Issue 20 2009 £12 €18 $25 Rs.300 www.asianhhm.

com

Advance Care Planning

A new intervention

Technology and Patient Safety

Capturing the power of technology

Healthcare IT Spending
Effects of a changing global economy

www.asianhhm.com 
 A s ia n H o s p i ta l & H ea lt hcare M a nage ment ISS Ue - 20 2009

Healthcare Reforms in India
The right steps
If national and global targets of healthcare are to be achieved,
large-scale reforms are the right way forward.
T o say that healthcare reforms are the biggest challenge
facing Indian healthcare would be an understatement.
The enormity of this roadblock can be judged by the
fact that there has hardly been any change in the way
the state provides healthcare since independence.
True, things have changed dramatically with the entry
of the private sector. But access to basic healthcare
amenities is still considered to be a luxury in many parts
of the country. As a result, a country that has registered
staggering economic growth is struggling to fulfil the most
basic healthcare needs. The government’s spending on
healthcare continues to be one of the lowest in the world.
The monetary stakes are not high and this is reflected in
the condition of government-funded healthcare.
According to the report Global Infrastructure:
Trend Monitor Indian Healthcare Edition by KPMG, a
research firm, Indian healthcare is expected to double
in value between 2009 and 2012. This will be driven by
rising income levels and changing demographics and
illness profiles. Realising this potential will involve huge
investments in the healthcare infrastructure. And given
the healthcare system in place, wherein the respective
state governments control healthcare spending, chances
of disparities not arising are bleak. A state like Bihar,
for example, is not likely to do as well as Maharashtra
or Andhra Pradesh.
The government has been showing interest in the
Public Private Partnership (PPP) model to further its cause.
But so far this seems to have had limited success with
most of the activity happening in areas like emergency
ambulance services. Citing this, the KPMG report goes
on to state that “One of the major challenges remains
the need to develop scalable and sustainable healthcare
delivery models to deal with India’s diversity and changing
socio-economic population profiles.”
Foreword
Not surprisingly, the push for better infrastructure is
coming from the private sector. Of late, leading private
healthcare providers have shown interest in smaller cities
and towns. The economic benefits of operating in smaller
cities being a major incentive, this will help the private
sector tap into a virtually captive market that is eager
for high-quality services. Non-profit organisations have
been there for long time now and have been providing
basic care for virtually no cost.
What then can the government do about this trend?
At the least, it could help with putting in place the
infrastructure and quality standards for these providers to
get a foothold. Secondly, it could promote the non-profit
organisations by giving them economic incentives. A third
move, however improbable it may sound, would be to
compete with the private and non-profit organisations.
Competition spurs innovation with the patient being
its ultimate beneficiary. This would also mean that the
government would play a much important role in the
provision of care that just being a facilitator.
If national and global targets of healthcare are to be
achieved, large-scale reforms are the right first step. The
potential is there to be exploited. And by all means it
is more about when India will take the right steps than
whether it will at all.
This issue of Asian Hospital & Healthcare Management
presents insights from industry experts on what all needs
to be put into place for the potential to be realised.
Akhil Tandulwadikar
Editor
www.asianhhm.com 
 Contents

Healthcare in India
MILES TO GO

HEALTHCARE MANAGEMENT SURGICAL SPECIALITY

06 Quality of Healthcare 36 Surgery for Acute Heart Failure
Value of accreditation Stephen Large, Papworth Hospital, UK
Karen H Timmons, Joint Commission International, USA

08 Advance Care Planning DIAGNOSTICS

A new intervention 50 Three-dimensional Transesophageal Echocardiography
Fiona Randall, Royal Bournemouth and
Christchurch Hospitals Foundation Trust, UK
Early experiences
Nina Wunderlich, Cardio Vascular Center Frankfurt, Germany
Neil Wilson, John Radcliffe Hospital, Oxford, UK
12 The Lean Way
Jennifer Franke, University of Heidelberg, Germany
Improving healthcare performance Horst Sievert, CardioVascular Center Frankfurt, Germany
David Howard, The Manufacturing Institute, UK

56 Molecular Diagnostics and Personalised Medicine

16 Urgent Carew
CaseStudy

Present and future

The shift in emphasis Eddie Blair, Integrated Medicines Ltd, UK
Rick Stern, David Carson and Henry Clay
Primary Care Foundation, UK

29 Primary Healthcare in India

TECHNOLOGY, EQUIPMENT
An ideal approach
Geeta S Pardeshi, Dr. Shankarrao Chavan
& DEVICES
Government Medical College, India 60 Evolving Healthcare Technology
Changing processes

MEDICAL SCIENCES
Rajiv Varyani, Frost & Sullivan Healthcare, Singapore

32 Circulating Nucleic Acids in Plasma & Serum

A non-invasive approach
Peter B Gahan, King’s College London, UK

 A s ia n H o s p i ta l & H ea lt hcare M a nage ment ISS Ue - 20 2009

 22
Healthcare in India
Miles to go
Ranjit Shahani, Novartis, India

26
Indian Healthcare Reforms
A much needed prescription
Navin Chandra Nigam
Satyam Computers Services Ltd., India

FACILITIES & OPERATIONS

MANAGEMENT
62 Technology and Patient Safety
Capturing the power of technology
Shobha Phansalkar and David W Bates
Brigham and Women’s Hospital and Harvard Medical School, USA

INFORMATION TECHNOLOGY
65 SOA for Healthcare
Promises and pitfalls
Dennis B Smith and Grace A Lewis
Carnegie Mellon University, USA

70 Hospital of Tomorrow
Technology leads the way in Asia
Gerard Anthony Dass, Nortel Asia, Australia

72 Clinical Transformation
CaseStudy

Future of health IT at Marshfield Clinic

Robert A Carlson, Marshfield Clinic, USA

76 Healthcare IT Spending
Effects of a changing global economy
Rajiv Varyani, Frost & Sullivan, Singapore

www.asianhhm.com 
Advisory Board John R Adler
Professor
Neurosurgery and Director Radiosurgery and Editors
Stereotactic Surgery Akhil Tandulwadikar
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Stanford University School of Medicine, USA
editorial Team
Sana Syed
Sandy Lutz
Director Art Director
M A Hannan
Health Research Institute
PricewaterhouseCoopers, USA Senior Designer
Ayodhya Pendem

Pradeep Chowbey Sales Manager

Rajkiran Boda
Chairman
Minimal Access, Metabolic and Bariatric Surgery Sales Associates
Centre, Sir Ganga Ram Hospital, India Savita Devi
Murali Manohar
Sherley Jones
Harald Becher Mark Twain
Professor
Assistant Manager – Compliance
Cardiac Ultrasound
P Bhavani Prasad
Oxford University, UK
Compliance
Swetha Kalal
Peter Gross A N Rani
Chairman
CRM
Internal Medicine Yahiya Sultan
Hackensack University Medical Center, USA Sindhura Abburi

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www.asianhhm.com 
Healthcare Management
Quality of Healthcare
Value of accreditation
E
Accreditation is very day, people entrust their health
or that of a loved one to healthcare
recognised as a
organisations. Whether it is in a
framework to integrate hospital or at another type of facility, there
a quality management is a basic expectation of safe quality care.
system while reducing Additionally, patients and their loved ones
risk, and requires a expect and deserve that the care received
meets expectations. External validation
systematic assessment
of an organisation’s commitment to qual-
of hospitals against ity through international accreditation
explicit standards. is becoming an increasingly popular
choice among leading Asian hospitals.
Karen H Timmons As more hospitals compete to deliver new
President and CEO and better healthcare services to attract
Joint Commission International more patients, healthcare leaders must
USA
ask themselves, “What assurance of qual-
ity and safety do our patients and other
stakeholders need about our organisation?
Are quality and safety needs currently
being met as well as they could be?”
A new approach
Increasingly, organisations are seeking—
and patients are demanding—a proven
method for an objective, external quality
assessment of healthcare organisations,
which includes providing safe quality care,
competent and skilled clinical staff and
a safe environment. To accomplish these
aims and demonstrate a commitment to
quality, healthcare organisations are seek-
ing accreditation.
Few would dispute that doctors,
nurses and other healthcare practitioners
sincerely strive to deliver high quality care,
and in fact have an ethical duty to do so.
However, the systems and environments
that such dedicated staff work in every
day are frequently not designed to allow
them to deliver error-free or patient-safe
care every time. The needs and expecta-
tions of care for the international or
foreign patient may differ from
those of Asian patients because
 A s ia n H o s p i ta l & H ea lt hcare M a nage ment ISS Ue - 20 2009
of different social, cultural or religious
factors.
Accreditation is recognised as a frame-
work to integrate a quality management
system while reducing risk, and requires
a systematic assessment of hospitals
against explicit standards. International
accreditation programmes, such as Joint
Commission International’s, can go a long
way towards helping Asian hospitals not
only to improve their systems of care but
also meet the needs of their often more
diverse population of patients.
Value of accreditation
A recently published study shows how
stakeholders such as patients, govern-
ment authorities, healthcare workers and
external auditors all perceived significant
improvement in the overall performance
of a healthcare organisation within 15
months of implementing consensus
standards. In organisations that have
achieved accreditation, patients experi-
enced a culture of continuous quality
improvement within which their rights are
identified and respected, the assessment
and treatment processes are efficient, and
care is coordinated. Moreover, patients
are educated to participate in the care
process and better care for themselves
following discharge, staff are qualified and
have information to do their jobs well,
infections are monitored and control-
led, and care is provided in facilities that
provide a safe and supportive environ-
ment. Changi General Hospital, a 797-bed
public hospital in Singapore that achieved
Joint Commission International (JCI)
accreditation in 2005, found decreases
in needlestick injury rates and hospital-
acquired infection rates and lowered their
medico-legal and insurance costs as a result
of the accreditation journey.

Competitive advantage
Interviews with chief executive
officers, medical directors and directors
of nursing show that leaders at accredited
hospitals consider accreditation impor-
tant for public image, political reasons
and retention of existing staff. Leaders
further perceive accreditation as a useful
marketing tool to recruit new staff and
to attract top-performing physicians and
nurses to their organisations.
One case study is Singapore General
Hospital, a 1,400-bed acute tertiary care
public hospital. The oldest and largest
hospital in Singapore, it has long been
a healthcare institution admired and
trusted by the public for its quality care.
Although it is a public hospital, Singapore
General also attracts patients from outside
Singapore because of its reputation for its
standard of care in various medical and
surgical specialties. The hospital chose
to pursue JCI accreditation to affirm its
belief, as well as the public’s, that it is an
excellent organisation that delivers care
with a patient-centric focus. “We have
experienced many benefits through our
preparations for JCI accreditation. One
of the key findings is the teamwork and
commitment shown by our staff when
we achieved a common vision… This
has been an awesome discovery that has
further strengthened our organisation.”
Improving safety
A 2007 study in the Journal of Healthcare
Management found a strong association
between accreditation and the implemen-
tation of patient safety systems. The study
concluded that accreditation is a predictor
of healthcare organisations engaging in
actions to improve safety.
Bangkok Hospital Medical Centre
(BHMC) is a medical campus consist-
ing of four hospitals and a broad range of
specialised clinics. When the hospital, led
by CEO Dr. Chatree Duangnet, began to
pursue international accreditation with
JCI, it knew that preparation would be
necessary to ensure that its systems and
processes were functioning well and
conforming to JCI standards. It instituted
Healthcare Management
Tracer Rounds, based upon JCI’s Tracer customer satisfaction is through the
Methodology approach toward evalua- emphasis on collaboration with patients
tion of standards compliance during on- and their families. Healthcare organisa-
site accreditation surveys. This approach tions must work to establish trust and
requires the hospital to actually follow the open communication with patients and
care experiences of patients and follow to understand and protect each patient’s
the organisation’s systems and processes cultural, psychosocial and spiritual values.
of care by tracing them through the JCI’s patient and family rights standards
organisation. focus on improving patient outcomes by
For BHMC, environmental rounds involving patients and their families in
have also evolved into a series of inter- care decisions and processes in ways that
connecting pieces that must be in place match cultural expectations. At the same
to avoid any gaps in oversight. Top level time, many organisations have found
planning from all sectors is vital for a safe significant improvements in their patient
environment including the involvement satisfaction rates and fewer complaints
of the CEO, CMO, COO, CNO and from patients.
Virginia Maripolsky, Assistant CEO for Nursing Affairs, Bangkok Hospital
Medical Centre, shared the following comments as their hospital was
preparing to achieve Disease-Specific Certification for four diseases following
their successful JCI accreditation in 2007: “Our Customer Satisfaction Index
scores are usually quite high, however there was a significant and remarkable
jump in the scores of the departments affiliated with the disease-specific
pathways. No one would have predicted this so soon and no one expected
it. But the results told the story. Pursuing Disease-Specific Certification not
only promotes high quality care and improves patient outcomes, but it also
enhances patient satisfaction. We are living proof!”
hospital directors from the leadership Conclusion
team. None of the individual rounds, trac- Achieving JCI’s Gold Seal of accredi-
ers or surveys can stand alone to provide tation is a symbol to the commu-
and maintain a safe environment. Rather, nity that the organisation embraces
all the information and data gathered quality and will continue to do so.
from a variety of rounds is collectively What accreditation does is equally impor-
tracked, reviewed and analysed in the tant—by focusing on the systems that
Total Quality Center (TQC) to project meet patient needs, organisations create
the full picture of safety at Bangkok a healthcare experience that meets their
Hospital Medical Center. patient’s expectations for safe, quality
care, and in the process, enhances their
Promoting patient satisfaction customer satisfaction.
While all JCI standards contribute to
improved patient care, one impor- References are available at
tant way that accreditation promotes http://www.asianhhm.com/magazine
Karen H Timmons is the President and Chief Executive Officer
A uthor
of Joint Commission Resources, Inc. (JCR) and Joint Commission
International (JCI). Timmons also spearheaded the establishment of
the Joint Commission International Center for Patient Safety, and is
a past board member and Treasurer for the International Society of
Quality Assurance (ISQua).
www.asianhhm.com 
 Advance Care Planning
A new intervention
A
dvance Care Planning (ACP)
is no more, and no less, than
a patient planning in advance
for anticipated future loss of capac-
ity to make healthcare decisions,
with the assistance of their healthcare
providers.
Loss of capacity to decide whether to
consent to or refuse treatment options
offered, or to decide other healthcare
matters such as place of care, is common
in illnesses such as dementia, in delirium
from whatever cause and in the last days
of life. When the patient lacks capacity
to make such decisions, they must be
made by others on the patient’s behalf.
In many countries responsibility for deci-
sion making then lies with the healthcare
team. In others, relatives of the patient
may consent to or refuse treatment on
 A s ia n H o s p i ta l & H ea lt hcare M a nage ment
behalf of the patient, either as a matter of
course or via a special prior appointment
by the patient. Regardless of who must
make decisions on behalf of a patient
who now lacks capacity, knowledge of
the patient’s wishes, feelings, beliefs and
values whilst capacity was retained is
invaluable in deciding on behalf of the
patient.
In the UK, ACP has been defined
as, ‘a voluntary process of discussion
about future care between an individual
and their care providers, irrespective of
discipline. If an individual wishes, their
family and friends may be included.’
ACP should properly be seen as a
healthcare intervention, as it is basically
a healthcare professional encouraging
and assisting a patient to consider and
express wishes, feelings, beliefs and values
ISS Ue - 20 2009
about future treatment and care in the
event of future loss of capacity to make
the relevant decisions.
An ACP discussion may result in an
advance care plan, which may also be
called an advance statement, but only if
the patient wants this plan / statement
made or recorded in the healthcare file.
In the UK, if such a plan / statement
has been recorded the law (the Mental
Capacity Act) directs that it must be
taken into account in decisions once
the patient has lost capacity.
The difference between ACP and
care planning more generally is that the
objective of ACP is improving / directing
future decision making if / when capac-
ity is lost, and any plan or statement
formulated from the discussion will not
be used unless capacity is lost.

Cultural and political influences
promoting the ACP intervention
In some countries, notably including
the USA and the UK, there has been
recent enthusiasm for ACP. Two reasons
are particularly influential; first is the
acknowledged difficulty of making deci-
sions on behalf of patients who lack
capacity, especially decisions about treat-
ment which is not a cure but which has
potential to prolong or sustain life; the
second is increasing cultural and political
importance attached to patient ‘choice’ in
terms of treatment and location of care.
So ACP has been both professionally
and politically encouraged as a health-
care intervention, despite a paucity of
evidence regarding the balance of benefit
to harm and risk for individual patients,
and for the overall majority of patients if
its implementation is to be widespread
in a national health service.
Professional guidance
Since the nature, purpose and correct
clinical practice regarding ACP are often
misunderstood, two sets of professional
guidance were recently launched in the
UK. The first was written as part of
the UK End of Life Care Programme,
is aimed at health and social care staff,
and was revised in 2008. The second
was produced after review of all the
available evidence on ACP by a well
constituted group comprising healthcare
professionals from relevant specialties
and disciplines, plus patient and carer
representatives from relevant chari-
ties with a disease / health focus. This
guidance is clearly evidence-based and
was published by the Royal College of
Physicians of London. The two docu-
ments are consistent with each other, and
give the following guidance to healthcare
professionals.
When should ACP be instigated by
professionals?
ACP is definitely completely voluntary
for patients, who must be permitted to
decline to contemplate loss of capacity
and future illness scenarios, or to close
Advance Care
Planning is a
healthcare intervention
in which the patient
plans in advance
in making ones
healthcare decisions
for which we do not
know the overall
balance of benefit
to harm and risk.
Fiona Randall
Consultant
Palliative Medicine
Royal Bournemouth and
Christchurch Hospitals Foundation
Trust, UK
down the discussion at any time. ACP
should not be instigated simply as part
of routine record keeping or care, but
instead should be instigated only if and
when the professional makes a clinical
judgement that the likely benefits of the
ACP discussion for the patient outweigh
the possible harms and risks.
ACP should not be initiated with a
patient as a result of outside pressures,
such as from the family, or organisa-
tional pressures (which would include
political and managerial influences on
healthcare services).
The evidence indicated that insti-
gation of ACP is not appropriate just
after diagnosis of a terminal illness, or
at acute admission to hospital, or just
after nursing home admission. At these
times it may simply cause distress.
The time and setting should be
appropriate for a private ACP discussion;
evidence indicated that ideally the patient
should be in a stable condition and not
in hospital, so primary care might be
the best context in this respect.
Healthcare Management
What information will the patient
require in the discussion?
To establish preferences regarding future
treatment options in the event of loss of
capacity, patients will need essentially
the same information as they would be
need to give consent to the treatment,
in order to be sufficiently informed to
express true preferences. Regarding care
options including place of care, they
need information about what would be
available, and about the effect that loca-
tion of care might have on treatment
options available.
Regarding potentially life-prolonging
or life-sustaining treatment, for exam-
ple artificial hydration and nutrition,
antibiotics and mechanically-assisted
ventilation, patients will need to know
the likely effects of receiving and of not
receiving the treatment. To establish pref-
erences they will need to understand what
each treatment can and cannot achieve
and the effect of each treatment on the
course of the illness. Not only is this
quite a large amount of information,
but it is also potentially very distressing
as it will often be about ‘ways of dying’
from incurable illness.
What knowledge and skills will the
professional need?
Whilst good communication skills are
obviously important, the necessary
knowledge base to give the patient
adequate information is essential. The
guidance states that the professional
requires ‘full knowledge of the patient’s
medical condition, treatment options
and social situation’, and it notes that
the most appropriate professional might
be a specialist—either nurse or doctor.
So there are significant resource conse-
quences of professional time.
What is recorded?
The patient may wish to write an
advance statement / advance care plan.
Alternatively, the professional may make
a record of the outcome of the ACP
discussion in the notes, but what is
recorded must be explicitly sanctioned
www.asianhhm.com 
Healthcare Management
by the patient. The advance statement
/ plan might record whether the patient
would or would not want particular
treatments in particular circumstances,
or preferences regarding place of care
and death. It might also record beliefs
and values, for example attitudes towards
death and life-prolonging measures gener-
ally, and the importance to the patient
of the welfare of close family members
especially spouses.
The statement / plan is confidential,
and can be shared with other health-
care providers (and family members)
only if the patient agrees. However, the
more that patient restricts such sharing,
the less likely it is that the statement /
plan will be available when needed for
decision making.
What are the potential benefits to
patients?
The advance statement / plan provides
information about the patient’s wishes,
feelings, beliefs and values so that they
are better understood by those who must
make decisions on the patient’s behalf
when the latter lacks decision-making
capacity. In some countries (such as the
UK), the basis for such decisions is the
‘best interests’ standard, which means
what is considered best for the patient
when the benefits, harms and risks of
treatment and care options are consid-
ered together with whatever is known
of the patient’s wishes, feelings, beliefs
and values. In other countries, the basis
is the ‘substitute judgement’ standard,
which means the decision which it is
believed the patient would have made
in the circumstances had he / she been
able to do so. Whichever standard is
used, the record of the outcome of the
ACP discussion enables the patient’s own
preferences to be more accurately known
and taken into account.
In addition, the process of the ACP
discussion may itself be beneficial to
patients, increasing their understand-
ing of the illness and enabling them to
have some control over its course—to the
extent that this is possible—by expressing
10 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
preferences regarding future treatment
and care. Where patients wish to involve
family members in the ACP discussion,
they may achieve greater mutual under-
standing about the illness and treatment
possibilities, and about the patient’s
preferred location for care and death
and the family’s ability and willingness
to support that preference.
What are the potential harms and
risks to patients?
Patients may be emotionally traumatised
by confronting information about future
illness scenarios, much of it unpleas-
ant and pertaining to ‘ways of dying’.
Moreover, whilst likely and possible
scenarios will be discussed, many of
them will never arise so it can be argued
that this emotional trauma is avoidable,
The ‘unknowns’
ACP is a healthcare
intervention for which we do
not know the overall balance
of benefit to harm and risk
for individual patients and
for populations served
by a healthcare system.
Advocating its widespread
implementation is therefore
ethically questionable and
indeed difficult to justify.
unnecessary and unjustifiable. There is
a real risk that pressure will be put on
patients to engage in ACP because of
organisational / professional / political
pressures. Any such pressure is a risk to
the voluntary nature of ACP and increases
the likelihood of emotional trauma.
Conflict between patient and family
may occur as they may disagree about
future treatment and particularly loca-
tion of care and death, since the family
may have entirely legitimate interests in
the latter if they are expected to provide
practical care.
ISSUe - 20 2009
Patients are known to change their
minds! There is a real risk that changes
in a patients’ preferences for future treat-
ment/care will not be recorded, and such
failure to update the advance statement/
care plan will then result in erroneous
representation of the patient’s prefer-
ences when a decision is later necessary.
In such a case the advance statement/care
plan is arguably worse than useless!
Encouraging patients to record their
preferences in ACP can easily give rise
to unrealistic expectations regarding
what can actually be achieved in terms
of treatment and location of care and
death. For example, it is so often just
not possible to ensure that patients die
in the place of their previously expressed
choice!
What are the effects on services
and other patients?
It is acknowledged in the UK profes-
sional guidance that there is gener-
ally a paucity of evidence (especially
high quality evidence), on ACP. Since
much of the evidence is from the USA
caution should be used in applying that
evidence to other healthcare systems
and cultures.
We do not know the ‘professional
time’ resource consequences of ACP
discussions—a single discussion is
unlikely to be sufficient and very
knowledgeable and skilled profession-
als are required. Nor do we know the
resource consequences of complying with
patients’ preferences especially in rela-
tion to place of care and death. So we
do not know the ‘opportunity costs’ for
other patients if ACP is implemented in
resource-limited publicly funded health-
care systems. Such systems generally
allocate resources on the basis of patient
need and not merely patient choice,
as the former is seen to be a more just
principle. Implementation of ACP has
real potential to lead to unjust resource
allocation by prioritising patient choice
over need.
References are available at
http://www.asianhhm.com/magazine
www.asianhhm.com 11
 Organisational change and sustained
L
ean can provide better care, better
improvement can be achieved using the quality at low costs and that is
why many healthcare manag-
same principles of strong leadership and ers are using the principles, systems
lean deployment that have transformed and systems of Lean to stretch limited
major producers worldwide. resources, improve the quality of patient
care and safety, eliminate errors, reduce
David Howard waste, cut delays and reduce the length
Performance Improvement Practitioner of patient stays.
The Manufacturing Institute, UK
Sustainable Lean
A Lean healthcare review should start
by identifying all of the process inputs
from start to finish - working out where
value is being added and where it’s not.

12 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009


The Lean Way
Improving healthcare performance
This is similar to a medical diagnostic
process where the symptoms are identi-
fied to understand the current condition
and issues. Next step is to work with
the relevant team to develop solutions
for eliminating all the non-value added
steps within the process. In a healthcare
setting, it’s totally focussed on putting
patients first.
There are huge advantages of using
Lean in healthcare because it determines
a new culture and system of checks and
improvements—providing a sustainable
methodology to continuously improve
services.
Leading cultural change
To succeed in the long term, healthcare
organisations must be willing to rethink
how they do things and commitment
from management and executive teams
is crucial. A system to create these Lean
leaders is essential, as is the need to
encourage participation by all staff and
give all employees the necessary skills.
The Lean pillar of respect is funda-
mental to success and that means
listening to people, involving them
and empowering them to make the
lean changes from the bottom up. This
is particularly powerful in a healthcare
setting where by truly engaging with
staff it is possible to unleash the power
of hundreds of people to bring about big
changes. But unless senior management
demonstrates total commitment and gives
others the freedom, power and authority
Healthcare Management
to improve their department or function,
the momentum will slide.
Lean will only work properly if it
is driven from within and so it is vital
to equip staff with the knowledge and
skills to drive change. It is particularly
important to prepare a tier of staff at
all levels and within all disciplines to
lead and champion Lean—to promote a
culture of continuous improvement and
mobilise and involve everybody.
Best practice
The Manufacturing Institute’s lean
healthcare team—comprising lean lead-
ers with many years of experience in
industry–has been achieving powerful
results in partnership with UK hospitals.
Among them are:
West Middlesex University Hospital
Trust has applied lean thinking to its HR
www.asianhhm.com 13
Healthcare Management

department—tackling universal issues of
sickness and absence rates and recruit-
ment lead time. Process flow mapping,
root cause analysis and visual manage-
ment techniques are some of the strategies
that have been used to shrink recruitment
lead times from up to 9 months to a
standardised 53 days. A new sickness
and absence management process has
reduced the rate from 3.9 per cent to 3
per cent and has the potential to make
significant financial savings.
Said Nina Singh, Director, Workforce
Development for West Middlesex, “Making
changes in practice is one thing but making
sustainable improvements is altogether a
more difficult challenge. Our work with
the Manufacturing Institute has been
invaluable in understanding how to achieve
long term change and how to continuously
improve standard practice.”
At Blackpool, Fylde and Wyre
Hospitals NHS Foundation Trust
Pharmacy Lean is helping the team to
realise performance benefits from the
installation of an automated dispensing
system. Work began with value stream
mapping that highlighted a robust future
state system for installation of the auto-
mated dispensing system and beyond—
bringing smooth single piece flow to the
dispensing process and halving the time
required to prepare prescriptions.
Lean methodologies have also
been applied to capacity planning to
ensure full utilisation of facilities and to
improved workplace organisation using
visual management and 5S techniques.
New key performance indicators have
also been introduced to measure auto-
mation reliability, workload levels and
stock control of medicines.
Lean Pharmacy projects have also
brought benefits to the Royal Devon and
Exeter NHS Foundation Trust, where
inventory levels have been cut, and proc-
ess flow has been improved through a
new Lean layout—cutting an average 70
minutes from the process of preparing
prescriptions.
Lean principles are also improving
standards and efficiencies in medical
diagnostics. The Manufacturing Institute
has been working with staff in radiol-
ogy departments, endoscopy suites and
specimen labs to consider how they can
develop work processes and maximise
their contribution to patient care. One
example is the Royal Devon and Exeter
ultrasound department, where opportu-
nities were identified for better utilisa-
tion of this important asset. Constructive
problem solving and process redesign
was employed to increase throughput.
This improved the quality of interaction
between patient and doctor while bring-
ing down individual consultation time
from 24 to 15 minutes and eliminating
the need for extra evening and weekend
sessions.
Stockport NHS Foundation Trust
has integrated lean methodologies
into its long-term business improve-
ment model. With support from The
Manufacturing Institute, it set up the

Five key steps to Lean

1. Specify value in the eyes of the customer
Patients expect to receiv.e the best care and service
that can be provided, free of defects. This means iden-
tifying best practice in every step of the patient journey,
both information and physical flow, and then rigorously
applying gold standard work. This could mean always label-
ling samples at the bedside, applying care bundles rigor-
ously, or eliminating opportunity for transcription errors by
using IT effectively.
2. Identify the value stream
It is useful to start at the end of the process and follow the
activity right back to the beginning. This is because the
process of discharge often holds up the whole healthcare
system, whether this is blocked beds, or follow up appoint-
ment processes.
3. Make value flow…
No manufacturer would ever run every asset in the value
chain at 100 per cent. Customers would never contract
to use all the capacity of every supplier, as they know
this would guarantee failure the moment there is a small
change in demand. But hospitals often run their wards at
100 per cent occupancy. To enable patients to flow safely,
there has to be unused capacity. This is actually more
economic because the hidden waste in dealing with the
errors, cancelled appointments, initiative lists, missed
targets and lost activity is eliminated. This means turning the
traditional accounting view on its head, and counting the true
cost of broken flow.
4. …so the customer can pull
When a service is capable, adequate and available, with
good flow, it is possible to move to a system that is pulled
by patient demand, rather than pushed onto the patient. The
possibilities of this are fantastic! No need for outpatient
appointments and waiting list procedures, just turn up at a
convenient time. Wards call the emergency department to
ask for a patient to fill an empty bed—right patient, right
service, right time.
5. Continuously improve in pursuit of perfection
Visual management is essential to show what has been
achieved and how to improve. This ensures patients can
easily see what has been done to make their service better.
The Lean organisation will challenge every team to have a
daily review, and write on the wall what the staff will do to
make tomorrow even better than today.

14 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Healthcare Management

Stockport Improvement Programme (SIP)
—committing at the highest level to a
powerful programme of change.
As such, it firstly worked with The
Manufacturing Institute at an execu-
tive level on its lean leadership develop-
ment, then appointed and trained fifteen
‘Stockport Improvement Champions’
who undertook The Manufacturing
Institute’s intensive Accelerated Route
to Lean Healthcare 10-day training
course in preparation for supporting a
series of projects.
Lean implementation began with
value stream mapping within two key
departments of orthopaedics and emer-
gency medicine. By analysing the patient
journey both inside and outside the
hospital—from PCT referral through
all the complex steps to discharge
—a complete and detailed picture of
the process and the waste within that
Issues identified through the
Value Stream Mapping were tackled
through Rapid Improvement Events,
including:
• Reduction in the overall lead time from
referral to discharge
• Time taken for call centre to confirm
outpatient appointments
• Medical records and storage capacity
• Capacity within radiology balancing
existing and future demand
• Creation of additional emergency treat-
ment capacity
• Specifications for commissioning of
future services.
The early benefits of this work include:
• 33 per cent increase in throughput in
radiology
• 64 per cent reduced time to prepare
David Howard is successfully mapping Lean techniques, systems
A uthor
intravenous drugs
• 33 per cent increased capacity in treat-
ment room areas
• Outpatient appointments confirmations
reduced from 23.5 days to 12 days
• 43 per cent increase in optical scan-
ning
• 99.9 per cent availability of case
notes
Commenting on the Lean changes,
Teresa Hopley, Senior Personnel
Manager, Stockport NHS Foundation
Trust said, “The Manufacturing
Institute showed us how the principles
that have transformed manufacturing
industry can revolutionise healthcare by
eliminating waste, increasing efficiency
and delivering improved quality and
patient care.”

process emerged. Supported by The
Manufacturing Institute, the SIP team
was able to create an ideal future state
map to eliminate all the non value added
steps.
and principles in healthcare. Working in partnership with several
National Health Service Trusts, he is leading organisational change
and sustained improvement to improve the quality of patient care
and achieve better cost performance.

www.asianhhm.com 15
Healthcare Management
Urgent Care
The shift in emphasis
T
The UK National Health he National Health Service
(NHS) in England has benefited
Service has seen a
from an unprecedented growth
shift in emphasis in in funding over the last ten years. It is
managing urgent now bracing itself for an end to consistent
care, from preventing growth in budgets of 8-9 per cent a year
emergency admissions as the full effect of the global financial
crisis begins to bite. Increasingly, manag-
to better management
ers and policy makers will be looking for
of care outside hospital. improvements in care fuelled by greater
Benchmark out of hours productivity rather than more funding,
services and improving or for opportunities to improve patient
the management of care in ways that also reduce overall costs
to the healthcare system.
urgent care in general
As a reliance on national targets is
practice are the two recent relaxed, it is becoming more possible to
initiatives in this shift. focus on areas that have tended to be
overlooked. Media attention has focussed
Rick Stern on key targets involving 24 or 48 hour
Director access in general practice, the speed of
David Carson ambulances to emergency calls, and
Director reducing waits at A&E departments.
Henry Clay While all of these targets are important
Director
in their own right, they have distracted
Primary Care Foundation
UK
attention away from all other important
aspects of the system. The Primary Care
Foundation, an independent organisation
committed to developing best practice in
primary and urgent care, were commis-
sioned by the Department of Health
in England to look at two important
areas of the NHS—the management of
urgent care in general practice and the
performance of out of hours medical
services—and the results suggest that a
greater focus on these and other areas
could do more to improve the quality
and safety of patient care and offer better
value for money.
16 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
What do we mean by urgent care
and how is it managed?
Urgent and emergency care is being used
to describe all unplanned care; a need
for a rapid response to an immediate
health problem rather than a developing
complaint that can be managed in a
planned way. Within unplanned care,
emergencies cover care for conditions
that are, or could be, immediately
life threatening. Urgent care is more
difficult to define and is likely to be
differently understood by the patient
rather than the clinician. In the end,
the Department of Health has avoided
a technical definition and prefers to give
priority to the patient’s perspective, so
whatever that patient thinks is urgent, is
presumed to be so until they have been
properly assessed by a clinician.
The patient is also faced by a confus-
ing array of choices in accessing care when
they have an urgent health problem. The
table below shows that after consider-
ing self care, they can contact a range of
services that vary depending on develop-
ments within their local healthcare system.
They can contact, their GP surgery, or
potentially a series of community based
nursing or therapy services, which may
now be based at a new Walk In Centre,
if it is out of normal practice hours they
can call their ‘GP out of hours service’,
they can dial 999 to call an ambulance,
or go direct to a hospital Accident &
Emergency (A&E) Service. Recent
studies have shown that while patients
understand the role of their GP surgery
and of A&E, everything else is far from

clear. This has led to new ideas to pilot a
national 111 number for urgent care, to
sit alongside the 999 number for genuine
emergencies.
A whole system perspective: An
urgent & emergency care pathway
There has been increasing attention given
to developing ‘urgent and emergency care
networks’ to ensure that all the different
agencies co-operate together and ensure
that patients do not slip between the
different care systems. Our focus, at the
Primary Care Foundation, has been to
ensure that we have a better understanding
of each part of the chain of urgent care.
Below we describe our work looking at
two key parts of this whole system.
Improving the management of
urgent care in general practice
An estimated 300 million primary care
consultations take place in some 9,000
practices throughout England each year.
Practices vary considerably in their size,
staff mix and way of operating. The cities,
towns, villages and populations they serve
vary too. In a diverse and complex system
for providing primary care, it is clear that
one size does not fit all.
Urgent care in general practice is
important from a number of perspec-
tives. It matters to patients, who may
be harmed or distressed if diagnosis and
treatment is delayed. It matters to the
NHS as a whole, because urgent care
arrangements which have not kept pace
with other operational changes within
the NHS place pressure on the rest of the
system, driving people towards A&E and
avoidable hospital admissions. It matters
to general practices, where workloads can
become unmanageable if urgent care is
not handled well. It also affects the repu-
tation of the service – unhappy patients
tell their family, friends and colleagues
about their experience.
In April 2009, a report funded by the
Department of Health ‘Urgent care: a
practical guide to transforming same-day
care in general practice’ was distributed
to all practices in England.
It describes our work with practices
across five very different communities,
CaseStudy
including a survey of how 150 practices
currently manage same day urgent care,
as well as supporting eight practices to
make rapid improvements. It focused on
three simple questions concerning care
for patients who contact their practice
with an urgent need:
• Will they get through?
• Will they be identified?
• Will they be seen rapidly?
The report asked practices to apply
the principles we outline to their own
practice and system (see table below).
The decisions on what solution to put in
place must rest with the practice and its
team rather than imposed centrally.
Our findings highlighted a number of
potential barriers to accessing services. This
included difficulties in booking appoint-
ments on the telephone, with over a third
of practices within the study having insuf-
ficient lines or reception staff to manage
calls at peak times. We also found a large
variation in the number of appointments
available over a working week, suggesting
that many practices simply did not have
enough capacity to meet demand. In other

Which implies
Developing the
Secondary principles
principle for urgent Must deal with patients wherever
they present
cases presenting to Minimal delay reacting to a
patient that presents
general practice Must avoid long queues (for initial phone
call assessment or face to face)

Receptionists have adequate training / process

to indentify potentially urgent cases
Urgent is defined by patient
until assessed Potentially urgent cases should be assessed
Fundamental principle by a clinician as early as is practical

The system must be

safe for the patient Must have adequate receptionsts for
calls and face to face

Plans and capacity to Must have ‘duty clinicain’ or other arrangement

respond as needed for early assessment

Must have capacity and plans to react if patient

needs to be seen

Build ‘safety netting’ (advising callers what to do if the

condition worsens / does not improve) into the process
In cases of doubt, then err on
the side of safety
In case of doubt ensure that the patient is
assessed or seen sooner rather than later

www.asianhhm.com 17
Healthcare Management
practices, it was less an issue of the over-
all number of appointments, but rather
trying to ensure a better match between
when people were seeking appointments
and scheduling appointments. The clear-
est example of this is that while there is
between 20-30 per cent more demand in
almost every practice for appointments on
a Monday morning, few practices schedule
extra appointments at this time. Simple
changes to the way patients access care
and the practice manages its appoint-
ments can have a big impact on whether
patients are seen rapidly when they have
an urgent need.
It also highlighted the importance of
non-clinical reception staff in spotting
potentially urgent cases. While there was
a high level of consistency in identifying
and responding to potentially life threat-
ening cases, there was greater variability in
other cases that were potentially urgent,
so that patients might wait longer than
necessary for an appointment with a
clinician. In a similar way, request for a
home visit were often left until the end of
the morning, even though they are more
likely to require an urgent response. We
found one example of a number of small
practices working together to employ a
doctor who would pick up all urgent
home visits as soon as possible, follow-
ing an initial call from the practices to
check if an urgent response was needed.
This prompt response to urgent requests
for home visits led to a 30 per cent reduc-
tion in emergency hospital admissions,
freeing up resources for the practices to
use in better ways.
The report highlights five key
areas that all general practices should
address:
1. Address urgent needs of a patient,
whether they choose to access the
service by phone or in person.
2. Match capacity to demand—both
in responding to patients initial call
and recognising the different demand
patterns for same day and advance
appointments.
3. Ensure that the full range of cases
that might need urgent attention will
18 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
reliably be recognised by staff when the
patient rings or presents in person and
that the process is understood
4. Set deadlines for assessment and
intervention and measure perform-
ance against these, paying particular
attention to the needs of those request-
ing home visits where the chances are
that the case may be more acute or
complex
5. Review and audit the processes to refine
the way that they operate
An example of how one innovative
practice developed their service will help
to illustrate these issues.
The Birchwood practice, a medium-
sized rural practice in Norfolk, is a pioneer
in urgent care and has developed a
comprehensive urgent care service. GP
Paul Everden led a national project to
give ‘appropriate care at point of need’
(ACAPON). Its aim is to take away barri-
ers to care.
The practice has established a genu-
inely integrated team, working across
primary care, based on clear patient
pathways. It includes an experienced
GP, a nurse practitioner, emergency care
practitioner and a healthcare assistant.
The aim is to assess patients as early as
possible and to make sure that they are
seen by the right person, best able to
provide timely care.
When a patient presents with an
immediate need a message goes to a team
leader who makes an immediate telephone
assessment. The patient is directed to the
most appropriate clinician, who makes a
full assessment, rapidly discusses what to
General Community Out of
Practice Services Hours
Service
Self Care
Patient
ISSUe - 20 2009
do with the wider team and implements
an agreed pathway.
The results have been impressive. Lives
have been saved that might well have been
lost; there is better use of other services
such as ambulances and paramedics;
patients are being treated quicker and
with better results. This has led to 16 per
cent fewer hospital admissions than other
local practices, saving money across the
system. It offers a good example of how
general practice can change the way it
manages urgent care.
Driving up standards through a
national benchmark in out of hours
care
The national out of hours benchmark
is a new initiative to drive up the qual-
ity of care and improve value for money
across England. The first round of the
benchmark was completed in March 2009
by the Primary Care Foundation and
involved 63 different services measured
on a wide range of performance indicators,
ranging from cost, to quality, outcomes,
productivity and patient experience. The
benchmark is rigorous being based on a
sample data extract typically of several
thousand cases, supplemented by web
based questionnaires, as well as a specially
commissioned patient experience survey.
All of this ensures that we are genuinely
comparing ‘like with like’.
Although the benchmark, initiated
by the Department of Health, has been
up and running for less than a year, more
than half the PCTs across England have
made separate decisions to buy into this
Medical or
Ambulance Accident &
Surgical
Services Emergencey
Assessment
services
in Hospital

service for three years. Commissioners
understand that this type of information
is the currency for world class commis-
sioning of urgent care. There is already
evidence that the benchmark is a power-
ful catalyst for action and there are good
examples of how it has led to changes in
the way services are delivered and signifi-
cant improvements in patient care.
The benchmark marks a new
approach, driven by data extracts supplied
by out of hours providers for four separate
weeks over a six month period. This is
supplemented by web based question-
naires for both commissioners and provid-
ers. Reports were sent to each commis-
sioner and service provider identifying
their performance, but providers currently
retain their anonymity. We also ran a
series of half-day workshops with both
commissioners and providers to help
them understand the different measures
and how they can be used to improve
performance locally. We have now further
refined the benchmark, with a second
round underway, with reports due on
up to 100 services in September 2009.
This includes a number of improvements
suggested by users as well as results from
the first patient experience survey.
The first round of the benchmark
has identified striking difference across
services. These include:
• Wide variations in cost per head (from
£3.69 to £12.76 per head) and cost
per case (from £31.41 to £119.91)
• Extremely wide variations in the way
providers identify callers as ‘urgent on
receipt’ ranging from 1.3 per cent to
60.3 per cent
• Substantial differences in the balance
between offering telephone advice
(21.2 per cent to 67.4 per cent), seeing
patients at a base (19 per cent to 69.2
per cent), or carrying out home visits
(3.3 per cent to 23.6 per cent)
• Striking differences in productivity of
clinicians at peak times ranging from
0.91 to 4.60 cases per hour
• Large differences in the percentage of
cases referred towards hospital (a key
indicator of the effectiveness of an out
CaseStudy
of hours service), although we have
asked providers to focus on the way
clinicians records this informational
outcome on their systems.
It is now clear that the benchmark is
encouraging greater consistency so that
like for like comparisons can be made in
all areas. As membership increases, the
strength and credibility of the benchmark
is enhanced. It has also provided a more
positive story in the media in a sector
that only tends to attract media attention
following a catastrophic service failure.
In the end, the value of a benchmark
is to drive improvements in care. One
example helps to illustrate the potential
for driving change, in this case, by under-
standing why their productivity was low,
leading to improvements in both quality
of care and value for money.
Urgent Care 24, providing out of
hours services to about 600,000 people in
the North-West of England, were involved
in an early pilot were broadly pleased with
the overall pattern of performance, but
were concerned by their comparatively
www.asianhhm.com 19
Healthcare Management
low level of productivity. This led them
to dig deeper in this area. They carried
out a further review of productivity by
each clinician (doctors and nurses) and
found an even greater variation across the
wide range of clinicians covering shifts
in their out of hours service. They then
fed back this information to all clinicians
and met with all clinical staff to discuss
the results and reflect on what this might
mean for an individual’s practice.
They also looked at other aspects of
clinical behaviour. They found out that
some GPs were logging onto the system
late for shifts, others in remote Centres
were not picking up telephone advice
calls and were often inactive, while their
colleagues undertaking triage at the main
base were over-stretched. By addressing
these and other issues they were able
to improve performance, patient care
and promote a culture of fairness for
all staff.
The overall result was that produc-
tivity at peak times more than doubled,
clinicians were happier that workload
was more evenly spread and patient
care improved. Their Clinical Director
commented that “by making clinicians
more productive—supporting them
as necessary, sorting out the problems
that they face and addressing one or two
poor performers—it has improved care
for patients because clinicians can focus
on the job that they are there to do”.
What are the lessons from these
new initiatives in the NHS for
improving urgent care?
There are a number of key learning points
for the NHS which may also apply to
other healthcare systems.
• General practice has a crucial role to
play in managing urgent care, but up
until recently, little was known about
their role and it has tended to be over-
looked
• The crucial factor driving the qual-
ity of care and the nearly all cost in
the NHS is clinical decision making.
We have begun to understand some
of the variations across organisations
20 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
CaseStudy
but underneath this is an even greater fix’. The reality is that rather than seek-
variation between individual clinicians. ing to improve urgent care by tackling
Understanding this variation, feed- the way patients are admitted at the
ing it back to clinicians and reducing front of about 300 hospitals across
unnecessary variation is a key route to England, there are probably better
improving quality of care at the same solutions to be found by improving
time as reducing costs the management of urgent care across
• The UK has relied heavily on a few 9,000 general practices. A series of
key central targets which have tended small, sustainable improvements are
to distract attention away from other likely to have a greater impact to the
potential improvements. In primary system as a whole
care we have focussed exclusively on • A key challenge is integrating urgent
24 hour and 48 hours targets to see a care within local care systems.
doctor or a nurse, rather than poten- Increasingly patients have more choices
tially more important focus on seeing for accessing care, including Walk-In
urgent patients much more rapidly Centres, Out of Hours Care, Urgent
• There is an understandable desire to Care Centres and now ‘Darzi’ Centres
try and develop a set of metrics across (named after the Health Minister, Lord
the whole of the urgent and emergency Darzi), but they are far from clear
care system, but it is proving difficult where to go when they need rapid help.
to identify suitable measures and even Introducing a new national three digit
harder to monitor them effectively and number (such as 111) for urgent care
consistently. It may be better to start may offer a new way in, but will only
in a less ambitious way, by finding an help if the services available locally are
effective way of monitoring perform- properly joined up
ance in each part of the system, as • There is a strong case to be made to
described in the out of hours bench- trust patients to make sensible deci-
mark, before then trying to join them sions about how to access care and how
up urgently they need to be seen, rather
• Politicians tend to push policy makers than trying to educate them into using
towards simple solutions in systems that a complex and confusing service in the
are too complex to respond to a ‘quick ‘right’ way.
Rick Stern was previously a Chief Executive of a Primary Care Trust,
responsible for commissioning NHS services for a community on the
South Coast of England. He is also leads the NHS Alliance Urgent
Care Network and is part of the Department of Health’s governing
board for urgent and emergency care.
A uthors
David Carson was a GP in Scotland before working in an Inner
London Health Authority leading primary care policy and perform-
ance. He is also author of a key report, known as the Carson Report,
for the Department of Health in 2000 that defined the way ahead and
set the standard for unscheduled care in the healthcare community
in the UK.
Henry Clay has spent over 15 years as a consultant to organisa-
tions in both the private and public sector. He has worked with many
Out of Hours providers and has a particular expertise in benchmark-
ing their performance.
ISSUe - 20 2009
www.asianhhm.com 21
 Healthcare in India
MILES TO GO
India is the leading supplier of generics to the world and yet in
India healthcare for all is a chimera. Research-oriented Indian
pharmaceutical companies spend less than 10 per cent of their sales
on research. Innovation plays a key role in mitigating unmet medical
needs. Future success in the healthcare arena will increasingly depend
on collaborations and partnerships between all stakeholders.

Ranjit Shahani
Vice Chairman & Managing Director
Novartis, India

I
ndia is the leading supplier of
generics drugs to the world and
yet in India healthcare for all is
a chimera. 65 per cent of our popu-
lation has little or no access to any
kind of quality healthcare. Government
spending on healthcare is abysmally low
particularly when one looks at countries
at a similar level of development as we
are. This seems particularly ironical
given the stature that India enjoys as
the leading supplier of generics drugs
to the world.
The advent of the patent law in
2005 provides an opportunity for phar-
maceutical companies that are research-
oriented. It is now more common to
read of companies like Dr Reddy’s and
Glenmark Pharmaceuticals out-licens-
ing some of their molecules to global
companies who have the wherewithal
to take these forward. Pharmaceutical
research is a high risk business where the
failures come more often than success
and the resources required are huge.
Indian companies, even those that

22 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

are research-based, spend less than 6 per
cent of their sales on R&D compared
to the 18-20 per cent spent by global
companies. While it is a good begin-
ning, more collaborative working can
reduce cost and speed up entry of new
medicines for unmet medical needs.
Status of healthcare in India
Let us take a look at where we as a
nation stood in terms of healthcare a
few years ago. As per estimates shown
in the World Health Report 2001, the
life expectancy at birth was 53 years for
men and 51.7 years for women. While
these figures by themselves speak, it
is important to note that the Report
goes on to state that the percentage of
life expectancy years lost as result of
the disease burden and effectiveness
of healthcare systems was 12.7 years
for men and 17.5 years for women in
India. Since then while some progress
has been made it also clearly brings into
perspective the need for a comprehen-
sive approach to healthcare where infra-
structure allows for access to quality
healthcare right up to the last mile.
Opportunity for Indian pharma
The Indian pharmaceutical industry
can contribute to mitigate this situa-
tion. It is estimated that currently it
takes between eight and ten years to
bring a compound from an idea to a
usable medicine and this entire process
could involve a total spend of up to
US$ 1-1.7 billion covering research,
development and testing costs. Clinical
development time has actually doubled
since 1982 and this only serves to make
a bad situation worse where a US$ 100
billion worth of drugs will be going off
patent over the next 2-3 years.
Pharmaceutical companies across
the world have a challenge and are striv-
ing to meet the increasing expectations
of all their stakeholders and to meet
the unmet medical needs of today and
tomorrow within acceptable costs.
There is a school of thought in India
which propagates the view that domestic
production of generic medicines will be
encouraged by preventing more medi-
cines from gaining patent protection,
and this in turn will serve to increase
access to medicines. Nothing can be
further from the truth. The truth is
that generics alone are not the solution
to access. Access to medicines is more
about making medicines available and
less about costs. It is ironical that in a
country like India aerated drinks are
available in the most remote corners of
the country but a medicine as simple as
paracetamol is not. While affordability
can be taken care of through several
ways including innovative models
such as tiered pricing, public-private
partnerships and patient assistance
programmes, access can primarily be
taken care of by improving healthcare
infrastructure in the country. Our coun-
try risks access to future medicines with
long term negative impact on public
health by ignoring the benefits of
innovation.
It must also be remembered that
generic medicines are not enough to
meet the growing need for new medi-
cines to counter issues such as drug
resistance or to fight new diseases or
even to treat specialised populations
and to offer patients both new and
better alternatives.
World class intellectual property
rights in India—A necessity
The pharmaceutical industry in India
has a strong manufacturing base with
the country having the largest number
of US FDA approved plants outside the
US. The recent development of the US
FDA setting up local offices in India
shows that Indian manufacturing in
the pharmaceutical field has come of
age. There is every reason to believe
that the same can happen in pharma-
ceutical research where all of global
pharma will be vying to either set up
its own research units in the country
or will be looking to collaborate with
national pharmaceutical companies so
as to leverage the strengths of both.
It is no longer a luxury to yearn
to have world-class intellectual prop-
erty rights in our country but rather
a necessity. The much written about
section 3(d) of the Indian patent law
will only serve to deter innovators from
looking beyond the obvious at areas
that could benefit public health. It is
proven that the invention of the wheel
forever changed the way transport took
place anywhere in the world. History
shows that subsequent improvements in
transportation were really incremental
innovations.
Incremental innovation or innova-
tion in sequential steps is the way in
which medical progress takes place. It
must be recognised that breakthrough
innovations are few and far between
not just in the pharmaceutical field but
in all fields. Forcing drug discovery
back to the drawing board each time
a new medicine is needed to meet a
hitherto unmet need will only serve to
ensure that overall costs will be astro-
nomical and that drug delivery is inter-
minably delayed. It will do India no
good if we as a nation fail to recognise
that incremental innovation actually
provides exceptional value for patients
and society. If we look at the medicines
available on the market today, we will
find that more than 70 per cent of these
were developed through incremental
www.asianhhm.com 23
 innovation on either a base compound
or an existing medicine.
While these advances on the surface
may seem minimal, in reality these
provide outstanding value and without
these so called building-block improve-
ments, medical science in general and
healthcare in particular would not have
advanced to where it is today. Allowing
patents for incremental innovations will
play a crucial role in improving domes-
tic public health in India and also help
bring new and better medicines to the
patients here.
Incremental innovation distinct
from ‘evergreening’
There have been efforts in several quar-
ters to liken incremental innovation to
‘evergreening’. The two are completely
distinct and must be recognised as such.
Evergreening is an attempt to extend the
life of a patent by making tiny changes
to a drug just before the expiry of its
patent. These changes do not repre-
sent any medical advances and in fact
many a time do not actually bring about
any additional therapeutic value to the
patient. Incremental innovation on the
other hand results in the conversion of
a compound in to a better medicine
while providing clinical efficacy and
exceptional benefits for both patients
and society at large.
It is important to note that it is the
patient who is the ultimate beneficiary
of pharmaceutical research and devel-
opment. We as a country appear to be
mortgaging the future for the current.
India is today known for its vast intel-
lectual capital and is recognised as a
knowledge economy with expertise in
ceutical industry through section 3(d)
and throws open the research space to
the best minds in the pharmaceutical
industry.
Exploring partnerships to leverage
research
I am of the firm belief that future
success in the healthcare arena will
increasingly depend on collabora-
tions and partnerships between all
stakeholders including national and
global pharmaceutical companies as
the struggle to deal with patent expiries
and rising research and development
costs comes to a head. India is in the
enviable position of having a large
English-speaking scientific pool and
this provides it a great opportunity to
become a hub for future drug discov-
ery programmes. While the concerns
with regard to world-class intellectual
property rights exist and enforcement
of these is an issue, I strongly believe
that putting in place an environment
that is conducive to innovation and
research will be for the ultimate good
of the pharmaceutical industry in India
and the people of this country.
Looking in to the crystal ball -
Miles to go for healthcare in India?
What then does the future hold for
healthcare in India? It would be nice
to be able to take a peek in to a crystal
ball to be able to foretell the future.
Life expectancy is expected to increase
further but much of this will be centred
on urban India where the focus of qual-
Ranjit Shahani is a Mechanical Engineer from IIT Kanpur and MBA
A uthor
ity healthcare currently lies. I do believe
though that partnerships and collabora-
tions between various stakeholders will
be the norm for the pharmaceutical
industry not just in India but around
the world and this will be for the overall
good of public health. Whether this
will translate in to taking healthcare
to the heart of rural India only time
will tell.
The World Health Report 2001
does see an India where there will be
some measure of success in dealing with
diseases such as polio, yaws, leprosy,
kala azar, t’ilaria and blindness by
2020. The one area where the prog-
nosis continues to remain uncertain
is that of HIV / AIDS. The rate of
maternal mortality in India is estimated
to reach world standards by 2020. Will
all of this happen? While I am a diehard
optimist about the overall growth of
the Indian economy, I am slightly less
optimistic about the country achieving
its healthcare targets. India needs to
aggressively pursue a policy of increased
expenditure on healthcare to reach these
goals. India also needs to quickly put in
place a world-class intellectual property
rights regime where patent rights are
respected both in letter and spirit and
where data protection is accorded top
priority.
India will move on as she must but
as Robert Frost wrote a long time ago,
“The woods are lovely, dark and deep,
but I have promises to keep and miles
to go before I sleep, and miles to go
before I sleep.”

from JBIMS, Bombay. He started his career with ICI in India in their
process chemistry and strong IT skills. businesses of Fibres & Speciality chemicals. He is a thought leader
The opportunity, therefore, is there for in the Pharmaceutical Industry and has been actively involved in
the asking but this can only be leveraged lobbying for a strong Product Patent law in the country and Data
Protection and liberalization of the price control mechanism for
once government removes the artificial Pharmaceuticals.
barriers it has created for the pharma-

24 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

www.asianhhm.com 25
 Indian Healthcare Reforms
A much needed
prescription
A
The first major change in s one of the largest industries,
Indian healthcare system Indian Healthcare takes care
of over a billion people. India
started way back in 1946
accommodates 20 per cent of the world’s
by the recommendation young population below 24 years which is
of ‘Bhore Committee’. a vibrant, achiever and economy builder
Since then it has been in many developed countries. Yet the
a journey of various Indian healthcare industry is a sleeping
giant on its home turf, it needs to be
swings in ups and downs.
awakened to unleash its real power which
The challenges are has potential to become the world’s best
enormous and remedies medical tourism destination and a state-
are limited. India, with of-the-art healthcare provider. It has what
huge population base, is needed to deliver unprecedented levels
of healthcare. But this potential yet to
needs reforms in areas
be unearthed.
of technology, resource India’s healthcare expenditure is
availability, public-private around 6 per cent of its GDP (US$
partnership as top priority, 13 per capita) which in comparison to
to redefine progression developed countries is way behind in
terms of absolute numbers. The abys-
in healthcare system.
mal state of availability of qualified
resources and healthcare infrastructure
Navin Chandra Nigam can be judged by current data which
Lead Consultant
Healthcare shows doctor and nurse patient ratio is
Satyam Computers Services Ltd., India 0.6 and .08 per 1000 people respectively
while bed ratio is 1.5 per 1000 people. A
comparison with the world ratio where
averages are 1.2 doctors and 2.6 nurses
and 4 beds per 1000 people shows a need
for improvement. There are more than
15000 hospitals of which two-thirds are
public owned. Of 1.1 Million hospital
beds available, 40 per cent are privately
owned. The private sector accounts for
26 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
approximately 80 per cent of healthcare
expenditure. Of the remaining 20 per
cent; more than three-fourth is funded
by respective state governments. Today,
the Indian Healthcare sector is valued at
approximately US$ 34 billion.
Currently, the Indian population is
growing at the rate of nearly 2 per cent
every year. It will be the most populous
country in the world by 2035. The year
2025 will see around 190 million people
with 60 years of age. One can imagine
the burden on healthcare expenditure
of a growing economy. For an example
increased life expectancies and alarm-
ing incidences of chronic health condi-
tions adds pressure to overall healthcare
system where chronic conditions account
for approximately 75 per cent of total
healthcare expenditures.
The rising concern of a changed life
style due to working conditions, abnormal
food habits in young population and
growing elderly population are forcing
for an immediate focussed approach with
appropriate investment in healthcare
before it becomes chronic. For example,
there is a need to add approximately 25,
000 beds annually for another 10 years
and invest annual budget of 50 million
per year for next 20 years. More than
70 per cent of the population resides in
rural India where accessibility to health-
care is almost negligible and illiteracy
prevents health education to reach to
the consumer which can be vital for
preventive health.
So what is needed to create an afford-
able, qualitative, accessible healthcare
environment available to all that competes
with world-class medical destinations? The
answer lies in a collaborative approach of
merging technology, innovative approach
in national health policy, guidelines,
infrastructure and a vision to create a
healthy society. The government initia-
tives for healthcare are much appreciated,
for example creating a framework for IT
infrastructure for health in collaboration
the private healthcare, establishment of
the National Knowledge Commission
(NKC), liberalisation of insurance sector,
elimination of certain diseases—yet the
desired results need to be realised. The
Ministry of Health, Department of Family
Welfare, Department of Communication
and Information Technology, state govern-
ment and the ISRO are those who have
played significant roles in the develop-
ment of healthcare strategies in India.
The recent announcement of rural health
initiatives is an encouraging step from
newly formed government. The time is
right for India to learn from the best
practices available across the world to
customise, adopt and implement for
its own betterment before it fails to
deliver fundamental public right of
good health.
Infrastructure and Resources
The availability of critical resources
to deliver medical care needs serious
inputs. The inadequate numbers of
public health facilities are struggling to
deliver basic healthcare. According to
PricewaterhouseCoopers, India needs
74,150 community health centres per
million populations but currently has
less than half that number. In addition,
at least 11 Indian states do not have
laboratories for testing drugs, and more
than half of existing laboratories are not
properly equipped or staffed.
The quality of healthcare profession-
als is also a concern. One part of Indian
healthcare system delivers world-class
competitive healthcare through private
channels and another part as rural health-
care struggles with dearth of qualified
professionals. The reluctance from quali-
fied professionals to work in rural areas
due to minimal basic infrastructure (water,
electricity and road) forces them to choose
the urban based private healthcare facili-
ties. This opens up space for unqualified
health professionals to deliver healthcare
in rural areas which further adds to the
woes of healthcare delivery.
This calls for an aligned strategy and
an immediate need for investment to
create the basic infrastructure to reach
out to common public. The primary
healthcare centres need to be equipped
with basic diagnostic facilities and avail-
ability of medical practitioner across the
country. The government should derive
innovative incentive schemes for medi-
cal professionals to attract them to work
in rural set-up. The community centres
(Nursing facilities, day care) in larger
towns should be facilitated to cater to
general public for health related issues
which does not need sophisticate medical
intervention. Also, these can be utilised
as gate-keepers to tertiary care hospitals
to maintain the optimum utilisation of
tertiary public healthcare centres without
overburdening them.
Healthcare IT Implementation
Healthcare is one of the key areas which
can benefit by the use of IT. The minis-
try of communication department
has initiated Information Technology
Infrastructure for Healthcare (ITIH).
In 2003, the Department published a
“Framework for Information Technology
Infrastructure for Health in India.” This
framework is centred on the philoso-
phy that “information is determinant
of health”. Despite initial progress, the
promising initiative fell short of imple-
mentation. The gap between policy
formulation and implementation needs
to be bridged with stringent processes,
procedures, tight timelines and deter-
ministic objectives. The IT investment
in healthcare industry is still seen as an
expenditure rather than investment for
future where results are long term. This
myth has to be broken. The pre-analysed
business processes rightly coupled with IT
investment strategies can save millions of
dollars in long term and provide quality
healthcare.

Health standard adoption state and national level. The meaningful information collected
from several sources can help the decision makers to be on the
forefront and analyse the future trends in healthcare.
Formulisation of national care delivery guidelines and healthcare
The adoption of clinical guidelines, treatment protocols
standards in line with international standards can be the first
and national policies can drive the unified healthcare to global
step toward affordable international healthcare establishment.
standards. Quality standards should be implemented in all
Adoption of proven health standards like HL7, HIPAA, SNOMED,
the care delivery organisations and collected data should be
ICD-10, X12, JCI accreditation can bring significant changes in
closely monitored on performance, clinical outcomes, patient
healthcare delivery system by cutting cost and fruitful results in
satisfaction and peer reviews. It is also important to introduce
long term. The adoption of some of the health standards have
mandatory continuing medical education programme to cope
been seen in recent past while others are gearing up. Nationally
up with fast changing healthcare practices. Collectively, efforts
defined guidelines with clear cut reporting of patient centric
will bring a disciplinary approach across the system and push
data captured in each of the healthcare delivery centres—
the healthcare professionals to hone their skills in line with
rural and urban, primary to tertiary—will help greater depth
competitive world.
of analysis for future trends and requirements at the districts,

www.asianhhm.com 27
 There is a need to adopt e-health strat-
egy which can primarily store the patient
database - accessible beyond boundaries.
The available clinical information database
can be utilized to help the patients and
clinicians to access the patient centric
information and past history at the time
of critical decision making, emergency
and natural calamity. Further, the central
patient database can help in systematic
health economics reporting and in deci-
sion making for continuous improvement.
The last decade has seen lot of mobil-
ity in Indian population and it is nearly
impossible to keep the medical records all
the time at all the places. Digitised form
of record capturing at all delivery levels
should be the first step to collect informa-
tion from all sources and further align all
the healthcare providers using national IT
guidelines creating clinical data repository
either at the state or central level. India
does not need to reinvent the wheel as
there are many worldwide initiatives to
learn from, adopt and customise health-
care IT practices for our own benefits.
Medical tourism exploration
Medical tourism is one of the major
external drivers of growth of the Indian
healthcare sector which is vouched to
become an industry itself and has a
potential to contribute US$ 5 billion to
Indian economy. Indian medical tour-
ism was estimated at US$ 350 million
in 2006 and has the potential to grow
into a US$ 2 billion industry by 2012.
The private healthcare sector caters to this
niche segment and renders world-class
affordable healthcare to patients using
state-of-the-art technologies at a fee which
is 10-15 times lower than anywhere in
the world. The Confederation of Indian
Industry and McKinsey together estimated
the Indian medical tourism sector to be
US$ 350 million annually. More than
180,000 tourists are treated every year
at Indian facilities and the number is
growing at 25-30 per cent per year. As a
result, the government is encouraging a
variety of incentives aimed at boosting
this sector.
28 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Apart from the allopathic medical
system, the Indian traditional proven
healthcare system ‘Ayurveda’ has come
of age and is becoming very popular in
western countries. A subtle approach to
chronic diseases, healthy living and well-
ness management with no side effects is
attracting a number of patients from all
over the world. A variety in treatment
and multiple options has given a boost
to alternative medicine which delivers
services and treatment covering whole
gamut of illness to wellness. It is attracting
around 20,000 patients annually and is
set to receive 100,000 by 2010.
Medical insurance
Indian healthcare is mostly out-of-pocket
payment based (98.4 per cent) which
keeps the poor out of accessibility network
or forces them to sell their belongings to
avail the best medical services. Once in
the hospital, patient either needs to pay
upfront or immediately at the end of the
treatment. This many a times leaves no
choice but to stay away from highly priced
private hospitals and rely on unqualified
professionals. While insurance has been
vital to bring positive changes since its
first launch in 1996-97, yet only 11 per
cent of the population has some form
of health insurance till recently. Private
health insurance has played a major role
in reviving the health industry after the
globalisation, yet it covers a little more
than 1 per cent of the total population.
State level insurance schemes have been
launched and gained well-deserved popu-
larity among economically deprived class.
Karnataka government initiative ‘Yashwini’
and Andhra Pradesh ‘Arogyashree’—a
perfect example of Public—Private part-
nership—has been a marvellous example
of micro-insurance too. It has benefited
Navin Chandra Nigam currently works as a lead healthcare consult-
A uthor
ant in Satyam Computers. His expertise lies in providing healthcare
solutions to customer. Over 12 years global healthcare experience
including NHS, Victoria Health and Canada Infoway, he is member of
HIMSS and equipped with international healthcare certifications.
ISSUe - 20 2009
millions of people at a minimal annual
cost (Rs 30 - 60) who were earlier deprived
of world-class healthcare due to non-avail-
ability of insurance.
A national level approach on micro-
insurance can change the way healthcare is
delivered to rural population. A collabora-
tive approach among government, private
hospitals and insurance bodies can create
a significant difference to make the basic
level of healthcare facilities accessible to
rural population at the minimum annual
premium. Insurance companies need to
open up new channels to reach out to
rural population in collaboration with
public and private hospitals. The govern-
ment should support the rural healthcare
by establishing more number of PHCs,
telemedicine centers, diagnostic facilities
and secondary care hospitals which can
be utilised at the optimum level.
Baseline
The national health policy 2002 was
derived keeping the well-being of all
the sections of society. Due to limited
financial and operational resources, the
implementation has been delayed, though
many issues are addressed. The need of the
hour is to create a self-reliant healthcare
environment with a clear roadmap and
aggressive timelines. The implementa-
tion of health policy is not the respon-
sibility of centre and state government
alone but health provider—public and
private—should also own the responsi-
bility to deliver for the benefit of the
society. Reforms in healthcare policy are
long due as need are changed. A collabora-
tive approach with government, private
healthcare providers, NGOs, insurance
companies has become essential to keep
the help Indians stay fit and contribute
to the society for a long time.
 Healthcare Management

Primary Healthcare in India

An ideal approach

Primary healthcare in India

needs to be revamped and is
in urgent need of reforms.

Geeta S Pardeshi
Lecturer
Department of PSM
Dr. Shankarrao Chavan Government Medical College
India

Geeta S Pardeshi is currently working as a lecturer in the department

of PSM at Government Medical College, Akola, Maharashtra, India.
She has also worked at Government Medical Colleges at Pune,
Kolhapur, Yavatmal and Akola in Maharashtra.

What is the difference between Primary
care and Primary healthcare?
Health services in India are provided
through a three-tier setup namely primary,
secondary and tertiary. Primary care is the
healthcare provided at the primary level
of care, which is the first level of contact
of the community with the health system.
Cases which are more complex and need
specialised care are referred to the second-
ary (District hospital) and tertiary level
(Regional and national hospitals).
Primary healthcare is an approach
defined as ‘essential healthcare made
universally accessible to individuals and
acceptable to them through their full
participation and at a cost the commu-
nity and country can afford.’
Primary care, which incorporates these
characteristics is primary healthcare and
forms a foundation of effective health
services.
What are the principles of primary health-
care? What services are provided under
primary healthcare?
The principles of primary healthcare
are equitable distribution, community
participation, inter-sectoral coordination
and appropriate technology. In addition
to this, team approach, decentralisation,
effective referral system are also important
elements of this approach.
The services under primary healthcare
are to be made accessible and available to
people as per the principles of universality.
It also asserts the role and responsibilities
of the state and recognises that health
is a multi-factorial entity and there is a
need of multi-sectoral approach to health.
This approach emphasises complete and
organised community participation and
ultimate self reliance of individuals and
community towards their own health.
Primary healthcare views health
as an integral part of socioeconomic
development of a country. It calls for
an integration of preventive, promo-
tive, curative and rehabilitative health
services. Traditionally, it is expected that
primary healthcare should include at least
education concerning prevailing health
problems and methods to prevent and
control them, promotion of food supply

www.asianhhm.com 29
Healthcare Management
and proper nutrition, adequate supply There are specific population norms
of water and basic sanitation, maternal for these health centres.
and child health including family plan- A sub-centre is the most peripheral
ning, immunisation against major infec- and first contact between the community
tions, prevention and control of locally and primary heath care system. Each
endemic diseases and provision of essential sub-centre is manned by a female and
drugs. Current reforms look beyond this a male multipurpose worker. Primary
basic package towards lifestyle disorders health centre is manned by a medical
and deal with health of everyone in the doctor, supported by14 paramedical
community. staff. It acts as a referral unit for 6
sub-centre s and has 4 to 6 beds for
What are the main goals of Primary patients. Community Health Centre is
Healthcare in India? manned by four medical specialists viz.
Primary healthcare was accepted as the Surgeon, Physician, Paediatrician and
best approach to achieve the goal of gynaecologist supported by 21 paramedi-
‘Health For All’ in the Conference of the cal and other staff. It has 30 indoor beds
World Health Organisation held at Alma with operation theatre, X-ray facility,
Ata in 1978. ‘Health For All’ is defined labour room and laboratory. It serves
as an attainment of a level of health that as a referral centre for 4 PHCs. As on
will enable individuals to lead a socially March 2007 there were 1, 45, 272 sub-
and economically productive life. The centres; 22,370 PHCs and 4045 CHCs
fundamental focus of this approach is in the country.
on universality, comprehensiveness and
equity in health. Is the objective of reducing the health
inequalities in introducing primary
How is primary healthcare provided in healthcare in India being met?
India? Overall, many health indicators for our
India was a signatory to the Alma Ata country have shown an improvement
declaration and the health system in over the years, but the gains have been
the country has been built up along the unequally distributed. Glaring inequali-
primary healthcare approach. India has ties are seen between different states,
a well-defined infrastructural setup for communities, between different strata
provision of Primary healthcare in rural in societies within the urban areas.
areas. It is important to understand that
A network of government-owned and the roots of health inequities lie in social
operated Sub-centres, Primary Health conditions outside the direct control of
Centres and Community Health Centres health systems and hence need to be
is designed to provide primary healthcare tackled through inter-sectoral coordi-
in the county. nation and cross-government action.
Health inequities
stem from social
Population norms for different centres stratification and
inequalities such
Population
Norms
as income, social
Centre
status, neighbour-
Plain Area Hilly/Tribal/ Achievements
Difficult hoods where people
Area live, employment
Sub-Centre 5,000 3,000 5,111 conditions, personal
factors etc.
Primary Health Centre 30,000 20,000 33,191 In addition when
Community Health 1,20,000 80,000 1.83 lakhs a major chunk of
Centre healthcare expendi-
Table 1
30 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
ture is made out of pocket at the point
of service delivery it increases health
inequities as the rich can afford to pay
and the poor cannot. In India nearly
75 per cent of the health expenditure is
such out of pocket expenditure.
Lack of accessibility and poor
quality of services also adds to such
inequities.
The target of equitable distribution /
universal coverage is yet to be achieved.
Universal coverage of health services is
necessary foundation for health equity. It
is necessary but not sufficient to achieve
health equity.
Universal access to health services
should be complemented by social health
protection through targeted interven-
tions for vulnerable groups and mobi-
lising for health equity through public
awareness and policy debates thereby
creating space for social movements.
How does the primary healthcare system
help with overcrowding at the hospi-
tals?
It is clear that if the quality of care at
the first level of contact is not satisfac-
tory, people will bypass this level and
seek care from higher levels of care.
This leads to overcrowding at hospitals
thereby affecting the quality of is services
adversely. This affects the overall health
service provision.
Primary healthcare approach, if
implemented in its true spirit, improves
the performance of primary care. The
comprehensive and integral nature of
services prevents and controls many
illnesses thereby reducing the burden
of illness. Early diagnosis and appro-
priate treatment of ailments ensures
that the patient does not land up in
complications. Good quality of services
encourages the community to seek treat-
ment at the primary level itself. Thus
only patients referred from the primary
level or those with complex health prob-
lems needing specialised care will seek
treatment from the hospitals and higher
levels. This will prevent overcrowding
at the hospitals.

In addition, provision of primary
healthcare in urban areas will also limit
the burden of cases at the hospitals.
Is the available healthcare infrastruc-
ture meeting the healthcare needs of
the people?
The health infrastructure in India is based
on the primary healthcare approach.
Over the past years there has been a
significant reduction in crude birth rate,
crude death rate, infant mortality rate
and an increase in life expectancy. But
these rates are nowhere near the values
achieved by the developed countries and
regional inequalities remain.
The country has an extensive network
of health centres. Yet the geographical
and quantitative availability of primary
healthcare facilities is far less than the
guidelines laid down by the government.
Studies have shown that only 20 per
cent of those seeking outpatient services
and 45 per cent of those seeking indoor
treatment avail public services.
Primary healthcare in India is in need
of urgent reforms to meet the needs of
the people.
Is primary healthcare as much a pressing
priority now as it was before?
Primary healthcare is as much of a press-
ing priority now as it was before. Social,
demographic and epidemiological transi-
tions along with globalisation, urbani-
sation and an ageing population pose
challenges of a magnitude not anticipated
earlier. Primary healthcare is an ideal
approach to deal with this complex situ-
ation of great magnitude.
In addition, in this scenario many
persons are likely to present with co-
morbidities which underlines the
importance of dealing with the person
as a whole which is possible with this
approach.
As societies modernise, there will be a
rise in expectations regarding health and
healthcare. A people-centred approach
like primary healthcare is likely to satisfy
such expectations of a knowledgeable
society.
Healthcare Management
Is primary healthcare in India facing a shortage of human resources?
There is a shortage of manpower at the centres providing primary healthcare. Overall
there is a shortage of all cadre of workers. There is a 7.8 per cent shortfall of the total
requirement of doctors at PHCs and more than 50 per cent shortage of the posts of
male MPW at sub-centres and specialists at community health centres.
In the present circumstances, medical personnel in general do not want to relocate
to rural and remote areas.
Attempts have been made to bridge this gap but have met with limited success.
Appointments on contract basis, posting interns and graduates and postgraduates
after there degrees in rural areas have been tried. However, concrete steps need to
be taken to tackle this problem.
It has also been observed that focuss- alternative for them. It is important
ing only on priority diseases through to focus on the team approach; a team
vertical programmes leads to fragmenta- of trained, motivated workers who are
tion of health services and short term able to establish ongoing relations with
gains while the holistic and person- the community to ensure continuity of
centred approach in primary health- care, a team which has the capacity to
care provides long term gains. Primary provide integrated services in response
healthcare in urban areas is the need of to the community needs.
the hour. Apart from urbanisation, the Primary healthcare is not the antith-
enormous social and economic stratifi- esis of hospital care nor can this care be
cation within the urban areas leads to isolated care provided through isolated
extreme marginalisation in the form of centres. Currently the referral system is
slums and street dwellers. ineffective and the health centres hardly
coordinate with other departments and
What are the issues and challenges of organisations. Ideally, primary healthcare
primary Healthcare in India? How should serve as an entry point for the
can primary healthcare be improved individuals, which ensures continuity
in India? of care by coordinating a comprehen-
Primary healthcare in India needs to sive response at all levels of care. The
be revamped and is in urgent need of problems of manpower shortage and
reforms. universal coverage are major challenges.
The misconception of primary Community participation and inter-
healthcare amongst policy makers and sectoral coordination are aspects which
field workers is that it is cheap, low will require special efforts. Effective
technology, non professional care for leadership and administrative skills
the rural poor and deals with few prior- are required to implement these prin-
ity diseases. It is important to under- ciples on field which appear simple on
stand that primary healthcare requires paper.
adequate resources and investment. It Public private partnerships in provi-
gives much better value for money than sion of primary healthcare are interest-
other alternatives. Currently the public ing avenues which should be tapped.
health expenditure on health is only Non governmental organisations and
0.9 per cent and needs to be increased corporate sector should show interest in
with major inputs for primary health- contribution to primary healthcare.
care services. With the trends of increasing
The community-level health work- urbanisation, planning and provision
ers can only complement the team at of primary healthcare services in urban
the health centres and cannot be an areas can no longer be neglected.
www.asianhhm.com 31
Medical Sciences
Circulating
Nucleic Acids in
Plasma & Serum
A non-invasive approach
A
CNAPS offers a non- lthough DNA was first demon-
invasive approach to a wide strated in human blood from
range of clinical disorders healthy donors, pregnant
women and clinical patients in 1948,
that will allow the basic the structure of DNA was still to be
information necessary not determined as was the elucidation of its
only for use in predictive role as the basis of the gene [Table 1].
medicine but also for direct Consequently, no interest was shown
use in acute medicine. in the presence of DNA in the circula-
tory system until high DNA levels were
demonstrated in the blood of patients
Peter B Gahan
Emeritus Professor
with systemic lupus erythematosus.
Anatomy & Human Sciences Department Similar observations were also made
King’s College London, UK in acute medicine, diabetes, oncology
and fetal medicine [Table 2, 4, 5].
Nucleic acid and nuclease content
Both DNA (1.8 - 35 ng mL-1) and
RNA (2.5ng mL-1) are found in and
plasma and serum from healthy donors.
These levels rise in patients with various
cancers, trauma, myocardial infarction
and stroke with values of over 3,000ng
DNA being recorded on occasions. The
amount of DNA and RNA present in
the plasma and serum will depend upon
the health status of the individual and
the level of nucleases present in blood.
The average blood plasma concentration
of DNAase I is 3.2 - 18.4ng mL-1 whilst
the average serum RNAase value is 104
units mL -1. Hence the relatively low
levels of circulating DNA in healthy
individuals may indeed be partially due
to peripheral blood DNAase activity,
although DNA from cancer patients
32 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
may be resistant to DNAase and the
DNAase levels may have just been low.
Similarly, high RNA levels may also
be due to RNA resistance to RNAase
digestion especially when high RNAase
and RNA levels are present together.
The RNA may be protected with a
glycolipid due to its apoptotic origin.
Furthermore, an RNA fraction is associ-
ated with the released DNA-complex
from healthy cells which appears to be
protected from digestion by RNAase
(see below).
Nucleic acid sources
There are six possible sources of blood
DNA, namely (i) breakdown of bacte-
ria and blood cells; (ii) viruses, (iii)
leucocyte surface DNA, (iv) necrosis, (v)
apoptosis and (vi) spontaneous release of
a newly synthesised DNA / RNA-lipo-
protein complex from healthy cells.
DNA
Only small amounts of DNA are yielded
by the first three possibilities with just
nasopharyngeal carcinoma Barr virus
and human papilloma virus carcinoma
DNAs having been identified and the
breakdown of bacteria and bloods cells
yielding only low levels of DNA.
Necrosis is clearly an option for the
origin of Circulating Nucleic Acids in
Plasma & Serum (CNAPS). However,
when the double stranded CNAPS DNA
is separated by gel electrophoresis, the
fragments tend to form a ladder rather
 Medical Sciences

RNA in the bloodstream is due to the

Some developments in understanding DNA and its cellular roles
availability and type of the RNAs and
Date Authors Discovery RNAses present (see above).
However, a newly synthesised RNA
1869 Miescher isolation of DNA (nuclein)
is released spontaneously from cells
1929 Levene building blocks of DNA identified together with the DNA-lipoprotein
complex. In consequence, RNA is prima-
1944 Avery et al. DNA as genetic material
rily released by apoptosis and through
1948 Mandel & Metais circulating nucleic acids in blood the DNA/RNA-lipoprotein complex.
1949 Chayen cytoplasmic DNA localisation Some RNA may also be derived by
necrosis e.g. some m-RNAs.
1953 Watson & Crick DNA structure

1953 Wilkins et al. DNA structure Applications of CNAPS in

1957 Sinsheimer
1959 Gartler
1962 Gahan
1962 Stroun
1965 Gahan & Chayen
1972 Stroun & Anker
1977 Stroun et al.
1977 Leon et al.
1989 Stroun et al.
1999 Kopreski et al.
than a smear. The ladder fragments are
mainly 180 - 1,000 bp in size and so are
likely to be formed by apoptosis. DNA
released by necrosis is incompletely and
non-specifically digested and so smears
on electrophoretic separation due to its
fragment sizes of about 10,000bp; this
is not a major source of CNAPS.
Apoptosis is confirmed as a major
DNA source especially since nucleo-
somes are present in the blood e.g. of
cancer patients. Naked DNA fragments
are also found in serum, possibly due
to apoptosis.
Therefore, the two major sources of
CNAPS are apoptosis and the spontane-
ously released DNA/RNA-lipoprotein
complex. The DNA is newly synthe-
sised and is released from the cell in
the form of a complex together with
newly-synthesised lipoprotein and RNA.
This complex is released homeostati-
cally from the healthy, but not dead or
diagnosis, prognosis and the
DNA-gene concept monitoring of treatments
DNA uptake by mammalian cells CNAPS in diagnosis, prognosis and
DNA mobility
the monitoring of treatments has
been applied in a wide variety of clini-
DNA mobility cal disorders and situations from the
messenger DNA emergency and accident ward to foetal
medicine. The general approach to clini-
released nucleic acids
cal application involves the taking of
circulating nucleic acids blood samples from which are separated
plasma, serum and leucocytes. DNA /
blood DNA levels up in cancer
RNA are removed from plasma / serum
cancer derived blood DNA and the surface DNA from leucocytes.
malignant melanoma serum mRNA The DNA / RNA are then subjected to
quantitative real-time PCR and RT-PCR
Table 1
prior to analysis by gel electrophore-
dying, cells whether human or other sis and mass spectrometry. Relating
mammalian cells or avian or amphib- the markers so derived to the clinical
ian. The DNA is double-stranded and condition permits the possibility of early
about 2,000 bp in size. Importantly, diagnosis, and prognosis as well as the
after leaving the cell, the complex read- possibility of monitoring the treatment
ily enters other cells where it expresses prescribed.
a biological activity that appears to be
cell-type specific (Table 3). Acute Medicine
RNA a) Trauma: Circulating DNA levels
RNA is only recently of importance increased in patients presenting with
through its exploitation in clinical diag- injury, the concentration relating to
nosis and prognosis. The stability of the severity of the injury with up to a
Presence of DNA and RNA in blood from patients with various disorders
Year Authors Marker disorder
1966 Tan et al. DNA SLE
2003 Rainer et al. DNA stroke
2003 Lam et al. DNA trauma
2003 Chang et al. DNA myocardial infarction
2004 Laktionov et al. RNA trauma
Table 2

www.asianhhm.com 33
Medical Sciences
patients levels were about 60 per cent
Cellular changes induced by the
higher than those of healthy individuals
uptake of CNAPS by cells
whilst the background retinopathy and
1. Initiation of cancer pre-proliferative retinopathy patients
showed increasing rhodopsin mRNA
2. Alteration of myocardiocyte contraction rates levels with increasing severity of the
retinopathy. Diabetic patients with-
3. Production of antibodies
out clinical features of retinopathy
4. Initiation of DNA synthesis also showed significantly higher levels
of rhodopsin mRNA so indicating
5. Blockage of DNA synthesis that retinal damage could have already
Table 3 occurred. In this case, rhodopsin mRNA
100-fold increase occurring in patients levels in peripheral blood could offer an
developing organ failure, multiple organ early detection of DR. Additional early
disfunction syndrome, acute lung injury predictive markers include increased reti-
and those who will die when compared nal specific mRNA, RPE65 levels and
to patients with uncomplicated injury. reduced retinoschisin mRNA levels.
Since the DNA normally has a short half- b) Diabetic Nephropathy (DN): DN
life in circulation and given the elevated patients have a higher mean amount
DNA levels in the first few hours after of circulating nephrin mRNA when
patient admission with potential organ compared with a control healthy
failure, the maintenance of the high cohort possibly due to a loss of nephrin
DNA levels could be used to anticipate mRNA from glomerular epithelial cells
that organ failure. which correlates well with pathological
b) Stroke: Circulating DNA levels are assays.
elevated after a stroke, the amount being
related to the extent of brain damage Prenatal Medicine
and it may be possible to use these Although fetal DNA accounts only
DNA levels as indicators of short and for 3-6 per cent of the total
long-term changes as well as post-stroke maternal CNAPS, its identi-
mortality. fication and isolation is facili- Possible CNAPS markers in foetal medicine
c) Acute Myocardial Infarction (AMI): tated by the majority of the
Pre-eclampsia
AMI patients have elevated circulating fetal DNA fragments being
DNA levels when compared to controls primarily >300 bp whereas the
including both AT-rich and GC-rich maternal DNA fragments are
fragments of DNA. This has yet to be >300 bp.
transformed into an early diagnostic Successful sex determina-
approach. tion has been performed on
ß-thalassaemia
d) Organ Transplants: Preliminary studies fetal DNA in maternal blood
on rejection monitoring with CNAPS using either paternal derived
by exploiting donor-DNA fractions fragments of the Y chromo-
showed a good correlation in the case some or paternal X-chromo-
Foetal sex
of pancreas-kidney rejection and elevated some derived fragments of
donor-DNA levels. the amelogenin gene and
multicopy DAZ sequence
Diabetes (Table 4).
Down’s Syndrome
a)Diabetic Retinopathy (DR): Comparison Working with the maspin
of diabetic patients without DR, with gene sequences, it was shown
DR and healthy subjects showed diabetic that if regions of the DNA
patients as a whole to have about 2.5 from the father were methyl-
Rh status
times the rhodopsin mRNA than the ated, but unmethylated from
control subjects. Diabetic control the mother then is was possi-
34 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
ble to distinguish the parental origin of
the DNA. Furthermore, hypermethylated
DNA was derived from the maternal
blood cells, whilst the hypomethylated
form was derived from the placenta and
hence of foetal origin. Although the
hypomethylated form was normally
cleared from the blood in pregnant
women, it increased by about six-fold
in the case of pre-eclampsia. Higher
levels of ß-globulin and SRY genes were
also present in pregnant mothers who
went on to develop pre-eclampsia and
intrauterine growth retardation.
When the foetus-specific circulat-
ing mRNA for corticotrophin-releasing
hormone increased ten-fold, the levels
relate to the severity of pre-eclampsia
(Table 4).
Foetal DNA can also be used for
foetal blood group genotyping with the
Rh status of the foetus being determined
successfully. There are strong indications
for the successful identification of other
blood types including Rhc, RhE.
Other approaches include the possi-
bility to determine Mendelian inher-
ited disorders especially through the
2005 Chim et al. hypomethylated DNA
Swaminathan/
2005 SRY gene
Butt
2005 Wong et al. ACTH
2008 Papasavva et al. δ-globulin SNPs
2005 Li et al. foetal DNA
2008 Vecchione et al. amelogenin gene
2008 Vecchione et al. multicopy DAZ
2008 Lo et al. PLAC4 gene
2008 Vainer et al. DNA
2004 Finning et al. DH exons 4,5,10
Table 4
 Medical Sciences

fragments involved and a particular type

Some CNAPS markers in oncology
Lung Cancer Cell-surface DNA
Hypermethylated p16 (INK4A), APC, DAPK
Colo-rectal Cancer K-ras mutations
General DNA level elevated
Hypermethylated APC
Breast Cancer Hypermethylated APC, RASSFIA, DAPK
Oesophageal Cancer v Hypermethylated APC
Prostate Cancer CpG dinucleotides methylated in GSPT1
Loss of heterozygosity for 3p24 and 8p21
Elevated microsatellite DNA
Telomere transcriptase m-RNA elevated
Liver Cancer Hypermethylated RASSFIA
Table 5
paternally-inherited alleles as can be seen from the maternal blood using an allele-
through the diagnosis of Huntington’s specific based real-time PCR method
disease, achondroplasia and mytonic and using eleven paternally inherited
dystrophy. Less easily detected are the SNPs with a high degree of heterozy-
aneuploid disorders due to the smaller gosity from the ß-globulin gene for the
increases in fetal DNA. However, modest diagnosis of ß-thalassemia.
results have been achieved with foetal
chromosome 21 status by measuring Oncology
either the relative concentrations of Initially, circulating DNA was used as
foetal-specific epigenetic markers on (a) an early marker for cancer seen as an
chromosome 21 to those on one or increased amount circulating and (b) in
more reference chromosomes or placen- monitoring treatment when the DNA
tal-specific mRNA species transcribed levels returned to normal levels upon
from a chromosome involved in an successful treatment. However, there was
aneuploidy, e.g. the PLAC4 gene on no specific correlation between the DNA
chromosome 21 for Down syndrome
using the RNA-SNP (single-inherited
nucleotide polymorphisms) allelic ratio Peter Gahan is Emeritus Professor of Cell Biology at King’s College
A uthor
of cancer (see Table 5). Nucleosomes
form one source of DNA released into
the blood stream but are not considered
to be suitable for cancer diagnosis due to
elevation of nucleosome levels in patients
with benign diseases. Nevertheless,
circulating nucleosomes can be informa-
tive for monitoring cytotoxic therapy
with strongly decreasing levels being
mainly found in patients with remis-
sion of disease whereas constantly high
or increasing values are associated with
progressive disease during chemo- and
radiotherapy.
Lung, Colorectal, Prostate, Liver,
Ovary, Breast, Oesophageal
Cancers
A range of markers have been proposed
for the identification of a particular
cancer, though there is frequent conflict
in the literature as to the effectiveness
of particular probes. However, recently,
hypermethylated CpG in the promo-
tor region of tumour suppressor genes
has been suggested to trigger local gene
silencing. Aberrant methylation of the
p26 tumour suppressor gene was the
first to be detected in liver, breast and
lung cancer. Other frequently methylated
tumour suppressor genes (Table 5) have
been used with varying success.
CNAPS
Although a relatively recent addition to
methodologies available for early diag-
nosis, prognosis and treatment moni-
toring, CNAPS offers a non-invasive
approach to a wide range of clinical
disorders that will allow the basic infor-
mation necessary not only for use in
predictive medicine but also for direct
use in acute medicine.

method, which has a high sensitivity London where he continues to teach. He is a director of the European
Association for Predictive , Preventive and Personalised Medicine
of 90 per cent and a high specificity of and researches the biology of the DNA/RNA lipo-protein complex
96.5 per cent. found in CNAPS and its possible role in cancer.
Pre-natal detection of ß-thalassemia
is also feasible using fetal DNA isolated

www.asianhhm.com 35
Medical Sciences

Surgery for Acute

heart failure

Stage A: asymptomatic patients at risk of developing

heart failure (with hypertension, coronary artery
disease for example),
ACC / AHA time line Stage B : those who are asymptomatic but have
classification of heart failure ventricular changes of heart failure (hypertrophy or
ventricular impairment),
Stage C: those with a current or past history of heart
failure in association with structural changes and
Stage D: those with refractory heart failure.
36 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
Table 1

As we consider the
surgical approach to heart
failure, it is helpful to distil
physiological themes that
support pharmacologic
treatment such as
reduction of after-load
to the heart or increased
force of contraction.
Stephen Large
Consultant
Cardio-Thoracic Surgeon
Papworth Hospital and
Associate Lecturer, Department of
Medicine, Cambridge University, UK
W
hen the heart starts to fail,
healthcare costs start to rise.
The cheapest option is to do
nothing as heart failure is lethal. Heart
failure is common and becomes more so
with age. Indeed it is the most common
diagnostic related group in the UK at
hospital discharge and is the primary or
secondary diagnosis in about 1 per cent
of the population consuming a similar
proportion of the country’s GDP every
year. So, how to recognise this monster?
The 2005 ACC / AHA guideline update
for the diagnosis and management of
chronic heart failure in the adult gives a
definition for heart failure as: “a complex
clinical syndrome that can result from any
structural or functional cardiac disorder
that impairs the ability of the ventricle
to fill with or eject blood”.
It is a progressive disorder and to
capture this ACC / AHA has proposed
a new approach to the classification of
heart failure set out in Table 1.
Although progressive the clinical
picture for heart failure is unpredictable.
It is difficult to characterise and especially
so in its early stages. This probably follows
its recognition as a “..largely a clinical
diagnosis that is based on a careful history
and physical examination”. When symp-
toms present they are predominantly made
up of fatigue, breathlessness and limited
exercise tolerance. Fluid accumulation
is apparent on the right side as depend-
ent oedema and on the left as interstitial
lung oedema. The condition is fickle and
patients describe a variety of symptoms.
Thus sequential clinical assessment finds
patients moving up and down the NYHA
(New York Heart Association set out in
Table 2).
Series of drug trials have firmly
established the current pharmacological
management of heart failure. These are
summarised in the ACC / AHA guidelines
with awarded levels of evidence. As we
consider the surgical approach to heart
failure, it is helpful to distil physiologi-
cal themes that support pharmacologic
treatment such as reduction of after-load
to the heart or increased force of contrac-
tion. Let us express these in the following
relationships:
The first
Cardiac output (CO) =
perfusion pressure
(arterial BP – venous P)
peripheral resistance(Ω)
This first relationship demonstrates
that inadequate CO can be improved
either by increasing perfusion pressure
(reducing venous pressure by diuresis,
haemofiltration or veno-dilatation) or
reducing peripheral resistance (using arte-
riolar dilators or strategies to uncouple
the augmented angiotensin-renin axis that
New York Heart Association
classification of heart failure
NYHA I
symptoms that appear only at levels
of exertion that would limit normal
individuals.
NYHA II
symptoms on ordinary exertion and
NYHA III
symptoms on less than ordinary
exercise
NYHA IV
symptoms of heart failure at rest.
Table 2
Surgical speciality
characterises heart failure).
The second
Cardiac output (CO) =
stroke volume (SV) x heart rate (HR)
The second indicates that an increase
in stroke volume or a raised heart rate
(to an upper limit dictated by adequate
diastolic filling of the ventricle or both),
will improve the lot of the heart failure
patient.
The third
Ejection fraction =
(end diastolic volume – end systolic
volume) x 100 per cent
end diastolic volume
This third relationship is often used to
describe ventricular function but it must
be used with caution. It is a derived value
and risks misinforming the clinician.
The fourth
Intra-ventricular pressure (P) =
2 x ventricular wall tension (T)
Ventricular radius (R)
or
T=PxR
2
Where ventricular wall tension (T) is
directly related to oxygen consumption
and ventricular work. This is La Place’s
law and its evolution was in the surface
tension of a bubble. It is not clear how
it relates to the working ventricle but
probably has its influence during diastole.
Starling’s law relating stretch of the ventri-
cle to power generated by subsequent
contraction (to a finite limit of stretch)
predicts systolic function.
Armed with these four relationships
this paper attempts to bring some clarity
to the apparent hotch-potch of surgical
solutions for the failing heart. An attempt
will be made to offer levels of evidence for
each operative approach (for definitions
of evidence levels see Appendix).
A Surgical approach to heart failure:
Cardiac output improvement is the aim
of all therapeutic approaches for heart
failure. Can a surgical approach affect
cardiac output? It would appear so though
either of two approaches:
1. either by removing the primary ventricu-
lar insult, so permitting recovery or
www.asianhhm.com 37
Surgical speciality

inter and intra-ventricular contrac-

Possible causes of heart failure
tion with normalisation of contractile
Impaired filling before the ventricle: reserve.
• electrical (normalisation of ecg and
i) extra cardiac obstruction: eg: pericardial constriction or venous
obstruction myocardial excitability)
• biochemical: normalisation of:
ii) intra-cardiac obstruction of inflow. eg: mitral valve stenosis or º high energy phosphate production,
obstructing atrial tumour
storage and oxygen use
Impaired filling of the ventricle:
º enhanced natriuretic peptide secre-
tion
i) hypertrophy. eg: congenital (genetic eg: HOCM ) acquired (pressure
º elevated renin-angiotensin levels
loading in hypertension )
º catecholamine levels
ii) infiltration. eg: fibrosis, acute and chronic inlamatory (myocarditis), º endothelin levels
giant cell, sarcoidosis, amyloidosis º markers of inflammation
3. Prognostic returning the patient’s
Impaired ejection of the ventricle:
expectation of survival towards that
i) of the wall: iron overload or chronic alcohol or glycogen excess), of peers without heart failure.
ventricular aneurysm formation, dilating cardio-myopathy, ischaemia
with hibernation, ischaemia with scarring, loss of ventricular inter-
dependence (bundle branch block, pacing), outflow tract obstruction The operations
(dynamic: septal hypertrophy, systolic anterior mitral valve leaflet The operations or interventions will be
movement. Fixed: subvalvar aortic stenosis) described in a standardised fashion accord-
ii) Miscellaneous: sustained excessive work load without obstruction: a-v ing to whether:
fistulae, super athelete, high output shock 1. the primary insult can be identified
and removed or
Impaired ejection after the ventricle:
2. the aim is to attempt to surgically
i) valvular aortic stenosis, regurgitation reverse remodel the ventricle.
ii) aortic coarctation (congenital or acquired) The outline of the procedure, effi-
cacy, safety and level of evidence will be
iii) hypertension
offered.
Table 3
1. Removing the primary insult:
In ideal circumstances the primary
2. By amelioration of the damaged (4th relationship above) and increased ventricular insult or remodelling force
ventricle with improvement of cardiac oxygen demand. As the remodelling is identified and removed. For example,
output (so called ‘reverse remodelling’ process continues it appears that the removing the pressure loading of the left
or ‘ventricular restoration surgery’). hypertrophied, pressure loaded ventricle ventricle by Aortic Valve Replacement
Where possible it is preferable to dilates and the enlarged, volume loaded (AVR) in aortic valve stenosis. Following
pursue option 1 to identify the cause and ventricle develops hypertrophy. this operation hypertrophy may regress
remove it rather than accept attempts Ventricular remodelling is malign and and morphology normalise. Physiology
to surgically reverse remodel the failing must be reversed, or at least halted if the improves too as does prognosis. Similarly,
ventricle. With this in mind an attempt patient’s symptoms and prognosis are to mitral valve repair for regurgitation
to identify the possible cause of heart be improved. corrects the volume over-loaded left
failure in Table 3. Surgical approaches should have the ventricle and dilatation may recede.
An obstructed or pressure loaded aim of reverse remodelling or restoring Removing toxins such as iron in haemo-
chamber seems to primarily remodel the ventricle to normality. If this is unach- chromatosis and alcohol (supplemented
through hypertrophy of its wall. On the ievable then the compromise is to force with thiamine) in alcoholic cardio-myop-
other hand, volume overload (eg: valvular a trend towards a more normal heart. athy has led to reverse remodelling of
regurgitation) leads to ventricular dilata- Such normality must be recognised in dilated and failing ventricles. Surgical
tion. An enlarging ventricle moves from 3 dimensions: strategies to control rate or rhythm in
a cone shape towards a spherical shape 1. Morphological (both at the gross persistent atrial fibrillation may lead to
with consequent (secondary) mitral anatomic and microscopic levels) reverse remodelling of the dilated heart
regurgitation. The increasing ventricular 2. Physiological in terms of: in tachycardio-myopathy. These surgical
radius also leads to increased wall tension • contractility: overall and as coordinated approaches will not be discussed further

38 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Surgical speciality

MRI image of a poorly functioning left ventricle in association with

coronary artery disease and A. Hibernating myocardium and B Scar

1 2 1 2
A B

3 4 3 4

Figure 1A Figure 1B

A. Triple vessel disease and poor ventricular function but preserved
wall thickness and no evidence of scar where 1 shows diastole and
2 systole and windows 3 and 4 evidence of wall thinning with fibrous
tissue, but showing neither (Hibernation)
B. Triple vessel disease and poor ventricular function. Frame 1 shows diastole,
2 systole and 3 and 4 evidence of loss of wall thickness (white arrows) and
the presence of the white image suggesting scar formation in the lateral free
wall (white arrows in images 3 & 4). History of extensive myocardial infarction
in the circumflex territory

is probably the most important cause

Survival of patients with no mismatched segmental flow
and function compared to those with mismatches
as they are well described elsewhere. Save
to say that the new offered sequential
classification of heart failure by ACC /
AHA indicates that all cardiac surgical
procedures can be regarded as ‘heart fail-
ure surgery’ in their attempts to prevent,
Figure 2
ameliorate or correct the condition. This
paper would not be complete without
some further attention given to the
hibernating ventricle, a consequence
of ischaemia.
Revascularisation: Myocardial ischaemia
of heart failure and is associated with a
substantial mortality. However, ischaemic
ventricular dysfunction may be revers-
ible. A temporary reduction in function
in response to an ischaemic insult has
been termed stunning if acute and hiber-
nating if protracted. Hibernation and
stunning are characterised by reduced
systolic and diastolic function, stunning
improving with inotrope and hiberna-
tion with restoration of blood flow.
Ramtoola’s description of hibernation
in the late 1980s indicated a reduction
in myocardial function that paralleled
fall in myocardial blood supply and
the restoration of function following
correction of ischamia may take some
time, on occasion, months.
Identification of hibernation is
probably best achieved with labelled
(F deoxyglucose uptake) positron emis-
sion metabolic tomographic studies (PET).
It can be demonstrated by dobuatmine
stressed echo with its characteristic
bi-phasic response to increasing levels

www.asianhhm.com 39
Surgical speciality

of hibernation compared to those

The arterial waveform with IABP counter-pulsation without (Figure 2).
mm Hg Increased Conronary
120 C Artery Perfusion Level of evidence: B level or
recommendation IIa
D F
Ventricular reverse remodelling surgery:
All too often the primary remodelling
100
process is not identifiable (eg: idiopathic
B dilating cardiomyopathy) or if it is, it is
not amenable to correction (identified
80 E genetic lesion e.g. HOCM). An attempt
A Reduced Myocardial is made to summarise these operations
O2 Demand in Table 4.
Figure 3
1) Intervention to improve cardiac
Operations to reverse remodel the failing heart output by reducing ventricular
afterload:
1) Intervention to improve cardiac output by reducing ventricular after-load
Intra Aortic Balloon Pumping: Kantrowitz
i) Intra-aortic balloon pumping (IABP)
introduced the intra-aortic balloon pump
ii) Resection of obstructed left ventricular outflow in hypertrophic cardiomyopathy (HOCM) (IABP) 4 decades ago. The principle
2) Surgical procedures to improve cardiac output by reducing left ventricular size involves inflation of an intra-arterial
(‘La Place surgery’)
balloon in early diastole augmenting coro-
i) The Myo-splint nary perfusion (D in figure 3) followed
ii) The CorCap® or Acorn device by pre-systolic (late diastolic) collapse
iii) The Batista operation which results in a lower after load or
iv) Left ventricular aneurysmectomy
effective lower systemic resistance for the
left ventricle (E) and so less work done
v) Mitral valve repair for 2ary regurgitation
by the heart.
3) Surgical strategies to re-power the failing heart Outline of procedure: A 35cc or 40 cc
i) mechanical Helium intra-aortic balloon is inserted
a) Cardiac resynchronisation therapy (CRT) into the femoral artery and passed, retro-
b) ventricular assist devices (LVAS, RVAS, BIVAS and total artificial heart) grade, into the thoracic aorta. Sensing
ii) biological
of heart rate through ECG or arterial
pressure monitoring allows the IABP
a) Dynamic cardiac myo-plasty
to inflated on the dicrotic notch of the
b) Heart transplantation systemic arterial wave form (onset of
c) Cell transplantation diastole) and be collapsed at the latest
d) Gene therapy point possible in diastole.
e) Up-regulation of natural pathways Efficacy & Safety: IABPs are in common
Table 4 use and are regarded as important in the
initial management of patients with acute
of inotrope. There is an initial improve- tion of hibernation as set out above. The coronary syndromes and those with heart
ment in contractility followed by a fall patient then undergoes coronary artery failure. It is a percutaneous device and
off in function as dobutamine levels bypass grafting, with the expectation restricts the patient to an intensive care
reach values of 25—40μg / Kg / min. of improvement in objective signs of bed.
Magnetic Resonance Imaging (MRI) is heart function, heart failure symptoms
showing promise too by unmasking scar and survival. Improvement of course Evidence: Level of evidence B, ACC
and viable muscle (Figure 1). maybe prompt or delayed by a number / AHA recommendation level I
of days. Resection of left ventricular outflow
Outline of revascularisation for Safety & Efficacy: Survival appears to tract: Patients with Hypertrophic
hibernation be better after coronary artery bypass Cardiomyopathy (HCM) may be trou-
This procedure requires the demonstra- grafting in patients with evidence bled by Left Ventricular Outflow Tract

40 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009


Impact of Myo-splint® buttons on ventricular radius
R
Where R > r
The Myo-splint®
Obstruction (LVOTO). Relief of this
obstruction leads to improvement of
cardiac output and prognosis. This is of
course not an example of reverse remodel-
ling surgery but ameliorative surgery as
the driving force for ventricular remodel-
ling is genetic.
Outline of procedure: Direct de-bulking
of a LVOTO can be undertaken by open
heart surgery or alcohol injection of the
first septal artery.
Efficacy & Safety: Echocardiographic
evidence suggests that both direct surgi-
cal resection and alcohol injection are
effective at relieving LVOTO in HCM.
However, of the two approaches surgery
appears to be more effective. Ommen
and colleagues 4 through retrospective
review demonstrated that surgical resec-
tion of LVOTO restored survival to that
r is crucial for successful treatment. This
Figure 4
Figure 5
of individuals unaffected by HCM.
Level of evidence: B
Recommendation: IIa
2) Surgical strategies to reduce left
ventricular size (La Place surgery):
The myo-splint: Ventricular diameter is
reduced by a series of trans ventricular
buttons placed across the short axis of
the ventricle. This tends to produce a
figure of eight cross section to the ventricle
producing a reduction of internal radius
(Figure 4).
Outline of procedure: The aim of this
operation is to reduce wall stress using
the La Place principle and so improve
ventricular function. Targeted patients
are those with heart failure resistance or
intolerance of medical therapy.
Efficacy & Safety: McCarthy and
Surgical speciality
colleagues reported benefit in a canine
model with improvement in ejection
fraction, ventricular volumes and wall
stress. There are reports of clinical work
in 20015 concluding that careful patient
selection with maintained medical therapy
has fallen out of clinical practice.
Evidence: Level C ACC / AHA
recommendation: IIb.
The Acorn CorCap device: Pfeffer and
Braunwald described progressive ventricu-
lar dysfunction leading to congestive
cardiac failure after myocardial infarction.
Five years later Kass’s group 6 concluded
that dynamic myoplasty (see below) was
probably nothing more than a sympathetic
cardiac constraint limiting further dilata-
tion of a damaged heart. Probably from
these observations came the CorCap, a
polypropylene mesh designed to be placed
about the ventricles at open operation.
Outline of the procedure: There is evidence
from animal models that passive constraint
improves left ventricular geometry and
myocardial stresses after myocardial infarc-
tion. The aim is to constrain the failing
and dilating left ventricle in patients with
NYHA class III or less. Clearly no imme-
diate benefit is offered by this cardiac
device and requires an operation with
all the hazards of surgery in those with
compromised heart function.
Efficacy & safety: A randomised study
including 300 heart failure patients was
reported to the AHA in 2004. Those
receiving a CorCap device appeared to
fare better than those without. There was
a significant reduction in left ventricular
end-diastolic and end-systolic volumes
with an improvement in quality of life.
This, unfortunately did not translate
into a reduction in mortality or hospital
readmissions for heart failure.
Evidence: Level B and AHA/ACC
recommendation level IIb.
Partial left ventricular resection: In contrast
to scar resections of damaged left ventri-
cles (see below) this procedure requires
the prescribed removal of muscle between
www.asianhhm.com 41
42 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
www.asianhhm.com 43
Surgical speciality

dom from death or transplant listing of

56 per cent. This compares poorly with
The CorCap® the results of heart transplantation. There
are few if any centres undertaking this
surgery now.

Level of evidence: Level B and AHA

/ ACC recommendation III.
Left ventricular aneurysmectomy (ventricular
scar resection): The aim of left ventricular
aneurysmectomy is to reduce an enlarged
ventricular volume and to reverse the
forces driving further ventricular remod-
elling (where dilating force is increased
wall tension through enlarging ventricular
diameter: equation 4 above). As with the
Batista procedure, a dyskinetic segment of
ventricle is removed reducing ventricular
Figure 6 diameter and so reducing ventricular wall
tension. However the segment removed
Cumulative survivals after resection of ventricular scar (Dor et al.) here is scar and not ventricular muscle.
Initially simple excision of post myocardial
100
infarction scar followed by ventricular
90 plication was undertaken. This produced
80 distortion of ventricular geometry led
70 Jatene to recommend an encircling stitch
Cumulative Survival

60 about the aneurysm neck, and Cooley

50
and Dor independently to recommend
a patch to the remaining defect. The aim
40
was to restore a more ’normal’ ventricular
30 geometry
20 Diskontic Outline of procedure: Patients with left
10 Akinetic ventricular scar and no evidence of hiber-
0 nating myocardium and who have symp-
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 toms of heart failure, angina or ventricular
Months Figure 7 arrhythmias are candidates for this surgery.
On cardio-pulmonary bypass the scar
anterior and posterior papillary muscles in guided by the arithmetic relationship is opened. If scarred or aneurysmal the
dilating, failing left ventricle. This proce- between circumference and diameter septum is plicated from within the left
dure was developed in Brazil almost two (where circumference = π. Diameter and cavity. The ’neck’ or edge of the scar is
decades ago by Batista. Its intention was to π = 3.142). Each 3cms of circumference then identified and an encircling stitch
offer a surgical solution for patients with resected by the surgeon is equivalent to placed about it. This is tied, reducing the
heart failure symptoms in the context of a 1cm reduction of ventricular diame- enlarged ventricular cavity. The remain-
dilating cardiomyopathy and specifically ter. This is often combined with mitral ing defect is then patched with synthetic
Chaga’s disease. surgery. material. The exteriorised scar edges are
Outline of procedure: The aim is to normal- Efficacy & Safety: Reports have demon- finally closed over the repair. Cryotherapy
ise cardiac volume/mass ratio, so reducing strated a reduction in LV end diastolic may be applied to the myocardial edge
LV volume, LV wall stress and improving and systolic volumes, an improvement of this repair in an attempt to abolish
systolic function. This surgery is usually in ejection fraction, cardiac index and ventricular arrhythmias should they be
carried out on cardio-pulmonary bypass stroke volume. Unfortunately death is present.
but has been reported to having been a frequent complication. Dowling and Efficacy & Safety: Dor and colleagues
completed off bypass. The surgeon is colleagues 8 reported a 12 month free- reported 9 their experience of resections of

44 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Surgical speciality

that survival was much the same as that

End diastolic ventricular volumes before, early after and late (12 months) following heart transplantation. This is
after left ventricular aneurysmectomy with linear closure, septal remodelling perhaps a little bit optimistic as recent
or endo-ventricular patch plasty (endoVP) reports suggest no difference in outcomes
for MR patient who have had or not
Technique EDV (mls)
had mitral surgery. Recent work suggests
pre early post late post
reasonable results from co-aption of papil-
linear 189 ± 25 143 ± 291 165 ± 24 lary muscle with attention being directed
septal 199 ± 36 150 ± 27 170 ± 26 towards the dilating ventricle which is
endoVP 251 ± 64 174 ± 32 187 ±27 probably the primary cause of this form
of mitral regurgitation.
Table 5

Survival after mitral repair in heart failure Bolling et al Level of evidence: Evidence level C
and AHA/ACC recommendation IIb.
1.0
C. Surgical strategies to re-power the failing
0.9 heart
0.8 i. mechanical support:
0.7 a. CRT (cardiac resynchronisation
0.6 therapy): Bi-ventricular pacing is consid-
Survival

0.5 ered when there is evidence of a lack of

0.4
0.3
0.2
0.1
0.0
0 12
’akinetic’ (without movement) and dyski-
netic (paradoxical movement) ventricular
scar resections with followed up over 9
years (Figure 7). Survival of those with
akinetic scar was worse than heart trans-
plantation at 5 years. Worryingly, further
work by Marchenko and colleagues
(Table 5) describes a trend of re-dilata-
tion of the left ventricle with time. This
appeared to complicate all 3 surgical
different approaches to aneurismal scar
resection. The STITCH trial has recently
ben reported at American College of
Cardiology in Orlando (2009). Although
results are not yet in print there appears
to be no benefit in survival, quality of
life or hospital stay to date.
Level of evidence: B and AHA / ACC
recommendation III.
Mitral repair for secondary mitral regurgita-
tion: It seems counter-intuitive to repair
the secondarily regurgitant mitral valve
(MR) in the face of poor left vetricular
24 36 48 60
Months Figure 8
function. It would seem that this action
shuts off retrograde flow, effectively rais-
ing the after-load to the failing heart, so
worsening failure.
Outline of procedure: However MR with
poor left ventricular function is associated
with a dilated annulus and a tendency
for the leaflets to be splinted open by
their chordal attachments, as the ventri-
cle dilates and becomes more sphericle.
These mechanisms are added to in the
case of ischaemia by papillary rupture,
ischemia or fibrosis.
Efficacy & Safety: Bolling and colleagues
10 reported a series of patients with severe
MR, ejection fractions of 8 per cent – 15
per cent and NHYA status of III – IV in
whom mitral valve repair was performed.
Heart failure symptoms reduced signifi-
cantly, ejection fraction increased and
both LV diastolic and systolic volumes
fell with a reduction in ‘sphericity’ of
the heart. Survival of these patients is
shown in Figure 9. The authors suggested
synchronous inter-ventricular contraction
eg: bundle branch block.
Outline of procedure: Pacing leads are
positioned directly within the right
ventriclar cavity and onto the left ventri-
cle through the coronary venous system.
Simultaneous stimulation re-introduces
co-ordination of Right (RV) and Left
Ventricular (LV) contraction. This ther-
apy is directed towards patients who have
had heart failure for at least 6 weeks and
who are in NYHA class III or IV despite
standard pharmacological therapy and
who have a reduced LV ejection fraction
(≤ 35 per cent) and a QRS on ECG of
> 120msecs.
Efficacy & Safety: CRT has been shown
to result in reduced inter-ventricu-
lar mechanical delay, an increased LV
ejection fraction, reduce mortality and
improved NYHA class. In addition
improvement of symptoms and qual-
ity of life have been reported
Level of evidence: Level of evidence
A and ACC/AHA recommendation I.
b. Ventricular Assist Devices (VAD):
The intention here is to off load the fail-
ing heart. This is achieved by the unload-
ing of blood from the ventricle and its
delivery into the arterial tree (pulmonary
for right ventricular assist or RVAD and

www.asianhhm.com 45
Surgical speciality

systemic for left or LVAD) by a ventricu- A display of various ventricular assist devices
lar parallel pump. Both left and right
ventricles may be supported simultane-
ously with BiVADs. Total excision of a
2
failing heart is occasionally undertaken 1 3
followed by replacement with an artificial
heart (Cardiowest, Abiocor) made up of
a mechanical replacement for both of
the heart’s ventricles. Ventricular assist
devices may be continuous in flow or
4 5
pulsatile and there is currently little to
discriminate between them, save to say
that pulsatile pumps are larger. Pumps
may be placed within the body or lie
outside being connected to the heart 1 and 2. temporary percutaneous continuous flow trans aortic valve VAD : Implella 3. Diagram
by pipes that cross the skin (para-copo- illustrating pulsatile BiVAD Thoratec devices. 4. Total artificial heart (pulsatile: Abiocor)
real). There is a risk of deposition of 5. Chest X ray illustrating Heartmate I as a pulsatile LVAD with ICD in place Figure 9
blood elements onto the inner lining of
pumps or their connecting tubes. This
Destination therapy (chronic VAD) compared to maximum
pseudo-intima may be responsible for the medical therapy: REMATCH study
generation of “cross-match antibodies”
that are sometimes found with VADs.
They may also act as a source of systemic
emboli, a particular problem of mechani-
cal heart pumps.
Outline of procedure: Generally a poten-
Percent Survival

tial VAD candidate presents with severe,

refractory heart failure with deteriora-
tion despite intensive medical therapy.
VADs are selected and may be tempo-
rary or long–term. Some are designed
for per cutaneous insertion into the
systemic arterial tree lying across the
aortic valve (Impella). More usually
VADs are inserted through a sternotomy
under general anaesthetic. It is possible
to place some devices without the use of
cardio-pulmonary bypass (eg: Levitronix).
Patients are often mortally ill with multi-
system dysfunction. Bleeding, control of
vascular resistance and multi-organ failure
are early problems and soon replaced by
risks of infection and thrombo-embolism.
Individuals are bridged to transplanta-
tion safely by the VAD. Interestingly
more and more patients (often those
with a short but aggressive history of
failure or myocarditis) have been found
to recover so much so that the VAD can
be removed and heart transplantation
avoided (bridge to recovery).
There is interest in the role of perma-
Months Post Enrollment
nent mechanical support for heart failure,
usually in patients in-eligible for trans-
plantation. Such chronic support is grimly
termed ’destination therapy’. REMATCH
was a land-mark CRT exploring the
efficacy of destination therapy. Survival
with a VAD was significantly better than
maximum medical therapy at both 1 and
2 years (Figure 10).
Efficacy & Safety: Mechanical support is
carried out in very sick patients and has a
substantial attendant mortality of 25 per
cent or so for LVAD and 40 per cent for
BiVAD. Infection is common but appears
to be less so for small, electrical implant-
Figure 10
able devices with lengthily sub-cutaneous,
tunnelled, trans-cutaneous cables. There
is no totally implantable VAD currently
because of problems with energy delivery.
As a result power cables must cross the
skin for all devices. Thrombo-embolic
events are common despite anticoagula-
tion and are most common early after
placement. Haemolysis is often seen and
is more likely with BiVAD with renal
support. Right-sided failure is often seen
with LVADs and is usually an early post-
operative event. Equally daunting to these
profound complications is the cost of
devices. Recent work suggests that this

46 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Surgical speciality

may be as high as £50,000 for each quality

adjusted life year gained. It is probably Dynamic cardiac
fair to say that there is still no perfect myo-plasty
device available to deliver a satisfactory
long-term outcome. Latissimus Dorsi muscle
wrapped about failing heart
Level of evidence: Level B AHA/ACC
recommendation I
Failing heart
ii. Biological:
a. Dynamic cardiac myo-plasty: The
intention here is to re-power the fail-
Latissimus Dorsi pacing lead
ing heart using autologous skeletal
muscle.
Outline of procedure: Skeletal muscle
(Latissimus Dorsi muscle) is mobilised
on its neuro-vascular pedicle and brought Figure 11
into the chest through a small thora-
cotomy (Figure 11) and wrapped about
the heart to deliver increased muscle bulk Survival of patient with cardiac myoplasty (DCMP)
to add power to ventricular contraction, and chronic heart failure (Reference patients)
improving systolic function. It is continu-
ously paced in order to transform fast
100%
twitch muscle to slow twitch (Salmons
and Streeter) and secondly to synchronise
80%
the skeletal wrap contraction with cardiac (41)
Actuaarial Survival

contraction. The patient group targeted (10)

are those in heart failure but who do
not have NYHA IV, mitral regurgitation,
atrial fibrillation, pulmonary wedge pres-
sure > 25mmHg, ejection fraction <12 per
cent, multi-vessel coronary artery disease
and peak oxygen consumption <10 mls/
Kg/min. as poor surgical outcomes have
been reported in these groups.
Efficacy & Safety: Despite promising
animal work improvement in systolic
function in patients has been inconsistent.
However some improvement in load inde-
pendent measures (Kass) of diastole have
been described. This procedure is rarely
undertaken now. Figure 11 contrasts the
survival of 68 skeletal myoplasty patients
to a matched group of 58 patients with
chronic heart failure.
Evidence: Level of evidence B and
AHA/ACC recommendation IIb.
b. Heart transplantation: The replace-
ment of the failing human heart by a
’normal donor heart’ appears a little
extreme. But since its introduction by
Barnard in South Africa in 1967 it is
60%
40%
DCMP Patients (N=68)
20%
Referance Patients (N=58)
0%
0 6
regarded as the best that can be done
for patients with severe, refractory heart
failure (AHA/ACC stage D). Heart
transplant activity is dictated by donor
heart availability and can be seen to be in
decline World-wide since a peak of just
under 4,500 procedures in 1994.
The insertion of several hundred
grams of foreign protein by transplanting
a human heart excites a rejection response.
As a result the patient is dependent upon
life-long immune suppression.
Outline of procedure: The recipient is
selected to avoid significant secondary
complications that may arise through
(16)
(21)
(26)
12 18 24
Months
Figure 12
immuno-suppression. Therefore patients
with a recent history of malignancy or
persistent acute or chronic infection
are excluded. There is evidence that the
donor hearts manage poorly in the face of
moderate pulmonary vascular hyperten-
sion. A right heart study defines the size
of the trans-pumonary pressure gradient
(TPPG = mean pulmonary artery pres-
sure—mean pulmonary wedge pressure).
Patients are required to have a TPPG of
14mm Hg. or less. Rarely are patients
selected with significant co-morbidity
and consequently heart plus other solid
organ transplantation is unusual.

www.asianhhm.com 47
Surgical speciality

Level of evidence: Level B and AHA /

Changes in heart transplant activity and donor age ACC recommendation I.
South America
c. Cellular transplantation: The concept
4500 of re-powering the failing ventricle by
North America
4000 Europe cellular transplantation has attracted a
Australia / Ocean great deal of attention. It requires that
3500
Asia
the new cells will:
3000 Africa
• be retained within the tissue into which
2500
they have been injected.
2000 • engage as part of the cardiac syncy-
1500 tium.
1000 • differentiate into myoblasts.
• lead to an improvement of contrac-
500
tion.
0 • improve the outcome for the recipi-
1982

1984

1986

1988

1990

1992

1994

1996

1998

2000
Figure 13 ent.
Outline of procedure: Stem cells, be they
the pleuri-potent cells of bone marrow,
Actuarial survival after heart transplantation (ISHLT registry 2005) adipose tissue, skeletal muscle or embryo
100 are injected into the myocardium where
they are expected to grow. This injection
80 is either via the coronary arterial system
or directly into the myocardium.
Survival (%)

60 Efficacy & Safety: Results in the laboratory

40
20
0 with a region of poor ventricular func-
0 1 2 3
The donor organ is reviewed
by the donor team and its function
assessed by pulmonary artery catheter
or echo-cardiography. If satisfactory
it is subjected to cold diastolic arrest
and excised before being transported
to the recipient hospital in cold saline.
Donor to recipient matching is made
by blood group (according to the rules
of transfusion) and body size (either
height or weight). The recipient heart
is removed and replaced by suturing
at mid left and right atrial and mid
pulmonary and aortic arterial levels on
Cardio-Pulmonary Bypass (CPB). The
new heart is usually capable of support-
ing the recipient after 30 minutes of
reperfusion.
Efficacy & Safety: Survival with the
diagnosis of severe refractory heart
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Years Figure 14
failure is appalling. The REMATCH
study demonstrated 28 per cent one
year survival falling to eight per cent at
two years in medically managed patients
with severe refractory heart failure. The
ISHLT registry (Figure13) of survival
after heart transplantation compares well
to this natural history with an overall
half-life after heart transplantation of
11 years.
Additionally, many studies have
demonstrated quality of life of heart
transplant recipients to be good.
However there are persisting concerns
with personal appearance and sexual
dysfunction. Surprisingly there have
been no prospective randomised trials
exploring the position of heart transplan-
tation in the management of patients
with class D heart failure.
have been encouraging with a suggestion
of improvement in heart function. Skeletal
myoblasts have been harvested from the
quadriceps muscle in a series of patients
tion and who were expecting coronary
artery bypass surgery. Autologous skeletal
myoblasts were isolated and expanded
in numbers by cell culture. Using this
approach in a recent prospective, blinded
randomised clinical trial (MAGIC study)
patients received transport medium, low
concentration or high concentration
suspension of autologous skeletal myob-
lasts as a series of injections into the area
of poor ventricular function. This trial
failed at interim analysis and has been
suspended. A further 60 patients, five
days after trans-mural myocardial infarc-
tion received autologous bone marrow
cells at the time of angioplasty. There
was a suggestion of small but significant
improvement in ventricular function.
Level of evidence: Level B – C and
ACC / AHA recommendation IIb
d. gene therapy: It is very early days
in this arena. The aim appears to be

48 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Surgical speciality

better known for its abuse by athletes, has

The myocardium of a patient with aortic stenosis showing evidence of been reported to increase the likelihood
myoblasts (vital staining: blue) and mitotic activity marked by white arrow.
of recovery in patients being bridged to
Right panel an enlargement of white boxed area in left
transplantation by VAD.
More excitingly, however, is the recent
identification of the human cardiac myob-
last. Recent clinical reports have demon-
strated both cellular hypertrophy and new
myocyte production within the myocar-
dium stressed by aortic stenosis (Figure
14) Level of evidence: Unknown

Concluding remarks
Interventions for heart failure are prolif-
erating as interest in this patient-group
heightens. It is true to say that all heart
surgery can be regarded as Heart Failure
Surgery in the light of the new, sequential
classification of heart failure by the ACC
and AHA. Direct surgical approaches to
Figure 15
reverse remodel the dilated and failing
left ventricle appear to be less success-
Appendix ful at restoring normality than if the
primary ventricular remodelling insult
A. Level of evidence: can be identified and removed. Where
a. Data are derived from multiple randomised clinical trials or meta-analysis.
such approaches are not possible due to
an advanced state of heart failure the
b. Data are derived from a single randomised trial or non randomised studies.
results of heart transplantation remain
c. Only consensus opinion of experts, case studies, or standard of care.
impressive, now 40 years after its intro-
duction. Despite concerns over donor
B. Levels of recommendations (ACC / AHA) heart supply for transplantation the future
Class 1: Conditions for which there is evidence and / or general agreement that a given in this area is encouraging following the
procedure / therapy is beneficial, useful, and / or effective
recent identification of a possible inter-
Class II: Conditions for which there is conflicting evidence and / or a divergence of
opinion about the usefulness / efficacy of a procedure / therapy. nal recovery system through the human
cardiac myoblast. Perhaps it is not too
IIa: Weight of evidence / opinion is in favour of usefulness / efficacy
romantic to imagine a future time when
IIb: Usefulness / efficacy is less well established by evidence / opinion
temporary mechanical support allows for
Class III: Condition for which there is evidence and / or general agreement that a
procedure / therapy is not useful / effective and in some cases may be harmful.
a failing heart to be re-powered by up-
regulated autologous-myocyte production;
cells bourn into the syncytium and able
up-regulation of biochemical pathways would result in improved power produc- to contract?
by gene delivery. tion by the heart is of current interest.
Outline of procedure: There is some For example, Clenbutarol, an anabolic References are available at
animal work to suggest that up-regu- steroid with β agonist properties, perhaps http://www.asianhhm.com/magazine
lation of SERCA (Sarco/Endoplasmic
Reticulum Ca2+-ATPase) through adeno-
virus vecta may increase the likelihood Stephen Large is full-time cardiac surgeon in Cambridge University’s
A uthor

of recovery of ventricular function Papworth Hospital. His interests have focussed on various aspects
of the failing heart. Apart from this his professional interests lie in
with mechanical ventricular support. medical education and hospital management. He did his MBA from
Level of evidence: Unknown the Open University. Stephen’s research interests have generated
e. Up-regulation of natural pathways: some 220 papers to date. He enjoys drawing, walking and ski-ing!
Promotion of intrinsic pathways that

www.asianhhm.com 49
Diagnostics

Three-dimensional
Transesophageal
Echocardiography
Early experiences

M
Imaging, especially echocardiography, plays a key inimally invasive catheter-
role in structural, congenital and valvular heart disease based treatment of struc-
interventions; not only for the evaluation of the disease tural, congenital and valvular
and selection of eligible patients, but also for guidance heart disease is a rapidly growing field.
Imaging plays a key role in the guidance
of the procedures and in follow-up examinations. of these procedures. As a result there
Live 3D echocardiography has recently added new has been considerable advancement in
dimensions by providing new views which help to image guidance technology.
get a better idea of the 3D character of the defect. Echocardiography fulfils the needs
by providing real-time imaging, thus
Nina Wunderlich
reducing the dose of ionizing radiation.
Director It is cost-effective, widely used and most
Department of Cardiology interventionalists are very familiar with
CardioVascular Center Frankfurt, Germany this imaging format.
Neil Wilson In the past, percutaneous interven-
Director
Department of Paediatric Cardiology
tions were guided by 2D Transesophageal
John Radcliffe Hospital, Oxford, UK Echocardiography (TEE) in addition to
Jennifer Franke fluoroscopy in most catheter laborato-
Fellow ries. 2D TEE, however, has limitations
Department of Cardiology due to merely two spatial dimensions.
University of Heidelberg, Germany
In most cases it is possible to get an idea
Horst Sievert of the 3D character of the structures,
Director
Department of Cardiology but not in one single view.
CardioVascular Center Frankfurt, Germany Recently, a new generation of TEE
probes with a novel matrix array tech-
nique was introduced that allowed three-
dimensional visualisation of cardiac
structures in real time thus overcoming
some of the major limitations of 2D
TEE. The pathomorphology of defects,
surrounding structures, catheters and
devices can be visualised quickly and

50 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009


accurately while presenting the 3D
character in one single view.
Our first experiences with this new
technique in the guidance of percutane-
ous cardiac interventions using a matrix
array 3D TEE probe (X7-2t, Philips
Medical Systems) connected to a 3D-
capable echocardiographic system (iE33,
Philips Medical Systems) are discussed
below.
Clinical applications
Closure of Patent Foramen Ovale (PFO)
Percutaneous PFO closure was first
performed by Bridges et al. in 1992.
Transcatheter closure of PFO has become
a routine procedure for patients suffer-
ing from cryptogenic stroke with low
complication and recurrence rates.
Multiplanar 2D TEE is widely used
as an imaging technique for guidance of
procedures in most centres worldwide.
However, it has limitations—wires, cath-
eters and devices cannot be fully imaged
in relation to the surrounding structures.
With 2D TEE, scanning of several views
is necessary to mentally reconstruct the
3D anatomy. 3D TEE provides three-
dimensional spatial orientation in one
view allowing monitoring of the entire
procedure with excellent imaging quality.
3D perspectives enable monitoring of
all steps of the intervention—from the
passage of the guide wire and delivery
catheter through the PFO to the final
assessment before device release.
The following figures illustrate that
guiding of a PFO closure procedure
with 3D TEE is feasible.
Figure 1a demonstrates the passage
of the guidewire through the PFO track.
The wire stretches the PFO tunnel and
the tenting of the channel within the
interatrial septum is clearly visualised.
Figure 1b shows the sizing balloon in
the left atrium. We perform balloon
sizing of all defects because the size of
the PFO is unpredictable in TEE. After
balloon sizing the specific introducer
sheath is advanced. In Figure 1c, cross-
ing the PFO with the delivery sheath is
shown. Figure 1d shows an Amplatzer
occluder with both atrial discs deployed.
Before device release the correct and
secure position of the occluder has to
be ascertained. One single 3D perspec-
tive shows the correct device position,
which is a major advantage of real-time
3D TEE. After placing the device in
the right position, it can be released
as demonstrated in Figure 1e which
gives an en-face view from the left
atrial side.
Figure 2 shows a complication. The
patient had a large atrial septum aneu-
rysm. First a 25-mm Amplatzer PFO
occluder was implanted. Figure 2a shows
a 2D TEE image of the entire occluder
being slipped into the PFO tunnel.
Figure 2b shows the same situation with
an en-face 3D view of the left side of
the atrial septum where both atrial discs
can easily be identified on the left atrial
side. This occluder was retrieved and
replaced by a 30-mm Amplatzer PFO
occluder. On this occasion, the septum
secundum is embraced adequately by
both discs. This is shown in Figure 2c
with 2D TEE imaging. Figure 2d shows
the same with 3D TEE imaging where
a single disc can be visualised on the
left atrial side. Conventional 2D TEE
(Figure 2a, c) enables the assessment of
Diagnostics
appropriate device position but requires
scanning of several image planes. In
contrast, 3D TEE offers exact visuali-
sation of the device position and its
relations to the interatrial septum in
one single view.
Closure of Atrial Septal Defects (ASD)
Since the first transcatheter closure of an
ASD by King and Mills in 1976, device
closure of ASD has become an alterna-
tive to surgical closure. Normally, 2D
TEE is used in combination with fluor-
oscopy to monitor the interventional
procedure, but due to the limitations of
2D TEE it is difficult to obtain optimal
visualisation of the complex anatomy
of ASDs. The dynamic variations of the
defects are insufficiently appreciated by
2D TEE. 3D TEE provides en-face views
of the interatrial septum and therefore
can clearly identify the morphology
of the defect as well as its relation to
surrounding structures, which cannot
be achieved with any other available
imaging technology.
The following examples demonstrate
that 3D TEE guidance of ASD closure
procedures is feasible and helpful. Figure
3a shows a 3D TEE stop-frame image
of the ASD displaying an en-face view
from the left atrium. This view allows an
Monitoring of
PFO closure
(PFO Patent Forament Ovale
LA Left Atrium
IAS Interaitrial Septum
RA Right Atrium)
Figure 1
www.asianhhm.com 51
Diagnostics
assessment of the complete circumfer-
ence of the ASD. The size, shape and
rim of the defect can be judged in this
single view. The exchange wire is passing
through the ASD. Figure 3b shows the
positioning of the delivery sheath. Figure
3c shows the delivered left atrial disc
and the pull-back towards the interatrial
septum. It is also possible to close multi-
ple defects in one procedure. In Figure 4,
Monitoring of a mitral
valvuloplasty
(LA Left atrium
LV left ventrucle)
52 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Monitoring of a
complication in a
PFO closure procedure
RA Right Atrium
LA Left Atrium
Figure 2
an example of a patient with two defects
is shown. Preferably, the smaller defect is
closed first followed by the second, the
larger defect. In Figure 4a, we see two
Amplatzer occluders; the smaller one
is positioned in a more caudal located
defect. This occluder is sandwiched by
the larger Amplatzer occluder located
in the more cranial defect which covers
the larger ASD. 3D TEE shows in one
image that both occluders
are positioned correctly in
relation to each other and
to the interatrial septum.
Figure 4b illustrates the
final result in an en-face
view from the left atrial
side.
Mitral valve
procedures
3D TEE provides en-face
views of the mitral valve
from the left atrial and
left ventricular aspects.
This allows a detailed
assessment of the mitral
valve anatomy. Ring size,
precise valve morphology
and pathomorphology of
leaflets such as prolapse
can be visualised clearly
which is extremely help-
Figure 3
ISSUe - 20 2009
ful in assessing the mitral valve before
and during interventional and surgi-
cal procedures. Eligible patients for
specific mitral valve procedures can
be identified more accurately and the
likelihood of procedural success is more
predictable.
Since its introduction by Inoue et
al. in 1984, percutaneous mitral comis-
surotomy (PMC) has been successfully
and safely performed in large series of
patients at numerous centres.
Our experience shows that it is feasi-
ble to monitor balloon mitral valvu-
loplasty with 3D TEE. By receiving
a three-dimensional impression of the
valve, less favourable anatomy such as
valve calcification, severe subvalvular
disease, echocardiographic score, can
be assessed accurately. The procedure
described was performed in a 42-year old
patient with history of rheumatic fever.
Figure 5a shows the valve anatomy with
typically thickened leaflets. There was
no severe calcification and no subvalvu-
lar disease. In Figure 5b, the thickened
leaflets and the narrowed mitral valve
area is clearly visualised in an en-face
view from the left atrium. The Inoue
balloon is positioned in the left atrium
before passing the mitral valve. Figure
5c demonstrates the correct position
of the inflated Inoue balloon in the
stenotic mitral valve.
For patients who suffer from mitral
valve regurgitation, a percutaneous non-
surgical repair with the MitraClip® can
be an option. Results from studies so far
show that the MitraClip® can provide
successful reduction of mitral regurgi-
tation. Furthermore, the studies have
shown that with resumption of proper
valve function improved left ventricular
remodelling significantly during 12-
month follow-up.
Evalve has developed catheter-based
technology, which, by apposing the edges
of a regurgitant mitral valve, results in
edge-to edge repair .The MitraClip®
grasps affected parts of the anterior and
posterior leaflet similar to the Alfieri
surgical procedure. The challenge of

the technique is to position the Clip
perpendicularly to the coaptation line
of the mitral leaflets in the area of the
affected parts of the leaflets. The inten-
tion is not to favour one side of the
created two mitral orifices. Figure 6a
shows the procedural outcome from the
left atrial side. The leaflets are grasped
in the middle (A2 and P2 parts) of the
anterior and posterior leaflet and the
two created mitral orifices have a similar
size which is a good result. In Figure 6b,
the Clip can be identified from the left
ventricular side. Patient mitral regurgi-
tation declined from grade IV to grade
II after the procedure.
Paravalvular mitral leak closure
Valve replacement surgery is the second
commonest cardiothoracic operation
after coronary artery bypass grafting. A
potential sequel to surgery is the devel-
opment of a paravalvular leak due to
incomplete apposition of the sewing ring
to the native tissue. This may be a conse-
quence of suture dehiscence. Detection
has increased as a result of improved
techniques, particularly transesophageal
echocardiography. Percutaneous tran-
scatheter closure techniques have also
been applied to paravalvular leaks. A
routine TEE may document the pres-
ence and severity of regurgitation but is
often not sufficient to assess the accurate
location of the defect, the exact size
and shape of the defect, course of the
leak and hence, less chances of success-
ful percutaneous repair. The irregular
three-dimensional structure of these
defects has to be taken into account
and this cannot be imaged entirely by
2D TEE. Thus, guidance of paravalvular
Multiple
ASD closure
(RA Right atrium)
Figure 4
leak closure is very challenging even
for experienced echocardiographers
and interventionalists. If the defect
itself cannot be adequately visualised
echocardiographically, percutaneous
closure is less likely to be successful.
3D TEE is able to provide an en-face
view of the mitral valve which allows
complete and adequate assessment of the
three-dimensional character of paraval-
vular leaks. This information is crucial
particularly for the determination of the
technique and choice of device size and
shape. The following 3D TEE images
of a paravalvular closure procedure
emphasise these facts.
Figure 7 shows the example of a 51-
year old woman who had a mechanical
mitral valve replacement (SJM 29 mm)
because of severe mitral regurgitation
after a bout of endocarditis. A few
months later she developed severe mitral
regurgitation due to a paravalvular leak.
Figure 7a shows a very clear image of
the size and the oval shape of an ante-
rior-medial located paravalvular leak.
A 14/5 mm Amplatzer-Vascular-Plug
III occluder (AVPIII) was implanted.
This device is especially designed for
paravalvular leak closure and has an oval
shape. Figure 7b demonstrates that the
device can be identified very easily, and
Diagnostics
the 3D image shows the exact position-
ing of the device perpendicular to the
defect. This could not be seen with 2D
TEE. The final position of the device
where the occluder is now properly
aligned to the defect can be seen in
Figure 7c. This example underlines the
enormous potential benefit 3D TEE
can provide with a better outcome for
the patient.
Percutaneous Aortic valve
replacement
Degenerative aortic valve disease is the
most common valvular heart disease
and its prevalence increases with age.
The morbidity and mortality of surgical
aortic valve replacement is increased in
elderly patients with multiple high-risk
comorbidity.
Percutaneous aortic valve replace-
ment has become an alternative thera-
peutic option to surgical valve replace-
ment in selected elderly patients with an
unacceptably high risk of surgery. Early
improvement in left ventricular ejection
fraction and mitral regurgitation follow-
ing pecutaneous aortic valve implan-
tation has been reported. Recently, it
has been shown that echocardiography
is important in case selection, guid-
ing valve placement and in detecting
complications during and after the
procedure.
Figure 8 shows an example of an
82-year old woman with a severe symp-
tomatic aortic stenosis. Figure 8a shows
the aortic valve in a short axis 2D TEE
view and Figure 8b the correspond-
ing 3D TEE image, giving a spatial
impression of the aortic valve and its
surrounding structures. Figure 8c show
Monitoring of a
miral valvu repair
procedure with
the MitraClip
device
(LA Left atrium
LV left ventrucle)
Figure 5
www.asianhhm.com 53
Diagnostics
Monitoring of
paravavular leak
closure
(LA Left atrium)
the partially deployed valve in 2D TEE
and Figure 8d the completely deliber-
ated valve in 3D TEE imaging.
It provides a clear three-dimensional
view of the aortic valve, the LVOT and
its surrounding structures. The relation
of the anterior leaflet of the mitral valve
to the LVOT can be imaged particularly
well. This is of major importance for the
final positioning of the self-expandable
CoreValve® prosthesis to ensure that the
movement of the anterior mitral leaflet
is not constrained.
As the technical aspects and clinical
understanding of this technique continue
to evolve, echocardiography and espe-
cially 3D TEE will have a crucial role in
the future development of the treatment
of aortic valve disease.
Left Atrial Appendage closure
(LAA)
The left atrial appendage is the most
common source of cardiac thrombus
formation in patients with atrial fibril-
lation. More than 90 per cent of all
cardiac thrombi in patients with non-
rheumatic atrial fibrillation forming
in the left atrium originate in the left
atrial appendage. Occluding the left atrial
54 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
appendage would, there-
fore, seem to be a logical
approach to minimise the
risk of thrombus formation
and subsequent embolisa-
tion. Surgical attempts at
left atrial appendage closure
have drawn interest towards
percutaneous interventional
techniques and led to the
development of devices
specifically for this purpose.
The earliest device, the
percutaneous Left Atrial
Appendage Occluder
(PLAATO) [36] is no longer
available. The Watchman
Left Atrial Appendage
System and most recently,
the Amplatzer cardiac plug
(ACPIII) are currently in
Figure 6
clinical use.
To determine eligible patients for
the procedure and for device selection
measurements of the LAA orifice and
the LAA length are of major importance.
Using 2D TEE, several views have to
be scanned to get an idea of the size
and shape of the LAA orifice. 3D TEE
enables us to get an en-face view of the
LAA orifice which allows us to clearly
identify the correct dimensions in one
Monitoring of percutaneous aortic
valve implantation (CorelValve prosthesis)
LA left atrium
LV left ventriole
Ao asc Aorta ascendens
MV Mitral valve
ISSUe - 20 2009
view. Figure 9 demonstrates the guid-
ance of a LAA occlusion procedure with
a Watchman device in a patient with
permanent atrial fibrillation. Figure 9a
shows the LAA which is examined for
thrombi before the procedure. Figure
9b provides an en-face view of the LAA
orifice and the left upper pulmonary
vein which is a unique view only avail-
able with 3D TEE. Figure 9c shows
the guidewire being advanced into the
LAA and Figure 9d shows the plac-
ing of the delivery sheath in the LAA.
Figure 9e shows the final position of
the Watchman device. Fixation barbs
around the mid-perimeter engage the
occluder to the wall of the LAA. The
major advantage of 3D TEE in this
procedure is providing the en-face view
of the LAA entrance, which gives a
clear impression of the orifice of the
LAA where the occluder is finally posi-
tioned.
Conclusion
Real-time 3D TEE is a novel tech-
nique to guide cardiac interventions.
We have learned from our early expe-
rience that this new technique adds
previously unavailable anatomical
information of cardiac structures and
defects. Information on the pathomor-
Figure 7
 Diagnostics

Monitoring of
LAA closure
(LAA left atrial
appendage
LA left atrium
LUPV left upper
pulmonary vein)
Figure 8
phology and the relation of defects to This may likely lead to safer and
surrounding structures can be provided shorter procedures with higher techni-
quickly and accurately. High quality cal success, a diminished amount of
real-time 3D TEE imaging with good radiation exposure and therefore lead
spatial and temporal resolution has to better outcomes for the patients,
great potential for guiding interven- which has to be proven in further clini-
tional procedures. cal studies.

Nina Wunderlich is the director of non-invasive Cardiology at the

CardioVascular Center Frankfurt, Sankt Katharinen. Dr. Wunderlich
received her medical degree at the University of Frankfurt, Germany
and completed a fellowship in cardiology. She has been involved in
a number of clinical trials, and has authored peer reviewed medical
publications and book chapters.

Neil Wilson is the director of the department of paediatric cardiol-

ogy at John Radcliffe Hospital, Oxford, United Kingdom and he is
also a Pediatric Cardiologist practicing in the UK.
A uthors

Jennifer Franke is a fellow in cardiology at the University Hospital of

Heidelberg, Germany. She graduated from the University Frankfurt,
Germany and performed her doctorate thesis on Carotid interven-
tions at the CardioVascular Center Frankfurt. She has coordinated
over 20 clinical trials and has been the scientific secretary of the
International Course on Carotid Angioplasty (ICCA).

Horst Sievert is the director of the CardioVascular Center Frankfurt,

Sankt Katharinen, and the Department of Internal Medicine,
Cardiology and Vascular Medicine of the Sankt Katharinen Hospital
in Frankfurt, Germany. He is also an Associate Professor of Internal
Medicine / Cardiology at the University of Frankfurt. Dr. Sievert re-
ceived his medical degree at the University Frankfurt, Germany.

www.asianhhm.com 55
Diagnostics
Molecular Diagnostics and
Personalised Medicine
Present and future
A
Rationally developed cceptance of the personalised
therapies used medicines paradigm is strictly
dependent on this approach
diligently in the
clearly benefiting patients with minimal
healthcare marketplace effects on the actual delivery of health-
can undoubtedly care. The use of molecular diagnostics to
benefit society, and predict how an individual will respond to
the role of good particular medicine, in terms of safety or
effectiveness, offers considerable benefits
quality predictive and
over the current practices of prescribing
diagnostic molecular and monitoring patient responses.
tests is unambiguously
a great advance What’s the present situation?
for pharmaceutical With the increasing number of ‘block-
buster’ drugs, i.e., those individual enti-
medicine.
ties that reach global sales of more than
US$ 1billion per annum, being marketed
Eddie Blair
and prescribed, it has become apparent
Managing Director
Integrated Medicines Ltd, UK that many of these drugs only benefit
part of the intended patient cohort, with
estimates suggesting that overall effective-
ness ranges from 80 per cent to as low
as 20 per cent depending on the disease
area addressed. These observations about
the relative effectiveness of medicines,
equally fuelled by concerns about safety
of medicines, the rising costs of supply-
ing medicines and other macroeconomic
factors affecting healthcare budgets, are
leading to new models of how medi-
cines are prescribed. Such new models
of prescribing increasingly involve health
technology assessments, undertaken by
agencies modelled on the UK National
Institute of Clinical Excellence (NICE)
and now prevalent across Europe and
the US, two of the largest geographic
pharmaceutical markets.
Amongst the many activities of
these agencies, there lies a role in the
56 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
decision-making around reimbursement
for medicines, and indeed the level and
timing of reimbursement. The timing of
reimbursement in particular is interest-
ing and begins to touch on the poten-
tial role of molecular diagnostics in how
medicines are supplied to appropriate
patients. For example, two years ago,
UK NICE ruled that the UK National
Health Service (NHS) should only pay for
a ubiquitin proteasome inhibitor, bort-
ezomib (Velcade) when it had been proven
effective, as measured by the response
of a single validated biomarker, Serum
M Protein (SMP). There is now open
discussion that this model of ‘proven
efficacy preceding reimbursement’ as the
preferred model for regulators, payers and
healthcare providers in all major pharma-
ceutical markets. What this model then
does is to remove the perceptual barrier
that protected the block-buster mentality
and heralds the opportunity for segment-
buster and niche-buster medicines i.e.
medicines based on higher response rates
with minimised side-effects (Figure 1).
The segment-buster opportunity
extends the healthcare tool-kit to include
companion diagnostics and monitoring
tests. Such tests will tend to use tradi-
tional diagnostic technologies based on
protein and/ or small molecule detection,
although the increasing use of molecu-
lar diagnostics in nearer-patients settings
may extend the tool-kit somewhat. The
niche-buster model is predicate upon the
careful definition of the responder popula-
tion during drug development and then
the careful identification of individual
responders in the market place; it is this
 Diagnostics

Migration from blockbuster treatments to high-value that are most likely to respond to specific
targeted treatments medicines, either as individual entities
(cetuximab) or as part of a specific drug
class (EGFR kinase inhibitors). Case
study examples of these types of tests
—predictive tests of safety or effective-
ness—are discussed in Boxes 2 and 3,
by way of illustrating the real value that
these tests offer.

What’s the future situation?

(SAE = Severe Adverse Event; CDx = Companion Diagnostic; PGx = Pharmacogenetics)
predictive role that is a key benefit of
molecular diagnostics in the personalised
medicine offering.
Predictive tests—see Box 1 to under-
stand the differences between prognostic
and predictive tests—are now available
for guiding the metabolic potential of
individuals and the often-linked propen-
sity to suffer serious adverse events, as
well as tests that robustly identify those
The role of molecular diagnostics in the
future delivery of healthcare is not as
simple as guiding the right treatment to
the right patient at the right dose and
at the right time, but also impacts on
health economics by delivery benefit at
the right price. As a general consequence,
the prediction of response and the early
treatment of disease is likely to have a
more favourable outcome on the health
to individuals. This, however, has two
long term effects: firstly, individuals may
be on therapies for considerably longer

www.asianhhm.com 57
Diagnostics
Predictive vs Prognostic Tests
The Genomics Health Oncotype Dx test
commands a substantial and fully re-
imburseable price of about US$ 3,500
because it identifies patients likely to suffer
a relapse and / or metastasis of primary
breast cancer. It is known to have a very high
prognostic value in determining the likelihood
of an individual to experience a particular
outcome, i.e., recurrence-free survival.
The various tests that indicate the
likelihood of an individual responding to
trastizumab (Herceptin) or to imatinib (Gleevec)
are known as predictive tests because the do
predict with reasonable confidence whether
treatment periods and, secondly, indi-
viduals are likely to stay functionally
well for much longer. In terms of health
economics, costs may well switch from
expensive primary, secondary and / or
tertiary care provision, such as hospital
beds, mechanical interventions etc. to the
costs of providing long-term treatments
to many more symptomatically well indi-
58 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
the particular form of breast cancer resent is
likely to be sensitive to treatment. As many of
these tests use relatively simple technologies
to conduct the predictive diagnosis, they do
not command a high reimbursable price,
despite offering high value information.
It is possible for predictive test to also
have prognostic value and vice versa, but
it is the primary application of the test that
determines its real value and positioning.
In addition, such tests may also be used
for response monitoring but generally their
pricing means that alternate platforms will be
used for this purpose.
Box 1
viduals. In fact, the scenario above is one
that many healthcare systems as moving
to; they are supplanting symptom-based
reactive medicine with objective testing-
based predictive medicine. Thus it is clear
that molecular diagnostics tests as guides
to prescribing tailored (or personalised)
medicines have an impact way beyond
the current scenarios described in Figure
ISSUe - 20 2009
1. Indeed, the use of molecular testing
to offer better medicines at earlier times
with more favourable outcomes may well
have longer term effects on societies as
a whole.
Many healthcare commentators,
particularly those with a predilection
for the problems of the pharmaceutical
industry, can get very preoccupied by
issues such as dry development pipelines,
inexorably increasing costs for medicines
R&D and the difficulties in getting
medicines approved and reimbursed at
an economically fair rate. However, the
real challenges for the future of health-
care are readily summed up by two
words—‘aging populations’. In almost
all countries globally, life expectancy
is increasing—driven in part by basics
such as clean water, better sanitation and
plentiful food supplies—with effective
medicines playing a considerable role;
at the same time the quality of life is
not increasing. Indeed, in India, dietary
 Diagnostics

1 Kras-based efficacy prediction

It has been known to molecular oncologists for many years that
the signalling cascade, initiated by occupancy of the epidermal
growth factor receptors (EGFRs), continued downstream via the
ras transducer molecular to result in the nuclear activation of
gene expression and DNA replication. This cascade is managed
by series of on-off switches – actually mediated by the opposing
processes of phosphorylation and de-phosphorylation—which
ensure that signal transduction operates in a controlled and
environmentally-responsive way. Equally, molecular oncologists
have known for many years that the ras family of proteins can be
altered by gene mutations such that they remain in a permanently
activated form resulting in permanent downstream activation
that manifests itself as the unregulated growth of cancers cells.
Thus when exciting new EFGR-modulating products, such as
panitumumab (Vectibix) and cetuximab (Erbitux), reached the
marketplace, it was reasonable to expect that individuals with
activating mutations in ras might respond less well. This sadly
has indeed proven to be the case. Individuals expressing a
normal Kras molecule, on the basis of Kras genotyping, show
substantial benefit, in terms of improved survival (overall and
‘progression-free’) whilst those with ‘activating’ mutations in
the Kras gene show no benefit from cetuximab treatment. Kras
mutation tests, offered by several vendors, are now featured
on drug labels in the EU and are likely to be approved for full
reimbursement by UK NICE, such is the predictive value of these
molecular diagnostic tests.

Box 2

2 Abacavir hyper-sensitivity safety prediction

The nucleoside-based reverse transcriptase inhibitor, abacavir
(Ziagen), became an important component of multi-drug HIV
therapies following clinical development in the mid- to late-
1990’s. However, its role at the vanguard of successful HIV
management was compromised by a rare but potentially fatal
hypersensitivity reaction in AIDS patients. Following a genome-
wide genetic association study by several independent groups,
it was found that mutations at a major histocompatability
locus, i.e., a part of the genome that expressed regulators of
immune response and tolerance, appeared to be retrospectively
associated with the majority of hyper-sensitivity reactions.
Prospective studies confirmed the association of this single-
nucleotide polymorphism (SNP) locus, called HLA-B*5701,
with hypersensitivity and established a clinical utility for the
test. The test, offered by a number of clinical lab organizations,
now appears in the label of all abacavir-containing drug
formulations, and since its introduction there have been no
reported SAEs associated with abacavir hypersensitivity. In
essence, this predictive test has rescued a whole disease-
management strategy for HIV/ AIDS.

Box 3

changes are causing a huge rise in the
levels of Type 2 Diabetes (T2D) and in
China the affordability of cigarettes is
seeding respiratory problems, particularly
Chronic Obstructive Pulmonary Disease
(COPD). In Western populations, the
management of previously lethal disease
conditions, including some, but not all,
cancers, is allowing all members of socie-
ties to live longer; however, the rise of
degenerative disease, particularly associ-
ated with the Central Nervous System
(CNS), is substantially reducing the
quality of life in later years for many
diligently in the healthcare market- However, disease will not become a
place can undoubtedly benefit society, thing of the past; disease will remain and
and the role of good quality predictive will be manifest in different forms from
and diagnostic molecular tests is unam- that observed and so well-managed today.
biguously a great advance for pharma- It is clear that in ensuring a healthier
ceutical medicine. The increased use of future, we should be careful about what
predictive tests will surpass the benefits we ask for and be careful about what
already seen by traditional companion we deliver.
diagnostics to the point that earlier inter-
ventions will herald the rise of predictive References are available at
medicines. http://www.asianhhm.com/magazine
Eddie Blair is a MD of Integrated Medicines Ltd, enabling personal-
ised medicines by combining diagnostic-type testing with new and
A uthor

individuals. Thus some care must be existing medicines. He is non-executive director of IDS Holdings
taken in assessing benefit over perhaps plc and a visiting scholar to the Cambridge University-MIT Masters
inappropriately short time frames. Programme. He also lectures on personalised medicines and offers
occasional bespoke courses based on his best-selling books. He
has published more than 40 primary papers on the subject and is
In conclusion… named inventor on a dozen patents.
Rationally developed therapies used

www.asianhhm.com 59
Technology, Equipment & Devices
Evolving Healthcare
Technology
Changing processes
C
ontinuous rise in population,
As and when technology
substantial economic transfor-
changes and new mation in low income countries,
products come into the rapid urbanisation and consequent changes
markets, a situation is in lifestyle are few of the many changes
created wherein newer happening around. In parallel to these
developments, rapid technology evolution
types of services are
isn’t stopping either. New innovations in
to be brought into in-vitro diagnostics like microarrays and
picture. This change lab-on-a-chip has brought a revolution
also leads to newer in the field of diagnostics. Furthermore,
business models that preventive as well as personal care devices
and home therapy devices are emerging
are to be implemented
and showing a very high growth rate and
by the market players. opportunities in entire spectrum of the
market. Intelligent devices i.e. robotic
devices for surgery and diagnosis are show-
ing a potential to reshape the modern
face of the healthcare sector. Tissue
generated devices and site-specific drug
delivery devices are being developed for
more sophisticated healthcare delivery.
Table 1 illustrates the major technology
Rajiv Varyani
Program Manager happenings in APAC today.
Frost & Sullivan Healthcare As and when technology changes and
Asia Pacific, Singapore new products come into the markets, a
situation is created wherein newer types
of services are to be brought into picture.
This change also leads to newer business
models that are to be implemented by the
market players. Apart from this new sets
of competitors emerge and the need for
exploring newer geographies also comes
into place. Eventually these developments
lead to changes or upgrades in the entire
value chain or delivery. The bottom line is
when there is technology available there is
a reactive effect—direct or indirect—on
various industry participants.
60 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
How are the various industry
participants affected?
At the supplier side, the need arises to
address rising costs of consolidating
newer technologies, concentrate on large
volumes of sales and set up plans for
lowering the cost of manufacturing (e.g
basic medicines / vaccines). As a result,
contract manufacturing and other viable
techniques come into picture. There have
been tremendous changes in supply chain
and logistics resulting in emergence of
regional distribution centres to match
raising volumes. At government level
there are various newer regulations for
medical devices coming into place, which
Technology Developments in
Medical Device Sector
Top - 10
Medical device-based platforms
for the next decade
1 Infection control devices / Wound care
2 Home / Self therapy devices
3 Total disc replacement
4 Robotic devices
5 Advanced In Vitro Diagnistics
Virtual reality
6
7 Intelligent / Automated devices
Electrical stimulation
8
9 Site specific drug delivery
10 Tissue generation devices
Source: Frost & Sullivan
Table 1

Future Trends
From
Fragmented Business Model
Invasive Diagnosisi & Treatment
Provider Centric Focus
Centralised - Hospital Monitor
One size fits all Approach
Therapuatics / Diagnistics
Tools
/ Devices
Treating sickness Objective
Source: Frost & Sullivan
in-turn affects the business model at all
the levels. Need for changes in geography
of operation have emerged and newer
alliances, mergers & acquisitions have
become need of the hour. Newer tech-
niques have also changed the research
and development process of medical
devices.
High-end medical device technol-
ogy has lead to reduction of errors in
diagnosis, thereby, improving the care
delivery altogether. In other words, early
diagnosis and targeted treatment regimes
has saved countless lives. Wireless tech-
nology in devices has enabled ambulatory
care delivery. Medical grade power system
and 802.11 wireless allows for room-to-
room movement without shutting down
changed treatment process. Addressing
vast demographics has been made possible
by the growth of telemedicine. Again
thanks to medical devices like portable
ECG monitors equipped with ECG soft-
ware and multi-parameter monitoring
systems. Last but not the least, medical
research and academic teaching tech-
niques have also dramatically improved
because of advent of technologies.
At the consumer level, introduction
of devices i.e. virtual patient monitoring
tools / home monitoring there is a whole
lot of a concentration on preventive care.
Thereby over a period of time a preventive
care mindset is forming within patient
groups. It will not be long when various
disease management programs would be
Technology, Equipment & Devices
To
Integrated & Automated
Less invasive, Preventative Image
Based
Patient Centric
De-Centralsed - Shift to Community
Personalised Medicine
“Theranostics”
Preventing sickness - “Wellness”
Figure 1
in place, wherein patients would have
signed up and undergoing therapy. For
example, diabetics will be able to moni-
tor their blood glucose by self-monitor-
ing devices and in turn keep their sugar
levels in check. The result is change in
treatment of the disease which has been
brought due to such technology coming
in place.
Modern healthcare system is on the
horizon and experiencing a paradigm
shift. Figure 1 captures the evolution
in a nutshell.
Evaluating the impact of new innova-
tion can be complicated. Because of the
size of the health sector and its diversity
(thousands of procedures, products, and
interventions) and the fact that inno-
vation in the healthcare sector occurs
continuously also renders any direct
measurement impractical. For exam-
ple, a single technology or disease may
show cost savings based on the costs
and benefits of the new technology if it
replaces a more expensive technology and
provides health improvements, while an
analysis of healthcare system-wide costs
may show cost increases if the new tech-
nology results in greater utilisation than
the old. Thereby while it is not possible
to directly measure the impact of new
medical technology on healthcare, the
impacts of various changes interrelate
and are inevitable.
References are available at
http://www.asianhhm.com/magazine
www.asianhhm.com 61
Facilities & Operations Management

Technology
and Patient Safety
Capturing the power of technology

While healthcare
H
ealthcare Information
is beneficial in the Technology (HIT) forms a
pivotal component of the
aggregate, it may American healthcare reform bill being
also result in harm. proposed by the Obama administration.
Information technology HIT is being looked upon as a solution
may be used in a variety that can improve the quality of healthcare
of ways to improve the and patient safety, while at the same time
reducing the costs associated with medi-
safety and efficiency cal mistakes and the inefficiencies of a
of healthcare. largely frag¬mented healthcare delivery
system in the US. Many other nations
Shobha Phansalkar have already made similar investments,
Instructor especially in electronic health records in
Medicine
the outpatient setting, though hospital
David W Bates
Professor and Chief
systems lag behind in most nations.
Some Asian countries already have wide-
Division of General Medicine and
Primary Care, Brigham and Women’s spread implementation of HIT in at least
Hospital and Harvard Medical School some sectors of their systems—notably
USA Singapore, Hong Kong, South Korea and
Taiwan—and others are also embarking
on this path.
In the past decade, the field of HIT
has experienced significant growth, but
even more can be expected in the coming
years. A multitude of technologies and
solutions have paved their way to the
patient’s bedside and in outpatient
settings, with the promise of making
care safer and more efficient. A few
innovative solutions remain key to lever-
aging the power of technology to improve
patient safety.
Computerised Physician Order
Entry (CPOE)
CPOE systems allow providers to elec-
tronically enter orders for therapeutic
interventions such as medications,
laboratory tests, and radiology orders.
CPOE systems are widely recognized as
the single most powerful HIT interven-
tion for improving medication safety.
Medication errors are the largest cause
of hospital adverse events. Use of CPOE
systems has reduced the serious medi-
cation error rate by 55 per cent and
the overall medication error rate by 81
per cent in the inpatient setting. The
Leapfrog Group-a coalition of the largest
employers in the United States, estimates
that by averting Adverse Drug Events
(ADEs), CPOE systems could potentially
lead to savings of US$ 2 billion every
year in the US alone.
Despite studies that highlight the
economic and the quality of care benefits,
penetration of CPOE technology has
been very slow in the US and in other
nations. Adoption has largely been

To lower healthcare cost, cut medical errors and

improve care, we’ll computerize the nation’s health
record in five years, saving billions of dollars in
healthcare costs and countless lives.
US President Barack Obama, 24 January 2009

62 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009


impeded by the high cost and complex-
ity of these systems. Implementation of
CPOE systems is not just a technological
intervention; it has significant implica-
tions on the cultural and behavioural
aspects of how medicine is practiced.
Adaptation for countries in which it
has not previously been used has been
especially tricky, in part because customi-
sation is needed nearly everywhere. It
is only recently that qualitative evalua-
tions have revealed the impact of CPOE
systems on behavioural changes such
as perceived loss of autonomy and the
shifting of power among clinical disci-
plines. With respect to the complexity,
the domain of informatics is still strug-
gling to define the core functionality
needed in a CPOE system. This has lead
to great variability in the definition of
a CPOE system and limitations related
to its evaluation.
As a minimum, CPOE systems allow
physicians to enter orders electronically.
This produces legible orders that possibly
contain all of the information needed
to correctly dispense a medication thus
reducing potential medication errors and
decreasing pharmacy call-backs. However,
the full benefit of CPOE systems can be
realised only when they are integrated
with other components of clinical infor-
mation systems such as, pharmacy, radiol-
ogy, laboratory and billing systems, and
they are linked with Clinical Decision
Support (CDS). The integration allows
seamless flow of information from order-
ing applications into the relevant clini-
cal application with minimal manual
intervention. Providing CDS at the
point–of-order entry is perhaps even
more critical to realising benefit.
Standardising the definition of a
CPOE system and addressing issues
related to core functionality will help
understand the value that these systems
can provide. Rapid adoption can be
enabled by a better understanding of
the institutional strategies and resource
consumption required for successful
implementation in a variety of health-
care settings.
Computerised CDS
This innovation includes a wide variety
of decision support capabilities that can
be incorporated in an electronic medical
record (EMR) both in the inpatient and
outpatient setting. CDS can facilitate
a variety of clinical functions, such as
notification about critical test results,
computerised ADE monitoring, etc.
Automated CDS systems vary depend-
ing on the level of sophistication, the
nature of the CDS provided viz. inter-
ruptive or informational, the modality
of the CDS viz. whether it is an alert
or a reminder, and whether the infor-
mation is provided in a synchronous
The full benefit of
CPOE systems can be
realised only when they
are integrated with other
components of clinical
information systems
such as, pharmacy,
radiology, laboratory and
billing systems, and they
are linked with clinical
decision support (CDS).
or asynchronous manner. Synchronous
alerts are generated during the process
of ordering while asynchronous alerting
consists of delivering the information to
the prescribing physicians as an email or
another form of communication follow-
ing the ordering process.
Depending on the level of sophistica-
tion, CPOE systems can provide basic
or advanced decision support. Basic
CDS includes the ability to provide
default values for drug doses, routes,
and frequencies. Advanced CDS provides
the ability to perform a range of drug
interaction checking, such as drug-allergy
and drug-drug interactions. Medication
decision support forms a large part
of the CDS used in CPOE systems.
Facilities & Operations Management
Kuperman, et al. provide a framework
for defining the categories of basic and
advanced decision-support. While a lot
of focus in the literature has been paid to
the content of CDS, little is known about
the human factors aspect of generating
alerts. Additionally, the dangers of over
alerting and consequent ‘alert fatigue’
are now well- known but our knowledge
of how best to fine tune alerts remains
limited. Lack of standardisation hinders
the implementation of a basic set of CDS
rules that should be present in all EMR
and CPOE systems. The National Health
Service (NHS) in the UK has adopted
an approach of clinical governance to
provide more uniform CDS. The US is
slowly adopting this approach of oversee-
ing the certification and the availability of
basic CDS across EMRs. These changes
herald an era where HIT interventions
will meet an international standard both
to facilitate content sharing as well as
to improve patient safety.
Bar-code technology
Bar-coding medications provides a safe-
guard to assure that the “five rights”
of medication administration - right
patient, right medication, right dose,
right time, and right route of admin-
istration, are adequately confirmed. In
case either of these constraints is not
met the system visually alerts the nurse
about the error.
Use of bar-coding technology forces
a substantial modification on the work-
flow of nurses and pharmacists. While
adequate training can ease the learning
curve associated with correctly using the
technical components, organisational
culture needs to be addressed to success-
fully incorporate bar-code technology in
the clinical workflow. Successful imple-
mentation of bar-coding at the bedside
requires both technical and socio-techni-
cal investments. The technical capabilities
needed are uncomplicated and include a
wireless network infrastructure, mobile
computing cart and a bar-code scanner.
The socio-technical capabilities needed
are complex and include modification
www.asianhhm.com 63
Facilities & Operations Management

of organisational culture to improve that an EHR system should meet. Core

communication, understanding human
factors, and providing administrative
and technical support. Without careful
consideration of the workflow danger-
ous work-arounds could be developed
which would undermine the utility of
this technology.
Smart pumps
These computerised pumps promote
medication safety by alerting clinicians
regarding programming errors when
administering intravenous (IV) infusion
medications. Infusion pumps can alert
clinicians about a range of dangerous
errors. Examples of advanced alerting
capabilities incorporated in ‘smart’ pumps
include, generating alerts when limits for
total dose and minimum infusion time
are exceeded, or the ability to calculate
Body Surface Area (BSA) doses, especially
for chemotherapy infusions, etc.
This is a fairly new technology that
was introduced in 2001 and as compared
to other HIT interventions has enjoyed
a high rate of implementation. A 2009
American Society of Health-System
Pharmacists (ASHP) medication safety
survey revealed that while only 25 per
cent of hospitals had bar-code technology
almost 60 per cent had implemented
smart infusion pumps. The high adop-
tion rate is facilitated by the fact that
hospitals receive incentives based on best
practice measures and quality improve-
ment by use of this technology.
Developing International standards
on safety in health IT
A lot of work has gone into building HIT
standards that can allow interoperable
sharing of information across EMRs.
While adequate
training can ease the
learning curve associated
with correctly using the
technical components,
organisational culture
needs to be addressed to
successfully incorporate
bar-code technology in the
clinical workflow.
information networks (NHIN) and ulti-
mately these may be extensible globally.
In other nations, for example the United
Kingdom and Singapore, much more
central approaches have been taken. The
central approach raises concerns about
privacy and also has limitations in terms
of semantic interoperability since it may
be difficult to exchange data meaning-
fully unless all entities adopt the same
data definitions. From a technological
standpoint we need to define and adopt
terminologies that allow us to commu-
nicate semantically equivalent concepts
across institutions. This in turn would
enable us to achieve the next step, which
is the adoption of a standard set of CDS
rules that can be globally implemented.
In order to make global implementation
possible we need international buy-in to
create a certification process and defini-
tion of a set of minimum functionalities
Shobha Phansalkar is a clinical informaticist at Partners Healthcare
and an Instructor in Medicine at Brigham and Women’s Hospital and
Harvard Medical School. Her research interests are in the design,
implementation and evaluation of clinical information systems. Key
A uthors
CDS needed in CIS may differ little
from country to country and developing
standard sets could make implementation
of CIS more cost effective.
Development of international health
information networks would be espe-
cially beneficial from a public health
informatics perspective. The recent
H1N1 influenza threat brings to light
our difficulties in sharing information
to assess global public health threats.
Development of large scale, real-time
surveillance systems could enable event
detection and monitoring of critical
public health indicators. An epidemic
such as the Severe Acute Respiratory
Syndrome (SARS) outbreak in 2003
could be better managed by leveraging
an international data sharing network.
Understanding the incentives that could
drive global participation and arriving
on commonly agreed terminologies and
standards will facilitate meaningful infor-
mation exchange.
The time is ripe for HIT to bring
about a change in the way medicine is
practiced globally. Understanding the
multi-faceted nature of HIT interven-
tions can help us be better prepared for
accepting the organisational changes that
they can bring about. The next era of
HIT should focus on defining the govern-
ance models to facilitate long term global
EHR adoption.
References are available at
http://www.asianhhm.com/magazine

Despite these efforts interoperability research topics include medication decision support, patient safety,
remains elusive. In the United States, and electronic prescribing.
the development of Regional Health
Information Organisations (RHIOs) David W Bates is Chief, Division of General Medicine, Brigham
has been the approach that has been and Women’s Hospital and Medical Director of Clinical and Quality
Analysis for Partner’s Healthcare Systems. He is a Professor of
selected for facilitating the sharing Medicine at Harvard Medical School and Professor of Health Policy
of clinical information. The hope is and Management at the Harvard School of Public Health.
that these regional organisations will
grow into a network of national health

64 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009


SOA for Healthcare
Promises and pitfalls
To realise the benefits
of Service-Oriented
Architecture (SOA)
adoption, including cost-
efficiency, adaptability,
leverage of legacy
systems, and the business
agility required to meet
new healthcare needs,
healthcare organisations
must adopt a realistic
strategy, establish
effective SOA governance
processes, perform
contextual evaluations
of technologies,
and recognise that
SOA requires a
different mind-set.
Dennis B Smith
Lead
System of Systems Practice Initiative
Grace A Lewis
Lead
System of Systems Engineering Team
Software Engineering Institute
Carnegie Mellon University, USA
F
or some time, national govern-
ments and the healthcare industry
have pursued the development of
effective health information systems. Just
recently in the US, the Obama admin-
istration pledged, “…the immediate
investments necessary to ensure that
within five years, all of America’s medi-
cal records are computerised” [Obama,
2009]. However, so far the widespread
adoption of health information systems
has been elusive.
This slow pace can be attributed
to a number of factors, including a
historic lack of funding, challenges in
achieving regulatory compliance, frag-
mentation in the healthcare industry,
strongly hierarchical decision-making
within organisations, extensive needs
for security and difficulty in reaching
consensus on shared data.
Constraining factors like these point
out that the healthcare industry has a
number of unique business needs, such
as a unique set of business processes and
data, a heavy regulatory environment and
different sets of stakeholders with often
conflicting needs and goals. However, the
industry also confronts a set of IT prob-
lems common to many industries, such as
defining and modelling essential business
information and business rules; storing
and accessing information in support
of business processes; and assuring the
security, performance, availability and
usability of IT systems. One promising
systems development and implementation
approach, Service Oriented Architecture
(SOA), can enable business agility, lever-
age of legacy investments, adaptability
and cost-efficiency all of which support
the goal of developing effective health
information systems.
Information Technology
Basic SOA concepts
SOA is a way of designing, developing,
deploying and managing systems, in which
reusable business functionality is made
available in the form of services, and the
services can be reused by a number of
different applications. This reuse is enabled
by a SOA infrastructure that supports
discovery, composition and invocation of
services through a set of common proto-
cols and standards [Lewis, 2008b].
A service-oriented system has three
major components: services, service
consumers and SOA infrastructure.
• Services are reusable components that
represent business tasks, such as patient
lookup, medical test order, insurance
lookup, or patient history lookup.
Services can be globally distributed
across organisations and can support
a number of business processes
• Service Consumers use the functionality
provided by the services. Some exam-
ples of service consumers are end-user
applications, portals, and internal and
external systems
• A SOA Infrastructure connects service
consumers to services through an agreed
upon communication model. It often
contains elements to support service
discovery, security, data transformation,
and other operations.
Figure 1 illustrates the relation-
ship between these major types of
components.
Avoiding the traps of common
misconceptions
Currently SOA is the best option available
for achieving the interoperability, agility
and reuse goals that are common to many
healthcare organisations. However, in
some cases expectations have far exceeded
www.asianhhm.com 65
Information Technology
High-level representation of a service-oriented system
Insurance Research and
Patient
Company Public Health
Portal
System System
SOA Infrastructure
Get Get
Patient Physician
Info Info
Patient Physician
Record Record
System System
the reality. This section outlines several
common misconceptions, as well as advice
on how to avoid falling into common
traps [Lewis, 2007a].
SOA provides the complete
architecture for a system
SOA is an approach to systems develop-
ment and not a complete well-crafted
architecture. In addition SOA cannot be
bought off the shelf. For example, if an
organisation acquires an Enterprise Service
Bus (ESB) or any other middleware prod-
uct, the organisation has simply acquired
an SOA infrastructure. A set of engineer-
ing decisions need to be made to realise
the concrete remaining elements and
interactions that make up the complete
architecture of the system, in such a way
that meets the qualities that stakeholders
expect of the system.
All legacy systems can
automatically be integrated into a
SOA environment
Migrating legacy systems to SOA envi-
ronments is neither automatic nor easy.
The organisation needs to conduct an
upfront and hands-on analysis of techni-
cal feasibility and cost-benefit for each
individual system to answer questions,
such as:
• Is it technically feasible to expose
capabilities of the legacy system as
services?
• How much would it cost?
66 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
potentially leading to a situation for a
patient that could be severe and even
life threatening.
Service
Outpatient Inpatient
Consumer The most common approach to SOA
System System
X
Service Consumers implementation is that of Web services,
which relies on widespread, stable stand-
ards that include HTTP, SOAP, XML
Infrastructure
and WSDL. Unfortunately, this fact has
Get Create contributed to the misconception that
Service
Test Lab Test
Y standards guarantee interoperability. While
Info Order
Service Interfaces
there is standardisation at the basic levels
to support syntactic interoperability, in
System Web Services there are over 250 standards
Laboratory System
X to support other qualities such as system
Service Implementaion
security and availability and many of them
Figure 1 are unstable, immature, incomplete and
• Is this cost plus the cost of maintaining even conflicting. Web Services do not
the legacy system greater than the cost guarantee semantic interoperability; there
of replacing it with a new one? has to be a careful selection of appropri-
• What changes will have to be made to ate standards, as well as tools, to support
the legacy system? other levels of interoperability [Lewis,
• How much will these changes affect 2008a].
current legacy system users and other
production systems? SOA is all about technology
It is tempting to assume that specific types
The use of standards guarantees of technologies or tools will provide the
interoperability answer to a healthcare organisation’s IT
True interoperability can only be achieved problems. However, SOA adoption also
with agreement at both the syntactic and entails changes to the organisation’s IT
semantic levels. Interoperability exists at governance model—the set of rules and
the syntactic level where there is agreement regulations under which an IT depart-
on the representation of data, such as test ment operates, and the mechanisms to
order codes represented as 5-digit numbers ensure compliance with those rules and
or patient temperature represented as a regulations. SOA implementations need
number with two decimal places. Semantic to address system life cycle issues, such
interoperability requires agreement on as processes and rules for
the meaning of the exchanged data. An • service requirements and definition
example, an instrument reports tempera- • service development, composition and
ture in Fahrenheit. The receiving system testing
receives a number with two decimal places, • service evolution and change manage-
which is syntactically correct. However, ment
the system assumes that the temperature It also needs to identify and enforce
is in Celsius and interprets it as such, other mechanisms, such as service registry
Pillars of SOA adoption Strategic alignment
Successful SOA Adoption
Strategic SOA Technology Change of
Alignment Governance Evaluation Mindset
SOA Principles
Figure 2
ISSUe - 20 2009
www.asianhhm.com 67
Advertorial
Information Technology
Service-Oriented systems require a different development approach
Traditional systems development
Tight coupling between system components Loose coupling between service consumers and services
Semantics shared explicitly at design time
Known set of users and usage patterns
System components owned by the same
organisation
management, definition and collection of
metrics, runtime monitoring mechanisms,
enterprise-wide policies, and service-level
agreements between service consumers
and service providers.
Developing applications based on
services is easy
A complete service-oriented system is
composed of services, service consumers
and an SOA infrastructure. In an organi-
sation with a well-managed registry that
contains highly reusable services, building
applications is relatively easy. However,
there may not have been much thought
put into the definition of services or service
requirements or the possibility that services
can be owned by different organisations.
For application development to be easy,
service providers need to design services
that meet the right Quality of Service
(QoS) requirements in areas such as secu-
rity, performance, usability and availability.
Service providers also need to anticipate
potential consumers and usage patterns.
If they build services that nobody uses,
they are simply wasting time and money.
Service consumers need to have the right
tools available, to easily find services at
the appropriate level of granularity for
their needs, and hopefully not have to deal
with major data and process mismatched
between the services used.
Pillars for successful SOA-based
systems development
Successful SOA adoption requires attention
to four pillars as illustrated in Figure 2.
[Lewis, 2007b]. These pillars are:
• strategic alignment with business
goals
68 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
Service-oriented systems development
Semantics shared without much communication between
service consumers and service providers
Potentially unknown service users and usage patterns
Systems components potentially owned by multiple
organisations
Table 1
• effective SOA governance
• contextual evaluation of relevant tech-
nologies
• recognition that SOA adoption requires
a change of mindset
Strategic alignment
Strategic alignment means that a success-
ful SOA strategy needs to be aligned with
business goals. Different business needs
can require different SOA strategies. For
example, a business goal of increasing
information available to patients may
lead to developing intuitive portals or
creating services related to patient infor-
mation. On the other hand, a business
goal of integrating with new health-
care partners may lead to activities for
back-office integration, interoperability
between different types of software and
hardware, and identification of common
business rules.
A successful SOA strategy includes
• relationship to critical business goals
• alignment with organisational enterprise
architecture and current and future IT
infrastructure
• realistic choices of technologies and
infrastructures
• plan that supports realistic and incre-
Healthcare has a good starting point for SOA adoption
Health Level 7 (HL7) and Object Management Group (OMG) jointly sponsored The
Healthcare Services Specification Project which developed “The Practical Guide for
SOA in Healthcare” [HSSP 2008]. It provides guidance on SOA adoption in a healthcare
setting by
• identifying core SOA principles
• developing a business case for SOA
• providing guidance on steps for SOA implementation
ISSUe - 20 2009
mental development and deployment
of components of the service-oriented
system
SOA governance
Governance is often considered the main
inhibitor of SOA adoption [InfoWorld,
2007]. SOA governance is the set of poli-
cies, rules and enforcement mechanisms
for developing, using and evolving serv-
ice-oriented systems, and for analysis of
their business value. It includes policies
and procedures, roles and responsibili-
ties, design-time governance and runtime
governance [Afshar, 2007; Brown, 2006;
Marks, 2008].
Design-time governance includes
elements such as rules for strategic
identification of services, development,
and deployment of services; reuse; and
legacy system migration. It also enforces
consistency in use of standards, SOA
infrastructure, and processes. Runtime
governance develops and enforces rules
to ensure that services are executed only
in ways that are legal and that important
runtime data is logged. From a life-cycle
point-of-view, design-time governance
applies to early activities such as planning,
architecture, design, and development.
Runtime governance applies to deploy-
ment and management of service-oriented
systems.
Technology evaluation
Because a SOA implementation may use a
number of technologies in novel contexts,
it is important to evaluate whether a
specific set of technologies is appropriate
for the task at hand. One way to deter-
mine the fitness of a specific technology
for a specific need is to perform a hands-
on contextual evaluation through methods

such as T-Checks [Lewis, 2005]. The T-
Check approach formulates hypotheses
about the technology and examines these
hypotheses against very specific criteria.
These criteria are defined taking into
consideration the expectations placed
on the technology by the organisation
as well as expected usage patterns. By
conducting focussed, extremely simple
experiments, it is possible to validating
specific technology claims, early in the
life cycle and at very low cost.
Change of Mindset
Service-oriented systems require a differ-
ent development approach to deals with
characteristics of service-oriented systems.
Some of the contrasts between service-
oriented systems and traditional systems
are presented in Table 1.
These differences affect the way soft-
ware is developed throughout its life cycle
and impact requirements, architecture
and design, development and system
testing activities.
Information Technology
Conclusions governance processes, and perform contex-
SOA adoption has the potential of provid- tual technology evaluation of technologies
ing real value for healthcare organisations of choice for their SOA implementations
to realise benefits such as cost-efficiency, to realise these benefits. Most importantly,
adaptability, leverage of legacy systems, organisations need to recognise that SOA
and the business agility required to adoption requires a change of mindset
meet new healthcare needs. However, that needs to be reflected in the full life
the benefits of SOA adoption, although cycle of service-oriented systems.
real, are not automatic. Organisations
need to align business strategy and References are available at
SOA strategy, establish effective SOA http://www.asianhhm.com/magazine
Dennis Smith’s current work focuses on principles, methods and
technologies that enhance the effectiveness of complex systems of
systems. It has specifically emphasized SOA strategy and adoption
A uthors
as well as the development of an SOA research agenda.
Grace Lewis’ current work and publications are in service-oriented
architecture (SOA), technologies for systems interoperability, soft-
ware development life cycle activities in systems of systems environ-
ments, and establishing a SOA research agenda.
www.asianhhm.com 69
Information Technology
Hospital of
Tomorrow
Technology leads the way in Asia
I
nnovative technologies are constantly
Hospitals of the improving the quality of healthcare
21st century will by ensuring improvements to the
have state-of-the- speed and reliability of information—
art communication critical to saving lives.
capabilities which will IT spending is driven by several
factors, the most immediate being the
not only speed us along need for organisations to upgrade their
the path to recovery, healthcare services to meet international
but also ensure that standards.
our personal health There are two goals here—a more
records will remain, efficient system and better quality
patient care. It is efficiency gaining
as they should do. and life saving combined.
It also makes good business sense.
Gerard Anthony Dass Medical tourism in Thailand now
Healthcare Solution Leader
Nortel Asia, Australia attracts over one million patients per
year, with earnings for 2008 forecast at
around US$ 1.2 billion. A conservative
estimate for the Asia region—prima-
rily Thailand, India, Malaysia and
Singapore—suggests combined revenues
of over US$ 5 billion by 2010. With all
of these countries vying for the prized
position as a regional ‘healthcare hub’,
the incentive to implement the latest
technologies has never been keener.
Most leading international healthcare
providers are taking steps to install the
latest technologies to help them stake
their claim to the lion’s share of this
lucrative and expanding market.
The leading players in Thailand’s
private healthcare sector, like their
70 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
counterparts across the region, are rush-
ing to implement unified communica-
tion systems, ensuring patient informa-
tion is available upon request, regardless
of location. Already, many local medical
practitioners rely on a range of wireless
communication devices such as mobile
PDAs to make bedside care decisions
more quickly. These devices also allow
them to connect with doctors or special-
ists in other locations for an immediate
consultation, or quickly access informa-
tion from a facility’s digital files without
losing valuable time with the patient.
Doctors can now share medical
imaging files with distant colleagues
for an immediate second opinion or
receive real-time alerts, wherever they
are, the moment a patient’s condition
worsens or needs their attention.
Hospitals of the 21st
century will ensure that
our personal health
records will remain,
as they should do, a
matter of patient / doctor
confidentiality.
 Information Technology

There is a strong drive to modernise
installing systems that allow medical
practitioners to do more, faster and with
fewer errors. For example, new technol-
ogy now allows hospitals to mobilize
clinicians and staff, unify multimedia
communications and make the most of
standardized digital health records—
enabling healthcare practitioners to take
better care of their patients.
While much of this new technology
may seem somewhat futuristic for many
of us, there are existing networks that
have already revolutionised the practices
of the organisations in which they have
been installed.
Kyushu University Hospital in Japan
upgraded its current IT system to a
all a patient’s information. This is an
excellent example of how technology can
improve quality healthcare services and
patients’ quality of life by simplifying
the complexity for medical providers
to access and share information.
With such fingertip access to infor-
mation, security is an understandable
concern. So, what measures have firms
implemented to ensure patient confi-
dentiality?
There are solutions that give
approved users access via the ‘office-
on-a-stick’, a specially-formatted USB
key that automates business network
Gerard Anthony Dass is Healthcare Solutions Leader for Nortel
A uthor
access when inserted and protects infor-
mation and applications by completely
removing them when the USB key is
removed. This solution combines hard-
ware, software and services to provide
simple, secure network access.
It is comforting to know that
the hospitals of the 21 st century will
have state-of-the-art communication
capabilities which will not only
speed us along the path to recovery,
but also ensure that our personal
health records will remain, as they
should do, a matter of patient / doctor
confidentiality.

new medical service infrastructure to
enable information to be more effi-
ciently stored, managed, retrieved and
shared amongst physicians and medical
staff. Next-generation networks provide
anywhere, anytime, quick access to
Asia. At Nortel, Gerard is responsible for driving sales and customer
relationships within the healthcare industry in Asia. Prior to working at
Nortel, Gerard was senior technology manager for Cerner Asia where
he managed technology projects in Asia. Gerard received a Masters
degree in Computer Sciences from Sheffield Hallam University and a
PhD in Computer Forensics from the University of Melbourne.

www.asianhhm.com 71
Information Technology
Clinical
Transformation
Future of health IT at Marshfield Clinic
E
With a 40+ year history stablished in 1916, Marshfield
of clinical computing, Clinic (Figure 1) serves a predom-
inately rural area covering close
Marshfield Clinic is
to 30,000 square miles of central and
rethinking the role and northern Wisconsin. Over 40 outpatient
function of Information campuses and a half dozen affiliated
Systems. New tools and hospitals share a common electronic
approaches will reshape medical record (EHR) serving a patient
population of over 1 million individuals.
the way medicine is
With 40+ years of clinical computing
practiced setting the and over a decade of having the EHR as
stage for Marshfield the legal medical record, the computer is
Clinic to be successful in a well established tool in the practice of
the new, evolving world medicine at Marshfield. Even with this
advanced fully implanted EHR, however,
of healthcare in the US.
Marshfield Clinic is rethinking the role
and function of Information Systems.
Robert A Carlson
New tools and approaches will
Chief Information Officer
Marshfield Clinic, USA reshape the way medicine is practiced
in the evolving world of healthcare in the
US. Changing demographics and declin-
ing reimbursement are key drivers for this
change. The growing number of elderly in
the general population will put tremen-
dous pressure on healthcare providers to
develop more cost-effective treatment of
chronic diseases. Information technol-
ogy plays an important role in meeting
these challenges.
The time when the job of Information
Systems was simply taking care of
the mainframe in the basement has
quickly evolved into a complex depart-
ment that touches all aspects of medi-
cine. Marshfield Clinic’s Information
72 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
CaseStudy
Systems Division now oversees three
broad domains at Marshfield: infra-
structure, knowledge management and
analytics.
Infrastructure
This rapidly growing area covers every-
thing from phone systems to PACS
archives. Managing a broadband network
that covers 30,000 square miles of rural
Wisconsin is no small task. Demands on
availability, storage, security and backup
are constant pressures. Implementing
a completely chartless environment
significantly increased the demands and
expectations on availability and response
time. Any system down of greater than
just a few hours quickly escalates into
significant workflow problems. It requires
24-hours a day, 7 days a week support
structure that can quickly respond to
correct any issue that may arise. The reli-
ance on the EHR also requires important
new investments to be made to support
the critical role of electronic informa-
tion in patient care. This past spring,
the Clinic opened a new secondary data
centre in Madison, Wisconsin, and this
fall will begin construction on a new
primary data centre in Marshfield, both
of which are Tier III.
Knowledge management
‘Record’ implies documentation of past
events. Certainly one of the important
www.asianhhm.com 73
Information Technology
functions of the EHR is documentation.
However, with the implementation of
tablet computers that can easily be carried
into exam rooms, new opportunities are
now available. Patient education (Figure
2) with access to current information
is now readily available at the point of
patient interaction. Decision support
is available at the critical time needed.
Checking for drug-drug interactions,
allergies and contraindications are impor-
tant safeguards that provide alerts before
mistakes are made. The EHR is now a
portal into knowledge sources to support
the practice of medicine and informa-
74 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment
tion for patients. Many of these knowl-
edge sources are third-party products.
Managing updates, links, licenses and
alert dialogues within and between these
products is an important task. Making
information available is important but
unless the right information can be
quickly and easily identified, it is easy
to overwhelm providers and render the
information unreachable and therefore
useless. Information overload is a grow-
ing problem that EHRs must address.
Practice guidelines, reimbursement
requirements, coding, PQRI and others
bring a level of complexity that require
ISSUe - 20 2009
EHRs to bring relevant information to
the forefront and not buried within large
databases requiring significant effort to
find. Perhaps a more appropriate name
for the electronic health record is elec-
tronic health assistant.
Related, and equally important, is
being aware of the impact on work-
flow and productivity. Documentation
requirements, coding and various other
required forms can quickly bring the
most productive provider to a grinding
halt. Efforts to understanding process
flow, roles, information sources, and
optimising work flow prior to imple-
menting yet another documentation
form requires direct involvement from
information systems far beyond the
traditional walls of an IS department.
Automating a bad or broken process
provides little help.
Analytics
As the amount of digital health informa-
tion grows, the opportunity to evaluate
and mine information for best practices,
new disease associations and other infor-
mation requires yet another important
role for the EHR-data input for the data
warehouse. The shortcomings of a stand-
ard EHR quickly become apparent. Lack
of standards, limited coded information,
poor consistency and accuracy limit the
usefulness of data mining. Promoting
standards, codification of information,
and striving for accurate and consistent
diagnostic criteria provide yet another
important opportunity for Information
Systems to engage in supporting the prac-
tice of medicine. Marshfield Clinic will
establish a new Center for Healthcare
Intelligence that brings together resources
within the data warehouse. Tools used
in traditional business analytics applied
to medical information will provide new
insight into better ways to provide health-
care more effectively and efficiently.
Three years ago, Marshfield Clinic
decided to commercialise its in house
developed EHR. Forged in the fires of
an active group practice of medicine, this
EHR, called CattailsMD, was created

in an environment where the daily chal-
lenges of medical practice were always at
the forefront. This relationship continues
today and as Marshfield Clinic looks to
the immediate future, its experience and
resources within information systems
will play an important role in reshaping
medical practice. To meet these chal-
lenges, those involved in information
technology will need to engage and
embrace areas beyond the traditional
walls of information systems.
Traditionally, medical practice in
the US can be likened to a repair shop.
Things break and you go in to get it fixed.
This often results in expensive hospitalisa-
tions that could have been avoided if the
risks could have been identified earlier.
Detecting weight gain in a patient with
A uthor
Promoting standards,
codification of
information, and
striving for accurate and
consistent diagnostic
criteria provide yet another
important opportunity for
Information Systems to
engage in supporting the
practice of medicine.
Robert A Carlson is a graduate of the University of Wisconsin
CaseStudy
to the emergency department and subse-
quent hospitalisation. The need to inter-
vene and prevent events that require
more expensive interaction requires a
change in the way health systems inter-
act. The new model will be more like
an air traffic control tower monitoring
health trajectories. Moving from a reac-
tive acute care model to a more proactive
one will require significant reworking of
existing practice patterns. Asia, with its
rich history of holistic medicine, may
find such change much less of a leap
and be able to incorporate these new
tools and approaches with greater speed
and success.

Medical School and is a Diplomate of The American Board of

known congestive heart failure while the
patient is still home could have provided
an opportunity to adjust medication and
avoid the more complicated, expensive
care provided when the patient presents
Pathology in anatomic and clinical pathology. He has been with
Marshfield Clinic since 1987 and is currently Director of Applied
Sciences and Chief Information Officer.

www.asianhhm.com 75
Information Technology

Healthcare
IT Spending
Effects of a changing global economy

W
ith the economy caught-up
in recession, many Care
Delivery Organisations
(CDOs) these days are in cut—down
mode. Although the healthcare indus-
try till now has not suffered directly
from the current economic slowdown,
future revenue and funding curtail-
ments will definitely cause a shift in
the spending patterns in the domain
of Healthcare Information Technology
(HIT). Furthermore, likely reduction in

76 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Information Technology

A prolonged or deeper economic slowdown will

inevitably be met by further reductions in IT capital and
operating budgets, so, even those health IT initiatives
that have a demonstrated ROI could become difficult
to fund. The IT services and solution providers have to
Rajiv Varyani
prepare themselves and develop some quick strategies Program Manager
to respond to the changed client behaviour and market Frost & Sullivan
Healthcare Asia Pacific
conditions in healthcare expected in 2009 and 2010. Singapore

secondary revenue sources like clinical
trials will lead to reduction in capital in
the healthcare delivery organisations.
Although countries such as Australia
and Singapore, where the health-
care is primarily publicly funded,
will be considerably sheltered from
the worst of the economic turmoil,
overall the healthcare providers’ spend-
ing may face internal pressures to divert
funds away from IT departments
and toward care delivery. But look-
ing on the brighter side—given how
deep-rooted IT has become in today’s
healthcare set-up and how little
of IT budgets are discretionary—
only new, large-scale projects with
long-term paybacks are expected to be
in risk.
Who is going to buy what?
The overall HIT market for Asia Pacific
region in 2008 was around US$ 4.7
billion, which is expected to rise by
around 3-4 per cent this year. Despite
the rapid growth in IT spending enjoyed
by healthcare providers during the past
three years, it is expected to undergo a
remarkable change in spending patterns
especially varying among the types of
buyers.
The Government and publicly
funded hospitals are expected to
keep healthcare funding stable
during the present economic phase.
The shared services model would
gain popularity as it is a universally
accepted cost controlling technique.
The IT budgets in these hospitals
would have to compete with other
budgets such as operational, care
delivery etc. IT budgets are expected
to rise in organisations where IT has
become an indispensable part and
elsewhere they are expected to remain
flat.
Private hospitals and other related
CDOs are most sensitive to such cash
and credit flow fluctuations. A freeze
in spending, halt on all large and new
initiatives, facility expansions and acqui-
sitions would be expected as a result
of such developments. But, once the
cash flow becomes more visible, it is
likely that systems and solutions with
a short term return to investment
would be approved over large long-
term projects.

Promising Not so promising

• Application Support • Large Enterprise Resource Planning
• Outsourcing of Services (Revenue Cycle Systems and solutions requiring lengthy
Management,Medical Coding etc.) implementation duration
• Custom Application Development • Other Clinical Information Systems
• Virtualisation • Data centers
• Standardisation Initiatives (ICD10, SNOMED etc.) • Hardware requiring huge capital investments

www.asianhhm.com 77
Information Technology

On demand service offerings

CIO’s expected response to financial crisis Considering that the economic down-
turn could affect the entire region, not
all the solutions of IT product and serv-
More oversight on charity / uncompensated care -
ice offerings will be uniformly affected.
More aggressive negotiation with payers - While some categories remain success-
Increases in changes - ful and perform above par, others may
Selective layoffs due to utilization reductions - not perform well. The strong offerings
Delaying health IT initiatives or display quick RoI, short term value and
lengthening timeframes for completion -
visibility in terms of quick problem
Delaying equipment purchases -
solving capabilities. The weak technol-
Delaying facility faulty upgrade investment or lengthening
timeframes for completion -
ogy areas display trends such as long
Reductions in specific departments budgets -
term RoI, complexity, huge investment
and underrated services. Overall the
Across the board cuts -
healthcare providers will heavily scru-
0% 10% 20% 30% 40% 50% 60% 70% 80%
Source: Frost & Sullivan tinise any investment happening in
Figure 1 this space. The listing below provides
As far as other smaller healthcare Certain leading HIT organi- details of solutions that show promise
delivery set-ups such as physician sations conducted a survey with and are expected to mark the industry
practices, clinics and nursing homes are the CIOs of leading healthcare institu- in 2009.
concerned, IT spending in this sector tions to establish this change in spend-
is anticipated to remain low with flat ing trends. The analysis is as depicted Need for a revised strategy
growth expectations. in figure 1. It is expected that such a trend of low

78 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009

 Information Technology

market movement would run through
2010. Asia Pacific market is consid-
ered next in line after the US market
in terms of growth and prospects and
holds wider opportunities for healthcare
IT and related services. Irrespective of
varied growth rates, projected vendors
are expected to be wary of the market
dynamics and thereby generate revenue.
The key aspects that need to be definitely
considered and are likely to influence
sales are:
• New offerings that have long term
deployment cycles are expected to face
long sales cycle or outright refusal.
The initiatives that are likely to gain
approval would either be derived from
a previously demonstrated benefit or
will address some mandatory compli-
ance parameter
• The solutions offering a better time-to-
value benefit will be preferred over long
term return on investment project
• Sales cycles during these challenging
times are expected to increase drasti-
cally, maybe to/by 1 to 2 years. The
projects that are able to justify a very
short return on investment are most
likely to sell. These aspects should be
kept in mind for all customer commu-
nications and sales pitches
ProductShowcase
• Proposing innovative solution deliv-
ery and maintenance models that
would enable sincere cost cutting to
prospective clients. Offshore develop-
ment centres, near-shore development
centres etc. are to name a few such
models.
Moving forward
A prolonged or deeper economic slow-
down will inevitably be met by further
reductions in IT capital and operating
budgets, so, even those health IT initi-
atives that have a demonstrated ROI
could become difficult to fund. Summing
up the various factors contributing to
the market dynamics are as depicted
below:
Drivers
• Constant Government funding and
Medical Insurance subscriptions
• Healthcare delivery has not taken any
direct hit i.e. patients are getting to
CDO’s and data generation from HIS,
EMR’s is non-stop
• Definite need for compliance to
universal standards i.e. HL7, HIPAA,
ICD etc.
• Proven improvements in clinical aspects
of CDO through IT enablement
• Need for efficient back office func-
tioning like human resources, material
management for cost reductions
• Ageing population which needs
continuous care demand IT in
healthcare
• Constant growth in Medical
Tourism.
Restraints
• Many healthcare IT projects take
long time to complete and there is
no immediate ROI
• Access to capital is expected to reduce
– donations from private and charita-
ble institutions are likely to lessen
• Tighter and more expensive credit
facilities today make investment
further difficult.
• Bad debts are anticipated to
increase
Overall, the IT services and
solution providers have to prepare
themselves and develop some quick
strategies to respond to the changed
client behaviour and market condi-
tions in healthcare expected in 2009
and 2010.
References are available at
http://www.asianhhm.com/magazine

DRIVEN BY CUSTOMERS’ INSIGHTS, SATISTFACTION

AND EXPECTATIONS
Based in Bangalore, Hospaccx India has over 300 customers spread all over Southern and Western India. With just
about 5 years in the industry Hospaccx has also built a large network of business associates in other zonal and regional
markets. Hospaccx has made its presence felt in all segments of the healthcare industry ranging from diagnostic centres
to large hospitals. The company is rooted in a strong professional value system. Some of the products highlighted here
are hospital cubicle curtains, the IV stands and design of a hospital ward layout. Hospaccx India is driven by “Customer
Insights, Satisfaction and Expectations.
Hospaccx India specialises in offering the latest high quality hospital equipment. The products of Hospaccx are
specifically designed according to customer requirements. Hospaccx not only provides the strongest and most durable
products, it also makes sure the customers’ requests for maintenance are taken care of without any further cost.
Hospaccx India derives support from customer feedback and referrals which contribute to 90 percent of its sales.

# 6, Chaithanya Complex, Site # 1, 17th Cross, Sir M.V. Nagar, T.C. Palya Main Road, Bangalore, India
Mob: 098452-08778/ 099028-61413 E-mail: manish_rastogii@rediffmail.com Website: www.hospaccxindia.com

www.asianhhm.com 79

Classifieds
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Rx Professions Clinical Research Academy is offering
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80 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009
Company Page No.
Diagnostics
Hitachi Medical Systems (S) Pte Ltd...................................... IBC2
Magna-Tek Enterprises.............................................................57
NDS Surgical Imaging..............................................................58
Orbitz Exhibitions Pvt. Ltd...................................................55, 61
Healthcare Management
Acuity Information Systems Private Limited..........................OBC3
Ahlstrom Corporation...............................................................25
Binary Spectrum .....................................................................10
Orbitz Exhibitions Pvt. Ltd...................................................55, 61
Xeralife ...................................................................................11
Information Technology
Acuity Information Systems Private Limited..........................OBC3
Binary Spectrum .....................................................................10
Elekta Limited .......................................................................IFC1
Sains ......................................................................................75
SEED Healthcare Solutions Pvt. Ltd..........................................69
Medical Sciences
Elekta Limited .......................................................................IFC1
Surgical Speciality
NDS Surgical Imaging..............................................................58
Technology, Equipment & Devices
Hitachi Medical Systems (S) Pte Ltd...................................... IBC2
Magna-Tek Enterprises.............................................................57
NDS Surgical Imaging..............................................................58
Philips.....................................................................................05
Company Page No.
Acuity Information Systems Private Limited..........................OBC3
www.acutysoft.com
Ahlstrom Corporation...............................................................25
www.ahlstrom.com
Binary Spectrum .....................................................................21
www.binaryspectrum.com
Elekta Limited .......................................................................IFC1
www.elekta.com
Hitachi Medical Systems (S) Pte Ltd . ................................... IBC2
www.hitachi-medical.com.sg
Magna-Tek Enterprises.............................................................57
www.magnatekenterprises.com
NDS Surgical Imaging .............................................................58
www.ndssi.com
Orbitz Exhibitions Pvt. Ltd...................................................55, 61
www.meditec-clinika.com
Philips ....................................................................................05
www.philips.com
Sains ......................................................................................75
www.sains.com.my
SEED Healthcare Solutions Pvt. Ltd..........................................69
www.seedhealthcare.com
Xeralife ...................................................................................11
www.xeralife.com
To receive more information on products & services advertised in this issue,
please fill up the "Info Request Form" provided with the magazine and fax it, or
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82 A s ian H o s p i t a l & H ea lt h ca re M a n a ge ment ISSUe - 20 2009