disease. Very
few patients with liver disease survive for
five years without treatment.

38 Asian Hospital & Healthcare Management ISSUE - 17 2008


with unresectable disease. In addition,
it may prolong the time to recurrence
after resection of hepatic metastases and
may bring patients previously judged
inoperable to resectability.
The combination of chemotherapy
and surgery is currently accepted as a
way forward for improving survival
in patients with initially unresectable
CRLM. Standard combination chemo-
therapy regimens comprising 5-fluorou-
racil (5-FU) plus leucovorin (LV, also
known as folinic acid [FA]) in combi-
nation with either irinotecan, typically
FOLFIRI or oxaliplatin (FOLFOX) have
been reported to facilitate the resection
of 9-40 per cent of initially unresectable
metastases, with data emerging from
randomised trials suggesting that the
addition of targeted biologic agents or
a third cytotoxic agent might
be even more effective.
Typically, the liver surgeon
is faced with three clinical
scenarios when assessing patients
with colorectal liver metastases:
i) Patients with clearly resectable
metastatic disease, ii) Metastatic
disease that is initially consid-
ered to be unresectable, prin-
cipally due to location and iii)
Patients that are unlikely to ever become
resectable. Current treatment practice
recommends surgery for resectable liver
disease and palliative chemotherapy for
those patients with initially unresectable
and the patients who are unlikely to
ever become resectable disease. However,
such chemotherapy may be an inte-
gral part of treatment with ultimately
‘curative intent’ if regression means
that surgical resection is subsequently
possible. In any assessment of chemo-
therapy regimens, it is necessary for
accurate patient classification / stag-
ing to facilitate, for example, a degree
of cross-trial comparison in a clinical
setting where few randomised trials
are likely to be conducted and where
resectability is such a subjective clinical
endpoint. It has been proposed that
a new staging system would facilitate
a move away from the old ‘catch-all
classification’ of stage IV disease to
allow stratification of patients from the
outset in terms of potential resectability
with a view to direct their therapeu-
tic management. The advantages of
such a new staging system would be
to alert physicians early to the possibil-
ity of ‘curative intent’ strategies and to
provide a clear indication of therapeu-
tic strategy. Whilst, the ultimate aim
of a new staging system would be the
better stratification of patients for clini-
cal trials. This is particularly important
as moving forward there are likely to
be more first-line randomised studies,
like the CRYSTAL and OPUS studies
where secondary surgical resection rates
are important secondary end points of
the analysis.
New trials need to be conducted that
link R0 resection to survival and with
new trial endpoints that can provide a
better measure of the efficacy of the
different treatment regimens.
Resectable colorectal liver
metastases
Indications for hepatic resection have
expanded with improvements in peri-
operative morbidity and mortality. The
underlying surgical approach to CRLM
is to identify and resect all macroscopic
disease in order to obtain cure. However,
debate continues over identifying those
patients who may benefit from defini-
tive surgery. The previous reports of
prognostic scoring systems can be useful
for proper patient selection, improving
the outcome after surgery.
Today, even in patients with resect-
able metastases, chemotherapy prior to
surgery can increase the complete resec-
tion rate, facilitates limited hepatecto-
mies, improves postoperative recovery,
treats micrometastases, provides a test
of chemo-responsiveness and identifies
M edical sciences
aggressive disease and spares ineffective
therapy. This is supported by the results
of the EORTC 40983 / EPOC study
where the Progression Free Survival
(PFS) rate at three years was increased
by 8.1 per cent in those patients who
received perioperative chemotherapy and
increased to 9.2 per cent by periopera-
tive chemotherapy when compared with
surgery alone in the actually resected
group of patients.
Historically, poor prognostic factors
for patients with liver metastases are
>1 liver metastasis, >5cm in diameter,
synchronous presentation, lymph node
positive primary and high tumour
marker levels. This group of patients
should receive neoadjuvant chemo-
therapy. The data from the EORTC
study showed quite clearly that nearly
all patients were able to toler-
ate neoadjuvant chemotherapy.
However, patients with a 2 cm
solitary metastasis should go
straight to surgery, with the
recognition that it accounts
for less than 10 per cent of
patients seen in routine clini-
cal practice. All other patients
with resectable metastases
must be treated upfront with
chemotherapy with the caveats that the
patient is able to receive chemotherapy
and the position of the lesion is not
going to be lost. All resected patients
should, if possible receive postoperative
adjuvant chemotherapy based on the
data for the resected patients in the
EORTC-EPOC trial. The question then
arises ‘how long should the period of
treatment be��
����
?’
One suggestion is that patients
should receive a maximum of six months
chemotherapy perioperatively. Thus,
patients with technically resectable
metastases would receive chemother-
apy until first response. In the case of
those patients whose metastases were
initially classified as unresectable,
chemotherapy should be administered
until an adequate response has been
achieved.
w w w. a s i a n h h m . c o m 39
M edical sciences
CT scan of the liver showing a solitary colorectal metastasis
suitable for surgical resection
Unresectable colorectal liver
metastases
Combination chemotherapy, typically
infused 5-FU / LV, in combination
with either irinotecan or oxaliplatin
but also triple cytotoxic drug therapy,
e.g. FOLFOXIRI and more recently
combination chemotherapy regimens
with the targeted agents cetuximab and
bevacizumab can render initially unre-
sectable metastases resectable in patients
with advanced CRC. The presence of
extrahepatic disease no longer precludes
surgery provided that it is also resectable.
Today, resection rates in excess of 20 per
cent are rapidly becoming the norm in
small single-centre and single-arm studies
provided that patient selection is well
done. As a consequence, 5-year survivals
of 50 per cent are becoming increasingly
common. Current treatment practice for
patients with initially unresectable meta-
static disease is to treat with the most
effective regimen, in terms of response
rate and Progression Free Survival (PFS)
that the patient can tolerate coupled
40 Asian Hospital & Healthcare Management
with the recommendation that surgery
should be conducted as early as possible
to minimise the effects of chemotherapy
on the liver.
So, the question arises ‘what defines
the most active regimen in this clinical
setting?’ In an ideal world it would be
hoped that ‘neoadjuvant’ chemotherapy
in patients with colorectal liver metastases
would not only shrink the tumour but
also reduces the recurrence / relapse rate
by killing any micrometastases that might
remain post surgery. Since response rate
correlates with resection rate, regimens
that could be selected based on present
knowledge are FOLFIRI / FOLFOX
alone, these regimens plus a biologic
or triple cytotoxic drug therapy in
patients with good performance status.
Both FOLFIRI and FOLFOX have been
shown to be highly effective in facilitating
hepatic resections in single-arm studies in
selected patients. However, the trend may
well be towards the use of three active
agents in the form of either combina-
tion cytotoxic therapy plus a biologic
ISSUE - 17 2008
or three cytotoxics. Certainly, data are
beginning to emerge from randomised
trials (CRYSTAL and OPUS) of the
added benefit conferred by the targeted
agent cetuximab on the response rates
and resection rates achieved with stand-
ard first-line therapies in patients with
advanced CRC.
Generally, the median survival time
of untreated advanced CRC is between
6-8 months. The efficacy of a regimen
may primarily be related to its ability to
induce sufficient tumour regression to
permit R0 resection, but probably what
matters most is that the occult tumour
cells that the surgeon cannot remove are
killed, resulting in a long, relapse-free
survival (RFS) post resection. The main
concern in the neoadjuvant setting for the
treatment of CRLM is that we have no
evidence for the impact different regimens
have on recurrence rates post resection.
Although the intent can properly be
termed ‘curative’, cure is rarely achieved.
Thus, new trials need to be conducted
that link R0 resection to survival and
with new trial endpoints that can provide
a better measure of the efficacy of the
different treatment regimens.
New treatment strategy
Today, patients with metastatic CRC
should be treated by multidisciplinary
teams comprising surgeons, medical
oncologists and radiologists. Evidence
of the benefit of perioperative chemo-
therapy over surgery alone, and the
demonstrable benefit of adjuvant
chemotherapy (post-liver resection) in
one trial caused a rethinking amongst
the experts particularly in terms of
the timing of the administration of
chemotherapy for CRC patients with
initially resectable liver and lung
metastases.
Discussion
Although the prognosis of metastatic CRC
is poor with few patients surviving for
five years or more, long term survival has
been reported following surgical resection
of isolated hepatic metastases.
w w w. a s i a n h h m . c o m 41
M edical sciences

Surgical resection of hepatic metas- CT scan of colorectal liver metastases initially deemed unresectable before (a) and
tases is safe. The median postoperative after chemotherapy (b), by which time these tumours are easily resectable.
(30 days) mortality is of the order of 2.8
per cent (0-6.6 per cent). The long-term
survival of patients undergoing R0 resec-
tions is significantly better (32 per cent
at five years) than that seen following R1
resections (7.2 per cent at five years) and
for those patients who did not come to
resection (0 per cent at five years).
Patients undergoing surgery may have
a better prognosis than other patients
with metastatic CRC as they are more
likely to be of good performance status
and have little or no co-morbidity. A few
retrospective studies have attempted to
determine the natural history of patients
with isolated liver metastases. In a study
of 125 patients with liver-only metas-
tases, many who had had no therapy,
the median survival was 12.5 months.
All patients died within five years and
survival correlated with the extent of
liver disease. However, the presence of Figure 2a Figure 2b
three or less liver metastases was associ- Figure 2
ated with a prolonged median survival
of 24 months. margins) that can only be determined three-year disease-free survival in patients
Recurrence of cancer is common following liver surgery. following liver resection. In addition,
after resection of CRLM because in modern chemotherapy will now convert
the majority of cases the extent of the Conclusions a significant number (10-20 per cent) of
metastatic disease remains underesti- Surgical resection of CRLM can be patients deemed unresectable at pres-
mated when using our current pre and performed safely with low mortality entation to surgical resectability. Future
intraoperative staging investigations. Of and morbidity rates. It was observed studies now need to address the question
those who recur, one-third suffers from that one-third of the patients who had of whether even more patients can be
disease recurrence in the liver alone, and undergone surgery were alive even after brought to such surgery with curative
occasionally may be candidates for repeat five years, which was not seen in those intent using either conventional chemo-
liver resection. The others develop recur- patients who were unsuitable for surgery. therapy or chemotherapy in combination
rence either synchronously both in the Perioperative chemotherapy will ensure with the newer biological agents.
liver and extra hepatic sites, or only at
extra hepatic sites.
Identification of those prognostic Graeme Poston is Director of the Division of Surgery, Digestive
factors that might predict the outcome Diseases, Critical Care and Anaesthesia at University Hospital
Aintree (UHA) Liverpool UK. He is also is a Council member of the
following surgical resection of CRLM
A uthors

European Society of Surgical Oncology and the UK and Ireland

could be helpful. They could help in
the identification of the patients most
likely to benefit from this intervention,
or equally assist in the identification of
patients who were unlikely to benefit.
However, the use of such scoring systems
Neuroendocrine Tumour Society. He has authored eight textbooks
of surgery, in addition to over 140 peer reviewed papers, mainly on
the subject of HPB diseases.
Vivek Upasani is working as a Specialist registrar in the renowned
supra-regional hepatobiliary unit at Aintree University Hospital,
Liverpool. Add two more lines.

remains controversial and indeed those

which are most published so far depend
upon variables (such as surgical resection

42 Asian Hospital & Healthcare Management ISSUE - 17 2008

 surgical speciality

Transection
of the Liver
Overview of techniques

Over the past 50 years, the postoperative mortality from liver resection has
fallen from 33 to 1.5 per cent. Whilst this is multifaceted, one key ingredient is
our ability to transect liver parenchyma in a ‘bloodless’ fashion. The emerging
new techniques for liver transection not only improve survival rates but also
reduce mortality rates considerably.

O
ver the past few decades, the
management of liver tumours
has become a truly multidisci-
plinary speciality. Advances in imaging,
medical oncology and interventional
radiology have now allowed treatment
with curative intent for many lesions that
previously would have received pallia-
tion only. However, surgical resection
remains the mainstay of management of
liver lesions and is the most important
method of achieving a cure for primary
and secondary tumours. Indeed, combined
with the above modalities and in the pres-
ence of favourable prognostic indicators,
the surgical resection of colorectal liver
metastases can offer five-year survival rates
of up to 40 per cent and a mortality of
less than 5 per cent.
Alun Jones
Specialty Registrar
Marv Rees
Surgeon
Department of Hepatobiliary Surgery
Basingstoke and North Hampshire
Hospital, NHS Foundation Trust, UK
Principles of transection
Dissection through the liver parenchyma
poses unique challenges. Firstly, the liver’s
inherent vascularity poses a high risk of
uncontrollable haemorrhage if blood
vessels are not identified and sealed in
a timely and effective manner. It is now
well established that morbidity and
mortality from liver resection is closely
correlated with intraoperative blood loss.
Furthermore, the need for blood transfu-
sions during liver surgery is strongly asso-
ciated with poorer long-term outcomes.
Therefore, surgical and anaesthetic tech-
niques have focussed on reducing intra-
operative blood loss when transecting
the liver. Secondly, the complexity of
the liver’s biliary structures necessitates
careful dissection and occlusion to avoid
postoperative bile leaks, another important
source of morbidity and mortality in the
post-liver resection patient.
The ideal surgical instrument for liver
transection must therefore be able to effec-
tively cut through the parenchyma whilst
simultaneously sealing any portal vessels
or bile ducts. In reality, because no such
single instrument yet exists, transection is
achieved by a combination of instruments

w w w. a s i a n h h m . c o m 43
surgical speciality
and techniques which firstly facilitate divi-
sion of the liver tissue with subsequent
identification and sealing of the vessels. In
this way, a ‘Two-surgeon technique’ has
evolved, whereby the first surgeon directs
parenchymal dissection and the second
surgeon is responsible for coagulation
and vessel sealing. Also, it reduces the
transection time—especially important
in limiting liver ischaemia during use of
the Pringle manouevre. It also acts as a
valuable training tool.
The significance of minimising intra-
operative bleeding has led to methods
aimed at achieving bloodless liver surgery,
involving surgical techniques to occlude
hepatic inflow and outflow vessels, and
anaesthetic techniques to minimise central
venous pressure.
Inflow vessel occlusion
Pringle firstly described portal triad
compression in 1908 in an attempt to
control bleeding from the liver in trauma
patients. The ‘Pringle manoeuvre’ is
achieved by application of a soft (non-
crushing) bowel clamp to the structures
in the hepatoduodenal ligament at the
porta hepatis. Whilst this is beneficial in
limiting parenchymal bleeding from inflow
vessels, it unfortunately has no effect on
back bleeding from the hepatic veins and
Inferior Vena Cava (IVC), which may
still be alarmingly profuse. In addition,
it renders the parenchyma ischaemic for
the duration the clamp is applied, and
intermittent clamping (e.g. 20 minutes
on, 5 minutes off) is preferred by many
surgeons, including our unit, to reduce
the risk of post-hepatic liver insufficiency
potentially caused by hepatocyte ischae-
mia. Where possible, inflow vessels to the
segment to be resected should be ligated
and divided prior to transection (the
extra-hepatic approach). In addition to
devascularising the segment to be resected,
this has the advantage of demarcating the
transection plane.
Outflow vessel occlusion
Heaney and colleagues were the first to
describe total vascular exclusion during
a liver resection by control of the supra-
hepatic portion of the IVC. This method
44 Asian Hospital & Healthcare Management
Techniques of liver transection
Finger fracture
Historically, parenchymal division was firstly described via the finger fracture technique
(‘digitoclasy’). Proposed by the Lin and colleagues in 1958, the friable liver tissue was
fractured between the forefinger and thumb whilst identifying and isolating the key
vascular and ductal structures, which could then be ligated and divided. This rather
crude and imprecise technique was subsequently refined by the use of ‘crush clamp’,
specially designed to crush liver tissue without damaging major vascular or ductal
structures.
However, the ‘near bloodless field’ described by the use of crush clamps was often
achieved at the expense of compromised oncological margins, and soon led to the
development of more precise and targeted dissecting instruments.
Ultrasonic dissection
An ultrasonic dissector such as the CUSA (Cavitron Ultrasonic Surgical Aspirator,
Tyco Healthcare, Mansfield, MA, USA) emits ultrasonic waves of a frequency high
enough to divide the liver parenchyma whilst sparing structures greater than 2 mm in
diameter, which can then be sutured or clipped. Using the same principle, the ultrasonic
shears (Harmonic Scalpel, Ethicon, Cincinnati, OH, USA), often used in laparoscopic
resections, uses ultrasound to divide and seal vessels up to 3 mm in diameter between
its jaws.
High pressure water dissection
Water jet dissectors use a pressurised jet of water to achieve transection. Both CUSA
and water jet dissectors have the advantage of removing a 5 mm diameter line of
tissue, important in achieving a margin where dissection is close to the tumour.
Radiofrequency dissection
The TissueLink dissecting sealer (TissueLink Medical Inc., Dover, NH, USA) uses
radiofrequency energy coupled with a saline to achieve both dissection and coagulation
of liver tissue. More recently, radiofrequency ablation, in which coagulative necrosis
is induced in a sphere of tissue around the tip of a probe, has been used sequentially
along the transection line to achieve ‘in line’ coagulation. A knife is then used to transect
the pre-coagulated parenchyma.
Diathermy
Diathermy uses high frequency alternating current to generate high local temperatures
which induces local coagulative necrosis. Some of the most popular instruments
currently available are the Argon beam coagulator (Valleylab, Tyco Healthcare, Boulder,
CO, USA), which allows coagulation of small vessels, and more recently, a bipolar
vessel sealing device (Ligasure, Valleylab, Tyco Healthcare, Boulder, CO, USA), which
seals arteries up to 6 mm and veins up to 12 mm in diameter.
Although some of these instruments (such as the harmonic scalpel and ligasure)
claim to be able to both dissect parenchyma and seal vessels, reports of bile leaks are
common following their use. It is, therefore, usually necessary following transection to
formally seal vessels in order to ensure meticulous haemostasis and prevent bile leaks.
Historically, this has been achieved by a combination of monofilament sutures, clips,
diathermy and topical agents (such as coagulative glue and haemostatic collagen).
More recently, stapling devices have also been successfully used to transect liver
parenchyma in addition to large vessels.
ISSUE - 17 2008
 surgical speciality

allowed a true bloodless surgical field that
could be safely maintained for a period
of up to 60 minutes while the liver was
transected. However, it was a compli-
cated and time-consuming procedure, and
was poorly tolerated in patients with low
cardiorespiratory reserve, as evidenced by
their mortality rates of up to 50 per cent.
This technique has further been refined
by the use of vascular stapling devices
to seal individual hepatic veins after
they are dissected out. Combined with
inflow vessel occlusion, this provides a
rapid and effective method of achieving a
near bloodless field during transection.
Low CVP anaesthesia
The higher the Central Venous Pressure
(CVP), the greater the venous engorge-
ment of the liver and the greater is its
tendency to bleed on transection. This
has led to an important role for the anaes-
thetist in reducing blood loss during liver
surgery. The intraoperative use of fluid
restriction and venodilators allows a CVP
of 0–5 mmHg in the face of a normal
blood pressure, and minimises blood loss
by limiting retrograde bleeding from
the hepatic veins during transection. A
number of studies have now shown that
low CVP anaesthesia is well tolerated and
that the theoretical risk of air embolism
is very rarely clinically evident.
Anatomical considerations
A better knowledge and understanding
of the segmental anatomy of the liver,
described in detail by Couinaud, has
revolutionised liver resection strategies.
The ability to perform segmental liver
resections has allowed the radical exci-
sion of lesions whilst maximising the size
of the remaining healthy liver, vital in
avoiding postoperative liver insufficiency.
In addition, the hepatic lesion must be
well imaged prior to surgery to determine
avoiding their accidental division. It also
enables an adequate resection margin
to be established around the tumour,
allowing curative excision.
Transection at our institution
Basingstoke is a large volume centre with
a throughput of 178 cases in 2007 and
a total of 1657 patients resected so far.
All patients are imaged preoperatively
using liver-specific MRI, which uses
two contrast agents (Gadolinium and
Resovist). The liver is approached via a
right subcostal incision and an assess-
ment is made of resectability and the
confirmation of the absence of peritoneal
disease or nodes at the porta hepatis,
which would render the case irresectable.
The liver is mobilised and resectability
is further confirmed by bimanual palpa-
tion and intraoperative ultrasound. The
resection margins are delineated with
diathermy. An extra-hepatic approach
is preferred for inflow vessel occlusion
where the tumour is close to the porta
hepatis. In cases where the tumour is
greater than 2 cm from the porta, extra-
Glissonian stapling of the portal triad is
preferred. The hepatic veins are stapled
where possible to enable total vascular
occlusion. Parenchymal dissection is
performed using an ultrasonic aspirator
(Cavitron Ultrasonic Aspirator, CUSA,
Tyco Healthcare, Mansfield, MA, USA)
with intermittent portal triad clamping
(20 minutes on, 5 minutes off. In steatotic
and cirrhotic livers the times are 10 and
7 minutes, respectively). During transec-
tion, vessels less than 1 mm in diameter
are sealed via the Argon beam coagulator
Alun Jones is a Specialty Registrar in General Surgery currently
working in Basingstoke and North Hampshire Hospital. He gradu-
ated from the University of Cambridge Medical School in 2003
A uthors
(Valleylab, Tyco Healthcare, Boulder, CO,
USA). Larger branches are clipped or
ligated with monofilament suture. The
two-surgeon technique is used, with the
lead surgeon on the patient’s right operat-
ing the CUSA, and applying clips and
sutures, and the second surgeon on the
patient’s left operating the Argon beam
coagulator. Both apply traction to the
liver in opposing directions to accentuate
the transection line. Following removal
of the specimen, the freshly transected
liver surface is sealed using coagulant glue
(Quixil, OMRIX biopharmaceuticals,
Belgium) and haemostatic collagen sheets
(Fibrillar, Johnson & Johnson Medical,
Ascot, UK). Using these techniques, a
median clamp time of 32 minutes and
blood loss of 330 ml was achieved for
2007, with a mortality of 0.3 per cent.
Conclusion
There is currently no single instrument
available that effectively addresses both
tasks of parenchymal dissection and vessel
sealing, and transection of the liver is
generally achieved using combinations
of the above instruments and techniques.
There is little evidence from randomised
controlled trials demonstrating superior-
ity of one instrument over another, and
the available literature suggests that all
current strategies for transection can be
used with equal effectiveness. Choice of
transection instrument and technique is,
therefore, based on individual surgeon
preference, and the most significant factor
in achieving an effective and safe liver
resection remains the experience of the
surgeon.

and subsequently completed a Basic Surgical Training Rotation at

not only whether it is resectable, but
also the nature of the intended resection
with respect to the location of hepatic
veins and major portal vein structures.
Careful examination of preoperative
imaging, further refined by intraoperative
Norfolk and Norwich University Hospital.
Merv Rees is a Hepatobiliary Surgeon based at Basingstoke
Hospital, North Hampshire, UK. He is currently President of the
Association of Upper Gastrointestinal Surgeons of Great Britain and
Ireland.

ultrasound allows anticipation of these

structures during transection, thereby

w w w. a s i a n h h m . c o m 45
surgical speciality

Treatment of Gastric Cancer

Role of radiotherapy

Radical surgery is the cornerstone in the treatment of gastric cancer, but results in
high locoregional recurrence rates and poor survival. Therefore, further improvement
is sought in pre- and postoperative multimodality approaches. High-precision modern
radiotherapy, in particular when combined with chemotherapy, plays an important role
in optimising clinical outcome.

G
astric cancer is the fourth most
frequent malignancy in the
world. It is characterised by a
high locoregional recurrence rate and
poor prognosis. Radical surgical dissec-
tion is the basis of cure in this disease.
However, because most patients are at
advanced stages, surgery alone provides
long-term survival of only 20-30 per
cent. Randomised trials have shown
that a more aggressive (D2) lymph node
dissection does not result in a clinically
relevant survival benefit, but is associated
with increased morbidity and mortal-
ity. To improve clinical outcome, several
therapeutic approaches have been pursued
both in the preoperative as well as in the
adjuvant setting.
Radiotherapy as single modality
treatment
Radiotherapy as single modality can be
a palliative treatment for uncontrolled
gastric bleeding and for irresectable
tumours. While no significant effect
on survival has been reported, locore-
gional control rates in the order of 70 per
cent have been reported. Radiotherapy
can be applied intra-, pre- or postop-
eratively (with or without concurrent
chemotherapy).
Intraoperative radiotherapy
In a small prospective trial patients with
non-metastatic disease at surgery were
randomised between Intraoperative
Marcel Verheij
Professor and Chair
Department of Radiation, Oncology
The Netherlands Cancer Institute
The Netherlands
Radiotherapy (IORT) and postoperative
external beam radiotherapy. Locoregional
recurrence rates were significantly lower
in the IORT group (44 and 92 per
cent, respectively), without an effect
on survival. Although this trial did not
show increased toxicity, recent studies
indicate that IORT is associated with
more surgical morbidity, which is most
likely the reason that this technique is
applied on a limited scale as compared to
sophisticated external beam techniques,
including three-dimensional conformal
and Intensity-Modulated Radiotherapy
(IMRT).
Postoperative radiotherapy
The role of postoperative radiotherapy in
operable gastric cancer has been evaluated
in several studies. In the British Stomach
Cancer group study, 436 stage II and
III patients were randomly assigned to
receive surgery only, surgery followed by
radiotherapy or surgery plus chemother-
apy. The five-year survival rates were not
statistically different between the three
arms: 20 per cent, 12 per cent and 19 per
cent, respectively. In an EORTC-initiated
trial, 115 patients were randomised after
surgery in four arms: radiotherapy only;
radiotherapy with short term concurrent
5-FU chemotherapy; radiotherapy with
long term 5-FU and combined short-
and long-term chemotherapy. Again, no
differences in survival were observed. In
summary, radiotherapy as single modality

46 Asian Hospital & Healthcare Management ISSUE - 17 2008


in the postoperative setting may have
a modest favourable impact on locore-
gional control, but does not result in a
survival benefit.
Preoperative radiotherapy
There are several reasons why preoperative
irradiation—with or without chemother-
apy—may be advantageous over postop-
erative radio (chemo-) therapy. First of
all, the dimensions of the radiation fields
can be reduced because of more accurate
target definition. Also, downstaging /
-sizing facilitates surgery, increases the
chance of radicality and provides an
early indication of treatment sensitiv-
ity. Finally, in general, fewer patients are
lost to protracted postoperative recovery.
A Russian trial which randomised 152
patients between surgery alone or radia-
tion one week before surgery showed a
non-significant difference in five-year
overall survival of 30 per cent and 39
per cent, respectively. A large Chinese
prospective randomised trial of 370
patients compared surgery only and
surgery with preoperative radiotherapy.
Five year overall survival was 19.8 per
cent with surgery only and 30.1 per cent
with preoperative radiotherapy (p<0.01).
Resectability (79.4 vs. 89.5 per cent) and
radical resection rates (61.8 vs. 80.1 per
cent) were also superior after preoperative
radiotherapy. Finally, a meta-analysis of
studies comparing surgery with surgery
preceded by radiotherapy, demonstrated
a statistically significant improvement
of three and five-year survival without
an increase in postoperative complica-
tions, while compliance of the radio-
therapy part was 100 per cent. Although
these studies indicate an advantage of
this neo-adjuvant strategy, most of the
current approaches focus on postopera-
tive radiochemotherapy and perioperative
chemotherapy (see below).
Radiotherapy as part of a
multimodality treatment
Postoperative radiochemotherapy
The postoperative delivery of combined
radiotherapy and chemotherapy has been
the topic of several studies. An early
trial from the Mayo Clinic reported on
62 patients with poor prognosis gastric
cancer who were randomised between
surgery and surgery with adjuvant radio-
therapy combined with concurrent 5-
FU. Both five-year survival (23 vs. 4 per
cent, p<0.05) and locoregional control
rates were improved in patients receiving
adjuvant radiochemotherapy. The Eastern
Cooperative Oncology Group (ECOG)
performed a study in patients with
residual or unresectable gastric cancer
randomising between chemotherapy and
5-FU based radiochemotherapy. This trial
failed to demonstrate a clear survival
benefit but did show increased toxicity
after radiochemotherapy.
The Gastrointestinal Tumor Study
Group (GITSG) completed two
randomised studies. In the first one,
90 patients were randomised between
postoperative 5-FU and methyl-CCNU
chemotherapy or split-course radio-
therapy with the same chemotherapy.
At initial analysis chemotherapy was
associated with superior survival (68
vs. 44 per cent), but at five years follow
up the outcome was in favour of the
combination arm: 18 per cent vs. 6 per
cent. In a subsequent study by the same
group (GITSG 8281), a single course
of radiotherapy with concurrent 5-
FU, methyl-CCNU and doxorubicin-
based chemotherapy resulted in a worse
outcome after radiochemotherapy. More
recently, a retrospective study from the
Mayo Clinic in 63 patients indicated
that postoperative 5-FU based radio-
chemotherapy was most beneficial in
those patients without residual disease
upon surgery.
Based on these studies, the SWOG/
Intergroup 0116 randomised 556 patients
between surgery only and surgery plus
postoperative radiochemotherapy. The
adjuvant regimen consisted of 5-FU
and leucovorin for five days, followed
by 45 Gy of radiation over five weeks,
combined with 5-FU and leucovorin
on the first four and the last three days
of radiotherapy. Two five-day cycles
of 5-FU/leucovorin were given after
surgical speciality
completion of the radiochemotherapy
part. Despite significant (mainly hema-
tological and gastrointestinal acute)
toxicity observed in the combination
arm, median overall survival was signifi-
cantly better after radiochemotherapy:
27 vs. 36 months (p=0.005). In addi-
tion, relapse-free survival was prolonged
from 19 months in the postoperative
observation arm to 30 months in the
radiochemotherapy arm (p<0.001).
Although consensus guidelines in the
US now consider postoperative radioche-
motherapy as standard treatment, many
have criticised this study, emphasising the
suboptimal quality of surgery. Indeed,
54 per cent of all patients underwent a
D0 instead of the prescribed D2 lymph
node dissection.
On the other hand, a large obser-
vational study from Korea showed that
544 patients receiving a comparable
radiochemotherapy regimen after a D2
resection had a superior five-year over-
all survival as compared to those who
did not receive adjuvant radiochemo-
therapy: 57.1 per cent vs. 51.0 per cent
(p=0.02). This suggests that postoperative
radiochemotherapy can improve survival
and local control, even after an optimal
D2-resection. In a meta-analysis 5-year
survival was significantly (p<0.00001)
improved in patients who were treated
with postoperative radiochemotherapy,
particularly when radiation doses exceed-
ing 40 Gy were applied and modern
linear accelerators were used.
Another important comment on the
SWOG/Intergroup 0116 study is the fact
that no data on late complications were
provided. We have shown that radioche-
motherapy for gastric cancer is associ-
ated with a progressive decline in renal
function when using common 2D or
3D radiation techniques. Radiotherapy
dose planning studies, however, demon-
strated that modern, Intensity Modulated
RadioTherapy (IMRT) techniques are
able to spare the kidneys and other criti-
cal organs. A final comment relates to
the limited and therefore suboptimal
interaction between radiation and
w w w. a s i a n h h m . c o m 47
surgical speciality
chemotherapy as applied in the SWOG/
Intergroup 0116 study.
Current approaches, including
our own, focus on optimising postop-
erative radiochemotherapy using other
cytostatic agents and more intensified
schedules.
Preoperative chemoradiotherapy
Based on the beneficial effect of preop-
erative radiochemotherapy as demon-
strated in an increasing number of
solid tumours, this approach has been
evaluated in gastric cancer as well. High
rates of radical resections and complete /
partial pathological responses have been
reported in several (small) series. In a
cohort of 33 patients who completed a
preoperative regimen consisting of 5-FU,
leucovorin and cisplatin, followed by
radiotherapy a 70 per cent R0 resection
rate was achieved. Pathological complete
and partial responses were found in 36
per cent and 29 per cent of operated
patients, respectively. Comparable results
were obtained in two other studies using
a preoperative regimen consisting of two
cycles of 5-FU, paclitaxel and cisplatin
followed by radiotherapy with concur-
rent 5-FU and paclitaxel.
A Swiss study also demonstrated
promising results with preoperative cispl-
atin and 5-FU based radiochemotherapy
and hyperfractionated radiotherapy. In
this study, five-year locoregional control
and overall survival were 85 and 35 per
cent, respectively. Finally, a Polish study
in 40 patients demonstrated a R0 rate
of 75 per cent, a pathological response
rate of 38 per cent and two-year survival
of 63 per cent after 5-FU based radio-
chemotherapy. Collectively, these results
illustrate the attractive combination of
the effectiveness of radiochemotherapy
and the advantages of a neo-adjuvant
approach. We therefore emphasise the
importance to further evaluate this
preoperative radiochemotherapy strat-
egy in clinical phase III trials.
Perioperative chemotherapy
Although the role of chemotherapy
as single modality falls somewhat
48 Asian Hospital & Healthcare Management
beyond the scope of this paper, the
most important findings are briefly
discussed. Preoperative or neo-adjuvant
chemotherapy could potentially down-
stage (advanced) gastric cancer and
thereby improves resectability and
survival. Indeed, pilot phase II studies
using this approach showed promising
results.
A randomised study by the Dutch
Gastric Cancer Group, however, was
unable to show a benefit from neo-adju-
vant chemotherapy with a combination
of 5-FU, adriamycin and methotrexate.
Numerous studies have been carried out
using chemotherapy in the postopera-
tive setting. Several meta-analyses of
these studies did not demonstrate a
clinically relevant survival benefit for
adjuvant chemotherapy. It should be
noted, however, that most of these
studies were underpowered and did not
include members of the latest generation
of cytostatic agents.
Recently, a Japanese phase III
study was published that randomised
530 patients to surgery only and 529
to surgery with 1 year of adjuvant S-1,
an oral fluoropyrimidine. All patients
had stage II or III disease and under-
went gastrectomy with D2 lymph-node
dissection. After median follow-up of 2.9
years, overall survival was 80.1 per cent
in the S-1 group versus 70.1 per cent
surgery only group (p=0.002); relapse-
free survival were 72.2 and 59.6 per cent
(p<0.001) respectively.
This study demonstrates that, at least
for Asian patients, prolonged S-1 chemo-
therapy after a D2 dissection improves
outcome. In the United Kingdom,
the Medical Research Council (MRC)
randomised 503 patients with resectable
gastric carcinoma between surgery only
A uthor
Marcel Verheij is a Professor in Translational Radiotherapy at the
Free University in Amsterdam and chairman of the Department of
Radiation Oncology at the Netherlands Cancer Institute-Antoni van
Leeuwenhoek Hospital. Here he holds a clinical / research position
and supervises several basic, translational and clinical research
projects.
ISSUE - 17 2008
and surgery with 3 preoperative and 3
postoperative courses of epirubicin, cispl-
atin and 5-FU (MRC Adjuvant Gastric
Infusional Chemotherapy (MAGIC)
trial). After a median follow-up of four
years, the group receiving perioperative
chemotherapy had an improved five-year
overall (36 vs. 23 per cent; p=0.009)
and progression-free survival (p<0.001),
despite the fact that only 42 per cent
of patients in the chemotherapy group
completed the entire treatment. A French
phase III trial confirmed the improve-
ment of disease free and overall survival
with preoperative 5-FU/cisplatin chemo-
therapy (five-year overall survival 38 vs.
24 per cent; p=0.02).
Concluding remarks
The treatment of gastric cancer is
rapidly changing. Optimal results will
be obtained after radical surgery in
combination with some form of pre-
or postoperative therapy. Which (neo)
adjuvant strategy should be given for
this treatment-resistant tumour is the
subject of various ongoing clinical stud-
ies, but requires careful patient selection,
intensive nutritional support and the
use of state-of-the-art radiotherapy and
optimal cytostatic drugs or biological
agents.
The Dutch Colorectal Cooperative
Group is currently accruing patients in the
CRITICS protocol (Chemoradiotherapy
after Induction chemotherapy In Cancer
of the Stomach; Clinicaltrials.gov
NCT 00407186) a phase III trial that
randomises patients after neo-adjuvant
chemotherapy (ECC— epirubicin, cispla-
tin and capecitabine) and standardised
surgery between postoperative chemo-
therapy (ECC) and 3D- or IMRT-based
radiochemotherapy.
 surgical speciality

Trends in Surgery of
Kidney Tumours
Shift to less invasive and
nephron-sparing techniques

Indications for nephron sparing surgery are expanding. In approach to partial nephrectomy,
open surgery is still the gold standard. Laparoscopic approach is applied only in
carefully selected patients. This method is more challenging, with a higher percentage of
complications, however, it is expanding.

T
he incidence of kidney tumours some articles published recently, which
in Czech Republic is the high- supported nephron sparing surgery in Milan Hora
Head, Department of Urology
est in the world. In 2005, it greater tumours (meaning category Charles University Hospital Plzeň
was in male 34.9 and in female 19.3 of tumour cT1b-2, i.e. tumours over Czech Republic
cases in 100.000 per year. Owing to this 4 cm – T1b or over 7 cm – T2) and
fact, urologists in Czech Republic are
focussed on surgery of kidney tumours.
At our department, we treat over 150 Status post left radical laparoscopic nephrectomy
patients with kidney tumour surgically
every year.
We can define three main trends
in less invasive surgery of kidney
tumours applied up-to-date in everyday
praxis:
1. Expansion of indications for nephron
sparing surgery.
2. Less invasive techniques—laparoscopy
and robotic surgery.
3. Ablative techniques. Of course, a lot
of new technologies and methods are
under investigation but they are still
experimental and are not topics of
this article.

Expansion of indications for

nephron sparing surgery
Broadly accepted indications for nephron
sparing surgery are tumours of category
T1a (less than 4 cm in the greatest diam-
eter) and located peripherally. There were Figure 1

w w w. a s i a n h h m . c o m 49
surgical speciality

in centrally located tumours as well.

Oncological results of nephron sparing Status post right laparoscopic resection of
surgery are worse in T1b than T1a, but papillary renal cell carcinoma of ventral part of kidney
a worsening prognosis as the diameter
increases shows no statistical differences
for either nephron-sparing or radical
surgery. There are three substantial notes
to the technique of partial nephrectomy
(open or laparoscopic):
1. Frozen section has minimal clinical
significance.
2. For surgical margin—minimal layer
is enough.
3. Enucleation has a high risk of incom-
plete excision. Nephron sparing
techniques are not more expensive,
oncological results are good, but
patients profit a lot from saving of
both kidneys.

Less invasive techniques –

Laparoscopy and robotic surgery
Laparoscopic Radical Nephrectomy
(LRNE) in clinical stages T1-2N0M0
is from oncological point-of-view
equivalent of open nephrectomy.
Radical laparoscopic nephrectomy is
accepted even in the EAU (European
Association of Urology) guidelines as
the gold standard for tumours T1-2.
And skilled surgeons are able to perform
this procedure in advanced cases as well
(category T3a-b, N+ = positive lymph
nodes). These advanced cases need care-
ful individual assessment of case with
respect to skills of surgeons. Successful
and safe radical nephrectomy has a lot of
conditions: skilled and patient surgeon
able to convert the operation, skilled
assistants and nurses and good technical
equipment (bipolar instruments, vessel
sealing systems or harmonic scalpel,
staplers, clips with lock, endo-catch bag
like a landing-net for fishes).
Laparoscopic Partial Nephrectomy
(LPN) has intermediate-term oncologic
and functional outcomes (renal func-
tion) similar to those of open in expe-
rienced centres. The main advantage
of LPN is miniinvasivity. But LPN
has its disadvantages as well: It is still
under development. LPN is challeng-
ing, is technically difficult, and needs a
very skilled surgeon and long learning
curve. There is a longer ischemia time,
higher rate of complications, mainly
hemorrhagic. Relatively good results are
published by ‘centres of excellence’ only
and the question is, what will be the
results in everyday urological practice.
At least in the first phase of introduction
LPN to urological departments—only
highly selected tumours can be indi-
cated for LPN. Larger series with longer
follow-up and prospective randomised
studies are needed to confirm the
safety and efficacy of LPN. In solitary
kidney and in chronic kidney disease,
open approach is a preferred method
because in LPN, there is a higher risk of
temporary or permanent dialysis after
operation.
Robotic-assisted radical nephrectomy
is feasible, but today it has probably
no substantial advantages. In robotic-
assisted partial nephrectomy, learning
curve is truncated, it is helpful mainly
Figure 2
in complicate cases due to less difficult
suturing in restrictive spaces (including
tumour of upper pole inaccessible for
regular laparoscopic instrument) and
suturing is faster as well. The most
important disadvantage is price of the
robotic surgery.
In laparoscopic surgery, it is recom-
mended to know the topographic anat-
omy of renal vessels through biphasic
CT angiography. This evaluation needs
high-quality CT (MDCT) scanner.
Ablative techniques
RadioFrequency Ablation (RFA) and
cryoablation are used routinely only.
Other techniques (HIFU, LITT, micro-
waves) are still rather experimental. RFA
and cryoablation are applied percutane-
ously or laparoscopically. Percutaneous
application is really minimally invasive.
Laparoscopic application needs general
anaesthesia of course, but it is technically
strongly easier in comparison with LPN.
But they are still not accepted for every-

50 Asian Hospital & Healthcare Management ISSUE - 17 2008


day practice; some of these methods
can be labelled as experimental and can
be recommended mainly for clinical
trials. The main disadvantage: In situ
destruction of tumours has a risk of
residual tumour. Higher risk of residual
tumour is in RFA (13,4 per cent) than
in cryoablation (3,9 per cent). Due to
this fact, cryoablation seems to be more
reliable than RFA. Cryoablation is a
very promising, safe and feasible tech-
nique with minimal morbidity, excel-
lent shortterm efficacy. Compared
to laparoscopic partial nephrectomy,
laparoscopic cryoablation has some
advantages. Less blood loss, it doesn’t
involve hilar clamping and technically
difficult reconstructive technique, it is
easier to treat less exophytic
tumours. But longer follow
up is needed. Percutaneous
cryoablation is still under
development, monitoring is
possible with MRI, CT and
ultrasonography. Laparoscopic
or percutaneous RFA has no
imaging control of lesion
during ablation, there was indentified
viable tumours cell within treated
lesion due to ‘skipping’ at vessels or
tissue junctions (collecting system).
RFA has a higher rate of local progres-
sion and metastatic progression
compared to cryoablation. RFA at
this time can not be recommended as
a first line treatment modality in abla-
tive techniques.
Routine application of ablative
techniques can be recommended
only in highly selected cases (poly-
morbide patient—but they can be
followed-up only, solitary kidney
mainly with multiple tumours, m. von
Hippel-Lindau—i.e. multiple bilateral
tumours).
We can not forget the broad spec-
trum of experimental methods—micro-
wave therapy—nearly abandoned
technique, HIFU, microwaves, lasers
(LITT—Laser Interstitial Thermal
Therapy, bloodless resections—to date
mainly in animal models), one-port
laparoscopy. One port laparoscopy is
performed through the navel mainly, it
needs special equipment—special port,
articulating graspers end endo-shears
and laparoscope with deflectable tip. It
has a lot of synonyms (SPA—Single Port
Access, SLIPP—Single Laparoscopic
Port Procedure, OPUS—One Port
Umbilical Surgery, E-NOTES –
Embryonal Natural Orifice Transluminal
Endoscopic Surgery). In animal
experiments, scarless laparoscopy is
applied (combination of transgastric and
transvaginal or tranvesical or transco-
lonic approach). These techniques are
not suitable for clinical practice to
date. We can read as well first notes
about using of microrobots working
Compared to laparoscopic
partial nephrectomy, laparoscopic
cryoablation has some advantages.
in abdominal cavity. It sounds to be
fantasy, but can be a reality in the next
ten years.
There has been intensive discus-
sion about the role of follow-up
(active surveillance) instead of surgery
or ablative methods (suitable mainly
for tumours < 3 cm in polymorbide
patients) and the role biopsy has in
this connection. What is the founda-
tion of this approach? There is negli-
gible growth rates in vast majority of
small renal masses (under 3 cm), rapid
growth correlates with higher grade.
Follow-up is an alternative mainly to
the formerly mentioned percutaneous
ablation techniques.
A uthor
Milan Hora is the Associate Professor, head of department of
urology in Charles University Plzeň, Czech Republic. He specialises
in urooncology, mainly for kidney tumour and laparoscopy. He is also
Editor-in-chief of the journal Czech Uroloogy.
surgical speciality
With respect of facts said above,
we can give the algorithm for treat-
ment of kidney tumour under 3 cm.
We have to add 2 important pieces
of knowledge: over 20 per cent are
benign and in renal cell carcinoma is
poorly differentiated (grade 3) in less
than 5 per cent. Preferred method is
laparoscopic resection with following
exceptions—tumour of upper pole
(open resection), centrally located
tumour (laparoscopic nephrectomy or
open resection), moderate risk patient
(percutaneous RFA or laparoscopic
cryoablation) and high risk patient
(follow-up only).
Conclusions
New trends in surgery of kidney
tumours for everyday praxis
are followed: Indications for
nephron sparing surgery are
expanding to cT1b and centrally
located tumours. Laparoscopic
nephrectomy is the gold stand-
ard in cT1-2 and faculta-
tive in cT3a-b, cTXN1-2. In
approach to partial nephrectomy,
open surgery is still the gold standard.
Laparoscopic approach is applied only in
carefully selected patients. This
method is more challenging, with a
higher percentage of complications,
however, it is getting popular. Robotic
systems make laparoscopic partial
nephrectomy easier. Laparoscopic
or percutaneous in situ destruction
are still experimental methods and
are recommended only in highly
selected cases or in clinical trials.
Cryoablation is safer than RFA. High-
risk patients with a tumour diameter
under 3 cm can only be followed-up
as well.
w w w. a s i a n h h m . c o m 51
 G
ood health for all populations
is a recognised international
goal. There have been broad
gains in life expectancy over the past
century, but the health inequalities
between the rich and the poor still
persist. The prospects for future health
depend increasingly on the relatively
complicated process of globalisation.
Health is not only a benefit of devel-
opment, but is also indispensable to
development. Illness too often leads
to ‘medical poverty traps’, creating a
vicious circle of poor nutrition, forgone
education and more illness. All of these
undermine the economic growth that
is necessary, although not sufficient,
for widespread improvements in health
status. Social determinants of health,
broadly stated, are the conditions under
which people live and work, which
affect their opportunities to lead healthy
lives. Good medical care is vital, but
unless the root social causes that under-
mine people’s health are addressed, the
opportunity for well-being cannot be
achieved.
Globalisation results in greater
integration within the world econ-
omy, through movements of goods
and services, capital, technology and
labour, which leads increasingly to
economic decisions being influenced
by global conditions. This resulted in
the increasing interdependence and
interaction among people, companies,
and governments of different nations,
driven by international trade and made
possible by innovations in information
technology. Globalisation has become a
two-way street as developed and devel-
oping countries tap each other’s markets
and economies creating a virtual world
labour and market force. Globalisation
52 Asian Hospital & Healthcare Management
today is viewed as a more comprehen- a stake on the potential profits of
sive phenomenon which is being shaped globalisation.
by a multitude of factors and events In the medical domain, economic
but at the same time is reshaping our aspects of globalisation of healthcare have
society rapidly. been the driving force behind the overall
Globalisation should not be seen process of globalisation over the last two
as a process that is inherently ‘bad’ or decades. Irrespective of the state of devel-
‘good’ but rather, a process capable of opment, globalisation has resulted in the
both positive and negative outcomes. increased speed with which information
The outcomes of globalisation are about new treatments, technologies and
entirely dependent on how policies are strategies for health promotion can be
guided and implemented. The promo- diffused. There are also more opportuni-
tion and resistance of globalisation ties for enhanced political participation
has taken shape both at a population and social inclusion that are offered by
and governmental level. It is believed new, potentially widely accessible forms
that such efforts can only hope to of electronic communication.
steer globalisation and not alter it. The consumer of the 21st century
Sadly, globalisation, to a large extent, is increasingly critical of quality and
appears to have economically benefited service, but more importantly he wants
the heavily industrialised countries the consultation, diagnosis and treat-
with serious adverse consequences ment, and if possible, cure, right there!
for developing nations, with some In addition, these consumers have
notable exceptions. They are alternative educated themselves on their medical
pathways for developing countries condition and are prepared to question
to allow a more gradual approach to their healthcare provider on the choices
introducing market economics thus available to them. They even come with
allowing developing nations to claim stacks of printed copies of information
The emergent global marketplace has following features
• New global governance structure influences the interdependence among nations as
well as the nation state’s sovereignty
• It is characterised by the emergence of global markets and a global trading system
• Global communication and diffusion of information enable the sharing of information
and the exchange of experiences around common problems
• Global mobility resulted in a major increase in the extent, intensity and speed of
movements and by a wide variety in ‘types’ of mobility
• Cross-cultural interaction between global and local cultural elements
• Global environmental changes threatening the ecosystems include global climate
change, loss of biodiversity, global ozone depletion and global decline in natural
resources.
ISSUE - 17 2008
With the increasing
complexity of
globalisation, escalating
cost of healthcare
and rapid advances
in technology—both
equipment and IT—the
challenges and choices
facing the practising
physician, managers and
leaders are daunting. The
effects of these changes
on patient care may be
even more difficult
to discern.

Basri JJ Abdullah, Professor

Ranjit Kaur, Lecturer
Department of Biomedical Imaging Faculty of Medicine, University of Malaya, Malaysia

downloaded from the Internet for confir-
mation and clarification. The increased
presence of the Personal Health Records
(PHR), centered on consumer, is empow-
ering them with full control over their
healthcare needs. It is not unthinkable
for them to insist that their health infor-
mation is updated into their records for
second opinion and safe keeping. They
will become their own gatekeepers.
With the growing trend in healthcare
toward higher operational costs, reduced
reimbursement and heightened compe-
tition among imaging service provid-
ers, healthcare facilities must carefully
plan capital equipment acquisitions
and budgets. Many of today’s high-end
modalities such as CT, MRI and PET /
CT are multi-million dollar purchases
that require strategic planning for imple-
mentation as well as detailed market-
ing initiatives that can help maximise
utilisation.
For organisations or practices to
remain competitive in this global envi-
ronment, they must recognise the new
healthcare marketplace and its effects on
their practices. These changes encompass
health consumerism, marketing, service,
recruiting and the networks.

w w w. a s i a n h h m . c o m 53
 Global marketing
While consumers search the Internet to
gain better knowledge about their health
and medical conditions, they are also
seeking out the most attractive healthcare
provider locally, regionally and inter-
nationally. They look at comments by
third-party providers and by the patients
themselves on blogs or testimonials.
Virtual services
Healthcare providers must now make
their services more readily accessible than
was ever physically possible and at an
amazingly reduced cost. Already, this
inevitability has reached the individual
clinician where doctors / institutions /
service providers recognise that Web-
based technologies will inevitably become
more central to their work.
Health tourism is another conse-
quence of this trend where we will see
greater collaboration between services and
54 Asian Hospital & Healthcare Management
centres across oceans providing complex
care. For example, health insurance
companies providing services for their
clients in other nations. The rationale
being increased speed of care at lower
cost with a seaside holiday thrown in
for recovery.
Global / Virtual recruiting
There is increasingly much broader and
more severe worldwide shortage of health-
care workers than the periodic shortages
over the past four decades. This short-
age reflects growing demand, shifting
demographics, a change in career expec-
tations and attitudes about work, and
worker dissatisfaction within healthcare
as well as greater mobility and interna-
tional recognition. To meet this demand,
providers will be forced to recruit staff
worldwide taking into consideration the
heterogeneous needs of workers from
various cultures.
ISSUE - 17 2008
Global networks
Global networks in medicine have
allowed individuals an access to organi-
sational and business linkages in both
international health and global medi-
cine. These networks have promoted
cooperative relationships in areas such
as standards and formulation of practice
guidelines, research in multi-centre and
multinational trials, visitor exchange,
humanitarian service as well as medicine
and supply donation.
Even though branding is very often
used to sell products with no real value
beyond what is often perceived by the
buyer, the promotion of vital and good
technology i.e. digital image manage-
ment, in the bigger picture may be point-
less unless its ‘brand’ is perceived to be of
value and requires the necessary buy-in
from governments, professionals, manag-
ers and the public. Therefore, the use of
price as the sole criterion for success in
the information-based industry may not
be enough as the tools for conducting
business electronically are low.
Other than medical imaging, digital
imaging and Information Technology
(IT) are also productivity drivers as they
allow providers to better manage vast
volumes of data at a lower cost. The
prevailing perception amongst hospi-
tal administrators and physicians is that
implementation of IT will provide a
competitive advantage. The better use of
technology and interoperable electronic
networks should accelerate integration;
standardisation and knowledge trans-
fer of the administrative and clinical
information especially in the context of
the globalisation of healthcare and efforts
in many countries to create a sustainable
health system. Only two elements exist
in a connected world: the customer and
the information. The key to the former
lies in managing the latter.
There is a trend toward using IT
solutions and sophisticated practice
management tools to help physicians
and administrators manage their practice
as a business. It is envisioned that the
key business data would be seamlessly
available for decision support. This could
cut costs by identifying and managing
process inefficiencies and track revenues
to improve business. Ultimately, it is
hoped that such use of data-mining
would result in better outcomes, more
cost-effective processes and overall
improved healthcare.
The future of healthcare outsourc-
ing and offshore services will vary
across the provider, payer, and supplier
sectors. The jury is still out, since major
challenges occur when one looks at issues
of cross-border transfer of digital image
information whether for purposes of read-
ing or management. This is, in part, due
to the highly regulatory environment
and national compliance requirements.
It is essential that organisations consider
the use of offshore services as a strategic
tool which must be integrated with their
business model. For example, would the
offshore services support and improve the
As the accrued benefits of globalisation vary between the
developed and less-developed nations, globalisation of healthcare
raises some serious issues including:
• How can countries deal with globalisation in the context of their existing cultures,
beliefs, resources and systems?
• How do we deal with the impact of globalisation on the healthcare delivery systems
of the various jurisdictions?
• How does one cope with the massive impact on a country’s economy of claiming a
share of the economic activity that the health industries and service sectors represent,
which incidentally is the largest industry on a global scale?
• How can developing nations protect their indigenous treatments from being patented
in industrialised nations?
• How can the serious brain drain of the limited healthcare personnel from developing
nations toward the industrialised West be moderated to ensure the needy have access
to the services of this invaluable resource?
• What mechanisms should be in place to ensure universal access to essential
medication and basic imaging facilities
organisation’s overall ability to deliver the “happening” community or hospital
quality services? Would patient safety at the forefront of healthcare!
or improved care delivery efficiencies Would the accrual of benefits high-
and service levels get better? lighted for the developed nations be
On the downside, the implemen- applicable to others? At what level and
tation of sophisticated healthcare IT at what cost? What models will be most
systems requires heavy initial investment. appropriate for this wide range of devel-
Upgrades or changes to the systems to opment states? What level of technol-
stay current come with risks and inconve- ogy would be most appropriate? What
nience to the users who have to learn to necessary actions have to be taken by
use a variety of different logins, platforms nations to make IT deliver its potential
and formats to access the data mergers, and promise in healthcare sector? Is the
and acquisitions between organisations— promotion of healthcare information
big and small and raises additional issues technology relevant? Are doctors to be
of integration of the digital management equally blamed for these excesses as a result
systems. of creative marketing? We may not have
In addtion, the role of IT in health- the answers today, but these are the issues
care in developing nations, where the that we must face sooner or later.
basic healthcare needs have not been
met, has not been clearly defined. Conclusion
Technology is very often promoted as the The increasingly complex and integrated
saviour to overcome the myriad of chal- world is blurring the borders between
lenges faced by developing nations. economics, culture and politics. This has
Technology is not infrequently seen as an resulted in changes in how our societ-
end in itself and not an enabler. Nations ies function today. These changes have
are often seduced into acquiring expensive the potential for serious consequences,
technology because it is seen as sexy! Or, which challenge the economic and politi-
technology is acquired as a marketing cal stability of the world. However, these
tool to convince the public that this is very changes could provide tremendous
w w w. a s i a n h h m . c o m 55
 opportunity for us to create a better
world. Therefore, to comprehend the
interconnected nature of a globalised
world and to understand the conse-
quences of our policy choices and
grasp the new face of the world, all of
us need to understand how globalisation
works, what policy choices we have now,
and what are the consequences of such
choices. While thoughtful, deliberate,
and innovative leadership is necessary
to help shape globalisation, the process
itself is inevitable, even if the final form
may be very different.
Due to the rising costs of living, access
to affordable health has become an area
of increased concern to the public. The
need to embrace sustainable development
that ensures equitable access to healthcare
for our future generations is both a neces-
sity and yet a tremendous challenge in
view of the different perspectives, priori-
56 Asian Hospital & Healthcare Management
ties and interests between the nations, care costs while providing high-quality
governments, business and communities. care and universal access is nothing less
Even though we are unable to predict than an exercise in leadership for this
the future, we have an opportunity to 21st century.
shape our operating systems, determine
the future scope and design of our health- References are available at
care systems. The need to balance health- http://www.asianhhm.com/magazine
Basri JJ Abdullah is currently teaching at the Department of
Biomedical Imaging, University of Malaya and Consultant Radiologist
A uthors at the Biomedical Imaging Unit, University of Malaya Medical Centre.
He is currently a member of the Executive Committee of the Asian
Ocean Society of Radiology as well as the President of the ASEAN
Association of Interventional Radiology and Treasurer for the ASEAN
Association of Academic Radiologists.
Ranjit Kaur is currently a lecturer in the Department of Biomedical
Imaging, University of Malaya and Consultant Radiologist at the
Biomedical Imaging Unit, University of Malaya Medical Centre. Ranjit
is currently actively involved in women’s imaging and musculoskeletal
radiology. She is also a fellow of the Royal College of Radiologists.
ISSUE - 17 2008
 D iagnostics

Echocardiography
New and evolving roles

Echocardiography plays a key role in the diagnosis of many cardiac conditions

and in the assessment of response to therapies. Despite the emergence of new,
advanced diagnostic tools such as cardiac computer tomography and cardiac
magnetic resonance, echocardiography still plays an important role in patient care
because of its unique capabilities.

• monitoring cardiac side effects in Point-of-care echocardiography –

Michael H Picard patients undergoing chemotherapy
Director for cancer,
Echocardiography • providing perfusion imaging and
Massachusetts General Hospital
USA
• helping in the early detection of
subclinical disease.
This review will briefly highlight
some of these exciting new areas.
Miniaturisation
Echocardiography has two main advan-
tages: mobility—it can be brought to the
patient bedside very easily—and capa-
bility to provide real-time assessment
(immediate processing of images without
any delay). In fact, ultrasound machines

N
on-invasive imaging of the
Real-time three-dimensional transesophageal
heart continues to evolve echocardiographic view of the mitral valve
and improve. Cardiovascular
ultrasound or echocardiography contin-
ues to play a key role in the diagnosis
and assessment of response to ther-
apy of many cardiac conditions. The
advantages of echocardiography are that
it is a safe non-invasive test without
radiation exposure and is a relatively
inexpensive method to rapidly evaluate
the structure and functions of heart.
New uses for echocardiography
include :
• providing point-of-care cardiac imag-
ing with miniaturised transthoracic
echocardiographic devices
• three-dimensional transesophageal
echocardiography for assessment of
valve disease prior to surgical and
transcatheter repair
• two-dimensional and three-dimensional
transesophageal echocardiography for
guiding catheter-based interventions The valve is viewed from the perspective of the left atrium which is similar to the manner
in which a surgeon would visualise the valve during an operation. A = atrial surface of
• playing a key role in personalised
anterior mitral valve leaflet; P = atrial surface of posterior mitral valve leaflet
genetic medicine
Figure 1

w w w. a s i a n h h m . c o m 57
diagnostics
Catheter-based procedures utilising
echocardiographic guidance
Percutaneous closure
• Patent foramen ovale
• Atrial septal defect (secundum type)
• Ventricular septal defect newly developed devices. Percutaneous
(muscular and membranous types)
• Paravalvular leak
• Aortic pseudoaneurysm
Percutaneous valve repair/replacement
• Mitral valve (repair)
• Aortic Valve (replacement)
Percutaneous mitral valvuloplasty
Left atrial appendage exclusion
Alcohol septal ablation
• Hypertrophic cardiomyopathy
Table 1
continue to evolve such that full capabili-
ties including three-dimensional echo,
two-dimensional echo, transesophageal
echo, spectral and colour Doppler imag-
ing, strain rate imaging and even intracar-
diac imaging can be performed on devices
that are increasingly smaller in size. Some
of these machines are now as small as or
smaller than a laptop computer. Thus,
it is easier to provide echocardiography
anywhere in a hospital, office or other
environments including underserved
areas of the world.
Three-dimensional
echocardiography
Much of medical imaging has switched
to three-dimensional (3D) display and
this is true even with echocardiogra-
phy. Real-time 3D echo imaging is
in its infancy and we are still learning
its strengths and weaknesses. To date,
however, the transthoracic 3D echo has
shown value in accurately assessing the
contractile function of the left ventricle
and the transesophageal 3D approach
has helped in improving the visualisa-
tion of some of the valve pathologies
(Figure 1). Standard machines are now
outfitted with the hardware and soft-
ware to perform real-time 3D echocar-
diographic imaging.
58 Asian Hospital & Healthcare Management
Guiding cardiac interventions
Many cardiovascular procedures that
once were performed in the operating
room and required open heart surgery
can now be performed with catheters in
a much less invasive manner, thanks to
coronary interventions such as balloon
angioplasty and coronary artery stent
placement are the most common exam-
ples of this evolution in cardiovascular
care. However, there are many other new
treatment opportunities in the cathe-
terisation laboratory that require imag-
ing of the heart in a manner different
from routine fluoroscopy so that the
position of the devices can be optimised
(Figure 2). By virtue of its ease of use,
safety, lack of radiation, low cost and
portability, echocardiography has come
to play a key role in selecting patients
for and guiding these procedures.
Table 1 lists some of these representative
procedures.
For example, recently transcatheter
percutaneous delivery of prosthetic aortic
valves—an aortic valve replacement
without a chest incision or cardiopul-
monary bypass—has become possible.
To achieve this, an expandable stented
bioprosthetic valve is mounted onto and
delivered to the correct location by a
balloon catheter. Echocardiography has
helped refine this technique in several
ways. The echocardiogram is used 1) to
help select potential patients with severe
aortic stenosis, 2) to guide delivery of
the transcatheter valve, 3) to assess the
integrity of the device once it is deployed
and determine if repeat balloon inflations
are required for optimum position and
function, and 4) to follow the durability
of the new valve.
Efforts are now underway to regener-
ate portions of diseased hearts through
the delivery of stem cells, genes and small
molecules. Current investigations involve
patients with ventricular dysfunction
from extensive myocardial infarction and
other cardiomyopathies. While catheters
can perform the delivery, imaging such
as with transthoracic, transesophageal or
ISSUE - 17 2008
intracardiac echocardiography is critical
to identify the diseased portions of the
heart and direct the delivery catheters
to specific regions.
There are many other examples of
how echocardiography has helped in
minimising the invasive procedures. All
of these examples highlight a future role
of the cardiac imager and echocardiog-
raphy for identification of appropriate
patients for these less invasive treat-
ments and in the real-time guidance of
the procedure.
A role in genetic medicine
Echocardiography has played a major role
in advancing our understanding of cardi-
ovascular physiology, disease mechanisms
and even treatment development. There
is hope that in the near future we will be
delivering care in a new way based on the
genetic characteristics of each individual.
This has been termed Personalised or
Genetic Medicine. However, before we
can enter this phase we need to under-
stand what role various genes play in
the cardiovascular system.
Echocardiography has a role in this
arena since it allows for descriptions or
phenotyping of cardiac structure and
function which can be related to various
genes. Two examples where echocardio-
graphic identification of pathology can
be linked to genetic characteristics are
arrhythmogenic right ventricular dyspla-
sia and hypertrophic cardiomyopathy.
Arrhythmogenic Right Ventricular
Dysplasia (ARVD) is a rare cardiomy-
opathy predominantly affecting young
adults but it accounts for up to 5 per
cent of the cases of sudden death in
young adults. Interestingly, vigorous
athletic activity is a common trait of
these individuals. Affected individu-
als frequently have palpitations and
ventricular arrhythmias. Pathologically,
RV dilation and fat infiltration of the
RV free wall are seen. The echocardio-
graphic features include RV aneurysms,
RV enlargement, regional RV dysfunc-
tion and RV trabecular derangement.
Recently a variety of mutations have been

Echocardiographic
imaging of
Atrial Septal Defects
(ASD)
during transcatheter
closure
Two-dimensional transesophageal
echocardiographic image of a secundum
ASD between the left atrium (LA) and
right atrium (RA)
Two-dimensional transesophageal
echocardiographic image of a secundum
ASD closed by an Amplatzer ASD closure
device (SVC = superior vena cava)
The Amplatzer ASD closure device
attached to a catheter
Real-time three-dimensional
transesophageal echocardiographic view
of the interatrial septum and its secundum
defect (*) viewed from the right atrium
Real-time three-dimensional
echocardiographic “en face” view of the
Amplatzer closure device (+) from the
left atrial perspective showing that it has
effectively sealed the defect.
Figure 2
diagnostics
identified in ARVD patients in genes
coding for the desmosomes. The desmo-
somes are proteins responsible for cell
to cell adhesion. It is hypothesised
that defective desmosomal proteins
permit loosening of the myocardial
cellular bonds and this initiates a series
of events in which there is fatty and
fibrous replacement of myocardial cells.
In turn, this leads to ventricular arrhyth-
mias and dysfunction. This degenerative
process may be accelerated by exercise
as this increases contractile load on the
cell to cell bonds and would first be
noted in the RV which is more vulner-
able than the thicker LV. At present it
is not cost- or time-effective to embark
on a search for genetic mutations in all
people with PVCs. However, echocardi-
ography can help to identify those with
the phenotype of abnormal right ventri-
cles. Echocardiography thus provides an
opportunity to narrow down the search
and identify only those individuals and
their families who need to undergo more
intensive genetic work ups and treat-
ment.
Hypertrophic cardiomyopathy includes
a spectrum of myocardial diseases with
regional or diffuse ventricular hypertrophy
with or without a component of obstruc-
tion to outflow of blood from the left
ventricle. Though it is among the most
common causes of syncope and sudden
death in young athletes, it does affect all
the age groups. Mutations or defects in
genes encoding several components of
heart muscle have been identified in this
disease. Similar to ARVD discussed above,
the structural abnormalities in this disease
are evident on echocardiography. As it
is not cost-effective to perform genetic
analyses at present on all patients with
syncope or sudden death, the echocardio-
gram can be used as an initial screen for
the disease thus narrowing the population
for the genetic evaluation. In addition,
echocardiography can identify those
patients who will benefit from treatments
such as surgical removal of obstructing
heart muscle or the new catheter-based
treatment to reduce obstruction.
w w w. a s i a n h h m . c o m 59
diagnostics

Monitoring and reducing side
effects from chemotherapy for
cancer
Deaths from cancer have not declined
to the degree that heart disease mortal-
ity has improved but there continues to
be significant advances in cancer treat-
ment. Unfortunately, there is a dark
side to some of these treatments. It is
well known that some of the popular
chemotherapeutic agents have toxic and
irreversible effects on myocardial func-
tion. Echocardiography is used to moni-
tor cardiac function to enable patients to
receive optimum doses of chemotherapy.
This allows patients to receive the treat-
ments without development of signifi-
cant decreases in left ventricular function. wall motion in a fashion similar to current
With echocardiography, we are
also gaining insights as to why
these cardiac side effects occur
and this may help in devising new
treatment strategies to reduce the
side effects. One explanation for
this cardiotoxicity involves free
radical production that results
in cardiomyocyte cell death also
known as apoptosis. Once symptomatic,
recovery from this cardiac dysfunction
is rare. So, our challenge is to find the
tools that identify cardiac effects of the
chemotherapy before they are clinically
evident so that doses can be modified or
not given and thus prevent irreversible
heart failure. Likewise, we need these tools
to be able to tell us when it is safe to
continue the drugs. Investigations with
echocardiography are currently under-
way to try to identify those markers of
subclinical cardiac dysfunction. Thus, our
future use of echocardiography in patients
undergoing certain cancer treatments may
be more than just a monitoring of the
development of cardiac dysfunction.
injected intravenously they travel through
systemic and pulmonary circulations.
Newer agents with enhanced stability
and which can be easily be detected in
the myocardium are thus capable of func-
tioning as a marker of coronary artery
perfusion. Such agents are currently
under development. Preliminary trials
of these agents suggest that when they
are combined with vasodilator stress, the
transthoracic echocardiogram can accu-
rately assess myocardial perfusion and
detect significant coronary artery disease.
If these observations hold true in larger
clinical trials, then stress echocardiog-
raphy could evolve to combine imaging
of myocardial perfusion and regional LV
Echocardiography also has a future role
in the public health disorders of diabetes,
obesity and metabolic syndrome.
radionuclide tests. The advantages of the
echocardiographic approach include no
radiation, a rapid real-time assessment,
lower cost and the fact that additional
structures such as heart valves, other
chambers and the pericardium can be
evaluated at the same time.
Early detection of cardiac disease in
risk populations
Echocardiography also has a future role
in the public health disorders of diabetes, to patient care, the future for echocardi-
obesity and metabolic syndrome. Heart
disease is an important component of
all of these disorders. Novel echocardio-
graphic techniques can identify subtle
involvement of the heart in these diseases
and thus trigger interventions at early
stages of the cardiac risk—when the
chances are higher that such efforts will
reduce development of cardiac disease. It
remains to be seen, however, if interven-
tions on patients identified with these early
echocardiographic markers of dysfunction
can improve outcomes. If such a link is
established, then it is exciting to think
of how we can utilise the miniaturised
point-of-care echocardiographic machines
to screen large populations at risk, identify
those who would benefit from interven-
tions and potentially reduce the worldwide
burden of cardiac disease.
Appropriate utilisation of
echocardiography
With these limited examples one
can see the broad spectrum of
future applications of echocardi-
ography. However, there is also
a danger of over-utilisation of
echocardiography and that would
add unnecessary costs to health-
care systems. To prevent such a
problem, it is critical that all who utilise
echocardiography practice appropriate
use of the technology. Although there
are complementary roles for various
cardiac imaging techniques, it is should
be ensured that there is no unnecessary
redundancy.
Conclusion
Due to new and evolving uses of non-
invasive cardiac imaging that are critical
ography remains bright. Cardiovascular
ultrasound, therefore, will stay viable and
its uses in clinical care and research are
bound to grow in the future.

Perfusion imaging
A uthor

Michael H Picard is the Director of the Clinical Echocardiography at

Echocardiographic contrast agents are
utilised to enhance image quality and
especially to improve the detection of left
ventricular endocardial borders. These are
microbubbles and microspheres that are
smaller than red blood cells and when
Massachusetts General Hospital and he is the Associate Professor
of Medicine at Harvard Medical School. Among the awards he
has received are the Young Investigator Award from the American
College of Cardiology and the Richard Popp Award for Excellence in
Teaching from the American Society of Echocardiography.

60 Asian Hospital & Healthcare Management ISSUE - 17 2008

 diagnostics

Diagnostics for the

Developing World
Challenges and constraints

In view of limited funding for healthcare, there is a great need and potential for
simple, high quality and affordable diagnostic products in the developing world. At
present, Immunochromatography-based Rapid Diagnostic Tests are able to meet
their requirement to some extent. Innovative molecular diagnostic tools are seen
as the future successful products.

from inadequate preventive measures building resistance to conventional

Natarajan Sriram such as improper sanitation, hygiene
Director, Tulip Group
Orchid Biomedical Systems and vector control, one of the most
India important reasons for the failure to
cure these diseases is inappropriate
treatment. As the treatment interven-
tions are largely empirical and based
drugs.
Effective diagnosis is a prerequisite
for successful therapy and early and
accurate diagnosis results in timely and
appropriate treatment.
In vitro Diagnostic (IVD) tools are

T
he healthcare challenges faced on clinical diagnosis, wrong treatment available for providing effective diag-
by the developing countries arising out of misdiagnosis not only nosis. IVD includes a broad spectrum
are vastly different from those increases the cost of treatment by way of technologies and technological plat-
in the developed nations. Owing to of further costly interventions, but forms comprising reagents, test kits and
the high poverty levels, there is a great could also lead to morbidity and equipments. These are used singly or in
dependency on the state for healthcare, mortality. It is also the main cause for combination to detect / estimate specific
the delivery of which has at best been
mediocre and highly mismanaged. Region-wise segmentation
With very limited budgets available of global IVD markets
for healthcare, the developing coun-
tries have not been able to put up any
significant infrastructure to address Europe Asia
their huge disease burden. The resulting
high morbidity and mortality rates and 34% 15%
huge treatment costs further impact
their economies. Lack of clear cut
policies and a poor regulatory envi- 11% ROW
ronment further add to the suffering
of the people.
Treatable and manageable infec-
tions and communicable diseases
43%
such as Tuberculosis, Malaria, HIV,
Typhoid and Dengue still take a huge
toll on the populations and econo-
mies of the developing world. Apart USA Figure 1

w w w. a s i a n h h m . c o m 61
diagnostics
analytes and disease-specific markers in
specimen such as blood, urine, saliva,
tears, cerebrospinal fluid and other
body fluids, stool and tissues outside
the body.
IVDs are used in human healthcare
for various purposes. These include:
1. Accurate diagnosis of clinical condi-
tion and disease; 2. Screening population
for disease / disease prevalence / disease
predisposition; 3. Prenatal and postnatal
screening; 4. Transfusion medicine—
screening of blood for compatibility and
blood-borne diseases; 5. Clinical manage-
ment of patients—monitoring treatment
and treatment efficacy; 6. Detecting treat-
ment failures / drug resistance; 7. Disease
surveillance / epidemiology.
However, as can be seen from the
worldwide market analysis of IVDs in
figure 1, there is very limited usage of
these tools in the developing world.
Almost 85 per cent of the global IVD
market is dominated by USA, Europe
and Japan. (Figure 1)
USA itself accounts for over 43 per
cent of the market. Asia contributes to
15 per cent of this market followed by
rest of the world at 11 per cent.
The reasons why IVDs are not
widely used for diagnosis in the devel-
oping world are:
• Affordability. Limited funds for health-
care
• Lack of priority for diagnostics over
treatment
• Non-availability of relevant and appro-
priate kits
• Lack of laboratory infrastructure
• Lack of trained laboratory
manpower
• Lack of awareness
• Logistic issues such as storage, pack
size, shelf life, transportation etc.
• Poor regulatory and quality control
environment
• Lack of direction / initiative in this
regard.
Keeping these reasons in mind,
the challenges in inducting IVDs as a
part of health intervention in resource
poor countries can be summarised as:
62 Asian Hospital & Healthcare Management
An ideal IVD tool for the developing or trained manpower and have a
world should, therefore, have the long shelf life at ambient conditions.
following features: They are also ideal for use as Point-
of-Care Tests (POCT) where the
• Adequate sensitivity and specificity testing can be done alongside the
patient in any setting. Some exam-
• Reliability and accuracy
ples are:
• Potential to provide quick results and
While they have made a significant
minimum hands on time
impact in diagnosis of some diseases
• Simple and minimum procedure such as malaria and HIV, RDTs for
• All the required features not needing many more diseases are available
any additional equipment and / or and are in the process of integrating
accessories
into healthcare systems. However,
• Minimal training without need for RDTs still have limitations of sensi-
specialised staff tivity and specificity for many
• No special storage conditions and conditions and hence, further improve-
long shelf life ments and refinement is required in
• Smallest pack size this technology to make these tests
• Single testing and batch testing more universal.
possibility Currently, molecular diagnostic
• Self-validation of each test platforms that allow direct detec-
• Lowest effective cost per test. tion of target DNA / RNA of the
infecting organism require instru-
• Making available affordable, practical Rapid test for HIV
and relevant and high quality diag-
nostic kits
• Strategising health programmes to
include diagnostics for better disease
management
• Creating uniform regulatory mecha-
nism and quality assurance system
• Mobilisation of funds to meet the
above objective
• Comprehensive insurance / social
security to cover diagnostics
• Focussed research and funding for
development of new reagents / markers
and for new and emerging technolo- Rapid test for malaria
gies
• Mass education and awareness
campaigns, especially in endemic
Negative
areas.
In the last few years, the develop-
ing markets have seen a significant PV Positive
rise in the use of Rapid Diagnostic
Tests (RDTs) that meet most of
Pf Positive
the criteria of an ideal IVD. RDTs,
as the name indicates, provide quick
results (5-30 minutes), are simple, Positive mixed infection
user-friendly, ready to use products
that do not require instrumentation Figure 2
ISSUE - 17 2008
 diagnostics

mentation, trained manpower, special
storage conditions, special laboratory
infrastructure etc. and hence are not
ideal for the developing countries.
However, the future is likely to see
the development of novel, simple and
inexpensive molecular platforms and
other technologies such as microfuid-
ics and nanotechnology that could be
used for better disease management in
these countries.
Humanitarian and aid agencies
are playing a big role in providing
and encouraging the use of IVDs
in developing countries. The global
fund for malaria, HIV and TB is also
such as WHO, FIND, DFID etc. are
funding projects to provide better
and novel technologies for the devel-
oping world including the develop-
ment of IVDs for ‘orphan’ diseases
that were earlier neglected by the
industry for the lack of profit motif.
There is also tremendous activity in the
industry itself with many regional play-
ers entering the market with better qual-
ity products and creating a competitive
environment that can only see more
Natarajan Sriram is the founder Director / Managing Partner of a
A uthor
novel products, higher standards of
quality at more affordable prices.
All these efforts are bound to
bring about a big change in the health-
care strategies of the developing world
in the coming years. These strategies
will help to mitigate the sufferings
of millions of people, improve their
quality of life, reduce disease burden
of the country and also make a posi-
tive impact on the economies of these
countries.

group of companies under the banner of “Tulip Group”, all in the

making available funds for procurement
of IVDs by the recipient countries.
World Health Organization (WHO)
is playing an important role in setting
quality standards and evaluation criteria
for ensuring the quality of IVDs by
procurement agencies. Organisations
field of medical biotechnology, based in Goa, India and manufactur-
ing and marketing a range of medical diagnostic reagents and kits.
He is a panel member of Diagnostics Evaluation Experts Panel set
up by the WHO, functioning as a temporary advisor to WHO. He
was also a panel member of the experts committee set up by the
Drugs Controller General (India) that formulated the current national
Diagnostics Guidelines.

w w w. a s i a n h h m . c o m 63
 Asian Diagnostics Market
Emerging opportunities

Suresh Vazirani
Chairman & Managing Director
Transasia Bio-Medicals Ltd. Advances in nanotechnology and genomics have
India
enhanced the role of diagnostics in the healthcare
market, allowing more tests to be performed at
the point-of-care and facilitating the shift towards
personalized medicine.
What are your views on the Asian diag-
nostics market? How has it evolved over
the past decade?
Asia’s ageing population is expected to
double by 2025, increasing the number
of people likely to require medical treat-
ment. Rising average life expectancies
along with more affluent populations is
expected to boost expenditure on health-
care treatments, including IVD.
Currently, lack of proper health
insurance in most countries coupled
with constrained personal finances has
resulted in low levels of consumer spend-
ing. In the absence of a strong medical
insurance sector, most of the healthcare
expenditure is borne by the individuals
themselves especially in countries like
India and China.
The Asian In Vitro Diagnostics (IVD)
market has, over the past few years, been
the only market experiencing a double-
digit growth rate. A growing and ageing
population and widening health insur-
ance penetration are advancing growth
opportunities in this high potential
market.
For the Emerging technologies in
the IVD Industry, Lab automation
continues to evolve. The drive or thrust ating procedures. Thus, made to order to actually get instruments interfaced to
for smaller, faster and more accessible solutions need to be developed for these various laboratory information systems.
devices is increasing. Emerging markets markets. Information technology has taken a
have different needs with respect to the Lab automation has also taken on a giant leap in the IVD industry thereby
test menus, technologies used and oper- new level of importance in the ability reducing the dependence on a technically

64 Asian Hospital & Healthcare Management ISSUE - 17 2008


qualified individual to be present at all
times during the analytical procedure
without compromising on established
levels of care.
Delivering the right data in a timely
and cost effective manner while improving
the sensitivity and specificity of the test
is the need of the hour and the industry
needs to gear up for single workstations
that can carry multiple workloads.
The diagnostics market in India has been
growing steadily over the years, what
areas of growth are likely to drive the
market here?
The emerging industry structure is headed
towards providing healthcare services as
an integrated comprehensive package
rather than the traditional concept of
providing healthcare infrastructure and
reactive medical care. Growing health
consciousness among middle and high-
income families in India is heralding a
new business opportunity—Preventive
healthcare. This has shifted focus from
in-patient treatment to a regular preven-
tive health check. Corporates offer annual
health check for their employees; insur-
ance companies conduct pre-insur-
ance policy check; and self paid health
checks have also led to the growth in
the market.
Today the diagnostics business is
mainly based on technology. The Indian
companies with their R&D facilities have
developed a range of good quality prod-
ucts for the local market amidst fierce
competition.
What are the new technologies driving
today’s diagnostics market?
The global diagnostics market is under-
going radical change. Advances in
nanotechnology and genomics have
enhanced the role of diagnostics in
the healthcare market, allowing more
tests to be performed at the point-of-
care and facilitating the shift towards
personalized medicine. There are new
opportunities in infectious disease test-
ing, molecular oncology and pharma-
cogenomics.
How do you think personalised medi-
cine and genomics are affecting the
diagnostics market?
Personalised medicine is rightly called
the ‘future medicine’ as it makes it
possible to give the appropriate drug,
at the appropriate dose and at the right
time. This has unleashed the potential
of significantly more effective diagnosis,
therapeutics and patient care. With the
breakthroughs in molecular diagnostics
and advances in laboratory equipment,
this piece of the diagnostics pie is going
to play an increasingly large role in early
diagnosis, monitoring and targeted phar-
maceutical intervention.
Delivering the right
data in a timely and
cost effective manner
while improving
the sensitivity and
specificity of the test
is the need of the
hour and the industry
needs to gear up for
single workstations
that can carry multiple
workloads.
Diagnostics are increasingly moving
closer to the patient through point-
of-care and home-based monitoring.
What do you make of this trend?
Timely, accurate diagnosis can
mean the difference between life
and death for a patient. The driving
profile
Suresh Vazirani graduated as an electrical engineer from the Nagpur University.
He founded Transasia Bio-Medicals Ltd in the year 1979. Over the last three dec-
ades the company has grown to become India’s number one diagnostics com-
pany. TRANSASIA today follows a 360 degrees approach to its business from
Manufacturing and Marketing to service and research.
diagnostics
notion behind point-of-care testing
is to bring the test conveniently and
immediately to the patient. Now most
clinicians acknowledge that point-of-
care testing is a prerequisite for early
recognition of life-threatening condi-
tions as they require that laboratory
results be made available in real-time
and, if possible, at the critically ill
patient’s point–of-care. Point-of-care
testing has come a long way from a
handful of simple waived tests to what
is today a multibillion dollar global
market that holds great promise for
the future.
However, it is not the magical potion
or remedy for all the ills of our current
healthcare system. Point of care acting
as a complement, and not as a replace-
ment, to central laboratory services can
bring about a complete turnaround in
clinical diagnostic testing.
Any other comments you would like
to make?
Good quality healthcare is a basic funda-
mental right and should be made avail-
able for all but our government’s health
systems are not able to provide even
basic healthcare to the poor people.
Per capita healthcare spending by
Indian government, which is one of
the lowest in the world, needs to be
increased substantially and all healthcare
products should be made totally free of
taxes, to make them affordable.
Public-private partnership should
also be encouraged in running
Government Hospital / Healthcare
centres. This will immensely help the
common man in getting access to the
latest technologies in healthcare system
at an affordable cost.
w w w. a s i a n h h m . c o m 65
technology , e q uipment & devices

Mechanical circulatory
support is an important
adjunct to the management
of patients with advanced
heart failure. Technology
advances in this area have
improved overall survival.
The challenge for clinicians
is to translate the clinical
evidence into selection of
the most appropriate device
that will provide benefit for
an individual patient.

Devices for the

Failing Heart
The future is here

M
echanical Circulatory Support
(MCS) is an important adjunct
to the management of patients
with severe heart failure. Because the
number of donor hearts available for trans-
plantation is limited, the use of MCS is
growing as a valid alternative to save the
lives of patients who are facing death.
There is substantial evidence that MCS
is able to revert the cascade of pathophysi-
ologic events observed in patients with
advanced heart failure. Although there are
established protocols to assess ventricular
recovery post-MCS, there is still no param-
eter available that allows estimation of
how long the improved cardiac function
will persist.
Diego Delgado Let us have a look at the current clini-
Professor cally available mechanical support devices,
Division of Cardiology and Transplantation their indications for use and the specific
University Health Network
Canada advantages and disadvantages associated
with each device.

66 Asian Hospital & Healthcare Management ISSUE - 17 2008


Indications for support
MCS is a life-saving option for the
patients who fail to improve or stabilise
with intravenous inotropes or vasodilators,
intra-aortic balloon pump support, and
mechanical ventilation. Patients requir-
ing mechanical support generally fall into
four categories: those with 1. Cardiogenic
shock resulting from Acute Myocardial
Infarction (AMI); 2. Post-surgical myocar-
dial dysfunction; 3. Acute cardiac failure
from myocarditis and 4. Decompensated
chronic heart failure.
Patients who present a cardiogenic
shock after an AMI are excellent candi-
dates for either short- or long-term
mechanical support because they have not
developed the systemic organ dysfunction
seen with chronic end-stage heart failure
and have the potential for myocardial
recovery.
For patients with the potential for
recovery, temporary short-term support
should be considered for a period of 5-7
days. Patients who fail to demonstrate
myocardial recovery within seven days
should be considered for conversion to a
long-term device. In patients who are not
eligible for transplant, device withdrawal
should be considered if destination therapy
with a long-term implantable device is
not an option.
Patients with post-surgical shock can
be divided into 1) Those with pre-existing
ventricular dysfunction and therefore a
low chance of recovery and 2) Those who
had normal ventricular function before
surgery and may recover with short-term
support.
An Abiomed BVS 5000 may be the
most appropriate choice for the patient
with previously normal cardiac function
while immediate use of an implantable
left ventricular assist device (LVAD) may
be the wisest choice in patients with pre-
existing severe myocardial dysfunction.
Acute myocarditis is another common
indication for cardiac mechanical support.
Short-term support is indicated in patients
with persistent hemodynamic instability
despite maximal medical therapy. Failure
to demonstrate adequate myocardial
technology , e q uipment & devices
recovery should prompt evaluation for
conversion to a long-term device.
Decompensation of chronic heart
failure is the most common indication
for long-term MCS.
Goals of mechanical circulatory
support
The majority of experience with MCS has
occurred in patients supported temporarily
as a bridge to transplantation.
One important observation during
the bridge-to-transplant experience was
that some hearts recovered sufficient func-
tion to have the device removed. Given
the shortage of donor organs, all patients
undergoing MCS should be systemati-
cally evaluated for evidence of myocardial
The Thoratec extracorporeal pump
Figure 1
recovery. The bridge-to-recovery will be
most successful in patients with post-
surgical cardiac failure, acute myocarditis
and AMI who have a high chance for
cardiac improvement in accordance with
the nature of their diseases.
The use of LVADs as an alternative
to heart transplantation (destination
therapy) has demonstrated significant
survival benefits in these patients.
Ventricular assist devices
There are several FDA-approved
Ventricular Assist Devices (VAD), in addi-
tion to the intra-aortic balloon pump.
Extracorporeal devices include the
Abiomed BVS 5000 and Thoratec, which
are both capable of biventricular assist-
ance. Implantable devices designed for
left ventricular support are the Novacor
N1000PC, the HeartMate Pneumatic
and the Vented Electric LVADs.
The next-generation devices consist
of axial flow pumps with non-pulsatile
flow, totally implantable LVADs. The
HeartMate II LVA System (Thoratec),
MicroMed DeBakey VAD System
(MicroMed), Jarvis 2000 Heart (Jarvik
Heart) and the VentrAssist LVA System
(Ventracor) are the subject of ongoing
clinical evaluation.
Extracorporeal Devices
Abiomed BVS 5000
The Abiomed BVS 5000 is an external,
pulsatile, mechanical support system that
can be used for univentricular or biven-
tricular support. The advantages of this
support system are its ease of use and
availability. Thromboembolic, bleeding
and infectious complications limit support
periods generally to less than 14 days.
Thoratec
The Thoratec paracorporeal pump is a
pneumatically driven, polyurethane sac
designed for long-term use (Figure 1).
The Thoratec VAD system is indicated as
a bridge to transplantation and a bridge
to recovery.
The pump is positioned on the
external abdominal wall with cannulae
tunnelled subcostally into the mediasti-
num. The Thoratec VAD provides uni- or
bi-ventricular support. These cannulae are
connected to an external pump (one for
each ventricle), consisting of a rigid hous-
ing chamber containing a polyurethane
blood sac. An external drive console sends
pressurised air to the pump, compressing
the blood sac and ejecting blood through
mechanical valves.
The external position of the
pump allows device exchange in cases
w w w. a s i a n h h m . c o m 67
technology , e q uipment & devices
The heartmate-VE left
ventricular assist device
Figure 2
of malfunction, thrombus or infection.
Furthermore, this also enables use in
patients who are poor candidates for
implantable devices. Patients require
systemic anticoagulation for the duration
of the Thoratec VAD implantation.
Continuous flow pumps
Axial or rotatory blood pumps have been
developed with the goal of intermedi-
ate-term as well as long-term ventricu-
lar assistance. These non-pulsatile-flow
systems have shown some advantages in
contrast to pulsatile systems: smaller size,
higher efficiency, less infections, lower
incidence of thromboembolic events and
lower cost. Early clinical experience has
shown that long-term non-pulsatile blood
flow is well tolerated.
Intracorporeal devices
HeartMate
The HeartMate LVAD is implanted in
a preperitoneal pocket, anterior to the
posterior rectus sheath and just below the
left costal margin (Figure 2). The inflow
cannula is connected to the apex of the
left ventricle and the outflow cannula
is anastomosed to the ascending aorta.
There are two types of HeartMate devices.
The Implantable Pneumatic LVAD (IP-
LVAD) is powered and controlled by an
external pneumatic drive console that rests
on a wheeled cart. The Vented Electric
68 Asian Hospital & Healthcare Management
LVAD (VE-LVAD) contains an electric
motor within the blood pump housing.
It receives external power and control
signals from an external microprocessor
via a vented drive-line. Both systems have
porcine valves and textured blood-contact-
ing surfaces that become covered by a
‘pseudoneointimal’ layer. This results in
a very low incidence of thromboembolic
events and, therefore, patients do not
require systemic anticoagulation.
Insertion of the HeartMate is difficult
in patients with a body surface area less
than 1.5 m2 due to anatomical constraints.
The major complications occur early and
include haemorrhage and right heart fail-
ure. Infection remains a common compli-
cation (30-50 per cent) with prolonged
use and is the biggest impediment to
long-term success.
Novacor
The Novacor is an implantable, electric,
dual pusher plate device designed for long-
term cardiac support. The pump housing
is constructed of a smooth polyurethane
pump sac with gelatin-sealed inflow and
outflow polyester grafts containing porcine
bioprosthetic valves.
The Novacor shares many similarities
with the HeartMate system including an
external drive system with a portable power
pack option. The device is implanted via
sternotomy with an inflow conduit to
the left ventricular apex and an outflow
conduit to the ascending aorta. The
pump itself is positioned in an abdomi-
nal subfascial plane or intraperitoneally
with the tunnelled drive-line exiting the
abdominal wall. A console or portable
system regulates the pumping rate. The
Novacor LVAD device requires systemic
anticoagulation to prevent thromboem-
bolism (risk 5-7 per cent). The incidence
of primary device failure is very rare.
CardioWest Total Artificial Heart (TAH)
The CardioWest is currently the only
total artificial heart approved for use in
the US under an FDA investigational
device exemption (Figure 3). This device
is pneumatically driven and implanted
in the orthotopic position. The pump
consists of a rigid pump housing that
ISSUE - 17 2008
contains dual spherical polyurethane
chambers. The dual ventricular chambers
are anastomosed to native atrial cuffs and
the outflow conduit is anastomosed to
the great vessels. Dual pneumatic drive-
lines exit transcutaneously to a console
control system which monitors pump
pressures and performance. Antiplatelet
and systemic anticoagulation are needed.
This device is used as bridge-to-transplant
in patients with biventricular failure.
AbioCor TAH
The AbioCor TAH is the first fully
implantable replacement heart. It has
been approved by the FDA as an inves-
tigational new device to be tested on
selected patients. The AbioCor consists
of an internal thoracic unit, an internal
rechargeable battery, an internal miniatur-
ized electronics package and an external
battery pack. The thoracic unit is equipped
with an internal motor that is able to
move blood through the lungs and the
rest of the body. The use of transcutane-
ous energy transmission eliminates the
need for the patient to be immobilised
permanently by tubes or wires connected
to an external power source thus possibly
reducing risk of infections.
Devices in clinical trials include the
Heartmate II, the Micromed DeBakey
VAD, and the Jarvik 2000 (Figure 4).
The DeBakey pump has already been
successfully implanted in a small number
The CardioWest
Total Artificial Heart (TAH)
Figure 3
 technology , e q uipment & devices

Continuous-flow devices

Heartmate II Micromed DeBakey VAD Jarvik 2000

Figure 4

of patients in Europe. The Heartmate
II and the Jarvik 2000 have also been
successfully implanted in humans.
Unfortunately, there are few options or
backup mechanisms other than replace-
ment. Additionally, since these devices do
not have valves, if a malfunction occurs
the patient may develop the equivalent
of wide-open aortic insufficiency.
Short-term support provided by
centrifugal pumps has been shown to be
a safe and simple cardiac support system
with an overall wean rate of 50 to 60 per
cent and a survival to discharge rate of
25 to 40 per cent. The use of short-term
devices in selected high-risk patients as
a bridge to long-term devices has shown
survival rates no significantly different
from the survival rate after long-term
support alone.
Successful transplantation is accom-
plished in 60 to 65 per cent of patients
who received a long-term device. Between
28 to 38 per cent of all supported patients
are discharged from hospital and managed
as outpatients. Patients with LVAD have
a higher survival to transplantation rate
than the non-LVAD patients.
CardioWest TAH provided a survival
Device Selection
Device selection depends not only on
specific patient characteristics and the
etiology of the patient’s heart failure,
but also on device characteristics, device
availability and the experience of the
surgical team.
Patients in profound post-surgical
cardiogenic shock require support to
avoid permanent end-organ dysfunction
and increase their chances of survival. The
preferred devices are the Abiomed BVS
5000 and Thoratec device. These devices
may provide full biventricular support re-
establishing near normal haemodynamics
while awaiting myocardial recovery. If
prolonged support is expected, conver-
sion to a longer-term device such as an
implantable LVAD or TAH should be
considered. The Thoratec device has
the advantage of providing long-term,
extracorporeal support.
Device selection for long-term
support is much more complicated and
often is subjective and based on the
surgeons experience and bias. For smaller
patients (BSA <1.5m2), the Thoratec
A uthor
device and eventually a continuous flow
pump are the only options. For the
larger patient, all devices are potential
options. Most frequently an implant-
able LVAD is used but the CardioWest
is useful for severe biventricular
failure.
Summary
Mechanical circulatory systems have
been shown to be an effective short-
term therapy as a bridge to transplanta-
tion and as permanent cardiac support.
The technological and human resources
required to implement a mechanical
assist device programme represent
major limitations. Unfortunately, this
technology is currently used only in
dedicated centres.
The next generation of mechanical
assist devices will provide hope for the
burgeoning number of patients with
end-stage heart failure, regardless of
their eligibility for transplantation.
References are available at
http://www.asianhhm.com/magazine

to transplantation rate of 75 per cent and
a survival rate post-transplant >80 per cent
There are limited published data regarding
axial flow pumps, AbioCor TAH, and
other LVADs; however, early results have
shown safety, efficacy and reliability.
Diego Delgado is an Assistant Professor in the Division of Cardiology
and Transplantation at the Toronto General Hospital, Canada. His
interests are immunologic aspects of heart failure and transplanta-
tion. He is the Past-Chair of the Canadian Cardiac Transplant Group.
He is the Vice-President of the Interamerican Society of Cardiology.

w w w. a s i a n h h m . c o m 69
technology , e q uipment & devices
Nano-Healthcare
Biotechnology & biomedical
perspective of disruptive potential
Nanotechnology has all the potential to become a disruptive and revolutionary technology
in terms of its healthcare application. However, there are a few ethical concerns which need
to be sorted out before its wide-spread use in healthcare.
Abhishek Dutta
Senior Research Analyst
Technical Insights
Frost & Sullivan, Singapore
N
anotechnology, or the science
of the small, has become the
buzzword of academic and
industrial circles, which has diversified
across various verticals such as health-
care, aerospace, defense, materials and
many more. The beginnings of nanote-
chnology could be attributed to Sir
Richard Feynman who in his landmark
lecture titled ‘There is Plenty of Room at
the Bottom’ envisioned the possibilities
of manipulating nanoparticles essentially
of atomic scale to modify and enhance
the properties of materials that are in use
today. Studies in the field have shown
that the constituent particles of nano-
science—namely fullerenes, dendrimers
and Carbon Nanotubes (CNTs)—are
the fundamental building blocks of
nanotechnology. Further, the change
of physical properties at the atomic level
that typically behave differently when
viewed at the macrolevel, beckons the
possibility of developing novel materials
with unique properties. Owing to these
changes, these nanomaterials could find
use across an array of applications.
70 Asian Hospital & Healthcare Management
The word ‘nano’ is being synony-
mously used with innovation in every
domain and the healthcare and life
sciences domain is no different. The
cardinally important application of
nanotechnology is in the field of mate-
rials; biomaterials to be more specific.
But since the application of biomaterials
is in variegated medical applications,
the penetration of nanotechnology is
seen in a myriad of uses in the medical
device realm.
The main reason behind the hype of
nanotechnology, in the biotechnology
and medical realms, is due to the basic
nanometer size of its material particles.
The nanometer size, allows the parti-
cles to be accouter in heterogeneous
biotechnological / diagnostic device
applications because the miniscule size
allows the nanoparticle to be used in
situations where a penetrating skin
barrier is needed. Further, due to the
nano size, the particles can be coated
or attached to individual molecules
and used to target specific molecules
within the human body. Facilitating
the research and commercial focus
on nanotechnology is the fact that an
assortment of nanoparticles, due to
their submolecular size, exhibit vari-
egated properties of molecular interac-
tion. One such property is ‘self-assem-
bly,’ which is primarily exhibited by
ISSUE - 17 2008
carbon CNTs, graphite nanoparticles
and organic fullerene particles. The
property of self-assembly allows the
particles when excited using a chemi-
cal or electromagnetic means to form
a spherical or rod-shaped assembly of
particles due to atomic forces such as
van der Waals forces and so on.
Some of the key properties of nano-
particles and how it helps in unlocking
potential applications in medical field
is depicted in Figure 1.
Key Unique Selling Prices (USP)
are generated through the application
of nanotechnology in most technol-
ogy / product domains. Conventional
technologies can be developed into vari-
egated applications based on the unique
properties rendering unique selling price
or unique value propositions. Examples
of such devices would be:
Application: Nanoanalytical devices
and reagents
USP:
• The nanoscale sizes will render lesser
samples to be used, thus saving on
wastage of reagents because the
acutely small sample size requires
lesser amount of samples
• More surface area for better diagnostic
testing
• More surface area will also provide
greater reactivity.
w w w. a s i a n h h m . c o m 71
technology , e q uipment & devices
NanoBiotechnology: The lock & key integration
The key properties:
• Self-assembly
• Better penetration Nanotech:
• More reactivity
+ analysis, diagnostics
• Compatibility The key
The Application Domains:
• Drug Discover & Delivery – DNA Nano Bio Technology & Lab Anaemia, Nano Fluidis Cancer
Therapeutics
• Coatings – Cell Staining, Antibody Coatings, Coatings an Prostmetics, Coatins on Sients
• NEMS – Nanobots (Swarm Ingranostics) for cancer, Quantum Dots, Nano Piezoelectric Sensors
Therapeutic Electrodes, Nanomagnetic sensors
• Microscopy – AFM (Cantilever), MFM
Application: Nanobiomaterials
USP:
• Nanoscale particles can help in develop-
ing nanofilms thus enabling efficient
orthopaedic coatings
• More surface area resulting in more
reactivity and thus better bioactivity
of bioabsorbable coating materials
• Self-assembly property resulting in
uniform coatings.
Application: Nano targeted drug
delivery and nanorobotics
USP:
• Nanoscale sizes result in easier pene-
tration and aids in targeting diseased
cancerous cells of micrometer sizes for
delivery of medicines
• More reactivity due to more surface
area results in more accurate sensing
of the diseased region inside the body
• Self-assembly property enhances the
effect as the nanoparticles will be able
to home into each other’s signals towards
the diseased region.
To the general population, nanotech-
nology is just another out-of-the-world
concept while in reality it is not so.
Here, it would be wise to keep in mind
that nanoparticle technology, or rather
nanotechnology, is not an out-of-the-
box concept that has been recently used.
Research performed by a Russian scientist,
Mal'tseva T. A., in the late 1960s exhibited
72 Asian Hospital & Healthcare Management
Biotech Better research tools
for testing gene
& Biomed: expression, proteomic
The lock & imaging
Figure 1
the antimicrobial facets of silver particles,
where the scientist coated fabric with tiny
silver particles, to render antimicrobial
property to the cloth. Hence the use of
miniscule metallic particles dates back
to antiquated research. Further, ancient
medicinal fields such as Ayurveda quintes-
sentially made use of powdered versions
of various substances as an effective cure
for a myriad of ailments.
Hence, the questions that automati-
cally haunt the mind are why there is any
need to mobilise funding and resources
and take a nosedive to explore nanotech-
nology on a large scale through a national
initiative? What will be the use and impact
of such an endeavour? And how will it
aid in developing better solutions?
It is best to state at this point, that the
intriguing part behind nanotechnology
is not in its conceptualisation, but in our
present day capability to create and control
nanoparticles (of different materials) in
vitro resulting in studying and excava-
tion of newer properties and applications.
Hence, here lies the driving force behind
the need to theoretically understand, prac-
tically research, and conclusively analyse
the developments in nanotechnology in
depth as only through further and organ-
ised research can the truthful implications
and futuristic applications of nanotechnol-
ogy be achieved. But a national initiative
doesn’t end the work process. It should
ISSUE - 17 2008
rather serve to be the stepping stone to
segregate work, take up responsibilities
and bring out safe and effective applica-
tions or product innovations with tech-
nical advantages and high-end utilities.
In case of some diseases, such as cancer,
a national nanotechnology endeavour
with a cardinal focus on biotechnology
or medical applications can bring forth
novel diagnostic or therapeutic kits and
life-saving technologies.
Nanobiotechnology and product
development are more of ‘An Evolution
than Revolution’. This was the comment
made by Phil Bond, the US Undersecretary
of Commerce in a conference. However,
on a closer look into this concept, it is
found that not only nanotechnology, but
most technological developments in the
present day world happen through the
process of necessity and evolution. In this
evolution of technology, the advance-
ments happen in a plethora of verticals,
starting from materials to electronics to
energy. A sudden revolution is seen when
different verticals suddenly come together
and integrate with each other, resulting
in the development of a quite out-of-
the-world technology from the present
day perspective. From Frost & Sullivan's
perspective, nanotechnology has all the
potential to become a disruptive and
revolutionary technology in terms of its
healthcare application. However, this will
depend on smaller and individual devel-
opments, which will eventually lead to a
revolution disrupting the present world
technology.
VC funding in nanobiotechnology has
seen a mushroom growth since 2005. This
is owing to the fact that the VCs have, in
recent times, seen constructive practical
healthcare applications of nano-based
products enter the commercial markets.
This has helped them allay their scepti-
cism and fear of the high risks in this
domain and invest more. However, there
is still a huge lack of standardisation and
regulatory gaps in the nanoanalytical tools
and devices domain, which might make
product commercialisation a big problem
at a later stage.

At present the vendor and supplier
bargaining power is high in this industry
owing to lesser number of industry play-
ers with an effective commercial product
to penetrate the market. This makes the
threat of new entrants higher into this
industry both as raw material suppliers
and as technology or product vendors. The
consumer bargaining power is also high
due to alternative technologies present in
the market. All these above mentioned
factors make this industry extremely
attractive and competitive.
With the advent of nanotechnol-
ogy and introduction of new concepts
based on the new technology, the field of
biosensors received a boost. Much fund-
ing and capital is being invested in the
development of nanobiosensors, which has
promise to be a disruptive technology once
it hits the commercial stage. Although
they could provide a non-surgical inva-
sive biosensing alternative, nanobiosensors
have to undergo enormous development
from the standpoint of biocompatibility,
controlling a nanoswarm in its environ-
ment, with the capability to be replaced
in case of defects.
Similarly, with the advent of nanote-
chnology, the field of neurostimulators,
like many others, will receive a boost, since
many new concepts are to be introduced
and implemented. This will continue
to happen as and when the excavation
through research and corresponding devel-
opments in the field of nanotechnology
happen. Concepts such as self-targeting
brain and neuronal implants, which can
invasively attach themselves at specific
locations of the nervous system, providing
automated in vivo neuronal therapy, now
seems to be a definite possibility. Much
funding and capital is being invested in
the development of nanoneuroprosthet-
ics, which will promise to be a disruptive
technology once it hits the commercial
stage. Although nanotechnology could
provide a myriad of variegated applica-
tions, nanoparticle therapeutic devices
have to undergo enormous advancements
from the standpoint of biocompatibility,
controlling nanoswarms in the in vivo
technology , e q uipment & devices
Ethical concerns
Nanotechnology as a field does have many bioethical concerns which might work
against it as a commercial product. Bioethics pertains to the ethical questions that
arise in the field of medicine and biology. Disagreement exists about the proper scope
for applying ethical evaluation while developing or licensing a technology for patients.
Bioethics generally deals with public policy questions, which are often excessively
publicised and politicised. There is a tendency among medical engineers, scientists
and others involved in the development of a technology to perceive ‘bioethics’ as an
attempt to derail their work and obstruct it regardless of the true intent.
Nanoparticles have emerged as a source of concern due to the possibility that they
may be absorbed through the skin, or inhaled, with as yet unknown health consequences.
Lab animal tests have indicated that some nanomaterials, such as carbon nanospheres and
nanotubes, can cause fatal inflammation in the lungs of rodents; they can also cause organ
damage in fish, and can kill ecologically important aquatic organisms and soil-dwelling
bacteria. A recent research published in Nature Nanotechnology reveals that some long
strands of CNTs are as toxic as asbestos and can cause cancer. Nanoparticles can also
stunt the growth of roots on several crops. A number of bodies—including the Royal
Society, Britain's scientific body, and the Royal Academy of Engineering—have stated
that nanoparticles could be a cause for concern.
environment, and in its capability to be human being who has his / her own set
replaced in case of defects. of values, principles, and ethics. Hence,
At present, the US and Europe lead nano-healthcare applications, especially
the way in applying nanotechnology for invasive ones, have to undergo a scrutiny
medical applications. The funding from at the end-user level, despite all FDA
federal governments, extensive collabora- approvals. A lot of turmoil is brewing
tions and opportunities for spin-offs are as nano-healthcare applications emerge
the key reasons for the leadership of these and arise because they are objects that
countries in the field. Asian countries the patients can never perceive with their
serve as hubs for contract research for own eyes. Moreover, their small size could
American and European conglomer- make it impossible to replace the sensor
ates. The revenue generated from such in case of a defect. Furthermore, products
outsourcing has slowly begun to boost the such as nanobiosensors and nanobots are
Asian economy towards investing heavily yet to be approved as ‘safe’ by the FDA,
in indigenous research and application. although huge funds are already at stake
in their research.
Conclusion Here lies the rift between nano-
The development of nano-healthcare healthcare applications and bioethics,
applications is influenced directly by which only time and dedicated research
the policies and principles of bioethics towards maintaining patient safety can
because the end user is primarily a diseased resolve.
Abhishek Dutta is a Research Analyst with the Frost & Sullivan
A uthor
Technical Insights team. He focusses on tracking and analysing
global emerging trends and technologies pertaining to the Healthcare
industry. He has authored several research studies in the medical
device domain and has consulted very many top medical companies
on technology/industry. He contributes to the medical device and
medical imaging alerts on a regular basis.
w w w. a s i a n h h m . c o m 73
facilities & operations management
T
he need to consider and manage
the safety of patients within
healthcare has been widely
recognised over the past decade. The
‘science’ of patient safety has grown, and
is constantly seeking to identify how
and why things go wrong in patient
care and what we can learn from other
industries and from other disciplines
such as psychology to make care safer.
The emphasis has moved away from
‘blame’ towards looking at how modern
healthcare is delivered in complex, busy
hospitals and clinics, and recognising
that sometimes the systems themselves
create problems.
What can go wrong?
The sort of things that can go wrong
for patients are as varied as patients
themselves and the people who care
for them. This includes errors such as
receiving the wrong drug or wrong site
surgery, or complications of surgery and
other treatments, or failure to diagnose
correctly or to spot the patient whose
condition is deteriorating and to do
something about it.
Sarah Williamson, Consultant, Patient Safety and Risk Management, SalSafe, UK
74 Asian Hospital & Healthcare Management
The outcomes for patients can range
from little or no harm and minor annoy-
ance to permanent disability or death.
The outcomes for families can be sudden
bereavement; for clinicians involved in
a serious error or incident can be loss of
career, or even criminal charges, and life-
long distress. When all the evidence that
is now being gained from wide spread
studies of patient safety incidents indi-
cates that a significant number of these
are preventable, there is no excuse for
failing to take patient safety seriously.
In specific incidents such as these,
patients can be let down by healthcare
systems which do not provide the best
care. This happens only when clinicians
do not keep themselves up-to-date with
new developments in care, and do not
review and change their own practice
when there is evidence that other meth-
ods are more effective.
The basic principles for safety and
quality of care
The basic principles for patient safety
are the principles for quality of care: to
do the right thing for the right patient
using the right method and at the right
time, and to communicate well with
the patient and the rest of the clinical
team—record findings, planning actions
promptly and clearly, ensure that instruc-
tions are understood and carried out,
and report concerns to a senior colleague
when necessary.
ISSUE - 17 2008
These principles sound very simple,
but most of the serious patient incidents
result from a sequence of small errors
or failures to act, rather than one large
dramatic event. If each of these principles
are analysed in more detail, the implica-
tions for both patient safety and good
quality of care will become clearer.
Doing the ‘right thing’
This might mean ensuring that the
correct test is carried out in line with
the patient’s symptoms; that the correct
drug is chosen and is given at the correct
dose; that surgery is performed on the
correct side of the body; and that obser-
vations are carried out on a sick patient
at the correct frequency. The procedures
and training to guide all the staff on
various means to improve safety and
quality of care—unambiguous and clear
prescription of drugs, proper and safe
administering of drugs, marking and
preparing patients for surgery, knowl-
edge of appropriate timing of tests and

Patient Safety
and Risk Management
A look at the basics
Even as modern healthcare
continues to achieve excellent
results, all too often patients
are put at risk either through
errors or through failure to
assess their needs properly,
manage their care and
recognise deterioration.
different methods of interpretation of
results—should be provided.
The ‘right thing’ might also mean
having up-to-date knowledge and skills
to allow clinicians to give their patients
the best care. Much of the patient safety
activity in the USA and UK at the
moment is focussed on good patient
management—using proven meth-
ods to avoid ventilation pneumonia,
for instance, or researching invasive
procedures and frequently used drug
regimes to see if they actually benefit
the patient.
A classic example is to restrict the use
of antibiotics to patients with bacterial
infections rather than viruses, to reduce
the spread of antibiotic resistance and
opportunistic bowel infections. The
need to do this has been recognised for
decades, but changing practices can be
facilities & operations management
painfully slow. All healthcare organisa-
tions need to consider how much they
can rely on individual clinicians’ judge-
ment and to what extent they can inter-
vene with directives or by taking action
to force compliance with changes.
The right patient
This sounds painfully obvious, but many
errors occur because patients have similar
names. Errors could occur when the
wrong patient is taken to X-ray, or a
doctor picks up the wrong set of notes,
or specimens are mislabelled, or even
because in a busy ward there is a new
patient on the bed. It should be routine
for staff to check at each stage of care that
they are dealing with the correct patient,
and if they have heard the patient’s name
correctly when they are asked to carry
out an instruction.
The right method
This includes, for instance, ensuring
that diagnostic tests are performed and
interpreted correctly. Similarly, many
errors occur where drugs are given
by the wrong route or in the wrong
concentration. One very well known
case in England involved a chemotherapy
drug, Vincristine, being administered
into the spine instead of a vein. When
this happens it is always fatal.
Obviously all invasive procedures
must be carried out by competent staff
or staff under competent supervision.
It is important that training and writ-
ten procedures are in place to ensure
that ‘right method’ is followed. It is also
very important that untrained staff know
that (and abstain from) they should not
perform certain tasks which carry signifi-
cant risks.
Ensuring the right method also means
having systems in place to keep medical
equipment clean and in good working
order. Patients are safer when staff do not
have to choose between similar pieces of
equipment which work in different ways,
such as one-hour and 24-hour infusion
pumps. It is not always easy to standard-
ise equipment, but when new equipment
is chosen, ease of use and potential risks
should be taken into account.
The right time
Again it seems obvious, but this includes
giving drugs as prescribed and not
getting confused by 24-hour clock.
More subtle care management such as
not giving a drug or treatment when
there is a contraindication, checking
the patient and recording observations
when required, recognising the need for
pain relief or other symptom control and
w w w. a s i a n h h m . c o m 75
facilities & operations management

nicians, pharmacists. Their relationship

Developing a patient safety culture and systems with each other requires sharing of infor-
mation and acting on instructions. The
This article has frequently referred to the need to have policies, procedures and training doctor or nurse on duty must know what
for patient safety. These are important, but they will achieve nothing unless they are was done to the patient the previous day
part of a patient safety culture where everyone, from the most senior staff to the most
and what is planned for the next day—
junior, understands the importance of patient safety and why it matters.
and why. And in their shift they must
Training of staff should show how everything they learn affects the safety of patients. record changes in the patient’s condition,
Senior staff should lead by example—juniors will imitate what they do. Staff should results of tests, new plans for care and
understand why it is important that equipment is properly used; that infection control anything else that everyone caring for
and hygiene are carried out properly; that instructions are clearly understood and
the patient needs to know.
followed; that prescriptions are written carefully; and so on.
The vital information remains useless
One way of helping staff to understand about safety and learn from mistakes is to if it is not shared. It will not be shared
have an incident reporting system. When something goes wrong, the staff involved if records are kept in different places, or
should be able to report what has happened without fear of undue blame, and the
if different professionals keep their own
events leading up to the incident or error should be reviewed to know what went wrong,
and to see if it can be prevented in the future.
records. Hospitals should review their
systems for storing patient information
Many useful lessons about safety have been learnt from similar incidents reported in and sharing it, through team reports,
different places. As a result, the common causes have been identified and the knowl- ward meetings or any other means. Many
edge has been shared.
errors occur when messages are not passed
It can be useful to have designated staff with responsibility for coordinating all the on, or something is not written in the
patient safety activities; for instance, ensuring that policies are up-to-date and that staff notes, or when what has been written is
receive training when they need to. But it is important that they are not seen as the not clear and can be misunderstood.
person or team responsible for patient safety. The people responsible for patient safety There should be policies and train-
are the members of staff who have anything to do with that patient—whether as doctor
ing to ensure that all records are kept
or nurse, therapist or technician, cleaner or cook, engineer or purchase clerk paying for
drugs. Anyone who has a job in a hospital makes patients safer when they do their job properly. The details of when and who
properly, and work well as part of the hospital team. should write in the records should be
clearly mentioned. They should also
specify the means to ensure that all the
acting promptly if the patient’s condi- their family. It helps not only patients information is filed correctly and new
tion is deteriorating. Many hospitals in understanding their condition but information is seen (such as test results)
in the UK and USA have introduced also healthcare providers in providing and dealt with appropriately.
‘early warning systems’ designed to alert proper care to patients. Listening to what Openness
staff about a deteriorating patient and patients have to say and respecting their Good communication is important
to guide and empower them to seek wishes forms the basis to healthcare in beyond the patient records—in how
senior assistance. the 21st century. Moreover, patients who staff talks to patients, and each other.
Good communication feel involved and in control of their care Many industries have learnt that it is
“In healthcare, information, especially tend to do better, and more satisfied with important for safety to have a culture
the one related to a patient’s health, is the care they receive. where no one is above criticism (because
key to the care provided. Faulty treat- Patient records any human being can make a mistake)
ments, in most cases, can be attributed Many teams are involved in the care and where junior staff can put forward
to improper communication of critical for patients in a modern hospital. This suggestions or concerns, and have these
data.” This opening comment in the includes doctors, nurses, therapists, tech- treated with respect.
editorial of Asian Hospital and Healthcare
Management Issue 16, illustrates clearly
why good communication about patient
A uthor

Sarah Williamson is a registered nurse with special interests in

care is as important a component of clinical risk management, governance, organisational and cultural
safety as all the treatments that a patient change, and staff development. She was Clinical Risk Manager at
receives. Sheffield Teaching Hospitals NHS Trust 2002-2007. She is a MA
in Communication Studies and currently a freelance consultant in
Other articles in that issue and patient safety. She is regular conference speaker and has published
recent editions talk about the need to several articles.
communicate well with the patient and

76 Asian Hospital & Healthcare Management ISSUE - 17 2008

 Improving
Reliability for
Safer Care
A proactive approach

Reliability and safety are now essential components of healthcare. However,

providing better care requires a proactive approach from the providers.

F
rom a scientific point-of-view,
healthcare has improved dramati-
Peter Lachman cally over the past 50 years. The
Consultant Paediatrician
Great Ormond Street Hospital for Children development of new treatment modalities
NHS Trust, UK has had a significant impact on many
people. This, of course, differs from
country to country, as well as within
countries and communities. Access to
the standardised and reliable care that
should be provided is often difficult to
obtain. It is a truism that if we applied
the knowledge we now possess, even
without any new innovations, millions
of people would be cured of the

w w w. a s i a n h h m . c o m 77
facilities & operations management
conditions that afflict them. The issue
now is to improve the delivery of health-
care rather than the development of new
treatment modalities. The urgent need
is to move from quality assurance to
quality improvement, to learn how to
measure improvement and to develop
systems that facilitate safety and reliable
delivery of healthcare which inherently
minimises risk.
In many countries, there has been a
move to examine the delivery of health-
care in terms of quality and safety. The
domains of quality, as delineated by
the Institute of Medicine (IOM) in the
USA, can be used as a framework to
define the way we approach the provi-
sion of healthcare worldwide. Although
these concepts of quality were devel-
oped in the most sophisticated of health
systems, they are sufficiently simple to
be applied to any system. The key factor
is that quality places the needs of the
patient at the centre of all that we do in
healthcare. The emergence of evidence-
based medicine over the past 20 years
has focussed our attention on ensuring
the effectiveness of healthcare, though
there was no surety that this will happen
every time. It is therefore necessary to
reconsider the way we organise and
deliver healthcare. The challenge is to
deliver the correct care reliably all the
time, according to patient needs.
What does reliable healthcare
mean?
The science of reliability was devel-
oped in other industries and is now
being adapted for use in healthcare.
The examples of highly reliable
organisations could be found in the
field of nuclear power, railways and
airlines. The key issue in highly reli-
able industries is the central belief that
systems need to be in place to ensure
the safety of consumers. It is the only
reason for them to survive in their
respective fields.
In essence, the patient should expect
to receive the correct and effective care
that is affordable every time he or she
78 Asian Hospital & Healthcare Management
Some approaches to develop
a highly reliable healthcare
organisation
• Safety should be the business of
healthcare
• Ensure that reliable care is provided
first time every time
• Understand the design of the
organisation
• Place the patient as consumer at the
centre of all you do
• Make prevention of failure a central
component of your work
• Develop a culture of safety at all
levels—from the CEO to the front line
to the patient
• Embrace diverse opinions
• Move from risk management to at least 90 per cent of the time. The
situation awareness
• Develop resilience
• Study and spread success
• Encourage the front line to innovate
and implement
• Simplify and standardise
• Eliminate artificial variability in
processes
• Use care bundles to deliver complex
delivery of care
visits the doctor or nurse. Unfortunately,
this is not the experience even in the
most highly financed healthcare systems.
The variability of healthcare provision
is immense and as providers we need
to redesign the systems in which we
operate to approach an environment
where the patient receives what they
need every time. The concept of reli-
ability requires some understanding of
the need for safety. Safety is not inherent
in the systems within which we work.
In order to have a reliable system, one
need to move from risk management
and reaction to proactive situation
awareness, this mitigates harm.
ISSUE - 17 2008
Reliability principles, which include
evaluation and calculation of the overall
consistency of a complex system, are
effective tools used in other industries
to improve both safety and the rate
at which a system produces consistent
quality outcomes. The challenge is to
adapt this reliability methodology to
the healthcare delivery system so as to
ensure the safe delivery of healthcare.
From an abstract point-of-view,
reliability is measured as the number
of actions that achieve the intended
result divided by the total number
of actions taken over time. The
concept of reliability in healthcare
is defined in terms of the number of
times the evidence-based care is not
provided. Level One (10-1) reliability
results when there is a failure rate
of one out of ten, i.e. we get it right
next level of reliability, Level Two
(10-2) refers to a failure rate of one
in a hundred. Nuclear power, which
is at the sixth level, operates at a
failure rate of less than one in million
(10-6). Chaos exists when the fail-
ure rate is more than two out of ten
attempts.
The provision of healthcare rarely
reaches more than the first level of reli-
ability. Most healthcare systems operate
in the ‘chaotic’ zone without common
articulated processes and many doctors
and health professionals continue to
work as individuals. Although it is
essential, the common approaches of
asking professionals to work harder,
undertake more training and to follow
guidelines do not produce more than
the Level One reliability. To attain Level
Two reliability, organisations need to
recognise the impact of human factors
on the delivery of safe healthcare. This
implies the need to introduce checklists,
memory aids, redundancy in processes,
and defaults in decision-making. Level
Three reliability requires a redesign
of the system so that it focusses on
processes, structure and their relation-
ship to outcomes.
 facilities & operations management

How does one develop highly
reliable healthcare delivery?
The first issue one needs to address is an
understanding of the need to approach
safety from a more proactive stance and
to accept that the human factors that
cause harm can be controlled if one
designs a system that prevents harm
in the first place. In our daily lives, we
accept reliability in most of what we
do; for example, how the trains run,
how airlines view safety, food quality
etc. We have often used the individual
requirements of the patient to assume
that it is not possible to apply some of
the key principles required e.g. standardi-
sation, routine, checklists. The problem
in the past was that we expected
hard work and good intentions
to deliver reliable healthcare.
Insisting that providers be more
careful and vigilant simply has
not worked.
Once safety becomes the
method of operation, one moves
to examine the system in which
we work, viz. how we have
designed the complex process in
reaction to previous mistakes, or
as a system that has placed safety in the
forefront. For example:
• Do we have systems that prevent
common errors from occurring?
• Do we define the way we want to
deliver healthcare to ensure that the
patient is protected from harm?
• Can we break down the problems into
small bites so that the system can be
addressed in a simple way?
Medication errors are a good example,
which probably account for the maxi-
mum harm in hospitals. The aim could
be to decrease the number of errors year
on year, until zero error is achieved. This
is a goal we have set at Great Ormond
Street Hospital as we strive to achieve a
redesign of the way we deliver healthcare;
not merely addressing external targets.
Understanding and then eliminat-
ing the artificial variability—which is
introduced by providers—and manag-
ing the natural variability brought by
clinical need go a long way in ensur-
ing consistency. The standardisation
of healthcare without decreasing the
individual requirements of the patient
is a difficult task and will require an
understanding.
The use of care bundles, the packages
of evidence-based care to ensure that all
elements are delivered, has helped to
eliminate most of the common prob-
lems like line infections and medication
The emergence of evidence-based
medicine over the past 20 years has
focussed our attention on ensuring
the effectiveness of healthcare, though
there was no surety that this will
happen every time.
errors in hospitals in Europe and North
America. The WHO World Alliance for
Patient Safety initiative introduced check-
lists to improve outcomes in surgical
care. This is a key element in the move
from Level One to Level Two reliability.
This approach requires a rethink of how
we deliver heathcare. We can no longer
accept delivery by health professionals
acting as individuals.
How does one bring this to a
universal audience?
In reality, the concept of reliable health-
care should not be difficult to sell either
A uthor
to the consumer or the provider. The
problem is that we have a preconceived
notion that we are already deliver-
ing reliable care. The right approach
must, therefore, include recognition
that unless one accepts the inherent
inconsistencies in the present healthcare
system, one will not develop a coherent
approach to safety. The theorists have
tended to make the concepts inacces-
sible to the patient and to the health-
care provider. To address this problem,
and to ensure that this is not a concept
only applicable to wealthy economies,
one needs to reinterpret the issues for
the relevant audience, using exam-
ples from outside healthcare and then
applying them to the local
environment. For example, one
can look to other organisations
that have solved the problem,
adapt the solution for local use,
measure the outcome and then
apply small tests of change.
Conclusion
The ideas of reliability can
either excite or turn off
healthcare providers. In order
to make this an attractive option,
one needs to reframe the debate for
managers, clinicians and patients.
Once the patient is in the centre of
the debate, the argument becomes an
essential component of solutions for
healthcare. Demystification of this
concept is essential. From a manage-
ment point-of-view, ensuring that
the patient gets the correct evidence-
based treatment the first time every
time, has a financial gain that will
make most executives satisfied with the
knowledge that the quality has been
enhanced.

transformational goal of Zero Harm. To
reach this ambitious goal, the organisa-
tion is committed to develope a culture
of not accepting the inevitability of harm
but rather developing one that accepts
its preventability. This requires a total
Peter Lachman is Consultant in Service Redesign and
Transformation at Great Ormond Street Hospital for Children and a
consultant paediatrician at the Royal Free Hospital in London. He
was a Health Foundation Improvement Fellow at the Institute of
Healthcare Improvement (IHI) in 2005-2006. He leads on the trans-
formation programme at GOSH.

w w w. a s i a n h h m . c o m 79
 State of Sustainable
Design in Healthcare
A commentary
A more transformative vision of ‘living’ and ‘regenerative’ hospital buildings
is beginning to coalesce worldwide. Primarily, this vision finds its roots in the
connection between buildings and health.
Robin Guenther
Architect
Douglas D Pierce
Architect
Perkins+Will, USA
T
he buildings that support the
delivery of healthcare services
encompass a broad range of build-
ing types—ranging from small commu-
nity outpatient clinics to large acute care
hospitals—and an equally broad range
of owners—philanthropic non-profits to
corporate entities. Globally, healthcare
is a significant service economy—while
the percentage of the Gross Domestic
Product (GDP) varies widely between
nations, there is general agreement that
the healthcare sector has the capacity to
define markets through what they build,
purchase and how they operate.
The US healthcare building sector is
making explicit links between the built
environment and health. The Ameri-
can Society of Healthcare Engineering
(ASHE) framed green building initiatives
as early as 2002 around protecting health
at three scales: the immediate health
of building occupants, health of the
surrounding community, and health of
the larger global community and natural
resources. The Green Guide for Health
Care, in defining green strategies for the
healthcare sector, includes specific ‘health
issue’ statements that introduce each
80 Asian Hospital & Healthcare Management
construction and operation topic—the
Green Guide is the foundation for the
US Green Building Council’s LEED for
Healthcare. Providence Health and Serv-
ices CEO John Koster, MD, in describ-
®
ing their new LEED Gold Certified
hospital in Newberg, Oregon, summed
it up this way: “In healthcare, sustainable
building represents a bold move toward
precaution and prevention. The build-
ing stands for health. In creating it, the
organisation is essentially saying, ‘We’re
investing in keeping people healthier.’
Being attentive to sustainability, well-
ness and resource stewardship presents
a holistic view of healthcare that has an
impact. We may not be able to meas-
ure or test, but I’m convinced it has a
tremendous impact on a person’s abil-
ity to attain health. Not just to be not
sick, but to be in health” (Guenther and
Vittori, 2007).
Beginning with operations, health-
care organisations globally are moving
towards total elimination of mercury
and implementation of Environmen-
tally Preferable Purchasing (EPP). EPP
practices prioritise less-toxic cleaners
and disinfectants, phthalate-free medical
ISSUE - 17 2008
devices, elimination of flame retardants
and formaldehyde in furniture and case-
work, and solvents in labs. Waste reduc-
tion efforts combine non-incineration
technologies for regulated medical waste
disposal with substitution of mercury-
containing devices and PVC plastics.
Healthcare Without Harm is a global
campaign assisting healthcare organisa-
tions in this important work.
State of the industry
Many healthcare organisations in the US
have begun environmental stewardship
programme by focussing on operations
and then have moved into sustainable
building. The US healthcare built envi-
ronment is highly developed—at the
time of writing this article, it is the second
most energy-intensive US building sector
(consuming energy at an average of twice
the intensity of commercial office build-
ings). Acute care hospitals drive this
excessive consumption, although they
represent only 25 per cent of the total
area of healthcare buildings. The aver-
age age of a US hospital building is 27
years—for the most part, the hospital
infrastructure is completely mechani-

cally conditioned, and is characterised by
deep floor plate, non-daylit diagnostic
and treatment blocks, with little regard
to orientation or passive system design.
These buildings operate continuously,
365 days per year, with multiple back-up
and redundant mechanical and electri-
cal systems, and only increase in energy
intensity as medical diagnostic equip-
ment with large heat loads continue to
enter the market place.
In 1996, a comparative study of
energy consumption between hospitals
in Europe and North America revealed
that North American buildings oper-
ate at approximately twice the energy
intensity of their European counterparts.
While the study did not look at system
differences, the most important ones
are obvious: European hospitals require
daylight in all occupied spaces, leading
to enclosed courtyard planning in lieu of
deep floor plates. Nursing units continue
to be naturally or passively conditioned,
and when mechanical conditioning is
installed, the prevalent system is displace-
ment ventilation (which introduces air
at the floor rather than the ceiling). As
the US healthcare market seeks ways to
facilities & operations management
reduce energy consumption, the exam-
ples of European healthcare buildings,
as well as leading sustainable buildings
in other regions, provide important ‘best
practices.’
Since the introduction of the Green
Guide for Health Care and the US Green
®
Building Council’s LEED programme,
the more than 340 healthcare buildings
have registered and more than 30 have
certified. This year, in a survey conducted
by Health Facilities Management and
ASHE, more than 50 per cent of the 600
respondents indicated they were using
the Green Guide or LEED on some of
®
their projects. The first LEED -Plati-
num medical office building, Oregon
Health and Science University’s Center
for Health and Healing, opened in 2006,
and the first LEED-Platinum hospital is
anticipated to receive certification this
year. Collectively, the first 30 projects
have reported energy demand reductions
ranging from 15 to 30 per cent, potable
water reductions in the range of 30 per
cent, successful integration of local and
regional materials palettes alongside a
host of environmentally preferable mate-
rial choices, and report improved indoor
air quality through enhanced ventila-
tion and occupant controls, low-emit-
ting materials, and an increased focus
on connection to nature (often through
the integration of outdoor places of
respite, or healing gardens). While the
majority of LEED-certified projects are
new constructions, a number of major
renovations or adaptive reuse projects
have achieved certification. These early
adopters have reported limited capital
cost ‘premiums’ associated with their
green building achievements. For many,
the basic design parameters of total
mechanical conditioning and deep floor
plates remain unchallenged—only those
that are achieving Platinum appear to
have optimised passive design elements
and floor plate depth.
What lies ahead
A more transformative vision of ‘living’
and ‘regenerative’ hospital buildings
is beginning to coalesce worldwide.
Primarily, this vision finds its roots in
the connection between buildings and
health that opened this article. Practi-
cally, it is manifested in a small group
of projects globally, including the
w w w. a s i a n h h m . c o m 81
facilities & operations management

Waste management at Embassy Medical Centre

With an anaerobic digester, organic waste, such as food waste, farming residue and ecosystems and ecological concerns. The
even human waste, can be converted into bio-methane (natural gas), and used as authors of Sustainable Healthcare Archi-
energy. As a means to collect enough organic waste, the Embassy Medical Center has
tecture conclude, “By critically reinvent-
the potential to employ an infrastructure system that would not only suit the needs of the
hospital, but also serve the surrounding community. Stationary, sanitation points placed
ing the hospital as a regenerative place of
throughout neighborhoods, can provide safe sanitation, proper garbage disposal, and healing, marshalling purchasing power,
showers. They would be places where a community can connect, and promote healthy and modelling health and wellness ... the
practices. As many as 2,000 sanitation points will be needed, and serviced regularly to healthcare industry can signal a new rela-
harvest enough waste. The organic waste will be transported from sanitation points to tionship to healing and health.” Through
temporary storage sites, before being brought back to the Embassy Medical system (all green construction and operations initia-
transportation via electric vehicles). It can than be placed in the digester and converted tives, hospitals can demonstrate a broad
into clean energy. commitment to more than high quality
patient care. They can demonstrate a
commitment to save lives and improve
health without undermining ecosystems
or diminishing the world.

Embassy Medical Center

Sambhavna Clinic in Bhopal, India and
Embassy Medical Center in Sri Lanka
(profiled here). It is informed by The
Living Building Challenge, a frame-
work developed by the Cascadia Green
Building Council in the US , and Health
Care Without Harm, a global non-profit
that has taken up the challenge of trans-
forming healthcare infrastructure from
today’s standard practice to zero-energy,
toxic-free, zero-waste, water-balanced
solutions. The long-awaited LEED®
for Healthcare, with increased focus on
daylighting, material health, and energy
demand reduction, will assist hospitals in
North America in beginning the journey
to this transformation.
The healthcare sector should not
need to argue that delivering high quality
healthcare requires a passport for waste
and energy intensity—or that saving
lives is somehow outside of broader
Healing institutions have a core mission
to regenerate the health of those they
serve. ‘Living’ or ‘Regenerative’ hospi-
tal design builds from that mission to
include nurturing the environment and
people in ways that extend deep into
the community. Social equity, environ-
ment, economics and education are the
four chambers of regenerative design
and they are much like threads in a
piece of cloth, woven together into a
uniform fabric that becomes an insepa-
rable whole.
The Embassy Medical Center is
taking the next step in design conscious-
ness to become a regenerative influence
in the city of Colombo, Sri Lanka. The
Hospital will synthesise knowledge and
perspectives from around the world,
merging local needs, customs and biore-
gional influences with appropriate tech-
nologies and global financing to form a
balanced union of regional and global
connectivity.
Much of Sri Lanka’s population
is challenged to meet their basic daily
needs, making the project’s regenerative
goals extensive. The project will create
a state-of-the-art hospital and healing
centre in an environmentally distressed
urban area; to serve effectively a broad
population of varying economic means;
to act as a regional economic incubator;
to educate its own staff and the tech-
nical trades that assist in their design

82 Asian Hospital & Healthcare Management ISSUE - 17 2008

w w w. a s i a n h h m . c o m 83
facilities & operations management

Sustainability Concept for Energy, Water and Sewage

1. Absorption Chiller—Utilises very hot water to

provide chilled water for cooling.
2. High Temperature Anaerobic Digester for Bio-
Methane with conversion to pipeline grade
Natural Gas. The Anaerobic Digester will also
act as the ‘Sewage’ Treatment plant for the
facility.
3. Solar Hot Water Panels provide High Heat Hot
Water for the Absorption Chiller and Domestic
Use. Use Natural Gas from Digester to boast
water temperature if needed.
4. Co-generation Plant—Generates Electricity
with steam heated by natural gas from
Digester—Hot Condensate is then sent to
Absorption Chiller.
5. Ground Contact Earth Tubes—Pre-cool and
Pre-Dehumidify fresh air for final touch-up
and filtering by the Mechanical System.
5A. Desiccant Dehumidification using hot water or
natural gas as an energy source will touch-up
the fresh air after exiting the Earthtubes.
6. Thermal Chimney used to ‘pull’ air through
Due to environmental constraints, and the magnitude of the new facility, it is critical that the earthtubes for delivery to the Mechanical
the Embassy Medical system has the ability to generate it’s own sustainable energyso System. Use Mechanical System to boast
as to maintain high quality indoor environments, and conduct healthcare practices. ‘pull’ if needed.
Sustainability Concept for Energy, Water and Sewage: The goal is to have the facility 7. Cisterns for collection of rainwater—used for
function off-grid, using grid sourced electricity and grid sources natural gas (If available) flushing toilets and as feedstock for Domestic
only as 2nd tier back-up. Wind Power Potential for the site is low and Solar Electric (PV) Water Filtration System. Cisterns can be used
technologies are expensive and space consuming at the scale required for this facility. as ‘Overnight’ Solar Hot Water storage.
Therefore, a primary goal is to use as little electricity as possible, relying on renewable
sources of heat (Solar Thermal and Bio-mass) as the main energy drivers. 8. Domestic Water Filtration System—Non-
Chemical.
A High-Temperature Anaerobic Digester creating pipe-line grade natural gas
(conditioned Bio- Methane) coupled with a solar hot water system will be pivotal 9. Living Roof Area(s)—Pre-Filtration for
energy technologies. Biomass Feedstock Goals are: 1/2 to 3/4 Sewage and 1/2 to 1/4 Rainwater heading to Cisterns.
Agricultural Residue and Organic Garbage. Sewage and organic garbage will come from 10. Stormwater Ponds for retention and filtration.
the feasibility and from the surrounding community. Agricultural residues will come from Use water for Irrigation and as feedstock for
the rural areas on the island. Electricity will be generated on-site using a natural gas Domestic Water Filtration System if Cisterns
fired co-generation plant. run low due to an extended dry period.

and construction; to be a self-maintain-
ing place of community refuge; and to
provide all of their own power, water,
sewage and medical waste recycling in
ways that are beneficial to the environ-
ment and the surrounding neighbor-
hood.
Few things are as regenerative to
individual and community health as
access to clean water. In 2007, the
World Health Organization (WHO)
reported that there are 4 billion cases
of diarrheal disease and 1.8 million
deaths each year globally from unsafe
water and hygiene. Thus, one regenera-
tive thread at the heart of the Embassy
project is to act as a ‘clean water center,’
providing sewage treatment and potable
water to several of Colombo’s underde-
veloped neighborhoods.
The medical centre will use living
roofs to capture and pre-filter rainwa-
ter. A reverse osmosis system, coupled
with carbon and ultra-violet filters, will
purify the rainwater for use in the hospi-
tal and distribution to underdeveloped
neighborhoods. Water from showers
and lavatories will be filtered through
constructed wetlands and ultra violet
filters for use in flushing toilets.
Another essential clean water strat-
egy involves converting sewage from the
hospital and Colombo’s underdeveloped
neighborhoods into carbon-neutral
renewable energy using a high-tempera-
ture thermophilic anaerobic digester.

84 Asian Hospital & Healthcare Management ISSUE - 17 2008

 facilities & operations management

Used in Western European cities, this
hi-tech compost system will naturally
create bio-methane that will be polished
into Bio-Natural Gas (BNG). The
BNG is then used in a co-generation
plant to power the hospital and water
purification systems. Excess BNG will
be generated by the hospital and used
to seed the transformation of Colom-
bo’s transportation sector to this clean
burning fuel, improving the respiratory
health of the community and ultimately
providing an improved environment for
the medical centre itself.
Water and energy efficiency are
essential to the project as it is more
cost-effective to conserve resources than
to produce them. Water efficient toilets
and lavatories will be used through-
out the facility where appropriate. To
improve energy efficiency and patient
health, narrow floor plates, courtyards
and light shafts will be used to harvest
daylight and natural ventilation.
This facility will also be the first of
its kind to consider high sea flooding,
Tsunami, earthquake and other cata-
strophic issues. The facility is being
designed to withstand the forces of
nature and remain open and function-
ing during a natural disaster—not only
to provide medical care for patients but
to provide refuge for the community.
Of course, providing regenerative
care for patients will be a key to the
facilities’ success. The Embassy Medical
Center will contain 180 private patient
rooms as well as full-service operational
medical support with a comprehensive
outpatient medical clinic. The facility
will include advanced medical innova-
tions, technologies and design features
to assist its doctors in offering world-
class medical treatment. As a result, the
facility will assist Sri Lanka in becom-
ing a worldwide medical destination,
providing a much-needed boon to the
area’s economy.
Though contemporary and cutting-
edge in terms of its medical advance-
ments, the facility’s design will be
appropriate to its specific location and
embody culturally specific design solu-
tions. The facility will demonstrate a
fine balance between Sri Lankan culture
and advanced medical design and tech-
nology that will result in a ‘healing
home’ environment. For example, each
private room will reflect all aspects of
natural healing, offering private open
air balconies so that patients and their
families can take advantage of the heal-
ing benefits of nature.
Upon completion, the Embassy
Medical Center will be the most sustain-
able and regenerative medical facility
in the world. It seeks to expand the
fundamental meaning of ‘Healthcare’
beyond immediate medical services, to
include the much needed work of creat-
ing healthy environments and healthy
communities.

Robin Guenther is a practicing healthcare Architect whose built

work has been published both nationally and internationally. She
has been playing an important role in defining the sustainable design
agenda in healthcare through a wide range of advocacy initiatives.
A uthors

She coordinates the Green Guide for Health Care, serves on LEED-
HC committee, is a board member of Practice Greenhealth and
the Center for Health Design, and is the co-author of Sustainable
Healthcare Architecture with Gail Vittori. Contact her at Robin.
Guenther@perkinswill.com.

Douglas D Pierce is a practicing Architect with over 25 years

of experience in sustainability theory and green design. He is
an advocate for carbon neutral, regenerative design within his
profession and teaches graduate level classes on the subject at the
University of Minnesota, School of Architecture.

w w w. a s i a n h h m . c o m 85
information technology
Understanding SOA
Caring about IT architecture
Increasingly, healthcare organisations are looking towards healthcare IT to help drive
efficiencies and improve care quality. However, they need to sort out the common
misconceptions regarding SOA before adopting it in their organisations.
Ken Rubin
Healthcare Architect
Martin Holzworth
Enterprise Architect
EDS, USA
H
ealthcare organisations face
many challenges today. Though
each organisation has its own
specific obstacles, a quick review of indus-
try literature quickly highlights that there
are many common problems: How do we
manage with the budget we have? How
can we do a better job of treating our
patients and improving care quality? How
can we prevent medical errors? How can
our EHR investment be successful where
others have been unsuccessful? Which
product or products are best for us? How
do we make all this technology work in
our organisation?
Globally, populations are both grow-
ing and ageing, creating pressure on the
healthcare organisations that manage and
treat them, a problem further exacerbated
by significant shortages of skilled health-
care staff. Result is the burgeoning needs
and limited budgets, where many organi-
sations are looking to healthcare IT for
answers on how to do more with less.
Before we can entertain a reason-
able discussion about either Healthcare
IT architecture or Service-Oriented
Architecture (SOA), we must first begin
with the business principles and ration-
ale behind making such investments.
This stems from the business functions
86 Asian Hospital & Healthcare Management
we enable, the objectives we are trying
to achieve and the outcomes we hope
to achieve as a result of our IT invest-
ment. We must first have a founda-
tion, and architecture to provide that
foundation.
Understanding Architecture
It all seems too easy to cobble together
some requirements, pick a product and
be done with it. The downside is that this
model is proven time and time again to
fail, and for a variety of reasons:
• No single vendor is best-of-breed at
everything
• Legacy systems do (and will continue
to) exist
• Organisational boundaries are constantly
changing, driving the need to adapt.
When making IT investments within
an organisation, we must not only consider
the needs of the users, but the needs of
the organisation itself as a business entity.
What are our drivers? Who are we looking
to benefit (clinician, patient, organisa-
tion)? What returns do we hope to get
on this investment? (Improved outcomes?
Streamlined workflow? More accurate
reporting?)
Enterprise Architecture (EA) is the
key discipline and building block to help
align business needs to IT investment. In
brief, EA models our understanding of the
business, captures business requirements,
relates those requirements to IT invest-
ment and demonstrates accountability of
that investment back to the business. The
result is a blueprint that frames how tech-
nology components, products, processes
ISSUE - 17 2008
and policies all come together to support
the needs of the Enterprise.
How does this work ‘in the real world’?
Let’s take an EHR example. Suppose, one
specific EHR vendor-offering appears
ideally suited to our business need. It
provides the clinicians with the informa-
tion quality and fidelity they want. It has
a user interface that is easy to understand,
multilingual and supports the modalities
(desktop, tablet PC, mobile phone) that
interest us. Seemingly, this would be a
good investment were it not for consid-
erations around the architecture.
Further investigation reveals that
this ‘ideal’ product that is unable to
integrate with our existing laboratories
(both government and commercial) is
unable to ingest data from our existing
registration system. It is unable to support
our planned personal health record. Quite
simply, the product doesn’t fit within the
context of our organisation.
How do we know this? We know this
because an Enterprise Architecture docu-
ments a bigger picture, formalising where
we are and where we plan to go, giving
us the raw data and insight to make
informed decisions. Though there are
dozens of EA frameworks and method-
ologies, most accepted approaches share
the following dimensions. These dimen-
sions are comprehensive and distinct, but
interrelated as the context of one view
affects the others:
Business View: Describes the purpose,
functions and organisational considera-
tions of the business. This view would
capture the core functions provided by
w w w. a s i a n h h m . c o m 87
information technology
the organisation, its policies, drivers and
so on. For example, Emergency depart-
ment, laboratory, financial management;
objectives such as reduced wait times,
improved patient safety
Information View: Identifies the informa-
tion of interest and pertinent information
standards / terminologies, such as what
might be captured in forms or stored in
systems (administrative data, registration
information, medical record information,
patient demographics etc.).
Systems View: Discusses the applications,
software, messaging, software services and
standards that comprise the IT landscape
within our organisation. It would include
commercial packages, such as our EHR
and speciality / subspeciality systems,
integration engines, workflow packages
etc.
Technology View: Identifies the underlying
infrastructure components upon which
systems will be built, such as the physical
network, hardware platform, key software
88 Asian Hospital & Healthcare Management
in the technology stack (operating system,
Java / .NET etc.).
So, what about SOA ?
If Enterprise Architecture is what helps
in making informed decisions about IT
purchases, why care about service-oriented
architecture? What is it? How does SOA
relate to EA? More importantly, why
would a business person care about SOA?
There is a common misconception in the
industry that SOA is a technology—the
embodiment of a solution that is offered
through a variety of vendor products that
will solve all our problems.
Just as its moniker, SOA is an
approach, a philosophy, a method for
integrating a broad spectrum of tools,
processes and people for business to real-
ise its objectives through adherence to a
set of core tenets. SOA is fundamentally
based on the services that an organisa-
tion provides and is thus owned by the
business and not the IT shop.
ISSUE - 17 2008
One of the pre-eminent SOA
organisations—the SOA Consortium
articulates its purpose to “Promote
and enable business agility via Service
Oriented Architecture which allows busi-
nesses to compete, innovate and thrive.”
Their focus is to help change the public
perception, particularly from business
executives that SOA is an IT integration
platform when it is more appropriately
considered a business agility tool.
How does this relate to healthcare
then? Quite simply, healthcare organisa-
tions are making significant investments
without an architecture. The result is
that they have little or no confidence
that their purchases will integrate, adapt
and evolve to support changing business
needs. SOA provides a framework for
thinking about healthcare IT that natu-
rally aligns to the needs of healthcare
organisations, improving alignment,
traceability, and ultimately consistency
with good EA practices.

Healthcare is service-oriented
Very often, care delivery is conducted not
by one individual, but by a care team, each
member of which has specific capabili-
ties and responsibilities. They collectively
engage and collaborate to meet the needs
of a given patient. For instance, a care team
may comprise many specialists: cardiolo-
gists, radiologists, physiologists, nurses,
nutritionists and so on. Each member
of the team provides a unique expertise
and performs specific functions. The team
is collectively governed by an authority
with an overall responsibility for the care
delivery, which orchestrates its operation
and coordinates its activities.
SOA embodies many of these
principles
Services themselves are not expected to
do everything, as they require collabora-
tion with others. A given service has well
defined role and responsibility, based on a
commonality of function and capability.
They require coordination among multiple
parts to work effectively, and work together
within the context of some governance
with responsibility for orchestrating work-
flow among them.
Authority is the underpinning of a
successful SOA
To adopt SOA in an organisation, we must
align our business processes, our policies,
our systems and the role that those systems
perform within our organisation. It is not
enough to purchase a new demographics
system that supports a web services / XML
interface. The new software does not make
that system authoritative, especially if we
do not have plans to “turn off” the legacy
system that also contains demographics
information.
The key difference lies in the poli-
cies and expectations of the new system.
Consider, instead, deploying our new
demographics system with a policy: As
of January 1, all demographics-of-record
will be stored in the new system, and
all Enterprise systems will look to it as
their source for demographic informa-
tion. The difference may be subtle, but is
Acknowledgement: The views in this article reflect the personal opinions of the authors and are not intended to be an endorsement
by EDS, Health Level Seven, the Healthcare Services Specification Project or the Object Management Group.
profound. This new system, coupled with
the above-stated policy is now moving
toward service-orientation. The demo-
graphics service is the authoritative source
for this information within the enterprise
(e.g. well-defined scope, responsibility,
authority).
SOA is not about technology
Web-services implementations and
XML do not make the organisation
SOA-enabled, as both can be used to
build point-to-point solutions as easily
as SOA-based ones. While it is true that
many SOA solutions do in fact leverage
technologies such as XML, SOAP and
Web-Services, the technologies themselves
do not fulfill the objectives of SOA. It is
how those technologies are applied within
the context of a total solution that makes
something SOA-based or not.
Get the core tenets right
There are hundreds of industry publica-
tions and articles highlighting key qualities
needed to realise effective SOA imple-
mentations. These qualities—a clearly
defined scope, formal interface specifica-
tions, loose-coupling (e.g. minimal direct
dependencies on other services)—ulti-
mately benefit the autonomy and compos-
ability of services. Some of the tenets that
drive this flexibility include:
Abstraction – Supports the ‘hiding’ of
underlying implementation details,
enabling and preserving the described
loose-coupling of SOA components.
Autonomy – Provides independent, self-
contained function of a service that is
not controlled or inhibited by other
services.
Composability – The ability to bring
together autonomous services in poten-
tially dynamic or unforeseen ways allows
SOA to grow to support complexities of
business needs.
Discoverability – The ability to identify
and leverage services as assets, resulting
in improved Return-On-Investment
(ROI) and ability to bring online and
leverage new capabilities as they become
available.
information technology
Why is this important? Services are not
systems. They are capabilities with singu-
larity of purpose that need to collaborate
with other services in support of business
needs. With services being defined and
scoped autonomously, but with the capa-
bility to ‘orchestrate’ workflow among
the parts, SOA-based solutions are more
adaptable and flexible than alternative
approaches.
Moving to SOA
Health organisations need to keep in mind
several aspects of SOA before adopting it.
Many have jumped onto the technology
bandwagon thinking that by installing
a Enterprise Service Bus, moving inter-
faces to web services, you have SOA. The
migration to SOA is a carefully architected
process that needs to balance business and
technology domains concurrently. SOA
is as much an organisational and cultural
change as it is technical. SOA cannot be
seen as the quick fix to the complexity
that has accumulated over the history of
the legacy landscape in healthcare.
Adopt a maturity-model approach
By adopting this approach, organisa-
tions can carefully plan the maturity of
their transformation. Industry maturity
models typically follow a similar pattern of
incremental improvement across domains
(architecture, technology, information,
governance, business process etc.) It is
critical to adopt a balanced approach,
particularly in a SOA environment, and
avoid the tendency to become too focussed
in one domain at the expense of another.
This is a long journey spanning several years
and requires commitment, flexibility and
governance in order to be successful.
Standards matter
Healthcare is a collaborative effort, involv-
ing participants from across a broad
spectrum of people, organisations, and
systems that support them. Even if your
organisation were to architect, deploy and
operate a SOA-based system absolutely
perfectly, there are factors beyond your
control. Vendors change their offerings
and technical direction. Health systems
interact with new organisations and
w w w. a s i a n h h m . c o m 89
information technology
business partners. Technologies change
and are replaced.
Standards form a basis to miti-
gate these challenges. Even if we insti-
tute a SOA-service to manage patient
identities (e.g. a Patient ID Service), what
assurances do we have that our business
partners will be able to interact with it?
It is for these reasons that efforts such
as the Healthcare Services Specification
Project (HSSP) exist. This effort is a collab-
oration involving primarily Health Level
Seven (HL7) and the Object Management
Group (OMG) to develop health industry
SOA standards. These specifications estab-
lish an industry position on the scope of
healthcare SOA services, their responsibili-
ties and bindings for their implementation
using specific technologies (such as web
services). Efforts such as these promote
interoperability among organisations while
still providing autonomy to vendors and
organisations to realise SOA in the way
that best fits their needs.
90 Asian Hospital & Healthcare Management
Act Locally being demanded. The onus is on each of
The mainstream ‘business as usual’ us to move the industry in the direction
approach toward buying products and that meets our needs. That means plac-
leaving healthcare institutions to force ing requirements such as standards-based
products that do not fit well or integrate interfaces and open architectures into our
effectively. This approach is not sustain- purchasing, sending a clear message to
able, particularly as increasing reliance and industry of our needs. Irrespective of
investments are made in healthcare IT. which technology path and architecture
The decisions you make within your you choose, you have to recognise that
own institution have broad industry there is no way to reach your destination
impact, as vendors won’t supply what isn’t if it is not defined clearly.
Ken Rubin is a Senior Healthcare Architect with EDS, is focussed on
informatics, EA and EHR interoperability, and has supported the (US)
Veterans Health Administration and the (UK) National Programme for
A uthors
IT. Rubin chairs committees for the OMG, HL7, Open Health Tools
and the Healthcare Services Specification Project (HSSP).
Martin J Holzworth is an internationally experienced Enterprise
Architect with expertise across healthcare, financial services, tele-
communications, and government sectors with an outstanding track
record of success. Holzworth has worked with numerous clients in
Australia, Asia and USA and is currently working with a large govern-
ment healthcare provider in Australia.
ISSUE - 17 2008
w w w. a s i a n h h m . c o m 91
information technology

Telehealth
in Asia
Healthcare for
the communities

The Internet and next generation

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

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

92 Asian Hospital & Healthcare Management ISSUE - 17 2008


A
sia is increasingly challenged by
the social disparities between its
urban and rural populations due
to the massive growth it experienced
in the recent years. Of the region’s 4
billion people, 80 per cent live in rural
areas often without adequate access to
education and healthcare.
Today, there is an immediate need for
the region’s governments, communities
and industry partners to address the chal-
lenges of the region’s existing healthcare
structures and ensure that everyone has
an access to adequate healthcare.
Currently most people in Asia rely
on state subsidies, while more than
130 million people can pay for private
healthcare. The majority of people in
the region survives on US$ 1 per day
and would by no means be able to access
basic medical care (The World Bank,
World Development Report 2008).
Governments, companies and communi-
ties need to find solutions that will allow
medical care to cross the geographical,
social and cultural barriers within the
health sector and ensure that everyone
is able to access healthcare.
In the developed world, the growing
availability of broadband Internet, Wi-Fi,
cellular networks and the move to digital
television are opening doors to an amaz-
ing array of telemedicine and telehealth
services. But even in far less developed
economies where broadband is scarce
and electricity and phone service may be
unreliable, commodity communications
technologies are being used to extend
healthcare services to those in need.
Microsoft believes that bringing
together of the region’s technology
capabilities with telehealth or the use
of Information and Communication
Technology (ICT) can help deliver
health services, expertise and informa-
tion over distances. Countries will be
able to improve the quality of care,
increase access and manage the cost of
implementation and management.
Telehealth allows us to access the innova-
tions and technological advancements
within the region and apply them to
information technology
support the communities including rural
and the aged.
Reaching the remote communities
Healthcare facilities in most rural areas
are usually non-existent or lack proper
resources. Further, transportation prob-
lems to metropolitan hospitals pose a
real barrier to access for the rural popu-
lation. The low population density in
rural areas makes it inherently difficult to
deliver services that target persons with
special health needs, including people
with HIV/AIDS, people with chronic
illnesses, mothers and children, the aged
and people with disabilities.
Telehealth is not designed to replace
clinicians or other healthcare staff, but to
improve access to healthcare for people in
remote locations or those for whom the
access to healthcare is limited by culture,
language or clinical resources.
One key success has been the
Microsoft pilot project with Dristee in
India’s Barielly and Madhubani districts.
Seventy per cent of India’s population
(some 700 million people) lives in rural
areas and the per capita expenditure on
healthcare is not more than US$ 7 per
day. Limited financial resources coupled
with the limited medical resources (there
are about 60 doctors per 100,000 people
in India) make the delivery of healthcare
more challenging.
With the assistance of a medical
facilitator and by means of a compu-
ter and dial-up Internet connection,
villagers are able to discuss their health
concerns with a medical professional
at an urban centre. Vital signs, photos,
medical records and other information
can also be shared. Simple problems can
often be addressed then and there. People
needing more care can be referred for
an appointment in a town, but with
greater assurance that when they make
the long trip to get there, they will see the
appropriate specialist for their particular
ailment. The computer is fitted with a
solution developed by Neurosynaptic,
a Bangalore-based firm Microsoft is
partnering with.
w w w. a s i a n h h m . c o m 93
information technology

The situation is further exacerbated increases. Commodity telemedicine solu-

“This is for the villages that
have few medical facilities. It
will save their time and money.
This works on a low bandwidth
on normal dial-up connections.
It can connect to any one
in the world. It can transmit
reports and prescriptions
can be printed out,” says PL
Bhartheesha, an Engineer with
Neurosynaptic.
The pilot project is a key example
of how technology is able to bring the
world of specialised healthcare to those in
need of it. Dristee’s team of workers also
educates the villagers who are unaware
of their health conditions or the neces-
sary steps required to treat them. The
programme aims to provide a technol-
ogy platform for rural communities and
gives citizens greater access to qualified
health information and medical serv-
ices. The platform uses simple dial-up
Internet access, computers and web cams
to connect care givers and patients in
remote villages with more highly qualified
medical professionals in urban centers.
Digamber Jha, a retired school teacher
in Mangrauni South Village suffers from
a persistent stomach disorder and goes for
regular check-ups and follow-up sessions
with his doctor who is 150 miles away via
telelink. “I am confident that the doctors
there will be more qualified than those in
Madhubani. Despite my poverty, I will
try to follow the treatment they prescribe
to the best of my ability”, he says.
Preparing to care for the aged
A key priority for Asian governments is
the provision of adequate care for the
ageing population. Over the past 50 years,
by the shortage of qualified health
workers.
According to the World Bank, there
is a shortage of 4.3 million health work-
ers around the world and 57 countries
do not have enough health workers to
provide even basic health services.
A key to manage the rising demand
of aged care is to empower patients.
As Professor Branko Celler, CEO of
Australia’s TeleMedCare explains, “the
empowerment of patients with the tools
and the knowledge to self-manage a long-
term condition, the facilitation of an all-
population approach to improve health-
care outcomes at a distance by integrating
social care, telecare and telehealth services
throughout the primary care sector.”
Professsor Celler’s team has devel-
oped Medications Management and
Reporting System, MEDSafe that is
designed to facilitate medication admin-
istration at the point-of-care. Delivered
via a medical grade tablet computer, the
system works to reduce the possibil-
ity of medication errors and provides
comprehensive management reporting.
TeleMedCare conducted a trial with 22
patients aged between 58 and 82 with
chronic illnesses. The patients found the
solution easy to use and agreed that it
helped them manage and control their
health conditions better.
Empowering patients to better
manage their own medication, takes
the pressure off care takers and allow
patients to get involved in their own
treatment.
At Microsoft, we believe that as the
reach of the Internet grows, and the
number of ways to extend low cost,
two-way audio and video into the home
Gabe Rijpma is the Director of Government Solutions for Microsoft
A uthor
tions and an entire range of ehealth serv-
ices will emerge to help meet the demand
for health information and medical care
around the world.
Conclusion
Microsoft has a long standing commit-
ment to support the underserved through
technology. Our Unlimited Potential
programme ensures that we invest in
providing technology that enhances
education and employment opportuni-
ties. We are applying this belief to our
partnership in healthcare and through
the adoption of telehealth solutions,
we believe communities will be better
supported. Costs will be managed, care
given and innovation will continue.
At Microsoft, we believe that the
greatest impact will be through strong
public private partnerships. Through
these partnerships, telehealth solutions
will ensure that more efficient and effec-
tive care is delivered across the region.
Already, an Internet-enabled, commodity
telemedicine and telehealth service plays
an increasingly important role in extend-
ing care to those who need it. By ensuring
that these communities are supported by
public private partnerships, they will be
better supported. costs are better managed
and innovation will be continued.
Telehealth is real and has begun to
make an impact on the lives of people in
our communities. Microsoft looks forward
to the implementation of telehealth
solutions and strong partnerships across
the region that will ensure that the
sick in our communities are in better
contact with their health providers, care
givers and others dealing with similar
challenges.

the proportion of older people has been
rising steadily, and in the next 20 years
almost a quarter of the region’s popula-
tion will require aged care, placing an
enormous strain on existing healthcare
systems.
Asia Pacific, working from Singapore. Gabe started his career at
Microsoft in 2000 and joined as a Principal Technology Specialist
focused on helping government customers realize the value from
their Microsoft technology investments. Prior to joining Microsoft he
was the Principal Consultant at Software Spectrum Inc in Sydney
Australia looking after the business solution development practice
delivering solutions on both the IBM and Microsoft platforms.

94 Asian Hospital & Healthcare Management ISSUE - 17 2008

 information technology

Leveraging Authentic
Health Information
Key to patient empowerment

Advancements in medical knowledge have led to increased complexity of care delivered by

multiple teams often across organisations. As the population ages, delivering such care will
become increasingly difficult. Real-time digital medicine, enabling patients to view their own
medical records, which contain high quality information, and enable them to make choices
about the care they receive affords the opportunity to empower patients and clinicians.

Amir Hannan
Lead
Information Management & Technology
Tameside & Glossop Primary Care Trust
Primary Care Lead North West Strategic
Health Authority, UK
programme which then continues for the
rest of their lives. A great deal of effort
is now being placed on trying to identify
people at risk of heart disease and even
on preventing it by targeting children
and young adults to improve their life-
style. As populations age and more and
more elderly people continue to live
How good is the information that
patients and the public have today?
The advancement of medical knowl-
edge has accompanied a plethora of
information to help the patient and the
public gain a better understanding of
what is available and what can be done.
(See Table 1)

I
n the 1960s, a patient admitted into
hospital with a suspected myocardial
infarction would be in bed for six
weeks. He was looked after and moni-
tored by the concerned nurses. After six
weeks, he would either be discharged
all ‘cured’ or succumb whilst in his bed
and die. No further follow up, tests
and no medication was needed. What
is the current scenario? Today, we are
able to do ECGs, measure troponin T
levels, arrange coronary angiograms
and perform primary angioplasty or
provide thrombolysis. In the immedi-
ate post-myocardial infraction period,
we can closely monitor patients’ every
passing second, beat by beat monitoring
for cardiac arrhythmias and institute
treatment appropriate to the patient’s
needs and even adjusted to the patient’s
own physiological parameters. Patients
are assessed for hypercholesterolaemia
and diabetic status and further ongo-
ing treatment is provided. They are
put through a cardiac rehabilitation
with ever increasing chronic disease, There is ample information available
the complexity of healthcare as well as to patients about anything they want,
the cost of treating and maintaining whenever they need it. The advent of
them rises. It is envisaged that by 2050, the Internet has made searching for
the number of people needing care will information even easier. But there are
rise to four times of what it is today. doubts regarding the authenticity of the
Already we have more people over age information provided by it.
of 65 than those aged below 18 in the Compliance is poor even for condi-
UK, indicating that there will be more tions such as arthritis (see Figure 1)
and more people who will need to be suggesting that the system at the moment
looked after by ever fewer people who is not meeting the needs of patients and
are at work. a need for a new approach.
Information sources for patients and the public
• Highly trained-clinicians (continuous professional development, appraisals, professional meetings,
specialist journals informing latest developments)
• Patient leaflets (information prescriptions)
• Posters (in waiting rooms, on billboard)
• Advertisements (in magazines, TV and radio, health provider websites)
• Self-help groups (chronic disease specific, e.g. Diabetes UK; or other broader areas e.g. Arthritis Care)
• Patient Information Forum / Patient Associations
Table 1

w w w. a s i a n h h m . c o m 95
information technology
Percentage of patients NOT complying with medication
by disease area
90
80
70
60
50
40
30
20
10
0 According to comScore in August 2007,
Asthma Diabetes Hypertension
Creating knowledge-based
healthcare systems
We now have the ability to economically
check patient’s blood pressures (data)
with sphygmomanometers that are avail-
able in the market. If patients browse
high quality websites which inform them
about blood pressure (information), they
can monitor their own blood pressure
and identify high and low blood pres-
sure (knowledge). But to do this safely,
patients should be taught certain skills
(how to check blood pressure, what
size cuff to use, use a machine that has
been validated for this purpose and is
regularly serviced and calibrated etc.)
and certain attitudes (e.g. being aware
of what needs to be done in case of high
blood pressure). People should also learn
where to check their blood pressure (e.g.
provider institution, pharmacy, doctor’s
waiting room, home). Once identified
as having hypertension, they should be
treated according to certain guidelines /
protocols (processes) to achieve a specific
outcome (reduction in risk of death,
myocardial infarction or cerebrovascu-
lar accident). Healthcare systems have
tended to focus on doing things without
encouraging patients to think through
why and what the consequences might
be if these things do not happen. Hence,
patients have not truly understood the
implications of not following the advice
96 Asian Hospital & Healthcare Management
Epilepsy Arthritis
Figure 1
given to them by their clinicians.
Clinicians can let patients see their
health information but not abdicate
their responsibility for providing care.
Those patients that are able to look after
themselves should be enabled to do so.
But clinicians should also be aware of
the patients who are unable to manage
themselves well and who need their help
and support. Multiple IT systems oper-
ating in different healthcare organisa-
tions or departments should be made
interoperable to pull together data to
display the information required for both
patient and clinician wherever necessary.
As people travel increasingly around the
world, SNOMED-CT may become the
common language to share such data in
a semantic interoperable way so that
data (such as blood pressure) can be
displayed on the local clinical system.
Such knowledge, skills and attitudes will
be necessary for both clinicians and the
patient to understand. This will lead to
a certain type of practice and experience
which can then also be measured e.g.
through surveys or recording patient
journeys.
In a knowledge-based healthcare
system, a patient or citizen may think
about checking their blood pressure and
begin to understand how to reduce their
risk of death by understanding how to
monitor and control their blood pressure.
ISSUE - 17 2008
(Data leads to knowledge). Conversely
they may think about reducing their
risk of death and realise that they need
to check their blood pressure and then
find out how to control their blood
pressure as a result (Knowledge leads
to what data to collect). This leads to a
better understanding of the care they are
receiving or what choices they can make
to ensure good health or even encourage
providers to meet their needs instead of
just providing a service.
But do people care about finding
out about their health?
there were 37 billion health searches
on Google and 8.5 billion on Yahoo.
Online Health Search 2006 found 80
per cent of American Internet users, or
some 113 million adults, have searched
for information on at least one of seven-
teen health topics. Forty-eight per cent
of heath seekers searched on informa-
tion for somebody else. Thirty-six per
cent of health seekers claimed their last
search was for their own health needs.
Fifty-three per cent of health seekers
felt the information they had found an
impact on themselves or how they cared
for themselves. Whilst 74 per cent felt
reassured that they could make health-
care decisions, 25 per cent felt over-
whelmed by the amount of information
they saw. Small groups felt frustrated
by the lack of information, confused by
the information or frightened by the
serious or graphic nature of what they
found online.
People are searching the Internet to
understand their health-related prob-
lems. But the quantity of information
is enormous. A search on Google for
myocardial infarction reveals over 5.6
million results. The quality of informa-
tion is variable and clearly not everybody
has time to appraise the information
whilst they need to make decisions
on how to care for themselves or their
patient. Even if people know that they
should learn about their health, it is not
clear where they should go, why they
 information technology

should go and how it will help them

Knowledge-Driven Healthcare Systems
get better care.

Towards a partnership of trust Data information Knowledge

Whilst the clinician may be an ‘expert’
in what modern day medicine has to
offer and what is available locally to
the patient population, the patient is
an ‘expert’ in how the disease is affect-
ing him or her or what they might be
at risk of, e.g. family history of condi-
tions, environmental factors or personal
behaviours that put them at increased
risk of developing certain conditions. The
mutual trust and shared understanding
between patient and clinician will help in
forming a Partnership of Trust. It helps
in formulating the future plan of the
treatment and also improves compliance
from the patient.
Ensuring better outcomes
Patients need to know what condi-
tions they suffer from, e.g. myocardial
infarction or hypertension. These are
terms that will be stored in their health
record. Giving patients access to their
own health records is the fundamental
key to a better unified understanding
between patient and clinician. If this is
contained in an electronic health record,
then the information can be instantly
shared with the patient as well as the
clinician as and when the need arises
(Real time Digital Medicine). The patient
can confirm the accuracy of the record
(past history, medication, allergies as
well as go over consultations, results
of tests and the plan of action includ-
ing next steps that have been jointly
agreed as well as reviewing any other
communication from other clinicians
or healthcare providers).
These terms in the record, e.g.
myocardial infarction, can then be linked
to high quality information that the serv-
Knowledge Skills
Structures Processes
areas It is being deployed around the
world and is available for patients in
the UK at present. Patient data can be
linked with information from the Map of
Medicine as well as other trusted websites
to develop knowledge. That knowledge
should enable the patient to improve
their compliance with treatment and
the agreed shared plan.
Role of the service provider
During consultations, the clinician can
record the shared plan of action, what
has been agreed by the patient and the
clinician and what should happen if
problems are encountered or a change
is needed. The patient may even be able
to add their own comments as well so
that a shared record is formed. This
builds transparency into the Partnership
of Trust and enables the patient and
clinician to know what to do. As it is
in the record and the patient can view
it, the patient can also choose to share
it with others who may also help (e.g.
other clinicians, allied health profession-
als) or others whom the patient trusts,
(e.g. carers).
Enabling access
The first step is to recognise the problem
and gain a better understanding of the
issues. The second step is to recognise
A uthor
Attitudes
Outcomes
Figure 2
that a solution does exist that allows
patients and the public to access their
health records online. Here in the UK
over 40 GP practices are now offering
the service. Almost 60 per cent of GP
practices have been enabled to offer the
service to their patients. We are currently
developing guidelines for patients and
clinicians on how to share health records
safely with patients for clinicians and
system suppliers. These could in future be
adapted to a world-wide audience. In my
own practice, over 400 patients are now
accessing their own GP records. We ask
everybody ‘Are you eMPOWERed yet?’
(The bottom-up approach of www.htmc.
co.uk, see attached poster). The third
step is to raise the issue at the WHO.
The International Council for Medical
& Care Compunetics is presenting a
paper to the WHO on patient access to
electronic health records . Raise this issue
with your member healthcare organisa-
tions (the top-down approach).
Enabling patients to access their
own health information can lead to a
patient-centred healthcare system that
does not provide tokenistic information
but rather patient-specific information
that is fit for purpose and could lead
to better and healthier outcomes for an
organisation as well as the individual
concerned.

ice provider has vouched for. An exam-
ple that has the support of the World
Health Organization (WHO) is the Map
of Medicine . It is an evidence-based
knowledge management tool that can
be localised for particular geographical
Amir Hannan is a full-time General Practitioner in Hyde, England. He
is the Primary Care IT Lead for North-West Strategic Health Authority
and is on the HealthSpace Reference Panel and the National Clinical
Reference Panel for the Summary Care Record at NHS Connecting
for Health.

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