ngh eu 1

www.nghealthcareeurope.com • Q2 2010

CROSS-BORDER CARE Is a Europe-wide health system a reality?

RE-IMAGINING THE NHS With UK Department of Health CTO Paul Jones

HOSPITALS OF THE FUTURE Inside Sweden’s Norrbotten Healthcare System

THE GREAT SWINE FLU SWINDLE Whatever happened to H1N1?

Why greater information sharing will be key to Europe’s healthcare revolution

PLUS Rosanna Tarricone EHTI | Neelie Kroes EU Commission | Didier Pittet WHO

UNLOCKING

POTENTIALCover 2.indd 1Cover 2.indd 1 7/4/10 16:31:387/4/10 16:31:38

BRACCO AD Q7a_mar09 06/04/2010 16:46 Page 1

BRACCO AD Q7a_mar09 06/04/2010 16:46 Page 2

NNIT AD.indd 1NNIT AD.indd 1 1/4/10 15:04:531/4/10 15:04:53

NNIT AD.indd 2NNIT AD.indd 2 1/4/10 15:04:591/4/10 15:04:59

ViforPharma_ad.indd 1ViforPharma_ad.indd 1 23/3/10 17:03:4723/3/10 17:03:47

March 21, 2010. Mark thedate, people – it could godown as one of the most sig-nificant in US history. Afternearly a year’s worth of polit-

ical wrangling, the Obama Administration’s health-care reform legislation was finally passed by theHouse of Representatives by a vote of 219-212. Thelegislation will give an additional 32 millionAmericans access to basic health insurance by 2019.

The news did not go unnoticed on this side ofthe pond, either. Indeed, as a result of eventsacross the Atlantic we’ve hardly been able to avoidthe issue of healthcare in the papers, on the blogsand over the airwaves in the last few months. Andwith good reason: healthcare is something that af-fects all of us at some point in our lives, and some-thing that most of us have an opinion on.

The net result of this increased visibility isthat it affords us in Europe an opportunity to re-evaluate our own health systems and approachesto see if they are working as they should, and lookat how they can be improved. For instance, theUK’s National Health Service has, in recent years,

responsibility for five large hospital systems.“These new technologies will play a key part inhow we get there, but they also mean that we haveto work in ways that we haven’t before.”

As Neelie Kroes, Vice President of theEuropean Commission and Commissioner forthe Digital Agenda, explains, information andcommunication technologies (and the greaterlevels of collaboration they drive) will be key tothe future of the sector – not just here in Europe,but around the world too. “There is no singleactor – government, doctor, patient or manu-facturer – setting the terms of e-health,” she says.“Instead, success will only come from a trulyjoint effort.”

It’s advice that leaders on both sides of theAtlantic would do well to follow. n

Senior Editor Ben Thompson

deployed around 32,000 different systems – every-thing from theatre systems in hospitals through tonew patient administration systems in communi-ty clinics – to help improve care delivery to pa-tients across its many disparate healthcare settings.Coordinating this effort has proved challenging todate, but it is a challenge that new Department ofHealth Chief Technology Officer Paul Jones is rel-ishing. “To realise the true benefits of e-healthwe’ve got to put certain building blocks – interop-erability, data standards, common identifiers – inplace,” he explains in an exclusive interview onpage 36. “Once you implement those buildingblocks, we can really set the NHS up for the future,which is what I care about.”

Certainly technology will play an importantpart in the development of the sector, but it willalso require strong leadership and effective deci-sion-making around the key issues to ensure theopportunities presented by the advent of health-care IT do not go to waste. “We need to think ofIT systems as a tool to support what we want toachieve,” suggests Elisabeth Holmgren, CEO forSweden’s Norbotten Läns Landsting region with

Does the passing of America’s health reform bill providean opportunity to reflect on European efforts tostrengthen healthcare?

FROM THE EDITOR5

Chance to reflect

“WHO undertook anincomprehensible action, up tonow not justified by anyscientific evidence. It gambledaway public confidence”

Dr Wolfgang Wodarg, Head ofHealth for the Council of Europe(Page 98)

“A lot of breakthrough innovationshave been developed in Europe butmarketed in the US – and that’s ourweakness. European systems arenot very friendly”

Rosanna Tarricone, Chairman, Director of the European HealthTechnology Institute (Page 82)

“To truly protect patients, it will take leadership,commitment, a range of actions,continuous assessment,experience-sharing, and time”

Professor Didier Pittet, UniversityHospitals Geneva(Page 106)

EDS NOTE_mar10 07/04/2010 17:00 Page 5

HANDGIENE AD.indd 1HANDGIENE AD.indd 1 23/3/10 17:01:3023/3/10 17:01:30

The great swine fluswindle?A pandemic of devastatingproportions, it was to cause a globalstandstill as hundred of thousandsof people around the world died andmillions more got sick. RebeccaGoozee looks at what happened toswine flu

26

36

Closing the gapWith high quality health servicesbecoming an increasing priority,discussions around cross-borderhealthcare systems are coming to a head,just what and where is the future ofcross-border healthcare in Europe?

Re-imagining the NHSPaul Jones, CTO for theDepartment of Health,outlines why the UK’s £12.7billion National Programmefor IT is still on track

98

48

The best system in theworld?A look at how healthcare systemsmeasure up in Europe and the US

CONTENTS7

CONTENTS_apr10 08/04/2010 10:56 Page 7

32 A new era in e-healthNeelie Kroes explains the positive impact ofICT on the healthcare sector

44 Addressing pre-operativeanaemia managementChristoph Springer explains the importanceof patient blood management

46 Making connectionsThe use of social media in healthcare,according to Matthew Lees

54 On the front lineThe vital role of the hospital in healthcare

60 Cloud technology to combatcancerCloud services are helping to treat cancer

patients, thanks to an enormous effort byEuropean researchers

62 A new pathSir Ian Kennedy on the value of innovativehealth technologies

66 Going digitalWith Frost and Sullivan’s Nadim Daher

72 The rise of medical imagingMartin Törnvik talks about the improvementscurrently going on in the world of medicalimaging

74 The future of private sectormedical imagingWhy the need for integrated diagnostic andvisualisation tools will drive the EuropeanPACS market

76 Healthy profitsTo build a smarter system, healthcaresolutions need to be instrumented, says IBM

82 Innovation instituteRosanna Tarricone, reveals the challenges of afragmented device industry

88 Healthcare goes mobileAkanksha Joshi explains why an ageingdemographic is boosting the uptake of wirelesspatient monitoring devices

94

106

110

Staying safe

Miracle cureDidier Pettit

CONTENTS8

ASK THE EXPERT

92 Sarah Whipp, Symantec


114 Comprehensive diagnosticsGuus Simons reveals where the moleculardiagnostics sector in Europe is heading

116 The new healthcare modelHealthcare may be buoyant now but a zombie

118And the winner is...

Moscow

90 A wireless worldSarah Morris looks at Wi-Fi in the hospitalsetting

94 Staying safeJames Koenig on the role of single sign-on inidentity access management

106 Save lives: clean your hands A call to action from Professor Didier Pittet

108 The importance of handwashing Richard J. Verdiramo reveals why HCAI ratesare decreasing

110 Miracle cureCan the emerging field of pharmacogenomicsprovide a lifeline to the industry?

54

On the front line

economy is driving the sector to a new modelof payment by results

118 And the winner is...A look at the impact of healthcare reform inthe UK

CONTENTS9

A new era in e-health

32

122 Design: Hospital 2.0124 Regional focus: Fighting anew Cold War126 On the shelf: Book reviews 144 Final word: Photo finish

IN THE BACK


Chairman/Publisher SPENCER GREENDirector of Projects ADAM BURNSEditorial Director HARLAN DAVIS

Worldwide Sales Director OLIVER SMART

Editor BEN THOMPSONAssociate Editor REBECCA GOOZEE

Deputy Editors DIANA MILNE, NICK PRYKE, JULIAN ROGERS, STACEY SHEPPARD, MARIE SHIELDS, HUW THOMAS

Creative Director ANDREW HOBSONDesign Directors ZÖE BRAZIL, SARAH WILMOTT

Associate Design Directors MICHAEL HALL, CRYSTAL MATHER, CLIFF NEWMAN, CATHERINE WILSON

Online Director JAMES WESTOnline Editor JANA GRUNE

Project Director NADIA BLACKMORE

Sales Manager LAURA WILLIAMS

Sales Executives IAIN GETHIN, JENNIFER PYLE, DAMON PARSONS

Finance Director JAMIE CANTILLON

Production Director LAUREN HEAL

Production Coordinators RENATA OKRAJNI, AIMEE WHITEHEAD

Director of Business Development RICHARD OWEN

Operations Director JASON GREEN

Operations Manager BEN KELLY

Subscription Enquiries +44 117 9214000. www.nghealthcareeurope.com

General Enquiries [email protected]

(Please put the magazine name in the subject line)

Letters to the Editor [email protected]

Next Generation Healthcare 4th floor, 3 Callaghan square, Cardiff CF10 5BT, UK

Tel: +44 (0)2920 729 300. Fax: +44 (0)2920 729 301. E-mail: [email protected]

Legal InformationThe advertising and articles appearing within this publication refl ect the opinions

and attitudes of their respective authors and not necessarily those of the publisher or editors. We are not to be held accountable for unsolicited manuscripts, transparencies or

photographs. All material within this magazine is ©2010 NGH.

GDS InternationalGDS Publishing, Queen Square House, 18-21 QueenSquare, Bristol BS1 4NH.

+44 117 9214000. [email protected]

Find Out MoreContact NGP EU +44 (0)2920 729 307

www.ngpsummit.eu.com

The NGP EU Summit is a three-day critical information gathering of the most infl uential and important executives from the pharmaceutical industry.

The NGP EU Summit 2010

Grand Hotel Huis ter Duin, The Netherlands

12-14th October 2010

A Proven FormatThis inspired and professional format has been used by over 100 executives as a rewarding platform for discussion and learning.

“An excellent venue for CIOs to exchange information on current topics, as well as, interact with a variety of industry vendors.” Jim Cramer, Scottsdale Healthcare

“A well organized and productive meeting with good topics and open discussion – worth the effort!” Mark Burfoot, Pfizer

A Controlled, Professional and Focused EnvironmentThe NGP EU Summit is an opportunity to debate, benchmark and learn from other industry leaders. It is a C-level event reserved for 100 participants that includes expert workshops, facilitated roundtables, peer-to-peer networking, and coordinated technology meetings.

CREDITS.indd 10CREDITS.indd 10 7/4/10 13:59:357/4/10 13:59:35

Symantec AD.indd 1Symantec AD.indd 1 23/3/10 17:03:2023/3/10 17:03:20

Over in the US a federal judge hasoverturned the patents on twogenes linked to breast and ovariancancer on the grounds that they’renot man-made or an invention,but products of nature. MyriadGenetics had patented the BRCA1and 2 genes and charged womenmore than US$3000 to test for ge-netic mutations. The AmericanCivil Liberties Union and individ-ual breast cancer patients took thecase to the federal court arguingthat the patent stifled medical re-search.

The company that owned thepatent, Australian-based GeneticTechnologies, initially demandedthat other laboratories stop

testing the genes, but underheavy pressure, agreed

to offer the tests forfree. However, theAmerican ruling couldhave implications for

another 40,000 patentson an estimated 2000

human genes globally. Courts have long backed the

idea of gene patents, however rapidadvances in technology are prompt-ing scientists and many intellectual-property experts to rethink theirsupport for them. Modern gene-se-quencers for example have madethe task of identifying genes and fig-uring out their function much easi-er than before.

Despite this, many biotechnol-ogy stocks fell after the ruling as in-vestors struggled to understand theimpact of a ruling that threw intoquestion thousands of gene patents.Biotech companies spend billionsevery year trying to develop newtests and treatments based partly ongenes that have isolated and patent-ed. Anticipating a negative reaction

The American

ruling could have implications for

another

patents40,000

UPFRONT12

A BLOW FORBIOTECH?

UPFRONT NGH EU1 NEW_25 June 07/04/2010 15:57 Page 12

from the industry the Judge in-cluded a footnote in his 152-page ruling, dismissing fearsthat invalidating such patentswould decimate the industry.

The decision invalidatingthe gene patents stunned manylawyers, who predicted the rulingto have a far-reaching ef-fect. “It’s really quite adramatic holdingthat would havethe effect of inval-idating, manypatents on whichthe biotechnologyindustry has investedconsiderable money,”Rebecca S. Eisenberg, a law pro-fessor at the University ofMichigan, told the New YorkTimes.

The ruling is currently onappeal, but eventually – if thejudge’s reasoning is upheld theinvalidation of genetic patentswould have the biggest impacton diagnostic companies likeMyriad that offers diagnostictests based on genes. However,

it would also be felt by agricul-tural biotechnology companiesand perhaps even traditionaldrug makers.

Some biotechnology in-vestors and executives arguethat the lack of patent protec-tion for DNA could diminish

investment and remove incen-tives to develop tests, slowingthe move towards so-called per-sonalised medicine, in which ge-netic tests are used to determinethe drugs that are best for indi-vidual patients.

But while industry watcherswere taken aback by the

ruling, some groupswere more positive.

Chris Hansen, astaff attorney withthe ACLU FirstAmendment

Working Groupsaid: “The ruling is a

victory for the free flow ofideas in scientific research. Thehuman genome, like the struc-ture of blood, air or water, wasdiscovered, not created. There isan endless amount of informa-tion on genes that begs for fur-ther discovery and gene patentsput up an unacceptable barrierto the free exchange of ideas.”

Professor Ian Olver, ChiefExecutive of Cancer Council ofAustralia, said the ruling was amajor breakthrough. “For acourt in the US – where many ofthe world’s gene patents are held– to reach such a determinationis a major breakthrough to-wards protecting the public in-terest from commercialmonopolisation of genetic ma-terial.”

Indeed, the ruling addsweight to the argument bysome geneticists that compa-nies and institutions shouldn’tbe allowed to patent basic ge-netic information that makespeople human. And it appearsthat this decision could ulti-mately be a boon for geneticresearch and public health.Still, the battle’s not over justyet: big pharma won’t take thislying down.

The invalidation

of genetic patentswould have the

biggest

on diagnostic companies

impact

UPFRONT13

US President Barack Obama signs the healthcare reform bill at theWhite House in Washington DC on March 23. The sweepinghealthcare reform bill passed the House of Representatives and ison track to bring the most profound changes to the nation’s socialsecurity system in more than four decades.

An installation titled the Death Clock, counts the number of tobacco-related deaths since negotiations began on the WHO FrameworkConvention on Tobacco Control on October 25, 1999. WHO estimatestobacco-related deaths at 5.4 million per year; one every 5.84seconds.

NEWS IN PICTURES

Dozens of demonstrators participate in a waiting line in front of theoldest public toilets in Paris. ‘Living without toilets' constitutes a'mortal risk' according to Action Against Hunger (ACF), whoorganised a flashmob to attract attention to the lack of toilets in theworld, causing unsanitary environments for over 2.5 billion people,on the eve of the World Water Day March 22, 2010.

“The ruling is avictory for the free

flow of ideas inscientific research.

The human genome,like the structure ofblood, air or water,was discovered, not

created”


HOSPITALS IN EUROPEAccording to the Cybermetrics Lab, a researchgroup belonging to the Consejo Superior deInvestigaciones Cientificas (CSIC), the largest pub-lic research body in Spain, the top performing hos-pital in Europe is found in Sweden, while Germanyfeatures in five of the top 10 places.

UPFRONT14

32

54

87

109

6

THE COST OF A LONG LIFE

TOP 10 1 Centre Hospitalier Universitaire Vaudois Lausanne (Sweden)

The Institute of Cancer Research Royal Cancer Hospital (UK)

Universitätsklinikum Gießen und Marburg (Germany)

Centre Hospitalier Universitaire de Lyon Hopitaux de Lyon(France)

Universitätsklinikum Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg (Germany)

Universitätsklinikum und Medizinische Fakultät Tübingen(Germany)

Landstinget I Östergötland (Sweden)

Universitätsklinikum Heidelberg (Germany)

Hopitaux Universitaires de Genève (Switzerland)

Universitätsklinikum Freiburg (Germany)

Aver

age

Life

Exp

ecta

ncy

Life Expectancy

Per Capita Spending (International Dollars)82.0

81.0

80.0

79.0

78.0

77.0

76.0

75.0

74.0

5000

4500

4000

3500

3000

2500

2000

1500

1000

500

0

UnitedStates

San Marino

Monaco

Switerland

Australia

Sweden

Iceland

Andorra

CanadaFrance

Italy

Austria

Spain

Norw

ay

SingaporeIsrael

Luxenbourg

New

ZealandN

etherlands

Germany

GreeceM

alta

Belgium

FinlandUnited Kingdom

Denmark

United States

Cuba

CyprusIreland

Portugal

Japan


AROUND THE WORLD IN 80 DAYS

Our guide to the last quarter’s global events – and theirimpact on your business.

DIABETES EPIDEMIC?Researchers have announced thatChina is set to face a diabetes epidemic,with almost one in 10 adults having thedisease with most cases remaining un-diagnosed. New tests suggest that morethan 92 million Chinese adults had di-abetes, representing a major publichealth problem as it is a factor in heartdisease, stroke and kidney disease. NGHEU impact rating: ****

CARE SHORTAGEPrimary care doctors in the US areconcerned with how to care for 32 mil-lion newly-insured Americans sincethe healthcare reforms have been an-nounced. Family physicians and nurs-es are already in short supply and theAmerican Academy of FamilyPhysicians predicts a shortfall of 40,000care providers. NGHEU impact rating: ****

COSTSRISINGElderly care in Scotland could rise toUK£8 billion from UK£4.5 billion injust over two decades, claims thecountry’s public health minister ShonaRobison. While the commitment toproviding free personal care to theelderly is set to continue, Robsionbelieves that streamlining needs tostart now if they are to cut costs.NGHEU impact rating: **

FLU THREATBird flu outbreaks have killed sevenpeople across several countries so farthis year, demonstrating that the virusremains a continuous threat to humanhealth, suggests the WHO, with a majorconcern being the mutation of the dis-ease. While numbers are still low, the fa-tality rate for humans infected with birdflu remains high at 59 percent.NGHEU impact rating: ***

HEALTH PROPOSAL?John Brumby, Premier of Victoria, hasasked Australian Prime Minister to re-think its AUS$50 billion hospitals planand asked for more details about the pre-ventive health plan proposed by thecommonwealth, that is supposed to helpput the commonwealth-state blamegame to an end. This could all sparkmuch-needed debate.NGHEU impact rating: ***

JUNK FOOD ADDICTIONA report from scientistsat ScrippsResearch Institute in Florida found thatbingeing on junk food is as addictive assmoking or taking drugs and couldcause compulsive eating and obesity,presenting compelling evidence thatdrug addiction and obesity are basedon the same underlyingneurobiological mechanisms. NGHEU impact rating: ****

UPFRONT15

HOSPITAL BEDS

NETHERLANDS TOP CHART

EURO HEALTH CONSUMER INDEXThe fifth annual edition of the Euro Health Consumer Index offersa user-focused performance-related comparison of 33 nationalhealthcare systems across Europe. The report’s most remarkableoutcome according to the authors is the outstanding position ofDutch healthcare, indicating that the ongoing healthcare reform ispaying off. The index is compiled by 12 basic indicators concerningthe design of systems policy, consumer choice, service level andaccess to information.

*Per 1000 people Source: nationmaster.com

Switzerland 18.3* Japan 16.4

Norway 14.4US 3.6

Netherlands 11.1Austria 8.8UK 4.1Sweden 3.7

Germany 9.2

France 8.4

Poland 5.1

863

819

811795

488

489

565630

671

682778

787

632

NETHERLANDS

DENMARK

ICELAND

AUSTRIA

GERMANY

FRANCE

UK

ITALY

PORTUGAL

SPAIN

POLAND

ROMANIA

BULGARIA


UPFRONT16

SOUND MEMORIES

A 12-week programme at Artsdepot,an arts venue in London, UK, is har-nessing memories to powerful effectby using theatre and stage to reignitethe lost memories of dementia suffer-ers. The project, In The Limelight, haswitnessed small glimmers of hope bybringing out people’s personal storiesthrough their re-inactment on thestage, with especially vivid imagesbeing termed the “reminiscencebump” by David Rubin, Professor ofpsychology at Duke University inNorth Carolina.

With long-term memory re-maining intact in dementia sufferersyears after their short-term memoryrecall has disintegrated completely, ithas also been found that the recollec-tion of music can often remain unim-paired for even longer. Combiningthese factors, the programme hopes tore-unite families, albeit only for a fewhours a week, with the person theyonce knew – free from the anxiety andstress that overshadows the disease.

KICK IT OUTGhanaian campaign group UnitedAgainst Malaria has plans to use thisyear’s World Cup in South Africa toboost awareness of malaria preven-tion, which kills one million Africanseach year – 85 percent of which arechildren under five years old. Ninefootball teams are already involved inthe campaign that hopes to use the ex-citement surrounding the World Cupas a catalyst for highlighting the im-portance of public health and theeradication of malaria, which is bothtreatable and completely preventable.

With the slogan of “victory is inthe net”, the group have alreadybroadcast on Ghanaian radio, re-minding pregnant women to taketheir anti-malarial drugs and for allfamilies to sleep under the treatedbed-nets provided. In addition, theyhave also awarded Ghana FAPresident Kwesi Nyantakiyi his own‘golden boot’ for his contribution tofighting the disease.

SAFE WATER

Reports from the World HealthOrganization (WHO) and the UnitedNations Children’s Fund (UNICEF)says the world is on track to meet oreven exceed the drinking-water targetof the Millennium DevelopmentGoals, which aims to halve the numberof people who don’t have access tohealthy drinking water. However, thereport notes that while approximately5.9 billion people use safe drinking-water sources, a staggering 2.6 billionpeople don’t use improved sanitation.Moreover, 4000 deaths per day occuras a result of unsafe water and poorsanitation. WHO and UNICEF reportthat a lack of access to water, sanitationand hygiene affects the health, securi-ty and quality of life for children.Evidence also suggests that girls andwomen are more affected than menand boys, as unfortunately they tend tobe the ones burdened with collectingdrinking water.


17

BEAUTY TEENS

The Physician’s Coalition forInjectable Safety has sent out a world-wide warning against “Teen Toxing” –the administration of Botox and otherinjectable products to individualsunder the age of 18 for cosmetic rea-sons. It follows after a story in which aUK mother was criticised for admin-istering Botox injections to her 15-year-old daughter. The Coalitionbelieves that this disturbing reportmay be an indicator of other question-able procedures, and is keen to high-light the potential complications andrisks of injecting at such a young age;especially as Botox doesn’t actuallyprevent natural ageing – so the adageof “preventing wrinkles” lacks credi-bility. To counteract this growingtrend, the Coalition is raising the ques-tion of responsibility and strongly ad-vising that all medical procedures forteens, plastic surgery or otherwise,should be reviewed with a board-cer-tified physician.

BACK TO WORK

The British Medical Journal websitehas just published a study deliveringevidence that a programme of inte-grated care, directed at both the pa-tient and the workplace, can helppeople with chronic low back pain re-turn to work, on average, four monthsearlier than those receiving the usualstandards of care. Researchers basedin the Netherlands and Canada eval-uated the effectiveness of an integrat-ed care programme in 134 patientswith chronic low back pain. The pa-tients were split into integrated care,consisting of adjustments to theworkplace and a graded exercise pro-gramme to teach patients how tomove safely while increasing activitylevels; and ‘usual care’, which wasbuilt on normal pain treatment andlittle to no workplace involvement.

Over the 12-month study period,patients on the integrated care pro-gramme returned to sustainable workafter an average of 88 days, comparedwith 208 days for the ‘usual care’ pa-tients.

TRAVEL CHOICE

A Polish pro-abortion feministgroup, known only by the acronymSROM, has caused a recent uproar bylaunching an ad campaign promot-ing the travel of women over to theUK in order to take advantage of thefree abortion clinics offered by theNHS. The poster ad, featuring a spinon the classic Mastercard campaign,ends with the strapline “For every-thing else, you pay less than an un-derground abortion in Poland.”Under EU regulations, Britain has areciprocal agreement with Poland toprovide free medical care for anyoneneeding treatment. However, aspokeswoman for the UKDepartment of Health declared thatthere is no provision for Polishwomen to travel to the UK for abor-tions. With one of the strictest abor-tion laws in Europe, Poland viewsabortion as illegal unless thewoman’s life or health is at risk, orthe pregnancy is the result of a crim-inal act.

UPFRONT


UPFRONT18

Hospital admissions due to obesity have riseneightfold over the last decade, say figures re-leased by the NHS Information Centre,which said that the nation’s growingweight problem was having a detri-mental effect on the health service.

With one in four adults inBritain now obese, latest statis-tics show that the number ofweight loss operations,which include proceduressuch as stomach stapling,performed on the NHS havedoubled in two years. TimStraughan, Chief Executive ofthe NHS InformationCentre, said: “This reporthighlights the impact ofobesity not just on society,but on the NHS. The figuresshow a clear rise in hospital ad-missions, surgical procedures anddrug therapies to help peopletackle their obesity.”

FAST FACT

adults in Britainare obese

1 in 4

OBESITY ADMISSIONS RISEN EIGHTFOLD IN UK

A Citizens Advice report has found that seri-ously ill people in the UK are being registered‘ready to work’ because of a poorly-devisedassessment. According to the report, peoplewith advanced Parkinson’s disease,Multiple Sclerosis, severe mentalillness or awaiting open heartsurgery have been registeredas fit to work by theEmployment and SupportAllowance (ESA), brought inin 2008 to replace IncapacityBenefit. The reformed systemwas brought in to give greater sup-port to those deemed able to return to someform of work and a revised fitness for worktest was introduced at the same time.

However, Citizens Advice has found theassessment often inaccurate and not suffi-ciently sensitive. Between last October andDecember, 22,618 people consulted CitizensAdvice offices about the ESA, the vast major-

FLAWED BENEFIT SYSTEMity of them with concerns about the work ca-pability assessment – the new system de-signed to appraise someone’s potential towork. Advisers working for Citizens Advicehave expressed “grave concern” about the

number of people unexpectedlybeing found fit for work.

The charity is callingfor a full review of the sys-tem, a rethink that wouldreassess who should be el-igible for the benefit, and

study the accuracy of themedical assessments.Responding to the report, the

Department for Work and Pensions said themedical assessment system was being adapt-ed and changes would soon be announcedthat would make it more sensitive to theneeds of cancer sufferers, people with learn-ing disabilities and autism, and those withfluctuating conditions.Source: guardian.co.uk

A joint study by the UK andGermany has shown thatblood pressure drugs can re-duce the ability of breastcancer to spread to otherparts of the body. The studyon patients taking beta-blocker drugs, showed thatthe medication reduced therisk of death from breastcancer significantly. Thewomen were 71 percent lesslikely to die from breast can-cer and less likely to havetheir breast cancer comeback in the same place. It isbelieved that the drugs mayblock the production of hor-mones that would otherwisetrigger the spread of cancer.

Earlier studies haveshown that the ability ofcancer cells to increase innumber and then spreadcan be boosted by stresshormones. Beta-blockershave the power to reducestress hormones’ ability tostimulate the cancer celland trigger the spread ofthe disease. However, thestudy has yet to be pub-lished so it is hard to assessit’s reliability.UN

DERP

RESS

URE

Between last October and

December

people consultedCitizens Advice offices

about the ESA

22,618


GATES PLEDGES US$10 BILLION FOR VACCINES

STUDY HIGHLIGHTS RISKS

provided treatment and doesn’t payfor emergency evacuation or repatri-ation – without an internationalhealth insurance policy, this couldcost several thousand pounds.”

Moreover, the studyfound that one in five

employers may beleaving them-selves exposed tosignificant liabil-ity costs abroad.

Twenty percent ofthose surveyed were

unaware that their em-ployers liability insurance may

not always cover staff working over-seas and that country-specific poli-cies may be required. The researchalso revealed that 48 percent ofcompanies neglect to conduct fullhealth assessments of the destina-tions they send staff to, while 44 per-cent don’t organise vaccinations fortheir employees where required. Ofequal concern is the finding that 32percent of companies surveyed failto make regular contact with staffworking abroad and that one in 10companies leave their expat em-ployees totally in the dark overwhere to turn to for healthadvice. A further 24 percent do notprovide Employee AssistanceProgrammes (EAP) for psychologi-

cal support while work-ing overseas.

At the reccent World EconomicForum in Davos, Switzerland,revered business tycoon andfounder of computer softwaregiant Microsoft, Bill Gates, an-nounced with his wife that theywill commit US$10 billion overthe next decade to help research,develop and deliver vaccines forthe world’s poorest countries.

According to Mrs. Gates,who announced the initia-tive last Friday, thevaccines are nowthe “number onepriority” of theGatesFoundationbecause of the“incredibleimpact” theyhave on chil-dren’s lives. BillGates added thatthe next 10 yearsmust be

defined as “the decade of vaccines”.The boost comes after a model

used by the Foundation and devel-oped by a consortium led by theInstitute of InternationalPrograms at the Johns HopkinsBloomberg School of PublicHealth stated that significantlyscaling up the delivery of vaccinesin developing countries could pre-vent the deaths of some 7.6 million

children.

patients were admitted to hospitalbecause of obesity in 2009

7990

FAST FACTTwenty percent of companies thatsend employees abroad for pro-longed periods fail to provide themwith international health insurance, astudy has revealed. Conducted byPMI Global – a pioneeringnew service offering anintegrated packageof insurance andhealthcare sup-port for employ-ees abroad – theresearch has high-lighted the need for agreater duty of careamongst many employers thatassign staff overseas.

The study also indicated that forthose staffed within the EU, as manyas 36 percent of companies rely on in-dividual European Health InsuranceCard’s (EHIC) for their employees’health cover. “It’s encouraging that alarge number of UK businesses arewell equipped for sending employeesabroad but the financial implicationsfor those that fail to provide employ-ees with suitable health insurance canbe considerable,” says Rachael Floyd,Operations Director, PMI Global.

“While the EHIC entitles anyresident in the UK to receive emer-gency healthcare treatment whiletravelling in the European EconomicArea (EEA) and Switzerland, restric-tions mean it isn’t a substitute forstandalone international health in-surance. For instance, an EHIC will

only provide access toemergency, state-

of companies rely on individual

European HealthInsurance Card’s for

their employees’health cover

36%

UPFRONT19


UPFRONT20

Health and environmental matters often take a back seat when obscuredby headline-grabbing issues of the day – in particular the economic crisis,growing public debts and rises in unemployment. But in reality, health andenvironment are key factors, which underpin, in addition to the well-beingof our citizens, economic performance, recovery and success.

There can be no sustained economic recovery without a healthy popula-tion, and without high environmental and health standards. It is thereforecrucial to understand how environmental factors affect the health of our cit-izens and of society as a whole.

The incidence of asthma and allergy is on the rise in Europe. One in everyfive children suffers from a chronic respiratory condition or allergy. Thismeans a lower quality of life for those children and more need for healthcare.There is a pressing need to address air quality and in particular in indoor en-vironments – we need to do more to tackle the effect on people's health.

Climate change is, of course, another significant factor with massive im-plications for us all. We are seeing more and more extreme weather events– such as floods, windstorms, heat waves and cold snaps. Changing climatepatterns trigger changes in the transmission and spread of certain diseases.Air quality presents problems in the event of heat waves as there is little orno dispersion of pollutants. And excessive heat, and excessive cold, leads toadditional deaths.

The European Commission and the EU Member States have made re-ducing the social impact of the financial crisis – and thereby reducing itshealth impact – a key priority. The Commission has already put forward aCommunication on ‘solidarity in health’ last year, to help member statestackle inequalities in health between and within EU countries. This is also akey priority of the current Spanish EU Presidency. In addition, addressinghealth inequalities is also part of the new European Strategy for smart, sus-tainable and inclusive growth (known as EU 2020), which the commissionput forward last week, and which will guide all EU policies.

The main achievement of the action plan has been the integration of thekey policy areas of environment, health and research at European level. Thetime has now come to build on progress made and do better and do more.

I am confident that we can find a way to further strengthen our cooper-ation for the years ahead. We can give greater political impetus to thisprocess and keep the momentum between the high level conferences thatgo on. Naturally, it is important that international cooperation is translatedto national level, and focused on helping member states effectively imple-ment actions.

Source: Speech at the WHO Fifth Ministerial Conference on Environment and Health

A FULL AGENDAIncoming European Commissioner responsible forhealth and consumer policy, JOHN DALLI, outlineshow he sees the synergies between health and theenvironment in Europe.


UPFRONT21

A NEGATIVE DIAGNOSIS

FAST FACT

Over the course of a day, the brain uses the sameamount of energy contained in

– just 12 watts of power

2 largebananas

Kevin Barron, who isChairman of the health commit-tee told the BBC: “The govern-ment must make a bold decision– if improvements fail to materi-alise, it could be time to blow thefinal whistle.” Meanwhile theNHS Confederation, the bodywhich represents PCT man-

agers, has retaliated byclaiming the re-

port does notaccurately re-flect the per-formance of

its members.Steve Barnett,

CEO of theConfederation, told the

BBC: “We continue to believethat the current system de-signed to achieve value formoney and hold organisationsto account has been beneficialfor NHS patients.”

The report follows the re-lease of figures showing thenumber of managers within theNHS has rocketed by 80 percentwithin the past decade.

UK health bosses are failing tokeep a proper eye on the hospi-tals under their authority. That’sthe verdict of a group of MPswho have raised concerns overthe conduct of primary caretrust chiefs, who are responsiblefor 80 percent of the UK£100billion NHS budget. The MPs,who are members ofthe House ofCommons healthcommittee, saidthe PCT man-agers oftenlacked the skillsor knowledgeneeded to encour-age the delivery of themost cost effective care. Theyalso criticised them for failing toensure hospitals use the most upto date drugs and treatments forpatients. It blamed some ofthese shortcomings on the con-stant reorganisation and highstaff turnover within hospitalsand urged the government toprovide more support for themanagers of PCTs.

The number of managers

within the NHS hasrocketed by

within the pastdecade

80%

BILLION SPENT ON FAKE MEDICINES

Outgoing European Union industrycommissioner Guenter Verheugensaid in December he was “extremelyworried” about counterfeit medi-cines after 34 million fake tabletswere seized at EU custom points injust two months.

Jim Thomson, chairman ofthe European Alliance for Accessto Safe Medicines, which receives

funding from the drugindustry, said tests

by his group hadshown that 62percent of med-icines pur-

chased onlinewere fake or sub-

standard. “Does in-dustry have a vested

interest in this? Absolutely. But Ithink society should have an evenbigger interest in getting thisstopped,” he told Reuters.“Counterfeit medicine is costingthe industry a huge amount ofmoney but it's costing healthcareproviders a lot more.”

Overall, 21 percent of 14,000people surveyed in 14 countries saidthey had bought medicines illicitly,with the rate ranging from 38 and 37percent in Germany and Italy, re-spectively, to 12 and 10 percent in

Britain and theNetherlands.

Weight-loss medicinesaccounted for nearly half of

all online purchases, followedby prescription treatments for

flu, such as Roche'sTamiflu; pills

for erectiledysfunc-tion; quit-smoking

drugs; andpain-killers.

Source: Reuters

Western Europeans spend an esti-mated €10.5 billion a year on illicit-ly sourced medicines, many of themcounterfeit, according to a Pfizer-sponsored survey published inMarch. Germans and Italians buythe most prescription-only drugswithout a prescription, either overthe internet or on overseas trips, innightclubs, in shops and via friends.

Counterfeit medi-cines often containthe wrong oreven toxic ingre-dients and are agrowing healththreat world-wide, especially inpoor countries, ac-cording to the WHO. Theyare also a thorn in the side of com-panies like Pfizer, the world's biggestdrugmaker, whose impotence pillViagra and cholesterol drug Lipitorare two of the favourite targets for il-legal counterfeiters.

Critics argue that the industryis keen to play up the issue in orderto back its demands for tighter con-trols on medicine supply and pack-aging, thereby protecting its brands.

But the problem is being takenseriously by European

officials.

of 14,000peoplesurveyed in 14

countries said theyhad bought

medicines illicitly

21%


UPFRONT22

Much has changed over the 150-year history of the post ofChief Medical Officer. Infections killed people early in theVictorian era and poverty, squalor and a lack of clean waterboosted their impact. And since then, while vast improvementshave been made, priorities have been moved to the disease, dis-ability and early detection, due to conditions including heartdisease, stroke, diabetes, cancers and chronic lung disease. Thepost has been taken by a series of exceptional individuals, fromSir John Simon who inisited on publishing independent annu-al reports on all subjects related to public health, to Sir WilsonJameson, who managed to sustain medical care during the blitz.

Most observers would also put Sir Liam Donaldson in thiscategory. Appointed in 1998, Donaldson has provided a widerange of policy recommendations to the government, such assmoke-free public places, embryonic stem cell research andconsent for organ and tissue retention. He has played a majorrole in campaigns that are now playing a crucial part in im-proving the health of the nation. The ban on public smoking –perhaps his greatest achievement – owed much to his supportagainst government opposition. In March 2009, he also startedan important new drive in the fight against alcohol by de-manding a minimum unit price, which while currently dis-missed by Gordon Brown, will certainly remain a key issue inthe days ahead.

Nevertheless despite his achievements, Donaldson has facedsome criticism, mainly for over-reacting to the potential swineflu threat, although it’s argued that at least Britain was preparedfor what may well have been a lethal epidemic. He has also in-volved in decisions regarding the Modernising MedicalCareers (MMC) systems and the Medical TrainingApplication Service (MTAS), which it claims champions com-petence rather than excellence and substantially reduces thelength of the training programme required to become a con-sultant. However, both been systems have been controversialsince inception and in an unprecedented demonstrationagainst it, around 12,000 junior doctors marched againstMMC and the associated MTAS in March 2007.

Despite some failures it is clear that Donaldson has alsoachieved much over the past 12 years and there is no doubt thathis successor has a lot to live up to to ensure that they match hisindependence and imagination.

A NATION’S DOCTORIn December 2009, SIR LIAM DONALDSONinformed the UK government that heintended to step down from his role as ChiefMedical Officer in the summer of 2010. NGHtakes a look at what he has achieved in the12 years he has held the post.


UPFRONT23

In this quarter’s issue of EHM, NGH’s sister publication focused on the UShealthcare sector, TERRY MASON, Commissioner for the Chicago Departmentof Public Health, explains the importance of effective IT for a Lean organisa-tion and reveals how technology can help manage both the day-to-day op-erations and drive the collection of data for performance metrics.

To read this, or any other article from EHM, go to the website www.exec-utivehm.com and click on ‘current issue’

For the first time an operation ofneurosurgery has been capturedand retransmitted live, in 3Dstereo and in full HD.Professor Jacques G.Verly and histeam from theLaboratory forSignal andImageExploitation(INTELSIG) ofthe Department ofElectrical Engineering andComputer Science (InstitutMontefiore) of the University ofLiège (ULg) designed the architec-ture of the entire chain of capture,transmission, and projection, andprovided the technical manage-ment of this 3D event.

The ULg-INTELSIG teamalso developed, in collabora-tion with IntoPIX,a solution for3D-stereo full-HD retrans-mission in

JPEG

2000, guaranteeing the spectatorsvisual quality. The transmissionof the images and the sound wasperformed using a set of opticalfibres capable of 1 GB. This com-

pany had to complete itsnetwork over 300

metres right in thecentre of the cityto bring the fi-bres to the cine-ma. The fibres

were entirely ded-icated to the project

and had to be fusion-spliced to provide a continuousglass conduit over the 16 km be-tween the CHU and the cinema.

At the far end of the chain,the 3D-stereo visualisation systemconsisted of DP2000 projector and3D glasses.

The European Healthcare Fraudand Corruption Network(EHFCN) has launched its aware-ness campaign highlighting thatmore the €56 billion is lost each yearto healthcare fraud and corruptionacross European Union countries.The EHFCN awareness campaignwants to stress that the money lost tohealthcare fraud and corruptioncould be used for purposes such asimproving healthcare infrastructure,healthcare education, technologyand other health services, for thebenefit of every European citizen.

In fact €56 billion would rep-resent the funding necessary to payfor over 2.5 million more nursesacross Europe every year; for over3500 new healthcare clinics inEurope every year; or for over 1.7million incubators in Europe everyyear. Conversely, every cent lostundermines healthcare systems’ ca-pacity to provide essential treat-ment and will ultimately lead tolower quality of care, and a reducedavailability of services, treatmentsand care.Source: www.european-hospital.com

€56 BILLION LOST TO FRAUD

A WORLD FIRST

An operation of neurosurgery

has been captured and retransmitted

live, in

and in full HD3D stereo

FAST FACT

The UK’s NHSbudget is

predicted to reach

by 2011

UK£110 billion


UPFRONT24

RECESSION BACKLASHThe effects of the recession are having a detri-mental effect on the nation’s workforce ac-cording to experts at HeartMath, arecognised authority on stress-reduc-ing and resilience-building solu-tions. The economic downturnforced many companies to cutback their workforce in orderto survive the recession andsince then cases of stress andabsenteeism have been on therise amongst the remainingworkforce, causing healthcarecosts to increase. Those whomanaged to avoid recession-related layoffs have beenburdened with heav-ier workloadsand longer

hours, forcing increasing numbers of employeesto turn to employee assistance programmes forhelp. A worldwide benefits consulting firm sur-

veyed 282 large companies and found that 22percent reported an increase in un-

planned absences, and 78 percent ofemployers cited “excessivework hours” as a leadingcause of employee stress.Towers Perrin also conduct-ed a survey of 321 compa-nies and found that the

2009 average annual health-care cost per employee is

US$9660 – an increase ofsix percent over

their 2008figures.

The Spanish Minister of Health has an-nounced that all autonomous communi-ties will be integrated into a single digitalhealth system by the end of 2010. Thenetwork will allow for all Spanish citizensto receive care in any health establish-ment, as well as allow physicians to ac-cess patient information. Theend-of-year deployment deadline wasannounced at the World of Health ITConference in Barcelona.

Not all information will be shared,only the primary history, such as hospi-tals visits and medications used; further-more, the patient will have the right toblock more intimate medical details. Allcitizens will be assigned an identity codegenerated by a database of the NationalHealth System. Minister of HealthTrinidad Jimenez, who announced thedeadline, added that Spain has become aleader in e-health with already 98 percentof primary care physicians using digitaltechnologies, such as electronic healthrecord systems.

The rest of Europe is close behind. Itis expected by 2015 the entire Europeancommunity will have a unique system ofelectronic health. Source: hitm.eu

INTEGRATION IN SPAIN

A third of children globally are not getting enoughexercise, according to a study by the World HealthOrganisation. The study led by WHO memberRegina Guthold found that a third of children spendthree hours a day or more watching TV or on com-puters. The study researched the lifestyles of 70,000teenagers in 34 countries between 2003 and 2007and the results were published this year in theJournal of Paediatrics. It defined adequate phys-ical exercise as being at least one hour spentdoing exercise, outside of school gym classes, fivedays a week. Those children who spend three ormore hours a day watching TV, playingcomputer games or chatting withfriends, were categorised as havinga sedentary lifestyle.

The survey found that only aquarter of boys and 30 percent ofgirls were getting adequate exer-cise. The highest percentage ofactive boys, at 42 percent, livedin Uruguay. MeanwhileZambia had the lowest numberat just eight percent. The most ac-

tive girls were in India with 37 percent doingenough exercise while Egypt had the least numberat just four percent. The least sedentary childrenhailed from Myanmar with just 13 percent of boysand eight percent of boys classified as sedentary.In the study Guthold didn’t explain the rea-sons behind the inactivity of children, buttold Reuters she believed urbanisation tobe a major contributor, as well as easy ac-cess to cars and TVs. “I guess it’s prettysafe to say we have a huge problem withphysical inactivity among school chil-dren around the globe and we shouldtake action,” she said.

CHILD’S PLAY


UPFRONT25

Companies in this issue are indexed to the first page of the article in which each is mentioned.

Aerometrix 117

AGFA 71

Allmed Medical 59

Bracco IFC

Centers for Disease Control

(CDC) 98

Circle 112

European Commission 26, 32

European Health Technology

Institute for Socio-Economic

Research (EHTI) 82

European Parliament 26

European Vaccine

Manufacturers 98

Foster & Partners 112

Frost & Sullivan 66, 88

GE Healthcare 53

Gremed Inc 101

HandGiene Corp 6, 108, 109

Health Care Strategy

International 26

healthCare cybernetics 26

Hermes Medical Imaging 75

Hôpitaux Universitaires de

Genève 106

IBM 76

ICT Results 60

iStategy 81

MDS Nordion 61

Meettheboss.com 47

National Health Service 48

National Institute of Clinical

Excellence (NICE) 62

NHS 36, 112

NNIT 2

Norrbottens Läns Landsting 54

Organisation for Economic

Co-operation and

Development 48

PA Consulting Group 116

Parliamentary Assembly of the

Council of Europe (PACE) 98

PathoFinder 114, 115, IBC

Patricia Seybold Group 46

PricewaterhouseCoopers 94

Relay Health 87

Symantec 11, 92, 93

Ubichem 34

Verizon 92

Vifor Pharma 4, 44, 45

Visage Imaging 69

Vital Images 79

Wi-Fi Alliance 90

World Health Organisation

(WHO) 48, 98, 106

Ziehm Imaging 72, 73, OBC

HOSPITAL 2.0Welcome to thehospital of the futureP122

MIRACLE CUREA look at the potentialof pharmacogenomicsP110

DON’T MISS...

COMPANY INDEX Q2 2010

INNOVATIONINSTITUTEWith EHTI’s ExecutiveDirector RosannaTarricone P82

FAST FACTAccording to the WHO,

every day around the world asa result of unsafe water and

poor sanitation

4000 people die


26 www.nghealthcareeurope.com

CLOSING THE GAP

SPECIAL REPORT

Cross border health.indd 26Cross border health.indd 26 7/4/10 16:25:227/4/10 16:25:22

www.nghealthcareeurope.com 27

On 2 July 2008, the EU Commission unveiled a healthcare package designed to make it easier for patients from one member state to get medical treatment elsewhere in the EU. Aimed at ensuring a clear and transparent framework for the provision of safe and high-quality cross-border healthcare within the EU, the commission issued a proposal for a directive on the application of patients’ rights

in cross-border healthcare. Under the proposals, patients would not have to get their doctor’s approval for non-hospital care abroad and would be able to claim up to the amount of what their treatment would have cost in their home country.

Jo Leinen, Chairman of the European Parliament’s ENVI committee on cross-border healthcare, believes that EU health policy should give all citizens equal access to quality healthcare. He says that policies should be centred on the patients and should aim to reduce inequalities in healthcare between and in the member states. “Th e EU can off er added value for the member states by providing instru-ments for sharing good practices, knowledge and information across national bor-ders, by supporting research and by pooling resource,” he explains, before going on to explain the potential benefi ts of the cross-border healthcare directive. “It aims to introduce rules for the provision of healthcare in member states diff erent from the patient’s country of affi liation, as well as to recognise prescriptions from other member states. Th e rulings from the European Court of Justice (ECJ) make it clear that there is a need for legislation on patient mobility. Th e defi nition and set up of these policies must, however, not be left to the ECJ, but to the elected representatives of the citizens.”

Leinen believes that in a Europe without borders, freedom of movement should be applied to the healthcare sector and set up in a favourable way to patients, while at the same time ensuring that the principles of access to appropriate healthcare in a geographical proximity is taken into account. He says that the fi eld can become a prime example of how the EU is working to improve the quality of life, and in particular the healthcare conditions, of its citizens. “Already a citizen of one member state is entitled to healthcare in any other member state when the purpose of the stay was not medical treatment – for example, in the case of accidents or sudden illnesses the costs of the treatment will be covered by the public health insurance system of the home country. Furthermore, planned healthcare in another member state is possible, if the treatment cannot be provided in the home country. However, problems with implementing the underlying EU regulation on the coordination of social security schemes remain and must be addressed in the EU legislation.”

Currently, with a lack of legal certainty regarding the entitlements of patients to seek healthcare in other member states – and more specifi cally, the limits that member states can impose on such healthcare abroad and the level of fi nancial cov-

With high quality health services becoming an increasing priority, discussions around cross-border healthcare systems are coming to a head. Will it ever be possible to fi nd a solution that suits all? And just what and where is the future of cross-border healthcare in Europe? NGH investigates.



erage – patients are left in a state of legal uncertainty, claims Leinen. “Th e EU is now seeking to clarify this situation with the goal to improve the mobility of patients. In particular, the issue of pre-authorisation of treat-ment in other member states needs to be clarifi ed again, in order to ensure that the fi nancial liability of national healthcare systems remains intact, and that they are still able to function properly.”

Last April, in the fi rst reading of the directive, the European Parlia-ment made it clear that the proposal was not about the free movement of health service providers but about patient mobility, and underlined that the autonomy of the health systems in member states should remain untouched. Th e parliament also voted in favour of the proposal to establish a Euro-pean Reference Network of highly specia-lised centres that will provide high quality care to patients to receive information and to share their experiences. Th e network could also help maximise the cost eff ective use of resources, as well as develop stan-dards and benchmarks.

Since the original proposal for a di-rective in 2008, little progress has been made towards it. In fact in December 2009, almost 18 months on, 11 out of 27 coun-tries, including Spain, Greece, Poland and Lithuania, blocked the ratifi cation of the draft European directive on cross-border healthcare. So why is there such opposition to a directive that is looking to improve healthcare systems across Europe?

Dr Constantine Constantinides, CEO of healthCare cybernetics, based in Greece, one of the countries opposing the directive, believes that the impact on healthcare and its delivery will be negligible. He says that while the directive may lead to a ‘forced’ improvement of the quality of care and increased effi ciency at home, as people are discouraged from seeking treatment abroad, it will create a logistical headache. “Some feel that the directive will lead to the emergence of new centres of excellence – facilities specialising in certain conditions – and that certain locations will become good at this because of the experience and knowledge associated with treating large number of ‘same condition’ patients,” he says. “Certain

technocrats, with incomplete understanding and appreciation of how healthcare delivery and consumption works, felt that this would allow for the more effi cient distribution of care provision. For example, they cited the possibility of an EU as opposed to a national waiting list system. Th is could alleviate congestion at some hospitals whilst providing work and revenue for hospitals with spare capacity, but is not necessarily practical.”

In January 2010, a group of ‘global health experts’ at the London School of Hygiene and Tropical Medicine and the Indian Institute of Management in Bangalore suggested fl ying British NHS patients to India, where there were no waiting lists and costs were considerably lower. Th e government

ruled it out, probably for political reasons, but also possibly on practical grounds – shunting patients between countries, even if it is to ‘near-abroad’ (less than a three-hour fl ight) destinations, is not feasible, says Constantinides. “At the International TEMOAS Conference in Cologne in November last year, my presentation looked at the concept of distributed healthcare delivery, where the diff erent elements of the care cycle could be provided at diff erent loca-tions and by diff erent providers – the opposite of a one-stop shop. I had to conclude that this, though technically possible, would be a compromise solu-tion as opposed to a choice solution, and defi nitely not in the best interests of the patient.”

And it’s not just continuity of care that is an important consideration in the directive; Constan-tinides believes that the fi rst big challenge to the successful implementation of the directive refers to

the provision of ‘legal certainty’, the defi nition of which is currently still missing from the proposal. “Countries are opposing the directive for very simple economic and logistical reasons – they feel that as it stands the di-rective will make them victims rather than benefi ciaries.”

He also reveals a number of other technical stumbling blocks that he believes mean that the proposal is currently unworkable, including the direction of patient fl ow, problems around fi nancial responsibility and reimbursement, patient safety and non-implementation of e-health. In terms of direction of fl ow, some countries fear they would be inundated by foreign patients, whilst others fear the fi nancial and political implication of their citizens fl eeing the country for treatment abroad.

Financial responsibility and reimbursement, including issues such as costing, pricing and payment procedures, has not been resolved either, says Constantinides. He believes the Disease Related Grouping System (DRG) suggested for costing and pricing services is fl awed and can only work if there is a large movement of patients and a balanced fl ow, which will tend to cancel out any credit and debit injustices.

Th e third issue – responsibility for ensuring patient safety – will in-volve the dispatching country taking responsibility for the safety of the patient going for treatment abroad; if nothing else, the authorities must be able to advise the patient on suitable and reliable healthcare facilities. Constantinides explains that in such a scenario, the authorities, or payers, will need to know who they will be dealing with – for example, whether the hospital or facility has some form of accreditation or medical staff with appropriate and adequate insurance cover.

“Countries are opposing the directive for very simple economic and

logistical reasons – they feel that as it stands

the directive will make them victims rather than

benefi ciaries”

Dr Constantine Constantinides

1

32

AimsThe three stated aims of the cross-border healthcare directive are:

• To help patients exercise their rights to access cross-border care

• To give patients assurances about the safety and quality of cross-border healthcare

• To help national health systems cooperate and achieve economies of scale



Constantinides believes that, unfortunately, the blocking of the di-rective by certain member states will change very little. He believes that during 2010 governments around Europe will have many other economic and fi nance related priorities. In fact, as it is, we are seeing even the best-run EU countries announcing freezing or cuts in healthcare-related spending. “Contrary to simplistic reasoning and thinking, during the recession we have documented a sharp drop in patient mobility and medical tourism.

Constantinides also highlights the important issue of e-health. While governments of EU countries have spent millions of euros on e-health initiatives, almost a decade later there is still no one consistent or broadly implemented system in clinical practice. Th is poses a huge challenge and he points out that the other issues of concern cannot be successfully addressed in the absence of universal e-healthcare adoption and implementation.

Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly growing practice of travelling across international borders to obtain healthcare. It also refers pejoratively to the practice of healthcare providers travelling internationally to deliver such care.

Services typically sought by travellers include elective procedures as well as complex specialised surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery and cosmetic surgeries. However, virtually every type of healthcare – including psychiatry, alternative treatments,

convalescent care and even burial services – is available. As a practical matter, providers and customers commonly use informal channels of communication-connection-contract, and in such cases this tends to mean less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.

Over 50 countries have identifi ed medical tourism as a national industry. However, accreditation and other measures of quality vary widely across the globe, and there are risks and ethical issues that make this method of accessing medical care controversial.

The future of healthcare?

CUBA has been a popular medical tourism destination for more than 40 years. Thousands of patients travel to Cuba, particularly from Latin America and Europe, and in 2006, Cuba attracted nearly 20,000 health tourists. Medical treatments include joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60-80 percent less than in the US.

Factoid: In 2006, Cuba attracted nearly 20,000 health tourists

GERMANY is a destination for patients seeking advanced medical technology, high standards, safety and quick treatment. A high hospital density, with twice as many hospitals per capita as the US, results in shorter waitlists for treatment. Costs for medical treatment compete well with other developed European countries and are commonly 50 percent of those in the US.

Factoid: German medical costs are commonly 50 percent of those in the US

INDIA’s medical tourism sector is expected to experience an annual growth rate of 30 percent, and estimates of the value of medical tourism to India go as high as US$2 billion a year by 2012. Advantages for medical tourists include reduced costs, the availability of state-of-the-art medical technologies and a growing compliance with international quality standards.

Factoid: Indian medical tourism is set to be worth US$2 billion a year by 2012

THE PHILIPPINES has been growing as a destination for medical tourism. The US Medical Tourism Association magazine reported that this services sub-sector grew eight percent in 2007. The number can be expected to grow as American healthcare costs rise, or if pending legislation results in an increase in patient wait times for surgical procedures.

Factoid: The Philippines’ medical tourism sector grew eight percent in 2007


During a recession, the associated uncertainty about jobs and personal fi nancial viability, means people are put off going abroad for care – unless it is absolutely necessary of course.”

Unlike Constantinides who foresees a logistical head-ache in the formation and implementation of the directive, Dr Uwe Klein, CEO of Germany-based Health Care Strat-egy International, believes that the healthcare system across Europe will benefi t from increased quality and fi nancial aid and sees a certain amount of innovation injected back into the industry, because countries will need to stay competitive in order to keep – and perhaps attract – patients. “Th e cross-border healthcare directive is important because it gives all the nationals of EU countries the right to select a healthcare provider of their choice. And undoubtedly there will now be a big stimulus for more customer orientation in the healthcare system,” he says. “As we all know, a focus on customers is not always a big issue for some medical institutions, so it seems this will become increasingly important as patients become more challenging in the types of services they demand.”

While Klein admits that the main challenge for the directive is the highly fragmented situation – for instance, there are various regulatory legislations across the region and the delivery system will need to be standardised – he says

that this not the intention of the directive; it is simply about opening up more choice for patients to select their healthcare provider. “We’re living in a democratic market and as such there are many private initiatives that are trying to ensure patients are as mobile as possible in terms of their health-care choices. Th ere are German insurers, for example, who are going abroad and setting up contractual networks with partner clinics. And beyond that there is a very clear jurisdic-tion from Brussels in the compensation of patients who have a reason to go abroad, such as long waiting lists and so on. If patients knew more about this, or if patients could get legal advice from a host country as opposed to their home country, the national health system would need to pay for it. Th is has occurred many times and every patient has won their case.”

Klein and Constantinides both believe that this brings a welcome opportunity for the EU to take the directive back to the drawing board and re-draft it. However, Constantinides

Dr Constantine Constantinides has a number of recommendations in regard to the challenges currently up against the directive:

Direction of Patient Flow: With regards to patient fl ow, we recommend that a study be commissioned (which could take the form of European action) to study the direction of patient fl ow, the volume and economic dimensions. The fi ndings of the study should be used to pre-emptively instigate suitable measures aimed at averting disruptive challenges to the health systems of EU-member states likely to be net recipients of patients.

Financial Responsibility/Reimbursement: As for fi nancial responsibility/reimbursement, we again recommend, as a fi rst step, that an EU-wide survey be conducted to determine which healthcare facilities are DRG and eBilling compliant, and can thus participate in the scheme envisaged by the directive. Furthermore, laggards should be encouraged or helped to conform. And as I commented already, the DRG system is fl awed, but this is the best we have for now.

Responsibility for ensuring patient safety: When it comes to responsibility for ensuring patient safety, we suggest that the authorities in the EU-member states involved in cross-border healthcare, collaborate to compile a (dynamic) database of assessed and approved healthcare facilities/providers. This database should be centrally stored and accessible by all interested parties. This database could be consulted by patients, authorities and referring physicians – for the obvious reasons.

Implementation of eHealth: Finally, on the issue of implementation of e-health, we have a similar recommendation – that an EU-wide survey be conducted to determine which healthcare facilities are e-health compliant, and can thus participate in the provision of cross-border health services. Furthermore, laggards should again, be encouraged or helped to conform. And of course, we will need to establish a new profession, that of Professional Medical Coder. In this regard, healthCare cybernetics has taken the initiative of developing a Medical Coder Course and plans to soon offer seminars on the subject.

Tackling challenges

“Patients are left in a state of legal uncertainty and the EU

is now seeking to clarify this situation with the goal to improve

the mobility of patients” Jo Leinen



“Th e cross-border healthcare directive is

important because it gives all the nationals of EU

countries the right to select a healthcare provider of

their choice” Dr Uwe Klein

“God only knows” when asked about the next step for the directive. “Even before the directive was vetoed, we started seeing the issue op-portunistically included in the agenda of conferences. Aft er the veto, we started seeing ‘topic-specifi c’ conferences being opportunistically

staged with academic, politicians, tech-no-bureaucrats and some real medical tourism insiders going round in circles, inconclusively regurgitating the same old mish-mash – what comes out of these debates, presentation and deliberations can be best described as waffl ing.”

Leinen, Chairman of the European Parliament’s ENVI committee on cross-border healthcare, concludes by saying that the Spanish presidency has promised to continue working on the directive and that in the meantime, Europe will rely on ECJ rulings when it comes to cross-border healthcare and treatment. “Th e parliament will certainly not reduce the

pressure on the council to work on this proposal and come forward with solutions and it will not allow member states to abandon this important dossier.” Indeed, with the proposal at a critical turning point, the very success of the directive depends on it.

is quick point out that a revised draft of the directive is yet to be seen. “If there are any individuals involved in ‘back to the drawing board’ activi-ties, they are keeping very quiet – we have not seen any signs that even a draft of a revised directive exists,” he says. “Practical and logical recom-mendations submitted during the original con-sultation, for the most part, seem to have been ignored by those draft ing the directive. And it’s unlikely we will see a second consultation. All I can say is that unless the identifi ed issues of concern are not only addressed but also resolved, we are unlikely to see any countries having a change of heart and rushing to sign.”

Uwe believes that the current directive dis-cussions have been frozen due to the fi nancial crisis. “I think we will just have to wait and see,” he says. “But, it all goes back to patient mobility, which has a basis in the philosophy of human rights and thus won’t go away – it’s the basic right of EU nationals to make a decision about their lifestyle and healthcare has to be part of that – it just needs to be feasible and organised so that the right systems are in place to allow this.”

Constantinides agrees that there will not be a defi nitive ratifi ca-tion whilst Europe remains in recession. In fact, he goes as far as saying


As European Commissioner responsible for the Digital Agenda, Ihave publicly stated that one of my priorities will be to acceler-ate the positive impact of ICT on everyday life. In that vision, e-health will play a key part.

There are many reasons for this. Latest research indicates that 29 percentof the EU’s population will be over 65 years old in 2050. And we are battlingthe deepest financial crisis in decades. These facts are not news – but com-bined, they tell us that great innovations will be needed to keep people healthyand comfortable in the coming decades. The grand theme of our time is theneed to do more with less. Improving e-health systems is one of the best wayswe can address this challenge.

At the practical level, powerful truths are lined up in support of e-health.Chronic disease management already accounts for seven out of every 10 eurosspent on healthcare. Knowing this is the area where e-health has the most po-tential, it would be foolish not to make the most out of it. I know all too wellthat it is easier to talk about these problems than it is to fix them. But the pointremains that the next few years represent a huge opportunity.

The commission has promoted and co-funded research in ICT for healthfor more than two decades. This has translated into more than 450 collabo-rative projects involving partners from all over Europe, and more than €1 bil-lion in funding. In addition to saving lives and containing costs, this hashelped to build a growing industry turning over €15 billion per year. And thisis the fastest growing market in the health sector.

This is good, but to truly harness this trend we must explore new avenues.For example, I see e-health as a way to offer more control for patients on theirown health. Already today, people go and look for health information on theinternet – often before they even speak to their doctor. Some say we shouldfight this trend; I say we should make the most of it. Simply, patients mustnow find their doctor on the internet. And the proof that this works is in ourearly success with telemedicine.

I also see e-health as a means to achieving economic recovery. E-healthis the fastest growing part of healthcare. And ICT is one of the main innova-tion factors of the pharmaceutical and medical devices industries – two in-dustries traditionally strong in Europe. So this is also about new jobs andsuccessful businesses, and taxpayer savings. E-health builds on two of the bestassets of Europe: its health systems, and its technologies.

E-health also requires collaboration among all players in the healthcaresector. There is no single actor – government, doctor, patient or manufactur-er – setting the terms of e-health. Instead, success will only come from a trulyjoint effort.

That last point is an important one. E-health has great potential, but weneed each other to realise that potential. In my mind, the technology is moremature than the market. Yet we have already come a long way – and I value

that. For example, our 2004 E-health Action Plan helped to test andexpand our boundaries – showing that political cooperation at theEuropean level was possible. After that, the Lead Market Initiative hashelped us to understand the true potential for the growth of e-healthmarkets. And now we are seeing that large-scale projects such asepSOS enable continuity of care across national borders. We areready to work with and support all member states in epSOS or simi-lar large-scale actions.

But we need to do more. Take, for example, the E-healthGovernance Initiative. This initiative consolidates not only new ways ofworking with governments across Europe, but also with stakeholders. Inmy view that delivers two crucial things to the field: 1) the predictabili-ty; and 2) the transparency that is so critical in enabling large groups ofinterests to work together.

Yet I am fully aware of just how difficult it will be to achieve thisagenda. To bring about change, we will need to convince various layers

of governments and policy areas, but also many industries and stake-holders – in particular health professionals and patients. We need to bepragmatic; I do not want to leave anyone behind. The economics ofhealthcare gives us all a mutual interest. In addition to better patient care,we all stand to either save or make money from the full development ofe-health. This is a very powerful driver for cooperation.

Earlier in March, the commission issued its all-encompassing strat-egy for the years to come, Europe 2020. In April, I will unveil the ICTchapter of this strategy, the Digital Agenda for Europe. It will be our vi-sion of how ICT can shape Europe by 2015 – and be assured that e-healthwill play an integral part of our ambition to make Europe a truly sus-tainable digital society. My intention for the Digital Agenda is to proposeclear objectives and specific targets. I believe we must focus on concretegoals to mobilise and address the legal and organisational barriers thatare holding back innovation in Europe. In doing so, we must also ensurewe do not compromise the values we believe in – the quality of our careand the privacy any individual is entitled to.

A new era in e-health


TECHNOLOGY

Neelie Kroes, Vice President of the European Commission and Commissioner forthe Digital Agenda, explains the positive impact of ICT on the healthcare sector.

“The grand theme of our time is the need todo more with less. Improving e-healthsystems is one of the best ways we canaddress this challenge”

NeelieKroes Ed_mar10 07/04/2010 15:53 Page 32

A key for success is to create pan-European interoperability between thevarious initiatives that emerge here and there. E-health is a very good exam-ple of that.

I have been inspired by examples such as the epSOS project. With 12member states on board (and hopefully more to join soon) and 31 industrypartners, epSOS shows we can set the bar high and clear it.

To me this is important because I don’t want to see us get stuck at thestage of delivering ‘only’ electronic patient records. That is, no doubt, a hugechallenge in itself. But we need also to work together to deliver tools for pa-tients that prevent health problems and personalise their healthcare. To give


just one example, wearable and portable personal health systems should bemainstreamed to become standard care. We can’t allow today’s difficulties todistract us from these long-term outcomes.

We made the right investments over 20 years to become the world leaderin e-health. The investments worked because we took them early and we tookthem together.

Now it is time to step up another gear. Our finances demand it. Our cit-izens expect it. The technology is ripe. We are all rightly proud of our healthsystems in Europe. We have every reason to be proud to be working towardse-health for all. n

NeelieKroes Ed_mar10 07/04/2010 15:53 Page 33

Ubichem AD.indd 2Ubichem AD.indd 2 1/4/10 14:59:221/4/10 14:59:22

Ubichem AD.indd 3Ubichem AD.indd 3 1/4/10 14:59:261/4/10 14:59:26


Re-imagining the NHS

THE BIG INTERVIEW

PaulJones_NHS ED_mar10 07/04/2010 16:17 Page 36


If there’s one thing the British public like complaining about even more than theweather, it is the state of the country’s healthcare system. Ask any cabbie inLondon what he thinks of the world’s most admired public health service andyou’ll be met with a stream of cockney invective about how it could be im-proved. Quiz people in Cardiff or Edinburgh and the response will be much thesame. While the accents might differ, it seems everyone from Land’s End toJohn O’Groats has an opinion on what is wrong with the NHS.

But such grumblings shouldn’t be mistaken for antipathy, for what is also striking isthe huge sense of pride most in the British Isles feel for the 62-year-old institution. The NHSis one of the largest employers in the world, along with the Chinese People’s LiberationArmy, the Indian railways and the Wal-Mart supermarket chain, and employs around 1.3million people – or approximately one in 23 of the working population. These staff mem-bers are in contact with over 1.5 million patients and their families every day, and eachmonth more than 23 million people (more than three times the population of London) visittheir GP surgery or practice nurse. In a typical week, 1.4 million people will receive help intheir home from the NHS, while community pharmacies dispense around 745 million pre-scription items per year. No wonder the British people feel they have such a personal stakein the service.

The UK Health Department’s UK£12.7billion National Programme for IT – theblueprint for a technology-enabledhealthcare system – has come under firein recent years for perceived cost overrunsand delays. Paul Jones, Chief TechnologyOfficer for the Department of Health,outlines why the project is still on track.


And it appears such affection is justified, too: in a survey of more than10,000 primary care physicians in 11 developed countries conducted recent-ly by leading US think tank the Commonwealth Fund, the NHS was rated topin a number of key areas – including being the only country where the ma-jority of doctors feel the quality of healthcare is actually improving. TheUK was rated top in several categories, including improvements in qualityover the past three years; managing chronic conditions with specialistteams; using financial incentives to reward doctors for good patient expe-rience; the use of patient satisfaction and experience data to improve ser-vices; and the use of comparative data to review doctors’ clinicalperformance. The UK was also the least likely to report long waiting timesfor patients referred for specialist care.

Many of these improvements have been achieved through greater useof IT, according to the Department of Health’s Chief Technology OfficerPaul Jones. Since transferring to the Department’s Directorate forInformatics from his previous role as CTO of Connecting for Health (CfH),


the organisation previously charged with delivering the UK Department ofHealth’s flagship National Programme for IT, Jones has been influential inrestructuring the IT function of the organisation to create a better balancebetween the needs of hospitals and facilities at the local level and the require-ment to have a coherent, interoperable and collaborative national system.

Could you give us some insight into your roles and responsibilities andwhere you fit into the wider IT picture of delivering IT to the NHS?I have a technology portfolio covering four main areas. The first is technolo-gy architecture assurance. So within the National Programme for IT there’sa variety of different elements, things like the London Programme for IT,PACS, Choose and Book, and many others. Each one of those has a smallteam of technical architects working on it to make sure that we design thesystems appropriately – that the systems fit in with everything else that’sgoing on. Because things are never quite as easy as you’d like, and you oftenhave to make decisions around things not being quite so ideal. What that

best practice,” says Tony Anstis, IT Services Manager at TheHillingdon Hospital NHS Trust. “To do this we needed a servicemanagement platform that would enable us to keep track ofthe requests that we have each day, evaluate the types of callsand work more efficiently as a team. The automated workflowprocesses will enable us to provide a faster, more organisedservice while freeing up staff to work on more strategic worklike bug fixes, development work and longer term projects.”

Anstis and his team evaluated several products via atender process. “They were judged on criteria that includedusability, functionality, flexibility and value for money,” heexplains. “It was also important to us that the culture of thevendor fit with our own ensuring a willingness to worktogether. Hornbill came out top, particularly in the usability ofthe system.”

Hospital drives efficiencies with ITSM

ITIL adoption aims to streamline IT operations and improve serviceto over IT 2400 users.The Hillingdon Hospital NHS Trust – the main provider of acutehealthcare to over 300,000 residents within the London Borough ofHillingdon – has selected Supportworks ITSM from Hornbill tounderpin IT service management provision to 2400 nurses, doctors andadministrative staff across two sites. The Trust will go live with incidentand problem management initially and plans to roll out a customerself-service web interface to staff, enabling them to log their own callsin the second phase of the implementation. This is anticipated toreduce the number of calls taken by the service desk significantly fromits current level of 1000 calls per week, enabling the IT team at theTrust to provide a faster, more efficient and more proactive service.

“We wanted to streamline our operations in IT and to providea more proactive service to our customers while working to ITIL


group is charged with is making sure that when we deviate from our idealposition, it’s done in a structured way so that people know why that’s beingdone. There’s an agreement there as to why that deviation’s been made andideally how we bring it back on track.

I also have a group who work on data standards across the NHS. So inthe NHS we have lots of standards used on a day-to-day basis. If you go toyour GP and you say, “I’ve got a cough”, he doesn’t type cough in, he types ina particular code, four or five digits called a Read Code. Those are managedby my team, as are the OPCS codes and the ICD codes which are used in hos-pitals for procedures and diseases. Combinations of those actually drive what’scalled Payment by Results – how many acronyms can you fit into one answer!– which is what actually drives the money for us across the NHS. So those arealso managed inside the technology office.

I then have a group working on infrastructure, who are providing adviceand guidance to the NHS around something called the NHS InfrastructureMaturity Model, which is part of the operating framework so Trusts can as-

sess where they are in terms of the infrastructure. The intention of that isn’tjust to be a scorecard, it is to help Trusts understand what they need to do nextand to help structure a plan for them. I think that we’re all guilty of doing thethings we like rather than the things that we need to do. One trust mighthave a fantastic network because the guy who’s in charge loves networks.Yet some of the desktop management might not be quite at the same levelas the network. What the Infrastructure Maturity Model aims to do is say,well look, if your network’s really good and your desktop’s not so good, then

that’s where you need to put your efforts, and here are the steps thatyou need to take. What we’ve tried to do is to work with sup-

pliers so that they can align their offerings with theInfrastructure Maturity toolset. So if your desktop man-

agement is at stage one and you need to get it to stagethree, suppliers should be able to say, “Here are the stepsthat we can help you with and here are the benefits.” Sothat’s the infrastructure area.

As part of the National Programme for IT, I alsohave responsibility for a test assurance function in the

National Integration Centre. So if you have a system thatyou want to plug into the spine then it’s got to go through the

National Integration Centre to make sure you’re not going to bring thewhole system down when you plug it in. So that’s my area.

I guess one of the challenges for a centralised IT function is gettingan initial picture of exactly where you are across such a huge andwide ranging system. How do you achieve that?I think it’s really important when you have a national function that you focus onthe things that it makes sense to do nationally, and don’t try to do too much –there are 20,000 people in the NHS who do IT and they don’t all report to me!They work very hard and there are very clear responsibilities for what they’redoing, and I’m not trying to tell them what to do. But there are things we can docentrally around providing best practice, advice and guidance.

We take responsibility for the nationally funded programmes; that’swhere we can provide more control, more advice, more assurance and takea much more direct, hands-on position. It’s not my role to make everythingin IT work exactly as I want it to work. It’s about providing advice andguidance. So right after this meeting I’m off to visit the Technology Boardfor Informatics, which has representatives from each of the SHAs that weconsult with to establish the important priorities for us to work on nation-ally. There’s no point in me producing advice and guidance on how to setup a wireless network for a hospital if they’re not interested or if they’ve al-ready done it. So the Technology Board is where we get that input fromTrusts, where they can tell us what it would be useful for us to do for themcentrally so that they only have to do things once rather than doing it 10times or 100 times.

The other thing I think we can do nationally is to share the positives.We really like to know about all the good stuff that’s being done in Trusts.I get to travel around and see lots of different hospitals and meet lots of in-teresting people, and often I’ll go to two hospitals not far from each otherthat are trying to do two very similar things but don’t know it becausethey’re across a different SHA boundary, or because the communication isn’tgreat, or whatever. I think there’s a lot we can do centrally to just let peopleknow what else is being done.


Hornbill will supply Supportworks ITSM, which willreplace an existing system that Hillingdon has outgrown,with a specialist ZENworks connector that will enable theremote management of machines and assets and improvedata quality. Supportworks ITSM’s powerful reporting willenable the Trust to easily identify trends and problemareas, for instance it can provide the top 10 issues and thetop 10 callers at the click of a button. This visibility willenable the team to see clearly how much work is beingdone and will identify key strategic areas so thatdevelopment work can be channelled in the bestdirection for maximum benefit.

The second phase of the implementationwill also include email integration so thatcallers may email requests for assistance, andthe details of their call will automaticallypopulate the Supportworks system. This willsave further time for the service desk agents.

Gerry Sweeney, CEO of Hornbill Systems,commented: “Technology is a great enabler, and asthe whole of the public sector, including the NHS, start tosee cut backs across the board, it is crucial for IT to beable to provide efficient services to support theorganisation. Self-service portals and encouragingcustomers to help themselves is a quick way for servicedesks to reduce their call rates and gain extra time toprovide better service aligned to the business needs ofthe organisation. Supportworks has been designed notonly to be easy for the service desk to use, but to providean intuitive look and feel for end customers encouragingthem to try self help before picking up the phone to theservice desk.”

Staff across the NHS are in contact

with more than

1.5 MILLIONpatients and their families

every day


So you see your role as more about facilitating collaboration be-tween different parts of the health system?Absolutely. In the space of about eight weeks I visited three Trusts andthey were all doing work on document management, all in differentphases. By simply emailing the same documents around I was able toaccelerate all of their procurement cycles because they could reuse partsof the documentation and share their experiences. We saved time,saved money, and if we could do that on a slightly more industrial scaleas opposed to just stumbling across it, I think that would be a real valuewe could add centrally. Again, it’s looking at what can you do nationally thatis very hard to do locally. So that’s very much what I’m trying to focus on.

The National Programme for IT plays directly into this. Can you tell us abit more about this programme – its history and its current status? How long have you got? Because there’s some myth and there’s some legend.The National Programme for IT is a very large set of programmes and pro-jects and – I feel like I’m putting a spin on this, but it’s true – an awful lot ofthat has been incredibly successful. Many of those are working, they’re fin-ished, they’re live, they’re used every day. They’re now completely embeddedin the NHS.

For example, one of the things that I think is a really impressive imple-mentation is N3 – the NHS national broadband network linking hospitals,

medical centres and GPs in England and Scotland. So before the NationalProgramme for IT, most hospitals weren’t actually connected to the internet– or if they were they weren’t connected by anything very substantive, andcertainly weren’t connected to each other in any meaningful way. But nowthere’s a broadband network across the whole of the NHS that is a fantasticexample of technology engineering. Frankly, if that was all we’d done it wouldbe held up as a paragon of how to do a public sector project. We’ve saved hugeamounts of money by taking a central procurement strategy. Everyone needsa network, so we might as well procure that centrally. Because when you getdown to it, an individual Trust as an organisation lacks buying power, cer-tainly in global terms. But when you group the NHS together as a whole it’senormous, and that’s when you get the real economies of scale.

In order to drive efficiencies in the NHS going forward, one of the things



we have to do is to be able to link medical records together. To linkmedical records together you need an identifier – and if you wantan identifier, you need a single place for the truth. So we’ve rolledout the Personal Demographic Service (PDS), which stores basic de-mographic information about each patient and their NHS number.I think last month 50 million messages hit the PDS where peo-ple were checking the NHS number was right, makingsure we’ve got the most recent address so that ap-

pointment confirmation letters and other pieces of cor-respondence don’t get lost, etc. That has a huge benefitin terms of being able to drive interoperability for-ward, but also to do simple things like reduce thenumber of letters sent out to the wrong address, whichin turn reduces the number of ‘does not attends’ thatreally adds to the costs for the NHS.

So those things have been delivered and work. Chooseand Book is another good example – my wife is currently deal-ing with the NHS so her GP had to make an appointment at the hos-pital, and through the Choose and Book system she was able to plan herappointment so she could drop the kids at school, get to the hospital, getback to pick the kids up, etc. That kind of stuff really helps patients in ameaningful way, and it is certainly cheaper for the NHS in terms of reduc-ing the whole paper trail.

The National Programme for IT has come in for a fair amount of criticismover project delays and cost overruns. Is this criticism justified?Lots of things inside the National Programme for IT have been delivered, areshowing benefits, and it’s a shame that the many people and suppliers who’veworked on those projects don’t get the credit they deserve, to be quite honest. We

don’t do this do be seen. We do this because we care and we want things tobe done better. So I think in terms of the National Programme for

IT, there’s been an awful lot of good stuff done. Where we’ve had challenges – and we’ve admitted to

them and we’re not trying to hide from them in any way– is dealing with the acute sector. The acute sector is big,it’s difficult, it is challenging. So one of the things we arefocused on right now is looking at the changes we need

to make to be able to have a plan of delivery for the acutesector that’s affordable, that ties with our current strategy

priorities and that suppliers are able to deliver. How do webring all that together?

There is a myth out there that the cost of the National Programmehas run way over, but that is not the case. The budget is UK£12.7 billion, and be-fore Christmas it was announced that this would be trimmed by a furtherUK£600 million. To date we’ve spent less than 50 percent of that, and that’s be-cause we don’t pay suppliers until they’ve delivered. So it’s about protecting tax-payer’s money.


The NHSemploys around

1.30 MILLIONpeople. This is

approximately one in 23 of the working

population


I think that touches upon an important point, which is that technolo-gy is really only an enabler, and it shouldn’t interfere with getting thejob done. Do you agree?Absolutely. I was at a patient conference last month and was asked whethermy target was to make everything in the NHS electronic. I don't think inthose terms, and that’s not a target I hold. My intention is that where thereare clear benefits to patients, clinicians and the NHS from enablingprocesses or systems through the use of technology, then we’ll enablethem. It’s about what can be made better, not putting in technology fortechnology’s sake. We’ve never done that.

How do you balance the needs of healthcare professionals at thelocal level with the need for a comprehensive view of the use of ITsystems nationally? Are there conflicting interests there?I don’t think there are conflicts of interest. You may get misunder-standings, you may get people being too dogmatic about certain things,but I don’t think we’ve ever had conflicts of interest between technolo-gists at the central and local level. What’s important for me in a na-tional service is that people feel that they can contact us and tell us whatthey’re planning to do just in case we can help. And even if we can’thelp in that particular instance, then at least the next time someonetells us they are doing something similar we can provide them withadvice and guidance based on the outcomes from that first instance,

and put them in contact with people who might have had sim-ilar or useful experiences in the past. So I don’t see a con-

flict of interest really. I do think our responsibility is totry and provide the glue to try and bring some of thistogether. We have national services I would like to seeused and if there are challenges that stop those servicesfrom being used, then I need to know about them so

that we can fix them together.

One of the items that has been much in the news re-cently is the idea of electronic patient health records. So

what are the challenges and opportunities presented by im-plementing a system of electronic health records?In the UK I think we’re years ahead of most other countries, particularly interms of primary care. Most GPs are using electronic systems and are paper-free in many cases. So regarding the benefits, go ask a GP – many of them arereporting clear benefits both in terms of the security of the electronic recordand the ability to retrieve it and share it. Many of the most significant chal-lenges in health happen because the right information’s not available at theright time and in the right place. When a certain piece of information is heldin a filing cabinet in a clinic or in a records management department in thebasement of a hospital, then there are challenges with regards to sharing thatpiece of information with the next care setting that requires it. And digitisingthat data is only part of the solution. For example, in Lincolnshire two sum-mers ago we had horrendous flooding, and some of the places that were af-fected were GP surgeries. In that case, even if you had electronic records, ifthey were on your PC on your desk, they were about as much use as the paperrecords that were floating around the office as well.

What we’re trying to do in the National Programme for IT is to say it’snot just about things being electronic, it’s about things being treated in a


So it is more like a roadmap than a single initiative? It’s made up of lots of individual programmes. I thinkacross the NHS we’ve deployed something like 32,000 dif-ferent systems, everything from theatre systems in hospitalsthrough to new patient administration systems in communityclinics. And the successes of those small-scale rollouts have led us to re-examine our strategy around system deployments.

A few years ago I visited a small community hospital in the Manchesterarea and they’d installed a relatively simple administration system that washelping drive some fantastic results. For instance, they’d managed to shortentheir waiting times for appointments from around six months down to aboutthree weeks, and it wasn’t the technology that had done that, it was the factthat they now had a standardised process for managing appointments thateveryone bought into and supported. Under the old model we’d probablyhave said, “Okay, that works for now, but at some point in the future we’ll re-place it with this big strategic solution.” But if you look at it, the existing sys-tem is incredibly valuable to them and working well; does a small communityhospital need an awful lot more than that? Is the pain and effort of doing an-other system replacement worthwhile for them? Is there a patient or a clini-cal benefit? If there is then that’s great, but let’s look at that decision rationallyrather than just saying we’re going to replace it for the sake of replacing it.

So where things have been deployed and are successful and there isn’t acase to make a change, we’re not going to force it through just because of anideological need. Let’s be sensible about it instead.

The overall cost of the National

Programme for IT is

UK£12.7 BILLION



Myth-bustingSince its inception, the National Programme for IThas evoked a huge amount of interest, debate andcontroversy – much of it unjustified.

• The technical architecture is flawedThe National Programme for IT is a platform that willensure that all systems within the NHS can worktogether. It is not one enormous IT system. There is arobust technical architecture designed to cope withenormous volumes of traffic, while the newapplications are being delivered gradually – there willbe no ‘big bang’ – which will ensure that the newsystems continually evolve and there is a resolution ofany problems that arise.

• The cost is spirallingThe overall cost of the National Programme for IT isUK£12.7 billion over 10 years, and the National AuditOffice’s report in June 2006 confirmed that the NationalProgramme for IT in the NHS is much-needed, well-managed and on budget. Independent analysts Ovumhave estimated that UK£4.4 billion is being saved throughcentral procurement of IT systems by the NHS comparedwith what could have been achieved by individual NHSorganisations purchasing the same systems separately.

• The project is plagued with delaysThe Summary Care Record, which will provide an electronicsummary of a patient’s medical details wherever they areneeded in England, is behind schedule. This is because thenew software is challenging and there is a debate in themedical profession about what information should go in therecords. But substantial progress is being made on otherparts of the National Programme for IT. The work is aboutdelivering benefits’ it is better to get the tasks right ratherthan sticking to a rigid timetable.

• Electronic patient records risk patientconfidentialityStrict and robust safeguards will be in place to protect thesecurity and confidentiality of every patient’s healthcarerecords. Access to records will be controlled by the use ofsmartcards that use chip-and-pin technology and have tobe inserted into a card reader attached to a computerbefore the user is allowed access to patient records. Howmuch they can see of the records will depend on their rolein the NHS organisation. Smartcards are issued only afterstringent identity checks.

professional way. If you go into your bank and you ask them for the bal-ance, they don’t have a computer on the desk with your bank details on it;your information is held in a secure datacentre and that datacentre has an-other datacentre about 30 miles away with dark cabling in between thatkeeps the information backed up and synchronised. That’s how we shouldlook after patient records and that’s what we aim to do with the NationalProgramme for IT: build out multiple datacentres. If you were to visit thedatacentre that holds the NHS spine, it’s very secure: it’s filled with securi-ty guards, and if there’s a power cut they’ve got three generators and weeksof fuel in there.

I think of patient records as being precious. And if something’s pre-cious there’re two things you need to do: you need to keep it secure and you needto be able to find it. I actually visited a records department where the lift had gotjammed because there were so many records falling down the lift shaft. It was areal horror story. And while those medical records were very, very safe – no onewas going to be able to read your medical details – they weren’t being treated asprecious. We need to treat medical records as precious, meaning you have themin secure datacentres, and you have them backed up at other datacentres. Then,in the case of severe flooding as in Lincolnshire a few years back, you could justmove to a different location, we could give you a new network and you’d be upand running with all your patient data safe, secure and available. That’s a hugebenefit. And that’s not just about it being electronic, that’s about it being elec-tronic and treated properly.

And so finally Paul, what are your technology priorities over the coming12-18 months?I think we have some challenges around interoperability. So for me there’swork to be done on our standards, there’s work to be done around work-ing with suppliers. That’s really key for me, but I don't see there being aninstant interoperability fix; I’ve learned that health doesn’t work thatquickly. But if we can change people’s mindset about how the relationshipbetween the suppliers and the NHS is supposed to work, I think it wouldbe a fantastic achievement.

I think we also need to put some effort over the next year into mak-ing sure that people know that the demographic service is out there and itcan be used. Millions of messages are being sent every day so we must beable to communicate that to the organisations that aren’t currently usingit for whatever reason. Because if we don’t have a unique identifier on apatient’s electronic records, then we can’t start sharing the data in anykind of safe way.

To realise the true benefits of e-health we’ve got to put these buildingblocks – interoperability, data standards, common identifiers – in place.Once you implement those things, everything becomes much easier andwe’ll start to see the benefits of that. I think by focusing on some of thosebuilding blocks we can really set the NHS up for the future, which is whatI care about.

I guess that’s part of your role really, isn’t it? Taking the longer viewthat the Trusts aren’t able to do because they’re mired in the day-to-day operations…Yes. But I hope we take that longer view with the Trusts rather than trying tofight against them; that we take those steps in a pragmatic way. I don’t wantto live in an ivory tower. That’s not a comfortable place to be. ■



How has Vifor Pharma’s expertise in providing treatments for iron defi ciency helped patients?Christoph Springer. Vifor Pharma is a lead-ing company in iron therapy and the man-agement and treatment of anaemia and iron defi ciency. One of Vifor’s leading products is Ferinject (ferric carboxymaltose), a novel formulation of intravenous iron indicated for the treatment of iron defi ciency when oral iron preparations are ineff ective or cannot be used, and has been shown to rapidly im-prove haemoglobin levels. Ferinject can be administered by a healthcare professional, and provides a choice of fast administration methods: high single dose drip infusions of up to 1000 mg iron, but not exceeding 15 mg iron/kg body weight, in 15 minutes only, or bolus injections of 200 mg iron. Th is gives Ferinject a dosing fl exibility enabling iron replenishment to be adapted to individual needs. Importantly, no test dose is required before the administration of Ferinject.

Vifor Pharma’s expertise in iron therapy enables it to work with clinicians to develop patient blood management strategies, which identify patients at risk of transfusion and provide a management plan to reduce or even avoid peri-operative transfusions. Patient blood management comprises three ele-ments: the correction of a low pre-operative erythrocyte mass or anaemia; minimising peri-operative erythrocyte loss; and using minimal haemoglobin-based transfusion triggers. Th us, patient blood management can potentially improve patient outcomes and may lead to considerable fi nancial savings as transfusions can be costly due to high blood acquisition and administration costs.

Why is patient blood management impor-tant?CS. Patient blood management has been ad-opted worldwide by a number of hospitals and health networks, and its success has led to many others considering implementing

this strategy. An expert-panel review of the medical literature on blood transfusions at the International Consensus Conference on Transfusion and Outcomes (ICCTO) con-cluded that the majority of studies show an association between red blood cell transfu-sions and higher rates of complications such as heart attack, stroke, lung injury, infection, kidney failure and death. Additionally, blood is a precious resource with an ever-limiting supply due to an ageing population.

Th e treatment of pre-operative anaemia is integral to patient blood management. Pre-operative anaemia is common: over a third (35 percent) of adults scheduled to undergo elective orthopaedic surgery were found to be anaemic at pre-admission testing. Th us, it is recommended that all patients should have their haemoglobin levels assessed at least 30 days before scheduled surgery, and if neces-sary, should be treated pre-operatively.

Why is it important to treat pre-operative anaemia?CS. Patients with iron defi ciency anaemia prior to surgery are at high risk of receiving a blood transfusion. An Austrian study of 3622 patients undergoing total hip replacement, knee replacement, hemicolectomy or coro-nary artery bypass graft surgery in 18 hospi-tals found that 62 percent of anaemic patients needed a blood transfusion compared with 32 percent of non-anaemic patients.

Patients with anaemia who undergo sur-gery face increased risk of mortality and mor-

bidity and an increased requirement for blood transfusion (and its own associated risks). Treatment options for anaemia linked to iron defi ciency are oral or intravenous iron.

Have any healthcare systems already ad-opted patient blood management?CS. Th e Western Australian government’s Department of Health is implementing pa-tient blood management as a standard of care state-wide. Th e reasons for this include the true cost of blood transfusions, which are es-timated to be up to fi ve percent of the Western Australia’s public healthcare budget; expected blood shortages because of an ageing popula-tion; patients being able to give informed consent for patient blood management; and growing knowledge of the limitations and adverse outcomes with transfusion.

Addressing pre-operative anaemia managementChristoph Springer explains the importance of patient blood management.

EXECUTIVEINTERVIEW

Christoph Springer is Global Head of Anaemia TA Marketing at Vifor Pharma, the pharma business sector of the Galenica Group, which researches, develops, manufactures and markets pharmaceutical products, with focus on the treatment of iron defi ciency. The Swiss-based company is a world leader in this particular fi eld. Springer is proud of Vifor Pharma’s growing reputation for developing novel medicines that treat unmet needs especially in anaemia.

“Th e treatment of pre-operative anaemia

is integral to patient blood management"

References available on request

Vifor.indd 44Vifor.indd 44 7/4/10 16:31:367/4/10 16:31:36

ViforPharma_ad.indd 1ViforPharma_ad.indd 1 23/3/10 17:03:4723/3/10 17:03:47


SOCIALMEDIA

What are the benefi ts of implementing a customer-centric approach and social media within the healthcare industry?Matthew Lees. Healthcare tends to have particular challenges around privacy and the seriousness of the conversations. In healthcare, if you are creating an environment for people to communicate and share their stories with each other – things that have worked for them, things that haven’t worked for them, ways of getting information you need or getting results that you need – whoever is sponsoring those con-versations needs to be particularly careful.

Part of it is ensuring a safe environ-ment. It’s part moderation and policing to make sure it’s a comfortable environment and that the community is a friendly and productive place.

Are there any approaches that have worked particularly well in the health-care sector regarding for the imple-mentation of social media or social networking in a community-centred task?ML. An example that’s oft en given, from the physician perspective, is the Sermo site, where physicians can communicate with each other. It’s password protected and anybody can join, though you need to be a physician to do so.

Th e site uses a lot of social and engagement approaches to helping physicians, not only with medical work, diagnostic work and reading be-tween the lines on diff erent products and medications and drugs, but also on the processes that physicians have to deal with.

From a patient perspective, what many people fi nd helpful is shar-ing their stories and reading the stories of others, people who have been in similar situations and are dealing with the issues, whether it’s helping support an elderly parent or children with medical conditions.

Regulation must be a key challenge for any healthcare organisation looking to get started on a crowd sourcing social media type initia-tive. What challenges do healthcare institutions face in terms of regulation around things like HIPAA?ML. HIPAA underscores the importance of involving your legal team in the early stages in the design of whatever customer-facing programme you’re setting up. Th ere’s not a lot of case law around online communities and legal aspects, whether it’s intellectual property or privacy of information.

Th ere haven’t been that many cases, and so there’s always some uncertainty there. But for any of these kinds of programmes, you want to make sure that your organisation is receptive to what you’re hearing and that you determine your business goals and your suc-cess. What would constitute success of the program ahead of time?

You fi gure out what technology resources you’ll need, what people resources you’ll need, and you need to think about risk. And you’ll want to in-volve your corporate communications and your legal team in those conversations early on.

You mentioned technology require-ments. What kind of considerations should healthcare organisations keep in mind when selecting a technology solution for their social networking ini-tiative?ML. One requirement relates to security and HIPAA. Th ere’s a huge trend towards soft ware-as-a-service and putting tech-nology in the cloud. So one question to be asked early on is, are we going to host the data? Are we going to host the com-munity, the crowd-sourcing programme? Is that going to be done internally on our own servers in our own datacenter, or are we using a vendor, a provider that hosts

everything in the cloud?Th ere are soft ware-as-a-service companies that run stuff out of their

own servers, which can meet any security constraints that there are. At fi rst, healthcare wasn’t using these companies so much. Th ey wanted to run them themselves, but as these datacenters improve their security and their compliance, these are stronger options.

Integration and extensibility are becoming important these days, and these applications, less and less, are living by themselves as islands. Everything is starting to connect with everything else. For example, there’s the social web: maybe there’s a crowd-sourcing application or a community that you’re running on a platform, but other people in the community are also on Facebook. Maybe some people are using Twitter.

It’s becoming an incresingly important technology requirement that these applications can integrate with other systems such as Facebook, such as Twitter, such as a CRM system with customer information. You want these applications to be able to talk to each other.

Making connectionsNGH talks to Matthew Lees, Consultant and Vice President at the Patricia Seybold Group, about

the opportunities that the use of social media can bring to the healthcare sector.

Matthew Lees is a Consultant and Vice President at the Patricia Seybold Group.

Matthew Lees.indd 46Matthew Lees.indd 46 7/4/10 16:27:237/4/10 16:27:23

IT’S A NEW BUSINESS YEAR: MAKE IT YOURS

the corporate ladder with exceptional executive learning: anytime, anywhere.

STEP UP

Where Future Leaders Learn

MeetTheBoss TV isincredible access to theworld’s business leaders –so you can learn their winning strategies andattitudes fi rst hand.

Jeff Hayzlett, CMO, KodakDriving Brand Awareness

Tony Hsieh, CEO, Zappos.comExceptional Customer ServiceExceptional Customer

Herbert Hainer, CEO, AdidasLeading Innovation

www.MeetTheBoss.tv

B2B SINGLE.indd 1B2B SINGLE.indd 1 8/4/10 10:57:548/4/10 10:57:54

The

Healthcare reform is a highly emotive issue on both sides of the Atlantic.NGH takes a look at how health systems in Europe and the US measure up.

COUNTRY FOCUS

world?in the

system best

Health system comparison_mar10 07/04/2010 15:50 Page 48

As the battle to reform the US healthcare system con-tinues, those of us in Europe look on with interest, andsometimes, frankly, puzzlement. Why do theAmericans seem to prefer to risk bankruptcy in theface of a particularly debilitating illness rather than en-sure that all citizens have health insurance? Why, inthe face of overwhelming evidence to the contrary, do

many of them proclaim their health system to be the best in the world?According to figures compiled by the Organisation for Economic Co-op-

eration and Development and the World Health Organisation, prior to thereforms being passed, the US spent US$7290 per capita on healthcare (16 per-cent of GDP). Infant mortality in the country stood at 6.7 per 1000 live birthsin 2009, and life expectancy at birth was 78.1 years.

Compare these numbers to two European countries with more universalaccess to care, France and the UK. In 2009, France’s healthcare spending wasUS$3601 per capita (11 percent of GDP) and the UK’s was US$2992 (8.4 percentof GDP). Infant mortality was 3.8 per 1000 live births in France and in the UK 4.8.French citizens could expect to live on average 81 years, and UK citizens 79.1.

Even a cursory glance at these numbers shows that something doesn’tadd up. The US spent more than twice as much on healthcare as France andthe UK, and yet its life expectancy is lower and – perhaps even more shock-ing for a country widely considered to be the most advanced and most pow-erful on earth – its infant mortality rate is decidedly higher.

With these facts in mind, NGH decided to have a closer look at howhealth systems on both sides of the Atlantic developed into the ones we knowand love – or not – today.


to cover wage earners. The country’s experiences during German occupa-tion led to the post-war adoption of the Securite Sociale, a programme ofhealthcare and pension benefits that remains the basis of French healthcareto this day.

Like its American counterpart, the system was initially fundedthrough payroll deductions: a 16 percent deduction from wages, with 10percent paid by the employer and six percent by the employee. However,in contrast to the US, the French government provided 80 percent of pay-ment, while private insurance companies covered the rest. The SecuriteSociale now provides healthcare coverage to 99 percent of the country’s

population.

Early advancesHealthcare in Germany also has a long history, begin-

ning with von Bismarck’s landmark bill in 1883. As earlyas 1885, statutory health insurance, known as GKV, pro-vided access to quality healthcare for 26 percent of thoseearning low wages, or 10 percent of the population. This

was gradually extended by raising the income level belowwhich people were required to contribute. In 1918, coverage

was extended to the unemployed; to seamen in 1927; and in1930 to all dependents.

In 1941, the German government extended coverage to retirees, andpassed legislation allowing those whose incomes had risen above the ceilingto continue with voluntary contributions. In later years, agricultural workers,students and the disabled also gained coverage. When Germany split in twoafter World War II, East Germany set up a centralised state-run system, withdoctors becoming state employees, while West Germany re-established theprewar system.

Health services in Scandinavian countries are also financed througha combination of government funds and private insurance programmes.In Denmark, most treatment is given by individual physicians, while in

The birth of public healthOtto von Bismarck is credited with establishing the world’s first univer-

sal healthcare system, when he introduced a health insurance bill in Germanyin 1883. However, most current systems providing universal coverage wereestablished after the end of World War II, following the signing of theUniversal Declaration of Human Rights in 1948. The related InternationalCovenant on Economic, Social and Cultural Rights, adopted by the UNGeneral Assembly in 1966, contains an article that recognises the right ofeveryone to “the enjoyment of the highest attainable standard of physical andmental health”. The US has not yet ratified the sections of the covenant deal-ing with social and economic rights, including healthcare.

One example of a universal system, the UK’s NationalHealth Service (NHS), was founded on July 5, 1948 by thenMinister of Health Aneurin Bevan. Bevan’s aim was toprovide good healthcare for all, financed entirelythrough taxation. For the first time, hospitals, doctors,nurses, pharmacists and others directly involved inhealthcare were brought together under one umbrellaorganisation.

Bevan wanted the new system to be democratically ac-countable to the people through Parliament, giving the HealthSecretary a lot of power over the funding and how the money wasused. The Health Secretary is in charge of the Department of Health, which isultimately responsible for running the NHS. The department sets priorities,allocates money and oversees the management of the service. Below this, thesystem is divided up into Strategic Health Authorities, and below that againit is split into Primary Care Trusts and NHS Trusts.

Across the channel from the UK, the case of the French health system isparticularly interesting. Although the French system has existed in some formfor 100 years, before World War II, people bought health insurance from fra-ternal associations, much as the Americans once did. In the 1930s, the gov-ernment brought in a mandatory system similar to the American Medicare

HEALTHSYSTEMSCOMPARED

Currently as many as

47.5 MILLIONAmericans (15.3 % of population) do not have health

insurance

FranceFrance boasts a national social insurance system withelements of tax-based financing and voluntary healthinsurance. The state regulates the health system and thestatutory health insurance funds. It sets the limit for healthinsurance spending, approves a report on health and socialsecurity trends and amends benefits and regulation.

The statutory health insurance system is divided into threeschemes. The general scheme covers about 84 percent of thepopulation, including employees in business and industry and theirfamilies; the agricultural scheme covers farmers and their families(7.2 percent of the population); the scheme for self-employedpeople covers five percent of the population. In 1999, thegovernment brought in universal health insurance coverage on thebasis of residence in France (99.9 percent coverage); and in 2004 aninsurance fund for dependent older people was established.


Norway, Iceland, Sweden, Finland and Iceland, it takes place at publichealth centres.

In Sweden, the central government is responsible for hospitals and healthservices, through the National Board of Health and Welfare. Services underthe 23 county councils are divided into the regional hospital service, theprovincial hospital service and the primary health service.

Each of the six Swedish regional hospitals is associated with a university;the universities are run by the central government, while the hospitals are re-

SwedenSweden has a compulsory healthcaresystem that is predominantly tax-based,providing coverage for every resident of thecountry, although there is some voluntaryinsurance that gives supplementary coverage. Thesystem is regionally based and publicly operated, organised on thenational, regional (23 counties) and local (290 municipalities) levels.

The Ministry of Health and Social Affairs ensures the efficientoperation of the system at a national level. The National Board of Healthand Welfare is the central advisory and supervisory agency for healthand social services, and there are several associated national institutions,such as the National Social Insurance Board, which guaranteesuniformity and quality in the processing of insurance and benefits.

GermanyThe German system is based on social health insurance and alsoconsists of three schemes. About 87 percent of the populationare covered. Mandatory membership applies to about 77percent (based on income) and is voluntary for 10 percent.Ten percent of the population are covered by private healthinsurance; two percent by governmental schemes and 0.2

percent are not covered by any third-party scheme. Coverage is fully portable, with eligibility andbenefits independent of any local

reinterpretations by insurers, politicians,administrators, or healthcare

providers. Universal coverage ishonoured by all medical centres and

hospitals.

gional. Private healthcare does exist, but on a limited scale: approximately 15percent of all medical consultations are given by private practitioners.

While several European countries brought in legislation to deliber-ately establish their universal healthcare programmes, the origin of the currenthealth system in the US was more haphazard. Up to the early 1920s, Americansspent an average of US$5 a year on medical care (US$100 in today’s money),mostly only ‘cure-all’ potions from dubious sources. Hospitals at this time wereprimarily places where the destitute went to die.

“As the populations of Westerncountries continue to age andhealthcare requirements increase,reformers must stress the messagethat the system in place in anygiven country is not necessarilythe best one to meet its citizens’changing health needs”


With the advent of modern medicine – particularly antibiotics – hospi-tals began to promote themselves as somewhere to go to be made better. Still,people only paid for care if they were desperately ill, and hospitals began tolook for ways to increase their patient numbers. Baylor University Hospitalin Dallas decided to offer a deal to a group of local teachers: they would pay50 cents a month and the hospital would cover the bills for any hospital vis-its. When the Depression hit, the scheme’s popularity soared, and iteventually became known as Blue Cross.

During World War II, factory owners used health in-surance benefits to attract workers. In 1943, the IRSmade employer-based healthcare tax-free, and a sec-ond law passed in 1954 bumped up the tax advantageseven more, paving the way for the existing multi-payer system.

What lessons can President Obama and his healthcarereform team draw from the history of those systems provid-ing more universal coverage? It is clear that the growth of a coun-try’s health system is largely a result of accidents of history. In a fewcases, such as the UK and Germany, universal care was established through leg-islation; but in other instances, most notably the US, one thing literally led to an-other. This is somewhat ironic, given that people often become irrationallyattached to their current system and put up strong resistance to change.

As the populations of Western countries continue to age and healthcarerequirements increase, reformers must stress the message that the system inplace in any given country is not necessarily the best one to meet its citizens’changing health needs. As the figures on the current American system show,just because it worked in 1943 doesn’t mean it does now. n

USAlthough now on the brink of reform, for many years the US healthsystem has been funded mainly by the private sector, throughinsurance available from employers or other private schemes.Currently as many as 45.7 million people (15.3 percent ofpopulation) do not have health insurance.

The federal government is involved in two main schemes,Medicaid and Medicare, each covering about 13 percent ofpopulation. Medicaid is funded jointly by the federal and stategovernments and covers low-income or otherwise needy groupssuch as the disabled or children from impoverished families.Medicare covers people 65 or older, some younger people withdisabilities and those on dialysis or undergoinga kidney transplant.

Most doctors practice privately and arepaid through discounted fees paid byprivate health plans, public programmesand direct charges to patients. Publicand private hospitals provide in-patient care, with hospitals paidthrough a combination of chargesper admission and capitation.

UKThe countries that make up the United Kingdom –England, Northern Ireland, Scotland and Wales – areindividually responsible for their own healthcare. They

fund healthcare mainly through national systemsof taxation, with services being delivered

through public providers. Purchasingresponsibilities have been devolved to

local bodies (Primary Care Trusts inEngland, Health Boards in Scotland,

Local Health Boards in Wales andPrimary Care Partnerships in

Northern Ireland). Coverage is available to all

legal residents of the UK, residents ofthe European Economic Community and

citizens of other countries with which the UK hasreciprocal agreements. Private medical insurance doesexist, but has quite a low uptake – about 11.5 percent ofthe population.

Sources: www.euro.who.int/observatory, news.bbc.co.uk/

“The NHS is one of the largest

employers in the world,along with the

Chinese People’sLiberation Army, theIndian railways and

Wal-Mart”


GE HEALTH AD P.indd 6GE HEALTH AD P.indd 6 6/4/10 16:50:346/4/10 16:50:34


INSIDE STORY

Hospital.indd 54Hospital.indd 54 7/4/10 16:16:467/4/10 16:16:46


Ensuring safety, improving effi ciency, modernising IT strategies, developing staff training: no doubt about it, hospitals across Europe have a balancing act on their hands. At Sweden’s Norrbottens Läns Landsting CEO Elisabeth Holmgren reveals why a focus on quality and effi ciency is imperative to improving hospital operations.

Playing a central role in healthcare delivery the hospital is oft en ig-nored in healthcare policy and by academics alike. But hospitals shouldn’t be underestimated. Firstly, they account for a substan-tial portion of the healthcare that patients experience – around 50-80 percent – and secondly, their position means that the policies the hospital adopts, which determines access to specialist service, has a major impact on overall healthcare. Also, techno-

logical development – as well as more attention to evidence-based healthcare – means the services that hospitals provide have the potential to signifi cantly aff ect population health. Numerous research studies have proven that signifi cant improvements can be made within limited resources if hospitals recognise what can be achieved, set stan-dards and invest in the relevant design expertise. Needless to say if hospitals are inef-fectively organised the potentially positive impact can be reduced or even negative.

An extremely stressful place for patients, families and staff , the hospital environ-ment is critical. However, for the most part, hospitals can be noisy, have a complicated layout, inadequate ventilation and air quality with poor positive distractions, or suff er from all of these to name just a few. Th ese environments are understood to contribute to medical errors, as well as lack of sleep and increased anxiety, which at the very least can slow down the healing process and may even result in serious injury or death.

And it’s not just daylight and space that can make a huge diff erence between a well performing hospital and one that isn’t quite up to scratch: the role of information tech-nology in providing high quality healthcare is rapidly growing. Traditionally health-care has seen lower levels of investment in IT than other service industries, which has resulted in a number of problems for healthcare providers with systems in desperate need of modernisation to overcome the challenges that have arisen over the years, including a disparate mix of soft ware systems that struggle to share information.

However, IT is changing and today’s models are enabling providers to improve the quality of patient care by fully exploiting the new tools and information that systems can provide. Soft ware supports core medical processes while hardware allows east access to information at the point of care.

And, while European national policy makers broadly agree on the critical ob-jectives of a universal healthcare system – the list is surprisingly straightforward – including universal access for all citizens, eff ective and responsive care and effi cient

Front LineFront LineOn The



Quality careCEO for Norbotten Läns Landsting county council, Elisabeth

Holmgren is typically found in a meeting with her top management team. Responsible for the entire organisation, including fi ve hospitals (Sunderby Hospital, Piteå Älvdal Hospital, Kalix Hospital, Gällivare

Hospital and Kiruna Hospital), she claims that the most im-portant issues for her are good communication with the

management team in order to do the most effi cient job possible and promoting top quality healthcare. “Out-

lining my leadership system is an infrastructure in which we have regular meetings and discuss certain key aspects of healthcare and how to make decisions around improving these areas. We also have tools

that we are working on to support our staff in order to help them achieve their goals. For instance, one of

our focus areas is around access to healthcare, which has traditionally been a problem in Sweden, however, we

have very good access to healthcare here and continue to work to ensure this remains the case.”

Ultimately the key for Holmgren is to have enough knowledge to know which tool to use and when. “No tool by itself could solve any focus area if we hadn’t decided – via the management team – what we wanted

use of resources, actually implementing this list has proved diffi cult to implement, particularly at hospital level.

A constantly changing – and improving – industry means that better treatment methods and more eff ective drugs are being developed all the time, and with patients demanding increasingly better service there is a huge demand on the healthcare system to defi ne and improve the role of the hospital to be able to deal with these ever mounting challenges.

In fact, now more than ever before, hospitals are challenged with ensuring safety while improv-ing effi ciency and increasing survival rates, as well as taking on board new initiatives contributing to a more universal healthcare system. Regularly fi nding itself top of worldwide healthcare systems, Sweden’s healthcare is the envy of many other coun-tries around Europe. But what is it that makes this system so successful? Well, fi rstly, the entire population has equal access to a healthcare service that is government-funded and heavily decentralised. And while the role of central gov-ernment is to establish principles and guidelines for care and to set the political agenda for health and medical care, ultimately the way care is managed falls to one of the 21 county councils in the country.

Norrbotten has reduced HAI’s by

50%

HEALTHCARE IN SWEDEN

Costs for health and medical care in Sweden amount to approximately nine percent of Sweden’s GDP, a fi gure that has remained stable since the 1980s. 71 percent of health care is funded through local taxation, and county councils have the right to collect income tax. The state fi nances the bulk of health care costs, with the patient paying a small nominal fee for examination. The state pays for approximately 98 percent of medical costs.



to achieve. And when we made that deci-sion we chose the right tool to support what we are going to achieve, and that’s a knowledge all by itself.”

One of the tools that Holgren places a great deal of importance on is IT. She

believes that it should be at the heart of what the hospitals are hoping to achieve and a key

factor in how to actually achieve it. “No doubt about it, we need to think of IT systems as a tool to support what we want to achieve is extremely important – and these new technologies coming through really need to support what we want to achieve and will play a key part in how we get there.”

With IT a huge aspect within the functioning of any hospital, ensur-ing that a system that supports the entire County Council of Norbotten has been a huge challenge for Holmgren. She explains that one of the IT systems in place has been around for two decades now and includes medical records as well as everyday activity that is connected to the care

of patients, which is unique for Sweden. Today, while other county councils around Sweden are still struggling to implement infrastruc-

ture that allows communication between hospitals and primary healthcare, Norbotten Läns Landsting has none of these issues.

However, the situation has changed recently regarding e-health in the country. Th ree years ago there was a decision at

a national level that meant Sweden was intending to build a national e-health strategy and an infrastructure that would make it possible to communicate between diff erent IT sys-tems in various regions in order to access medical records around the country. “Th ere has been great deal of money put

into the infrastructure from both the government and the diff erent county councils,” explains Holmgren. “We have come

quite a way on this and have the infrastructure all over the country which means that it is now possible to communicate between the vari-

ous county councils in Sweden.”As Norrbotten already had the one system in place it was easy on a

local level to ensure that all fi ve hospitals in the region were integrated, but now Holmgren is looking at spending money on this local system to bring it more up to date and look to support a system where, for instance, it will be possible to do long-distance consultations, or support doctors who are in surgery. “So far, it’s certainly a very worthwhile investment and it will certainly be a key feature of the system in the future and will allow us to continue to develop ways to work in a smart and effi cient way. It’s both a question of quality in the IT systems that are used and ensur-ing that they are safe enough, as well as understanding improvements in new techniques that enable us to continue working in a smart way.

“It also means, of course, that we have to work in ways that we haven’t before, because as a doctor or nurse, for example you have to prepare yourself and the patient to communicate in way that you haven’t before, so you may not be sitting in the same place for example.”

Rising costsAnd with increasing investments in modernising IT systems the

cost of healthcare continues to escalate across Europe and the rest of the

Kiruna:

Rheumatology is integrated with the

countywide function at Sunderby Hospital, and dialysis with Gällivare

Hospital.

Gällivar:

Functions as a medical centre for the Orefi elds district and is responsible for major and

resource-demanding surgery in the northernmost part of

the county.

Kalix:

Cardiovascular care, neurology and planned

activities in orthopaedics as well as polyclinic

gynaecology.

Piteå:

Planned activities in orthopaedics as well as polyclinic

gynaecology.

Each district hospital has its own area of specialisation:

Primary care is the core activity in Sweden and many clinics in locations far from hospitals function as mini-hospitals. Alongside the clinics are a regional hos-pital and four county hospitals with different areas of specialisation in addition to basic care.

The fi ve hospitals complement each other in terms of expertise and equipment. Sunderby Hospital is the regional hospital for the entire county and functions as a centre of excellence for health care in Norrbotten. It more than 400 care places and 17 operating theatres as well as a 40-room hotel for patients who do not re-quire round-the-clock care. The hospital is designed and equipped to enable a new approach to care. Care work is organised in various functional areas whereby person-nel work together, for example there are heart teams and diabetes.

HEALTHCARE IN NORRBOTTEN COUNTY



across the organisation. “We have various training to support doctors, nurses and other people in our healthcare system, which are very much connected to the improvements that we want to make and off er the op-portunity to learn new methods and support the improvements we want to make across the board,” confi rms Holmgren.

“We also have a leadership training programme in place, and per-sonally I believe it is important so that leaders at all levels have enough knowledge to know how to properly support staff and to organise the workload and get the right results – the results that we are working to-gether to achieve that support the goals for the entire system.”

Looking to a number of her future goals, Holmgren reveals why she believes the role of the hospital is so important: “Hardly any function of society is as creative and as constantly changing as healthcare. Better treatment methods and new, more eff ective drugs are being developed all the time. At the same time people have a need for security and continu-ity. Th ey need to come back to a familiar place and they need to be able to see the district nurse and the doctor they know and trust.”

And it is exactly this that Holmgren will be continuing to focus on in the coming 12 months as she looks to continue improve the hospitals in her care.

world. In fact rising healthcare costs are a major concern for the industry, particularly on the back of the worldwide economic recession in 2009. Being increasingly effi cient is of course vital in keeping costs down and Holmgren’s focus on providing a quality service has been critical in this area. “A systematic improvement in quality is what we are continu-ing to focus on and is proving critical in keeping costs down. And this is our main strategy at present, which is all about ensuring that, fi rstly, the structure is effi cient enough to sup-port this in the right way.”

One way in which this quality care continues to improve at Norbotten Läns Landsting hospitals, particularly in re-gards to the tricky issue of healthcare-acquired infections (HAI), is by using the World Health Organization’s (WHO) checklist. For several years Holmgren has been focusing on the vital issues of patient safety and infection, these issues are at the centre of everything, she says going on to explain about the national programme that started back in 2008. “Th e goal two years ago was to reduce healthcare-acquired infections by 50 percent and while this was a huge challenge – that to be honest, we didn’t think was realistic – we realised that if we wanted to reach those tough goals you have to have to face the challenges alongside it. On the whole, Sweden achieved extremely good results and in the Country Council in Norrbotten we reduced our healthcare-acquired infection rate by over 50 percent, so we exceeded the target and turned out to be one of the top performing areas in the country, which was absolutely fantastic.

“And we’ve actually implemented many more strategies too, both to do with patient safety and culture and things like that, but also so that our healthcare staff have the right clothes when they are working and the right products with which to wash their hands, for example.”

Th e Infection Prevention Act makes each county council respon-sible for taking measures to prevent infection, explains Holmgren. An infection prevention offi cer plans, organises and manages the county’s infection prevention programme so as to minimise the spread of dis-eases classifi ed as constituting a public danger as well as other infectious diseases. Th e offi cer also provides public information and advice on the prevention of infection.

Holmgren goes on to reveal that her staff have been very enthusiastic in regards to the targets they have been set and admits that it is inspir-ing to be driving an organisation where her colleagues are so interested and serious about what they are trying to achieve. She goes on to ex-plain that, in terms of human resources, there are a number of diff erent programmes going on to support and improve the skills of employees

“Hardly any function of society is as creative and as constantly changing as healthcare”


Allmed AD.indd 1Allmed AD.indd 1 31/3/10 08:47:2031/3/10 08:47:20

Cancer is Europe’s second largest killer and one of the most diffi-cult diseases to treat. There are dozens of therapeutic protocolsdesigned to respond to the vast diversity of cases that confrontdoctors. Radiotherapy has proven a particularly effective treat-

ment. Here a linear accelerator, or Linacs in the jargon, attacks the cancer di-rectly by delivering radiation from several directions. But treatment iscomplex. The direction, size and duration of dosages are all tailored to eachcase, and must be recalculated every time via simulation.

It is a phenomenally complicated computation, requiring lengthy process-ing time – so much so that it can mean delays and this has the knock-on impactof lowering the number of patients who can be treated by each Linacsmachine. Faster diagnoses would help, but the required comput-ing power is expensive, dramatically increasing the Linacs in-stallation and operation costs. It is a critical bottleneck.

Cloudy strategy clears bottleneckBut not for long. A cloud computing solution for ra-

diotherapy developed by the BEinGRID project uses acomputer grid. This type of infrastructure can share out re-sources like processors, storage, networking and software, wher-ever they are and on whatever platform. Grids can deliveron-demand hardware and software, and because they are combined into asuper system, they offer much more power at lower cost. The individual ele-ments of the system are hidden in the cloud, invisible to the user.

The new RadiotherapyGrid delivers two services: treatment plan verifi-cation and search. The search function is optimised to provide alternativetreatment plans based on the patient scan, treatment prescriptions and otherconstraints. Both services can run in the background. The doctor simply en-ters the details in a browser window, and is alerted by email when the resultsare ready. Security and Service Level Agreements (SSLAs) are a particularfocus of the RadiotherapyGrid.

Grids excel at delivering these kinds of benefits, because they ensure thatresources are used to the maximum of their capacity. Security can be guaran-teed because the computers on the grid behave like a single supercomputer.

Better and cheaperThe upshot is that doctors can call on enormous computing resources

without paying the full costs. It offers better performance, delivering faster re-sults, and only when the service is required. Hospitals do not have to pay whenthe machines are idle. “The system can also be extended and adapted, to usenew algorithms when new techniques and protocols are developed,” revealsAndrés Gómez Tato, a BEinGRID Business Experiment manager fromCESGA, one of BEinGRID’s partner.

The BEinGRID partners in the radiotherapy application are now look-ing to exploit the service commercially, and they believe the market is verypromising. Initially, the RadiotherapyGrid will be primarily marketed as a‘software-as-a-service’ platform at these institutions, but ultimately it may alsocome with hardware. Moreover, the RadiotherapyGrid could be applied toother treatment modalities, like the Image Guided Radiotherapy (IGRT),hadrontherapy or brachiatherapy.

So far healthcare organisations have been slow to benefit from the powerof cloud computing. The BEinGRID project, however, proves that clouds aremore than a just a cancer killer, they are a killer app. n

Cloud technology to combat cancer


Cloud services provided over grid technology are helping to treat cancer patients,thanks to an enormous effort by European researchers working closely with industry.

TECHNOLOGY

Cloud computing in healthcareThe Data Management Healthcheck 2010 survey, carried outby BridgeHead Software, found only 6.5 percent ofhealthcare respondents said cloud storage is currently partof their strategy for storage of archived data. Not only that,but only 33 percent of healthcare organisations said theyplanned to adopt a cloud storage strategy for any data overthe next 12-24 months.

“While preliminary, these results are highly indicativeof the industry’s concern about the security of

confidential and sensitive material,” says TonyCotterill, CEO of BridgeHead Software. “Second

to delivering excellent care, healthcare leadersare committed to protecting any and allinformation pertaining to patients.”

A major challenge for cloud computing issecurity of patient records and the need to

audit all the processes and systems because ofpotential breaches in confidentiality laws. At the

moment, there are no clearly defined laws for sharingpatient data across those clouds.

Nonetheless, a report by the European Network andInformation Security Agency (ENISA) entitled Benefits, Risksfor Information Security stated that cloud computing is setto see massive global investment in many sectors. Thereport, conducted in 2009, estimated that around theworld in 2013, €32.5 billion will be spent on the technology,with €6 billion being spent in the European market.

Article provided courtesy of ICT Results. For more information, please visitcordis.europa.eu/ictresults

Cloud technology ed_mar10 07/04/2010 15:47 Page 60

MDS NORDIAN AD.indd 1MDS NORDIAN AD.indd 1 23/3/10 17:02:2923/3/10 17:02:29

In January 2009, as part of its process of constantly updating andimproving the methods it uses to evaluate new health technologies,the National Institute of Clinical Excellence (NICE) commissionedProfessor Sir Ian Kennedy to carry out an independent study intohow NICE values innovation in its appraisals of health technolo-gies. The study involved evidence submissions and the use of a se-

ries of workshops involving the healthcare industries, patients and the widerpublic, together with representatives of the NHS to explore this issue.Professor Sir Ian Kennedy, emeritus professor of health law, ethics and poli-cy at University College London led the study.

“The study arose because there was a report by Sir David Cooksey whoadvises the government and treasury,” says Kennedy explaining the key aimsof the study. “He was concerned about industry generally – pharmaceutical,bio-engineering and bio-science – and the need for that industry to receiveincentives because it was an important part of the UK economy. The view wasexpressed to him and to a degree he endorsed it.”

Cooksey suggested that there be a complete study of the role that NICEplays in the architecture of healthcare, followed by a more particular and in-

depth study of how NICE deals with the notion of innovation and whether itencourages it sufficiently. While the government rejected the larger archi-tecture study, Sir Michael Rawlins, Chairman of NICE, asked Kennedy toconduct the study into how NICE responds, deals with and incorporatesinnovation in to the organisation. A huge subject to tackle, Kennedy ini-tially resorted to getting the primary thoughts from the industry academicsand patient groups.

“Getting all those themes together we then organised some workshopswhere we had fairly heated and very interesting exchanges on variousthemes we’d picked out and then that added to my understanding. Thenthere was a meeting with the Patient Involvement Network (PIN) groupwhere I attended their meeting and they gave me some views and put in asubmission and there was a meeting of the Citizens Council where the sortof questions that I was dealing with were answered and I was able to heartheir responses after two days. That was helpful – and then I went away andworked at it,” says Kennedy.

“The size of the project was in part a function of what I quickly came tosee as the need to expand the terms of reference somewhat, not just to talk

A NEW PATH


Sir Ian Kennedy talks about his report on the value of newinnovative health technologies and what he recommends for the

National Institute of Clinical Excellence.

TECHNOLOGY

Sir Ian Kennedy ED_mar10 07/04/2010 15:54 Page 62

about innovation but to talk a little bit about the background of how NICE isseen by the pharmaceutical industry and others as well as how it sees itself.”Kennedy also looked at the benefits that the pharma industry was anxious toput on the table in addition to the innovation payback – the industry didn’tbelieve NICE took account of these benefits, which were undoubtedly im-portant for patients.

Kennedy explains that this required him to operate at a series of levels:“The most abstract level being a kind of political philosophy of NICE, estab-lished by government to do a specific job – namely to allocate resourcesagainst the background of a fixed budget – and pharma, to a degree driven byAmerican models of healthcare, seeing the consumer as king, and if a patientwants something then it ought to be made available. The clash between twopolitical philosophies was a thread running through, as was the tension be-tween the idea of UK Plc needing a vibrant, effective, pharmaceutical indus-try for the sake of the economy and NICE being really not part of that UKeconomic philosophy, but rather a mechanism to allocate scarce resources.”

The report saw a number of findings, particularly between NICE and thepharmaceutical industry. Kennedy believed that NICE was often behind inexplaining it’s role and it’s impact on society. He says that it was ineffective inexplaining what it did and ineffective in it’s appraisals. The pharmaceuticalindustry on the other hand had to break away from American thinking andplay by the British rules.

“Having set the scene, I then said ok, are there certain benefits that NICEdoesn’t take account of which are important or which could be called healthgains,” says Kennedy. “I took the view that there were gains and that theyought to be taken account of in the cost effectiveness analysis to which ofcourse people inside NICE say ‘we always do that’, to which I say, ‘but you doit in a way that isn’t clear enough and isn’t transparent enough, so you’ve got

to make the process transparent so that everybody can see that you are takingaccount of these. You may actually have to take account of rather more thingsthan you currently do as we guard the wider issues that some people makingsubmissions argued for – namely the importance of a product to enable peo-ple to work or a productivity increase or people will be liberated to enter theworkforce – the so-called social values.”

Supply and demandKennedy argues that these should not be included in NICE’s ap-

praisal because of the difficulty of calculating them in themselves and alsosetting them off against other aspects of the public purse to work outwhat’s wining and what’s not. He did however suggest that further workshould be carried out if it is possible to formulate a model that is able totake account of those benefits.

With regards to innovation he took the view that there was an opportu-nity for NICE to provide incentives to the pharmaceutical industry and oth-ers in return for a focus on innovation. Kennedy defined innovation assomething that everyone talks about and is in favour of, yet nobody identifieswhat they mean, instead seeing it as being to do with a step change involving


“The clash between two political philosophies was athread running through, as was the tension betweenthe idea of UK Plc needing a vibrant, effective,pharmaceutical industry for the sake of theeconomy and NICE being really not part of that UKeconomic philosophy”


a product that meets a current unmet need and is effective to a degree ofaround 70 percent. “Something innovative may have gone through a stratifi-cation process so that we know the population is going respond to it.Currently it only works on 30 percent of the population, but we don’t knowwhich 30 percent, so you buy it and you waste money if it isn’t used by theright person. If all those criteria I suggested are met there might be an in-centive for pharma to concentrate on that rather than other things – youmight allow it to bust the threshold a little bit and you might allow it to dothat for a limited period, let’s say three years and then fall back in. So phar-ma’s got an incentive to focus on.”

Another innovation criteria could mean that the product meets theneeds required as declared by the NHS and Ministers so that they’re fo-cusing on incentives, but it must be real innovation now, adds Kennedy.“As regards to the innovation which is being promised, the pharma indus-try needs to be encouraged to do this now, I rejected the argument of spe-cial privilege for that on the grounds that we don’t know whether itcurrently will be an innovation and a significant development. Currentlywe’re not very good at conducting research and collecting data and phar-ma’s got no incentive to collect that data because it might prove that it was-n’t promising so we need to find creative ways of allowing further research


Innovative devices and diagnostics

In November 2009, NICE launched a programmefocusing specifically on the evaluation of innovativemedical technologies, including devices anddiagnostics. The new programme will both complementand operate in conjunction with NICE’s existingtechnology appraisal capacity. Professor Bruce Campbellhas been appointed to chair of the new MedicalTechnology Advisory Committee. As a ConsultantVascular Surgeon and Chair of NICE’s InterventionalProcedures Advisory Committee since 2002, Campbellhas extensive experience of NICE’s evaluation processesand guidance production.

What has caused the problems with medical technologiesin the past and how is the new Medical TechnologiesAdvisory Committee going to bring about change?Professor Bruce Campbell. There’s been no reallyorganised way of introducing medical technologies and

there’s been no mechanism to recognise and fosterthose new devices and diagnostics, which are likely toreally make a difference. The new Medical TechnologiesAdvisory Committee is going to be a very collaborativeventure with the industry, because the devices anddiagnostics that we will evaluate I think we will benotified, largely by the manufacturers, and the systemwill involve a manufacturer notifying us of a device ordiagnostic, which they think has some major advantageover what goes on in the NHS. This will be evaluatedagainst a clear set of criteria to see whether it fits withthe programme, and at that stage will be considered bythe committee, which will do two things: first of all, itwill take a closer look at each technology to seewhether it really does seem worthwhile; and then itwill be routed into one or another NICE programme.

What is this going to mean for the NHS?BC. Well, for patients, we are hoping that many of thedevices and diagnostics will have very obvious benefits,

Sir Ian Kennedy is a British academic lawyer who has specialised inthe law and ethics of health. He has been a member of numerouscommittees and enquiries. For nine years he was a member of theGeneral Medical Council and in 1978, he founded the Centre ofLaws and Ethics, of which he later became President. He has alsobeen a member of the Medicines Commission and the Departmentof Health advisory group on Aids.


and collection of data between NICE and the pharma industry or univer-sities. I also believe that all of this is to concentrate on what is called the de-mand side; the side of the people who are, as it were, representing thepurchaser or the user. However, the attention of pharma and the govern-ment should not solely be concentrating on the demand side, it should con-sider the supply side too – there’s a limit to what NICE can do on thedemand side and it can’t do anything about the supply side, however, itneeds to be addressed and fortuitously.”

Kennedy explains that if financial incentives are used then NICE, thegovernment and the NHS must realise that that will come at a price. “In toomany cases the cost effectiveness will destabilise the system at precisely themoment that public finances go over a cliff,” he says. “So the NHS will nothave the same amount of money or will have the same amount of moneybut inflation will increase, and in those circumstances pharma, the gov-ernment and the office of life sciences may have to comes to terms with thefact that to have an increased threshold for some.”

Moving forwardReflecting on his report, Kennedy hopes that it will be of assistance in

clarifying the role of the organisation and the way it works in the future.“Clearly there are those who are not entirely content with what NICE does,either because NICE exists, or the methods that NICE uses are not to theirliking because they’re frustrated or disappointed in certain circumstances.That being the case, I think it’s entirely appropriate for NICE to bring insomeone who as an outsider – with no axe to grind – and say what do youthink of the picture and then look at that, so that’s part of NICE’s constantattempt to engage with the wider world and to examine what it does and Ithink that’s welcome.”

Whether the report will have any wider implications it is hard to say.Kennedy believes that it is part of the jigsaw about how the architecture of theNHS is managed, its budget and the response to the changing nature of de-mographic circumstances and people’s illnesses. The Office of Life Sciencesreport emerged at around the same time as Kennedy’s report on NICE, con-cerning bigger issues than simply the institute, but rather the entire industryof life sciences, identified by the Prime Minister as one of the important partsof the UK economy. “NICE is a bit player. But that said, there is a propositionabout the development of something called an innovation pass whereby theneed for NICE appraisal and approval is bypassed,’ says Kennedy.

“Some could say that this is the thin end of a wedge to undermine NICE.I don’t think it need be, particularly as it’s recommended that it be managedby NICE. The money associated with the products that have the pass, should-n’t come from the NHS, but an earmarked ring-fenced fund, and that it be pi-loted for only a year and then reviewed. It’s kind of a toe in the water way ofdetermining how you can provide incentives to get drugs to patients that arecutting edge. I certainly derive some comfort from the Office of Life Sciencessaying in their report that they are committed to the notion that the NHS re-quires products that are cost effective. That’s what NICE does.” n


in terms of being comfortable, being less painful,resulting in less hospital visits. For the NHS, ifprocedures are being done as an out-patient rather thanan in-patient it might produce some cost savings. Or itmight be that a technology requires less staff.

There’s a large number of medical technologies around– how will you decide which ones to evaluate, and whatwill be the proves for how you work?BC. I think that may evolve to an extent. Getting goodresearch done on devices and diagnostics has been historicallyquite difficult. One of the aims of this pathway is to identifythe gaps in research that we need to fill in order to say that atechnology really should be used. And we will be doing that byproducing research guidance and hopefully by influencing theway in which collaborative research is set up betweenmanufacturers and the NHS. And we hope to make that easier.

In terms of setting up this committee, who have you beenworking with?

BC. The committee has been set up by negotiationsbetween NICE and the Department of Health, and alot of internal work within NICE, but with verystrong collaboration with industry, representativesfrom industry have been on the project board andhave been helping all along the way in thedevelopment. There have also been a number ofworking groups, comprising a great variety ofinterested parties, from industry, through membersof the Department of Health, throughcommissioners of healthcare, to providers inhospitals, and specialists in relevant disciplines. Ithas been a very complex process. And that’s one ofthe reasons it is, as yet, unfinished, even at the timeof launch. And even beyond the launch, I have nodoubt that this system, this pathway, will evolve aswe gain experience of the notifying procedures,having to work with them, collaborating withindustry, I think there are many aspects of this whichwill evolve as we gain experience.

“The attention of pharma and thegovernment should not solely beconcentrating on the demand side, it shouldconsider the supply side too”



DIGITALIMAGING

Daher ED_16 nov 07/04/2010 15:48 Page 66

Picture archiving and communications systems (PACS) have be-come important tools in a hospital’s digital data management ar-senal. According to Nadim Daher, Senior Industry Analyst forFrost & Sullivan’s North American Healthcare Practice, one of the

challenges is managing data throughout its lifecycle, while also minimisingthe incredibly high cost of using expensive storage media.

“Today PACS is also a lot about the distribution of images to other stake-holders in the imaging enterprise,” he says. “This is often spread outside theradiology reading room and into certain physicians’ office spaces and some-times to other hospitals or to the electronic library of patient records.”

Daher explains that the advantages of PACS are those of a digital envi-ronment when it’s working well. There are challenges pertaining to the tran-sition to digital, which has been going on in radiology for about two decadesin the more advanced countries. This has taken place progressively, but Dahersays there are still many places that are lagging behind and still largely print-ing out films.

“There is also a challenge regarding the investment that needs to be madeinto it,” he continues, “both from a clinical standpoint where you get a high re-sistance to change, especially among the older generation of radiologists andother users, and also financially. You have an important financial investment inthose systems, which have typically been acquired as a capital purchase. For anaverage 200- or 300-bed hospital with an average volume of 100,000 proceduresannually, it can easily cost up to US$1 million to install PACS.

“Because PACS has an important hardware component, it requires alot of equipment in the IT room, from servers and storage and network-ing, as well as probably the most expensive element, the software license.Then you have all the services, both to put it in and to support it, becausemost of these systems are supported through maintenance contracts, typ-ically over five years, and usually throughout the lifecycle of the systems.”

InvestmentOne of the first considerations for hospitals considering a major capital

outlay is return on investment. As Daher points out, for those facilities thathave never used PACS before, the ROI model is pretty straightforward, be-cause they’re going to be replacing film, which costs about a few dollars persheet, with digital. “Once they have the system in place it’s going to cost lessper procedure to manage study data,” he says, “unlike the film-based modelwhere every study is going to cost tens of dollars for printouts on high quali-ty silver-plated film.

“Various case studies that shown that PACS pays for itself in anywherefrom two or three years to six or seven years, depending on the case. But,replacing film would be the main ROI item for first-time PACS users.”


With the requirement for digital data tobe archived for up to seven years, theneed for efficient picture archiving andcommunications systems has never beengreater. Frost & Sullivan’s Nadim Daher

fills Marie Shields in on the current stateof the PACS market.

Daher ED_16 nov 07/04/2010 15:48 Page 67


However, market penetration is already high, with the majority of US hos-pitals – as many as 60 or 70 percent – already having PACS in place. Daher be-lieves the bigger question today centres on the users of first-generation PACS whoare looking to replace their systems. “The replacement PACS market is what’s at-tracting the attention of the entire PACS industry,” he explains. “This tends toleave the few remaining first PACS opportunities out there to the smaller com-panies, who are happy to take on a contract for a 60-bed hospital or a rural com-munity hospital that doesn’t have PACS. That represents a small contract value.

“The big players are all focused on the replacement PACS market and onbeing selected as a replacement vendor to put the next generation system inplace and get that new US$2 million or US$3 million deal for the large hospi-tals and hospital chains.”

With the next generation of PACS, the return on investment on all mod-els is much less certain. There are a number of benefits, but according toDaher they’re not easily quantifiable the way replacing film is: “They arenot very quantifiable because they would be something like reducing theturnaround time from study to report from two hours with the currentPACS, to 1.6 hours with the new PACS, for instance. While a business casecan be made for that 0.4 hours when you look at the productivity of theradiologists, what they’re being paid and what they could be doing if theysaved time on their current workload, it’s not as obvious as that for in-stalling a first PACS.”

PACS: a definitionIn medical imaging, a picture archiving andcommunication systems (PACS) is a combination ofhardware and software dedicated to the short andlong term storage, retrieval, management, distributionand presentation of images. Electronic images andreports are transmitted digitally via PACS; thiseliminates the need to manually file, retrieve ortransport film jackets.

PACS consists of four major components: theimaging modalities such as CT and MRI, a securednetwork for the transmission of patient information,workstations for interpreting and reviewing images,and archives for the storage and retrieval of imagesand reports.

Combined with available and emerging webtechnology, PACS has the ability to deliver timely andefficient access to images, interpretations and relateddata. PACS breaks down the physical and time barriersassociated with traditional film-based image retrieval,distribution and display.

A hospital organisation that has two or three hospitals in different locations, with imaging centres at each, can bring togetherthese geographically dispersed locations through an enterprise PACS system.

Daher ED_16 nov 07/04/2010 15:48 Page 68

Visage Imaging AD.indd 1Visage Imaging AD.indd 1 23/3/10 17:04:0423/3/10 17:04:04

Nevertheless, Daher believes there is a place for the next generation ofPACS, to help improve workflow, make the imaging enterprise more pro-ductive and open up better communication with referring physicians. “At theend of the day, as an imaging enterprise, your customers are those referringphysicians who send you patients to get images done. It’s important to haveefficient IT solutions and to make it work better for them.

“On the clinical side, a better PACS infrastructure can help physiciansmake better decisions, because they have greater access to imaging over time,comparing priors to new, comparing with other patients, when you startdoing things like data mining. It’s mainly clinical benefits, but also with astrong business component.”

PACS has been around for 10 or 15 years, so the first few academic cen-res that implemented the digital PACS that we know today are now attheir third generation of the technology. Another large chunk of the mar-ketplace is coming up to its second generation PACS, and Daher’s view isthat this is probably the main thing that’s still driving the market forward.

“Although the uptake has slowed down in the last two years, it’s a con-tinual process. Technology has to be upgraded at some point. You can’t keep10-year-old servers running in your IT department.”

External pressures have also exerted an influence, resulting in the last two-and-a-half years being very challenging for the American PACS market. “Themacro-economic pressures that occurred in 2008 did notspare the PACS market,” Daher says. “Traditionally it hasbeen more immune to outside market conditions, but thistime it was hit pretty badly. The IT projects hospitals weredoing were put on hold, if they weren’t cancelled.

“The fact that the reimbursement pressure is soheavy on imaging in general makes the ROI model forPACS less and less solid, because individual proce-dures are getting left without reimbursement. Some ofit is offset by the fact that procedure volumes continueto grow at a single digit of five or six percent a year.When you have to do more for the same amount ofmoney, IT is a solution for that, but at the same time you can’t spend therequired money on it. That has been the deadlock for the PACS marketduring the last two years.”

InternationalComparing the US market to parts of the world like Canada, the UK and

Scandinavia, Daher sees the major difference being that the US has a mostlyprivately operated healthcare system, and Canada, the UK and Scandinaviahave a publicly managed system.

This has had a direct impact on the way that technology has been imple-mented throughout the years. It has been more of a grass roots movement inthe US, of individual hospitals getting PACS and wanting to be competitivewith respect to the technology and the neighbouring facilities. On the otherhand, in Canada, the UK and Scandinavia, PACS adoption has been plannedmore from the top down; province-wide or state-wide agencies have planned,to put on PACS in several hundred facilities at once.

“Places like Scandinavia,” Daher says, “have been able to reach 100-per-cent penetration. They’ve been able to do it much more cost-effectivelythan in the US. The national programme for IT in the UK was also one ofthose top-down forces that has planned for PACS. They have had some

big failures and some important challenges, but they have been able to putin more PACS technology in more remote places and do it more cost-ef-fectively than in the US.

“They’re also able to get the systems to better talk to one another, becausethe first phase when you look at it over a long period of time is to have digitaldata everywhere. And the next phase, which is the major debate in US health-care IT today, is interconnecting all of these individual healthcare facilitiesinto something more widespread, so you can track diseases, track trends, trackeverything nationwide.”

Daher underlines that in the US, vendors have not been forced to com-ply to industry standards and have not been prevented from using proprietarytechnology, which has created a very challenging situation. “It’s very hard toget the legacy systems to talk with each other. In the legacy systems there is alot of proprietary technology; it’s almost like secret recipes the vendors areusing, and when it comes to replacing the system, providers find that they’renot able to read them.

“You don’t see this kind of thing much in the other countries I men-tioned, where the vendors are more forced to align themselves and the waythey do things. There was more put in the long-term planning so that one daythese systems will talk to each other, we will interconnect them. And you’restarting to see that in Canada, Scandinavia and the UK.”

Looking aheadLooking to the future, Daher says systems will be better integrated with each

other and there will also be better integration with electronic medical records,where PACS will become the imaging element of the EMR. “The EMR has a lotof components, an important one of which is images, and PACS is likely to bethe underlying system that handles this component.

“Also, we have what we call enterprise PACS, and there are two sidesto this. One is enterprise, meaning multi-departmental, so going beyondradiology and having a single system, or again, multiple systems, but thattalk nicely to each other; one for radiology, one for cardiology, for ortho-pedics. All the imaging is done in the departments outside radiology thatare also producers or users of images, so that you can have an effective wayof managing those images throughout the multiple departments.

“And the other side of it is by enterprise, which can mean also multi-site.When you have a hospital organisation that has two or three hospitals in differ-ent locations, with imaging centres at each, they can bring together these geo-graphically dispersed locations through an enterprise PACS system. That’sprobably the biggest market shift in those larger scale systems.”n

Nadim Daher is Senior Industry Analyst for Frost & Sullivan’s North American HealthcarePractice.


“When you have to do more for thesame amount of money, IT is a solutionfor that, but at the same time you can’tspend the required money on it. Thathas been the deadlock for the PACSmarket during the last two years”

Daher ED_16 nov 07/04/2010 15:48 Page 70

AGFA AD.indd 1AGFA AD.indd 1 23/3/10 17:00:0923/3/10 17:00:09


Medical imaging has the potential to play a central role in the global healthcare system as research increases and improves. What role does research and innovation play at Ziehm Imaging? Martin Törnvik. Research and development plays an extremely important and central role in our company. We invest more than 10 per-cent of our company turnover in R&D each year. We have a core competence in developing X-ray generators, imaging systems and soft -ware for image processing and these are the key components for us to provide mobile interven-

tional imaging systems today and tomorrow. We are focused and devoted to mobile C-arm solutions for many diff erent applications in interventional imaging. As these are our only products and we need to stay ahead of our competitors we are working to diff erentiate our products and provide better solutions.

There is no doubt that clinical applications are continuing to dominate the healthcare industry. In your opinion, which clinical application offers the biggest growth op-portunity and why?MT. I would say that one of the biggest growth opportunities in the healthcare industry will be the increase of minimal invasive surgery procedures. Th is is focused on the patient being in the hospital for as short a time as pos-sible and taking care of the patient without the need for big surgical intervention. Th is generates many positive eff ects in healthcare and industry overall. It impacts us specifi cally

since minimal invasive surgery techniques means the demand of high-level imaging sup-port in real-time is increasing tremendously. Th e surgeon needs more accurate image-guid-ance tools when performing minimal invasive surgery to be able to be safe and more accu-rate. Th e need for intraoperative, high-level subtraction angiography solutions, as well as, in many cases the need for 3D or multiplanar reconstruction (MPR) imaging, especially in spinal surgery application, will increasingly drive new fl exible solutions, which is positive in the view of investments to the hospitals.

Last year’s economic recession impacted industries around the world. What infl u-ence did it have on Ziehm Imaging and how did you go about tackling the associated challenges?MT. We saw the impact from the recession in healthcare last year of course and undoubt-edly some countries were eff ected more than some others, but in general business for us developed quite well and we had a reasonable growth of fi ve percent last year. Crucial to that was that we were able to stay focused and work closely with our partners and distribu-tors around the world, looking at each deal and what we could do to support and help out to get the purchase order. We had to be much more fl exible in order to fi nd solutions and of course great teamwork in the company is es-sential for accomplishing that. Employees in all departments across the company pulled together and worked hard last year and I am very proud about that.

Where do you expect to see innovations in mobile imaging over the next fi ve years and beyond? Can you give some examples?MT. I see highly increased improvements of image quality in the image guidance proce-dure and the possibility of using mobile in-terventional imaging to very high demanding procedures, which are today fi xed installed systems. I believe that the radiation dose will be reduced dramatically with more advanced image processing and digital technology. Further innovations in improving workfl ow, ergonomics and user-interface will also be in big focus the next few years. We need to take better care of the user that needs to handle the intraoperative imaging solution in criti-cal situations where everything has to work easily and simply with excellent results.

Martin Törnvik, Vice President Global Sales & Marketing of Ziehm Imaging GmbH, joined the company in 2003 as a Product Manager. He has 20 years of experience in the healthcare business. He has held various responsibilities in the position of Service Engineer, Sales Engineer, Sales Director and Business Manager.

The rise of medical imagingMartin Törnvik talks about the innovations and improvements currently going on in

the world of medical imaging.

EXECUTIVEINTERVIEW

“Th e surgeon needs more accurate image-guidance tools when performing minimal invasive surgery to be able to be safe and more accurate”

Zheim Imaging.indd 72Zheim Imaging.indd 72 7/4/10 16:32:037/4/10 16:32:03

Ziehm Imaging AD1.indd 1Ziehm Imaging AD1.indd 1 23/3/10 17:04:4923/3/10 17:04:49

Medical imaging has been pegged asone of the industry’s largest growthmarkets for many years, but it is ex-pected that over the next year it will

grow by an impressive six to eight percent. And withyear-on-year growth expected to happen for the nextfive years, Europe’s picture archiving and communi-cation systems (PACS) market is drawing more andmore opportunities within the sector.

Combined with available and emerging webtechnology, PACS has the ability to deliver timelyand efficient access to images, interpretations and re-lated data, breaking down the physical and time bar-riers associated with traditional film-based imageretrieval, distribution and display. A number of tech-nological advancements in both clinical applicationsand work-flow management tools are being intro-duced that have transformed the functionality ofPACS from a viewing and storage solution for im-ages, to a crucial decision-support system. There is growing evidence of work-flow efficiencies, improved quality of care and cost savings being realised in anumber of hospitals, which in turn, has generated interest in the adoption ofPACS among general physicians and private practitioners.

For example, PACS has become indispensable in a digital radiology en-vironment today, in spite of the many hurdles faced during its implementa-tion. According to London-based market research company Global Data, theEuropean radiology market contributed 67 percent to total PACS sales in2008, when it was valued at US$384 million. The radiology segment is pro-jected to grow at 5.5 percent for the next seven years to reach US$557 millionin 2015. Meanwhile, the cardio PACS market will be the fastest growing seg-ment in Europe at nearly nine percent compound annual growth rate between2008-2015 to reach US$93 million in 2015. Other PACS, which include mam-mography PACS and orthopedics PACS, are expected to grow at around sixpercent, to reach US$198 million in 2015.

The overall market will be driven by the late adoption of PACS in coun-tries such as Spain, Italy, Wales and Northern Ireland due to regional gov-ernment initiatives, increased adoption amongst private practitioners, and thereplacement market. Non-radiology PACS segments such as cardio PACS areexpected to be driven by the integration of computer-aided diagnosis/detec-tion (CAD) with PACS.

A number of regional PACS projects, such as the Hospital District ofHelsinki and Uusimaa regional PACS project (HUSpacs) in Finland, haveshown that when implemented correctly PACS can be instrumental in not

only providing superior quality of care, but also in reducing costs and im-proving efficiencies. Indeed, the challenge of convincing private practitionersto invest in a good PACS is being met by vendors through customisation, in-novative pricing models and by providing technical support for maintenance.While PACS represents an opportunity to reduce many costs, it requires asubstantial investment of time, personnel and financial resources and there-fore decisions about whether to go digital must not only meet local require-ments but also incorporate an awareness of regional, national, and evencontinental efforts to establish networks and data standards. n

The future of private sector medical imaging


The need for integrated diagnostic and visualisation tools for non-radiologydepartments such as orthopaedics, cardiology, oncology and mammography will drivetechnological innovation in the European PACS market, argues Jodie Humphries.

IMAGINGFOCUS

PACS in numbers

• The European PACS market will reach US$848 millionby 2015

• The radiology segment is predicted to grow 5.5 percent for the next seven years, to reach US$557 million in 2015

• The European radiology market contributed 67 percent to total PACS sales in 2008

• The cardio sector will be the fastest growing segment in Europe, reaching a nearly nine percent compound annual growth rate

Medical Imaging Ed_mar10 07/04/2010 15:52 Page 74

Reduce your costs by up to 80%

• Store and Distribute any clinical information

• Providing images from any modality, Serial Studies, Prints and Reports

• Radiology, CT, MR, SPECT, SPECT-CT, PET-CT, PET-MR

Interested? Please email:[email protected]

Hermes AD approved_euro 23/03/2010 17:02 Page 1


To build a smarter system, healthcare solutions need to be instrumented, interconnected and intelligent. IBM believes it has the answer.By Ben Thompson

TECHNOLOGY

Smarter Planet.indd 76Smarter Planet.indd 76 7/4/10 16:29:127/4/10 16:29:12


We live in an unpredictable world. You know it when you get caught in an unforecast storm on a sunny summer’s day; you know it when the stock market tanks and your previously rock-solid investments are

reduced to worthless junk; you know it when you hit unexpected gridlock on the way to that all-important business meeting. What you don’t always know are the hows, whys and wherefores – the myriad combination of variables that fell into place in order for those events to unfold.

But what if you did? Given better intelligence, is it possible to predict how such permutations might play out in future – thus avoiding the storm, selling high and dodging the worst of the traffi c? Can a better understanding of the way systems work help solve some of the challenges we face as a global society? And what implications could this have for that most complex system of all: human health?

IBM Chief Executive Sam Palmisano doesn’t claim to have the all the answers – but he’s working on it. From fi nancial crises to climate disruption, energy geopolitics to food supply hazards,

Palmisano believes solving the global challenges of today and to-morrow will be about the smarter use of information, and has spent over US$50 billion on acquisitions and R&D in preparation for the seismic shift in thinking such a move will require.

“Th e fi rst decade of the 21st century has been a series of wake-up calls with a single subject: the reality of global integra-tion,” he explains. “In business, global integration has changed the corporate model and the nature of work itself. In the last few years, our eyes have been opened to global climate change, and to the environmental and geopolitical issues surrounding energy. We have been made aware of the vulnerabilities of global supply chains for food and medicine. We entered the new century with the shock to our sense of security delivered by the attacks on 9/11. And, of course, we are now in the midst of a global fi nancial crisis. Th ese collective realisations have reminded us that we are all now con-nected – economically, technically and socially.”

And as the world continues to get fl atter, smaller and more in-terconnected, IBM is banking on something happening that holds

“If we are going to address the issues of access, cost and healthcare quality, we have to have better information technology to support that”



even greater potential: the prospect of our planet becoming smarter. “Th is

isn’t just a metaphor,” asserts Palmisano. “New intelligence is being infused into the way the world literally works – the systems and processes that enable physical goods to be developed, manufactured, bought and sold; services to be delivered; everything from people and money to oil, water and electrons to move; and billions of people to work and live. Th e future now beckoning us is one of enormous promise.”

His confi dence is based on three key developments. Firstly, the world is becom-ing instrumented. IBM claims that by 2010 there will be a billion transistors per human, each one costing one ten-millionth of a cent, while sensors are being embed-ded into everything from cars, appliances, cameras, roads and pipelines to medicine and livestock. Secondly, with over a tril-lion networked devices, the world is also becoming more interconnected, producing rising volumes of data each year. Finally, things are becoming more intelligent. Algorithms and powerful systems can analyse and turn those mountains of data into actual decisions and actions that make the world work better. Real insight, in real- time, is now a real possibility.

“With so much technology and net-working available at such low cost, what wouldn’t you enhance?” he asks. “What wouldn’t you connect? What information wouldn’t you mine for insight? What ser-vice wouldn’t you provide a customer, a citizen, a student or a patient?”

Healthcare is one such sector set to benefi t. “Our current approach to health-care is just not sustainable,” says Sean Hogan, IBM’s VP for Healthcare Delivery Systems. “However, the fi nancial crisis has highlighted the burden that healthcare costs are placing on our society, and as such is prompting a very engaging debate about what to do about it. And the conclusion is that if we are going to address the issues of access, cost and healthcare quality, we have to have better information technology to support that.”

Rising costs, limited access, high error rates, lack of coverage, poor response to chronic disease and the lengthy develop-

Case study: Integrating health systems

Servicio Extremeño de Salud (SES) is the public healthcare service for the regional Ministry of Health (Consejería de Salud) in Spain. The Mérida-based organisation delivers healthcare services to more than one million people in the Extremadura region in the western interior of Spain through approximately 13,000 professionals.

ChallengeEach hospital in the regional healthcare system had its own IT solutions, and only a few medical care centres received any application support. In addition, each facility had its own patient records system, and the data was not accessible regionally. SES realised that it needed to integrate both patient-related and administrative processes to serve patients better. This transformation required local solutions to be replaced with one integrated system, and extending access and application support to create a more cohesive regional healthcare unit.

SolutionSES selected IBM Global Business Services to design and deploy an SAP R/3 based integrated healthcare information management system that supports and manages all business processes at SES, including patient-related records management and administrative processes. This Linux-based solution leverages a single integrated data repository that stores medical and administrative data in a central location, making it available region-wide.

ResultsAs a result of the IBM solution, up-to-date patient information is available throughout the region to all hospitals, medical care centres and administrative offi ces, enhancing the ability of doctors, nurses and other healthcare professionals to provide the best service to their patients. The new solution connects almost 13,000 professionals, with the scheduling system managing nine million outpatient visits each year, while SES has seen reduced costs of paper and other media, and improvements in clinical and administrative effi ciency.


Vital Images AD.indd 1Vital Images AD.indd 1 23/3/10 17:04:2623/3/10 17:04:26


ment cycle for new medicines – Hogan explains how most of these could be improved if we could link diagnosis to drug discovery to healthcare providers to insurers to employers to patients and communities. Today, these components, processes and participants that comprise the vast healthcare system aren’t connected. Duplication and handoff s are ram-pant. Deep wells of lifesaving information are inaccessible.

IBM believes that a smarter healthcare system starts with better connections, better data, and faster and more detailed analysis. It means integrating data and centering it on the patient, so each person ‘owns’ his or her information and has access to a networked team of collabora-tive care. It means moving away from paper records, in order to reduce medical errors and improve effi ciencies. And it means applying advanced analytics to vast amounts of data, to improve outcomes.

“If you had a map of all industries and plotted the sophistication of the use of information technology within those industries, healthcare would be on the lower end of the spectrum – despite the fact that it is a very technology intensive and information intensive sector,” says Hogan. “But IT can help make the administrative process smarter and more ef-fi cient; it can enable health information to be shared between care pro-viders and eliminate redundant procedures; and it can better support the process of care so that physicians have the right information available to support the decisions they need to make.”

For instance, Sainte-Justine, a research hospital in Quebec, is auto-mating the gathering, managing and updating of critical research data, which is oft en spread across diff erent departments. With the help of IBM technology, the centre is applying analytics to speed childhood cancer research and improve patient care while drastically lowering the cost

of data acquisition and enhancing data quality. Another example is Geisinger Health Systems, which is integrating clinical, fi nancial, operational, claims, genomic and other information into an integrated environment of medical intelligence that helps doctors deliver more personalised care. Th is enables them to make smarter decisions and deliver higher quality care, all because they can easily turn information into actionable knowledge.

And true to the premise of Smarter Planet, healthcare systems like these hold promise beyond their particular commu-nities, patients and diseases. “Th e smart ideas from one can be replicated across an increasingly effi cient, interconnected and intelligent system,” says Hogan. “Th is should result in lower costs, better-quality care and healthier people and communities. In other words, we’ll have a true healthcare system with the focus where it belongs – on the patient.”

In fact, much of smarter healthcare is not focused on the next big break-

through in medical research. Smarter healthcare solutions start with the individual. Take the Medical Home model, for example, where primary care physicians act as ‘coaches’, leading a team that manages a patient’s wellness, preventive and chronic care needs. Th e doctor spends more time with each person, is available via e-mail and phone for consulta-tion, off ers expanded hours and coordinates care across the individual’s entire care team. Interest in the Medical Home is building in the United States and has caught on globally as well. Physicians, healthcare leaders, insurers, legislators, large companies and other stakeholders are focused on the fact that the Medical Home model of care improves quality and patient satisfaction and contributes to lower overall healthcare costs.

But while medical homes can be a cornerstone of transformation, they are not what Hogan calls “a silver bullet”. Th ey hold a great deal of promise, but many more supportive measures need to be undertaken to fully realise the benefi ts. For example, steps needed for full imple-mentation include improved access to patient information and clinical knowledge to improve prevention, diagnosis and treatment; changes on the part of other stakeholders (consumers, other physicians, hospitals, health plans, employers, governments and such life sciences as phar-maceuticals); and a robust infrastructure to support comprehensive, coordinated care.

Nevertheless, he believes the strides being made by IBM in terms of harnessing the power of technology for better healthcare solutions are signifi cant. “We are taking advantage of the fact that our society is much more instrumented, connecting that information and using intelligence to take actions that create benefi ts,” he concludes. “It’s a very exciting area.”


iStrategy Europe 5th-6th October 2010

The Millenium Gloucester Hotel, London, UK

Transforming the Enterprise with Digital Expertise

In 2009, companies with dedicated social media activity boosted sales by over 18%, while those with minimal or no presence saw a 6% decrease. As 2010 marks a shift in consumer mentality from recession to recovery, companies must adjust their strategies according to how customers make purchasing decisions. Brand differentiation will be key, and companies must be at the forefront in areas like social web, mobile apps and SEO in order to create a distinguished customer experience.

iStrategy October 2010 marks the next step in your marketing strategy. Here, you will learn:

• The biggest trends in consumer spending online• Innovative technologies for communicating with

customers and how to best implement them

• The top 10 most important factors in your social media strategy

• How to measure your social capital and monetize your efforts

• Hot buttons to bring people to your web store front • How to fi nd your best fi t in integrating email and social

media• How to deliver a response-driven, relevant message

The simple truth is that there is no magic one-size-fi ts-all marketing mix. iStrategy will arm you with the deep understanding of aligning social media and digital strategy according to your organization’s processes and operations to achieve the objectives you’re after. Join us in October to network, share ideas, and most importantly fi nd out how to build your marketing strategy to its fullest potential.

Participation in Social Media and Interactive Marketing is no longer

revolutionary.

it’s crucial.

For More Information, Please Call:Max Ford, Global Event Director. Tel: +44 (0) 117 915 4753. Mobile: + 44 (0) 7798 820 711

iStrategy Europe ad MAG SIZE.indd 1iStrategy Europe ad MAG SIZE.indd 1 1/4/10 14:25:281/4/10 14:25:28


Innovation institute

TECHNOLOGY

Rosanna Tarricone.indd 82Rosanna Tarricone.indd 82 7/4/10 16:28:517/4/10 16:28:51


As an independent research organisation the Europe-an Health Technology Institute for Socio-Economic Research (EHTI) is invaluable in developing data and evidence on the social and economic value of medical technology and its impact on the economy and welfare of European countries. Executive Di-

rector, Rosanna Tarricone has been at the helm of the research institute since its inception in 2007. Th e institute was created three years ago to stem the lack of scientifi c and economic evidence on medical devices, and has been working towards providing a systematic review and analy-sis of the major reimbursement and security systems in Europe, so as to have a deep and detailed understanding of how medical technology is currently procured and reimbursed, as well as who benefi ts from invest-ment in medical technology.

“Th is is something that, until some years ago, many people were not aware of – even at the policy level – because the sector is so diverse that reimbursement and procurement positions are decentralised throughout Europe, and even within countries themselves, decision makers were not aware of how the system was whole was working,” explains Tarricone.

Th is vital fi rst step in understanding the current system was crucial and has laid a foundation for where the institute currently fi nds itself – attempting to recognise how healthcare policies implemented by dif-ferent countries in Europe are actually eff ecting the consumption of medical devices in the same countries. Indeed, Tarricone stresses that the main improvement the EHTI has brought to the industry has been in terms of knowledge: “We have led a huge improvement in progressing research and building up scientifi c knowledge in this specifi c fi eld, fi rstly for academics and secondly for policy makers themselves.”

Th e industry today is undoubtedly much more aware of how sys-tems are implemented throughout Europe, such as the major diff erences between various countries and whether they have an impact on the dif-fusion and uptake of medical technology across the continent. So while the improvement is not something tangible there has been progression.

In an exclusive interview Executive Director of the European Health Technology Institute, Rosanna Tarricone, reveals the challenges of a fragmented device industry and the impact this will have on innovation.

By Rebecca Goozee



Indeed, Tarricone asserts that the last three years have secured a good foundation of knowledge from which to continue the institute’s mission.

InnovationAs a cornerstone of the health systems in Europe, innovation is key

to understanding more. Tarricone believes that she sees the benefi ts of innovation on several levels, including the patient, the hospital, the clinicians and the industry itself. “Even within the basic technology side, today we are able to deliver surgical intervention in many invasive ways, that were impossible just a few years ago,” she says, before adding, “Instead of opening the chest, for example, we can make a small hole in the chest and insert a medical device that means the patient can go back home and recover much more quickly. We are benefi ting the healthcare system and hospitals in that the costs are lower because we are using less intensive equipment and less time is spent in the operating theatre, but we are also providing a better quality of life to the patient as they are less exposed to the risks of major cardiac intervention and anaesthetics.”

Tarricone goes on to explain that innovation is benefi ting the entire economic system as technologies, approaches and procedures improve and allow increasing opportunities for patients to get back home earlier and get back to their job faster. However, despite technological innova-tion being crucial to a speedier recovery for patients, there is no doubt that it has recently been tainted with a bad reputation: innovation has been deemed to be at the root of the recent escalation in healthcare costs. Tarricone, however, completely disagrees that innovation is behind rising fi nances. She points to three studies that were published last year that prove that the rise in healthcare expenditure is due to personnel and other costs as opposed to innovation.

Recent data from Bocconi University that is yet to be published, for example, states that of all the expenditure in Italian hospitals over the last decade – the costs for medical technology and for innovation in general in the fi eld of medical technology – has actually decreased while other cost components such as pharmaceuticals and other healthcare services have increased. “I would like to see the evidence demonstrating that technological innovation is at the root of escalating costs,” says Tarricone. “Of course this doesn’t mean that innovation hasn’t contributed at all to the increase in costs, simply that it is not the most important factor. Obviously technological innovation contributes to higher expenditures, but today – simply because we have the opportunity of treating and making a better diagnosis than in the past. Th ink of the screening programmes, for vaccinations or genetic tests that weren’t available 10-15 years ago. We didn’t have the opportunity to make genetic tests help clini-cians target their medication in such a precise way.”

Going on to give an example, Tarricone explains that until 2007, the only way to treat patients with severe cardiac problems was by implanting heart valves, which actually translated into a high per-centage unable to go through with the procedure because it was too risky. Over the last two years several medical device companies have developed innovative ways to treat these patients and the risk of surgi-cal intervention has been decreased dramatically translating into more

eligible patients who go on to survive at least fi ve years longer than in the past. “Surely cost shouldn’t even come into this – we are not de-

livering these new systems or procedures because they are more costly than in the past – although obviously they are – but

for the benefi ts they bring. Th ere are incremental costs, but we should compare these against the incremental

benefi ts in terms of a longer and healthier life for patients,” says Tarricone.

ChallengesAnd potential cost increases are not the only

challenge facing the medical devices sector, the biggest challenge, claims Tarricone, is the very deep

lack of knowledge and understanding of the diff erences between the devices and other technologies, particularly

pharmaceuticals. Over the last decade pharmaceuticals have come under heavy regulation from both local governments and international organisations, such as the European Commission. A similar trend has developed as those organisations attempt to regulate the medical devices sector. However, the challenge is that the same individuals who are used to regulating, managing and controlling access to the pharmaceutical industry are looking to use the same principles and methods to regulate

Rosanna Tarricone

Overall savings from

telemonitoring range from

$430 to $821



“The fi rst reason is the rather obvious one that many devices are diagnostic. This raises two challenges, the fi rst being that the value of improved diagnosis cannot be separated from the value of the improvement in patient outcome resulting from the subsequent treatment. This problem is not insurmountable, but makes the economic evaluation of some devices much more complicated.

“The second way in which devices are different is in the diffi culties in undertaking randomised controlled trials (RCTs). By the time a drug reaches Phase III of clinical development, its dosage and route of administration will typically be set. Therefore, whilst it is well known that the effi cacy demonstrated in RCTs does not always translate into practice, the results from trials provide a reasonable basis for conducting an economic evaluation.

“The third reason why devices are different is that the effi cacy of a device depends not only on the device itself, but how it is used. Again, this is particularly true for devices used in surgery, as the clinical outcome can depend on the skill or experience of the surgeon. On the other hand, drugs are a classic case of an ‘embodied technology’. That is, as long as the drug is given in the right dose, the effi cacy relates solely to the drug itself, not the person administering it.

“The need to adjust for user characteristics further complicates the design of RCTs and user performance is a potential confounder in the analysis of observational data on the effi cacy of devices. Indeed it might be preferable to undertake more multicentre studies than is typical for all but the large Phase III studies of drugs. Whether these studies are randomised or not, the statistical analysis would be more complicated, since it would need to allow for treatment center effects. Taken in conjunction with the points made above, it is clear that the design and analysis of clinical studies of devices can be more challenging than comparable studies of drugs.

“The fourth way in which devices are different from drugs is that implementation of a new therapy involving a device can have wider economic implications. For example, there may be a need for training, or more fundamentally, the local organisational context

may be important for harnessing the improved cost-effectiveness of a device.

“The fi fth way in which devices are different from drugs is that equivalent clinical evidence may not be available for all products, making comparisons diffi cult. Those undertaking economic evaluations are often quick to ‘genericise’ their recommendations, unless there is specifi c evidence to differentiate products. This position is possibly driven from experience with pharmaceuticals, where there is clinical evidence on each product and where assumptions about class effects are common, unless there is specifi c head-to-head trial evidence to the contrary. In addition, there are now acceptable methods for making indirect, or mixed treatment comparisons, providing suffi cient clinical data is available (Ades et al., 2006).

“The sixth way in which devices are different from drugs is that prices are much more likely to change over time, because of the market entry of new products, or because of the ways in which procurement takes place in many healthcare systems. On the other hand, in many countries, once the price of a drug is negotiated, it is more likely to stay at or near that level until the patent expires.”

Extract from: Economic Evaluation For Devices and Drugs by Michael Drummond, Adrian Griffi n and Rosanna Tarricone.

Economic evaluationAlong with Michael Drummond at the Centre for Health Economics and Adrian Griffi n, Vice President of Strategic Affairs at LifeScan EMEA, Rosanna Tarricone recently released a report, Economic Evaluation For Devices and Drugs, arguing that the economic evaluation of devices raises additional challenges that international guidelines, written with pharmaceuticals in mind, frequently overlook. In the report the authors stress the six reasons why devices are different:



access to medical devices. “I can envisage a huge danger in this,” warns Tarricone, “there are deep diff erences in the way medical devices are developed compared to the pharmaceutical industry is managed.”

She goes on to explain that the medical device industry is extremely fragmented with around 80 percent of the companies operating in it being SMBs, compared to the pharmaceutical industry, which has a high concentration of super companies used to operating around the world. “Th ere are huge diff erences in terms of R&D, competitiveness and the lifecycle of medical devices in the two industries,” explains Tarricone. “When you have a new molecule for example, normally it will be present for at least 15-20 years until a new one replaces it. A medical device will usually be obsolete aft er around 18 months.”

If policy makers at all levels still fail to understand the key dif-ferences between these two industries, there is a risk that the medical devices sector will be regulated with pharmaceutical rules, killing the competitiveness and innovativeness of the sector, says Tarricone. “Th is translates into a huge responsibility for the EHTI – we need to unveil these diff erences from a scientifi c perspective through evidence demon-strating the diff erences and arguing the case for alternative policies and regulations to the policy makers.”

And while policy decisions will continue to impact the medical de-vices industry for some time, there is another challenge on the horizon, namely the aft ershocks of the economic downturn. While the medi-cal technology sector has not been directly or heavily aff ected by the worldwide recession, there has been an impact on other sectors of the industry, such as for instance, diagnostics and preventive medicine. Tar-ricone says that screening programmes for breast cancer, for example, have experienced a heavier impact as patients have started delaying the services because in many countries these services require co-payment from the patient. It seems that patients have started thinking twice of the necessity of performing some diagnostic tests and we have the data proving this.”

Tarricone goes on to explain that the economic downturn will probably have a bigger infl uence in the long run, as the impact is felt by the companies producing these devices. Th e risk here, of course, is that long-term this downturn has the po-tential to kill the most dynamic sectors of these companies, which are the R&D sec-tors. Th is is unfortunate considering that Tarricone believes the big potential for the medical technology industry in Europe is all about R&D and the emergence of break-through innovations. “You have to consider that a lot of breakthrough innovations have been developed in Europe but marketed in the US – and that’s our weakness. European systems are not very friendly in terms of facilitating, stimulating and welcoming in-novativeness in companies within Europe,” she says, going on to explain that Europe is wasting a lot of potential in terms of economic return on investment and positioning the region on a higher competitive level with the US and Asia. “I really would like to see many countries, in-cluding Italy, become more aware of what they are missing in terms of

opportunities and understand the advantages that could be delivered in keeping investment in Europe.”

Focusing on opportunity, Tarricone believes that the next three years will be important for the EHTI’s research agenda, fi rstly to un-derstand the impact of healthcare policies onto healthcare systems and the uptake diff usion of medical devices in diff erent European countries, and ultimately to understand whether the diff erent diff usion of medi-

cal devices in European countries is aff ecting the equitable access of patients. Tarricone goes on to stress her previous point that while researchers have always been asked to provide evidence of their fi ndings, policymakers have never been asked to supply the evidence of their work. “Policymakers are struggling with healthcare expenditures and while they are right to understand and try and implement diff erent types of cost containment policies – from procurement to reimbursement – none of them have been called to prove the impact of these policies on the effi ciency of the systems, the eff ectiveness of the systems and, more im-

portantly, the equity of the systems. “In modern-based societies health policies must be evidence-based.

We are the fi rst European institute that is dealing with this specifi c fi eld of research in a very structured way, specifi cally on medical devices, and I think that the output of all this research will be interesting, and in many cases surprising, for many stakeholders.” And with Tarricone so determined in her mission to improve these systems I have no doubt that she will succeed.

“Th ere are incremental costs, but we should

compare these against the incremental benefi ts in terms of a longer and

healthier life for patients”

Device analysis

An analysis performed by Dr Christian Elsner, Center for Healthcare Management, Leipzig Graduate School of Management on behalf of Eucomed CRM Telemonitoring WG found the following:

• Overall, the decrease in physician’s time ranged from 40 percent to 70 percent from the use of telemonitoring, depending on the perspective (e.g. payer’s perspective-only or societal perspective)

• Costs per visit ranged between $94 (France) and €281 (Germany). Transportation costs per visit ranged between $121 (France) and €43,5 (Germany)

• Overall savings from telemonitoring per year ranged between $430 (France, a saving of 30.1 percent) and €821 (Germany, a saving of 60.9 percent).


Relay Health AD.indd 1Relay Health AD.indd 1 1/4/10 14:41:001/4/10 14:41:00


Akanksha Joshi, Research Analyst for Frost & Sullivan, believes that the most important drivers in the growing market is the rise in el-derly population plus the increasing preference of this population to age at home. “Not only is the number of people over the age of 65 increasing, but there’s a preference for people to have a comfortable life at home and this is becoming a very important factor, which is accompanied of course by an awareness about the need to provide a better standard of living to them,” she explains. “Th e importance of providing rapid, real-time diagnoses is being realised due to the focus on home-based, wireless enabled patient monitoring devices.”

Alongside the desire to provide better patient care in a more com-fortable environment – namely, the home – the healthcare industry

As healthcare across Europe becomes increasing-ly digitised, there is a growing need to develop equally sophisticated information systems. Indeed the popularity of wireless and handheld devices in the healthcare area is poised to grow signifi cantly as the benefi ts of mobility and fl ex-ibility become progressively more important

to both physicians and patients – particularly in the European wireless patient monitoring devices market. New analysis from Frost & Sullivan, European Market for Wireless Patient Monitoring Devices, fi nds that the market earned revenues of €131.2 million in 2008 with estimates reaching €66.7 million in 2015.

As digital becomes an increasingly important function of healthcare IT, Frost & Sullivan analyst Akanksha Joshi reveals why an ageing demographic is boosting the uptake of wireless patient monitoring devices.

ANALYSTVIEWPOINT

frost and sulivan.indd 88frost and sulivan.indd 88 7/4/10 16:40:507/4/10 16:40:50


in Europe is also focusing on reducing hospital costs. “Part of those reduced costs is down to a diminished change of spreading an infec-tion,” says Joshi. “With vital signs easily and comfortably measured in a user-friendly way at home, wireless patient monitoring is becoming more popular as well as reducing costs. Assisted living devices and vital signs devices with a wireless option are certainly in demand.”

However, one of the challenges facing the industry is around the lack of clearly defi ned reimbursement. Joshi also says that there is an element of price sensitivity in the market: “If we are talking only about telecare devices and the sensors the price is not all that high, but if you include the service providers, which constitutes about 60 percent of the total cost of the treatment, obviously you are looking at increased costs.”

While the economic recession has aggravated price sensitivity in the healthcare market, Johsi believes that due to the wireless monitor-ing sector being in its infancy the sector has avoided any major impact. “People – both physicians and patients are moving towards homecare

because it is the most cost-friendly solution that they can come up with in terms of basic patient monitoring,” she confi rms.

Joshi also believes that the technology grid in Europe needs to be improved before the chance of further development in the fi eld. Better network and standardisation from the service providers would reduce the cost to patient. She also suggests that the manufacturer develops more of a relationship with the end user in order to get a better feel for what products are needed. “Initial testing of the system will ease up the process and I also believe that the manufacturer should do more to un-derstand the end user, especially in terms of the user requirements that are bound to be diff erent from country to country. Th is will enable the manufacturer to adapt their product to both a specifi c end user from a specifi c country as well as enable a better line of communication.”

Joshi indicates that the main regions that will see growth are the UK and Scandinavia, as these are the two markets with a greater aware-ness among patients as well as government organisations who are look-ing to cut costs and provide a better service for their citizens. Still in it’s initial growth stage, Joshi says that the market could grow explosively across the whole Europe region. “Specifi cally in the assisted devices region,” she says, “Basically those devices that fall into the sub-segment category, such as movement detectors.”

With the number of elderly rising across Europe, without doubt there is a considerable growth potential for wireless patient monitoring devices across the region.

Wireless Patient Monitoring Devices Market: Revenue Share By Country, 2008

Akanksha Joshi is a Research Analyst for Frost & Sullivan.

Benelux : 6%

Source: Frost & Sullivan

UK: 27%

Germany: 28%

Spain: 8%

Scandinavia: 9%

Italy: 11%

France: 13%

frost and sulivan.indd 89frost and sulivan.indd 89 7/4/10 16:40:527/4/10 16:40:52


A 10-year-old trade association, the Wi-Fi Alliance has 350 member companies that span the whole ecosystem from service providers to equipment makers, chip, silicon IC vendors and soft ware. Its goal is to ensure that Wi-Fi has full access to markets. Much of this is achieved through members coming together to design certifi cation

programmes around the needs of particular markets.As Sarah Morris, Senior Marketing Manger for the Wi-Fi Alliance, ex-

plains, most people associate Wi-Fi with wireless area networks (WLANs), but the diversity of uses for Wi-Fi has grown exponentially in the past few years. “In a traditional wired setting, a local-area network is a series of de-vices that are interconnected so that they are networked together,” Morris

explains. “So from a wireless standpoint, obviously that connection could be happening over Wi-Fi.

“And then there are the broader places that Wi-Fi is being embedded into; a lot more electronics devices as well as into mobile handsets, and smartphones in particular, are integrating Wi-Fi. What it then becomes is something a bit more pervasive where a single device may be using several diff erent kinds of connections. But from the end-user’s standpoint, you’re just connected.

“It’s still pretty common for people to associate Wi-Fi with internet connections, that’s one of the kind of core uses of Wi-Fi. But again, Wi-Fi is certainly broader than that. Th ere are Wi-Fi technologies that are about wide-area networking, otherwise known as mesh networking, that are used for public-area networks and municipal networking.

The Wi-Fi Alliance’s Sarah

Morris looks at the expanding use of Wi-Fi in the hospital setting.

A wireless world

WIRELESSNETWORKING

Morris.indd 90Morris.indd 90 7/4/10 16:28:117/4/10 16:28:11


“Th ere’s also a move within Wi-Fi right now to connect individual devices together without an access point. Th at’s a technology that was de-veloped in the Wi-Fi Alliance, called Wi-Fi peer-to-peer. It will be coming out under the tradename Wi-Fi Direct.”

HospitalsWithin the hospital setting, Wi-Fi is very well established as a com-

munication tool for a wide range of data functions. Voice over IP con-nections, for example, are a big deployment practice for Wi-Fi, as are mobile computing carts. Th is appears to be borne out by an estimate from ABI Research that Wi-Fi revenue for healthcare in 2013 will equal US$5 billion.

Morris says uptake of wireless among hospitals varies geographically in terms of what infrastruc-ture is already in place and where it makes sense. “If you look at hospitals as similar to typical enterprise networks, it’s as if you have an existing building and your alternative is putting in Wi-Fi access points versus running new cabling,” she explains.

“It also lets you be fl exible as you grow. You don’t have to pre-wire everything at the start, and you can add capacity to the network as it goes on. It’s very fl exible and cost-effi cient in that way. Depending on the individual circumstances, I think Wi-Fi is becoming a no-brainer choice for a lot of applications. And hospitals are in a similar place with regard to data.”

Morris points out that when we talk about hospitals as a single entity, IT managers are comfortable and familiar with Wi-Fi and data networking and the voice applications, and the next horizon that they have in terms of understanding, is not so much Wi-Fi’s limitations as the particular needs they have.

However, as these needs begin to encompass things like medical sens-ing applications, which are more about data and the monitoring of patients, it will become even more important for IT administrators to understand the needs they have in their specifi c environments.

“Wi-Fi is a robust, proven, reliable technology,” Morris says. “Th e focus for a successful deployment for IT managers is to understand the environ-ment they’re in as well as the requirements they have for the network.”

SecurityTh ere are always security concerns around any kind of patient data,

and perhaps even more so when it comes to electronic storage and trans-mission. Morris underlines the importance of putting Wi-Fi security in the context of the security of the whole network.

“When we talk about Wi-Fi security, we’re talking about two things: authenticating devices that connect to the network, guaranteeing that appropriate devices connect; and encrypting the transmission from that device to the access point.

“In those two regards, Wi-Fi is top notch. Th e Wi-Fi Alliance has a programme called WPA2, Wi-Fi Protected Access 2, and it has a sophisti-cated and robust security that includes government grade encryption.

“Questions about network security shouldn’t make anyone hesitate to install Wi-Fi. Th at’s not to say that IT manag-

ers don’t have other layers of security concerns, but the Wi-Fi piece certainly is a strong player. I wouldn’t say

anything other than a thumbs-up on that.”Wi-Fi can also look forward to a strong future

in the healthcare sector. Morris sees a lot of mo-mentum, with hospitals seeing the benefi ts of a robust, secure, wireless connection for their data

applications. “Th at’s happening right now, and it will continue to be the case, and penetrate further

and further into that market.“Th e next growing edge, the next opportunity for IT

managers and hospital administrators, will be where Wi-Fi can add value in the monitoring, and into patient services, for home

healthcare as well as hospitals. Th ey’re distinct needs, but they’re both places where Wi-Fi can be a real valuable part of the solution.

“Th e key is for hospital administrators to be thoughtful about what their needs are. Remote monitoring and dispensing is one example. We have members who are active in that area, where they are developing de-vices that might be a wireless blood pressure cuff , or something that could take vital information and report it over the network.

“Th at’s the early edge, and there are more developments to be made, but we certainly have members who are active and successful in those markets.”

“Questions about network security shouldn’t make anyone hesitate to install Wi-Fi”

The Wi-Fi Alliance’s mission is to:• Deliver the best user experience by certifying products

enabled with Wi-Fi technology• Grow the Wi-Fi market across market segments and

geographies, on a variety of devices• Develop market-enabling programmes• Support industry-agreed standards and specifi cations

r Wi-Fi,out r

have pacity to

hesitate toers do

Wi-an

im

awi

and “Th

managers a

It is estimated that Wi-Fi revenue for healthcare in 2013

will equal US$5 billion

What is Wi-Fi?Wireless fi delity (Wi-Fi) is a trademark of the Wi-Fi Alliance that may be used with certifi ed products that belong to a class of wireless local area network (WLAN) devices based on the IEEE 802.11 standards. Because of the close relationship with its underlying standard, the term Wi-Fi is often used as a synonym for IEEE 802.11 technology

Morris.indd 91Morris.indd 91 7/4/10 16:28:157/4/10 16:28:15


In a world where data is everywhere, it has become harder than ever for healthcare organisations to pro-tect confi dential information. In fact, more electronic records were breached in

2008 than in the previ-ous four years combined, according to Verizon’s 2009 Data Breach In-vestigations Report. Au-tomation of electronic medical records, clinical systems and medical im-aging poses increasing challenges to safeguard-ing the privacy of patient data and securing the IT infrastructure housing an organisation’s most sensitive information.

While the continu-ing onslaught of data breaches is well-docu-mented, what is far less understood is why data breaches happen and what can be done to prevent them. In order to get ahead of the data breach challenge, it is essential to understand

why they occur. Th ird-party research into the root causes of data breaches, including data from the Verizon Business Risk Team and the Open Security Foundation, reveals three main types: well-meaning insiders, targeted attacks

and malicious insiders.Well-meaning insiders

who inadvertently violate data security policies continue to represent a major factor in oc-currence of data breaches. In a 2008 survey of 43 organisations that had experienced a data breach, the Ponemon Institute found that over 88 percent of all cases involved incidents result-ing from negligence.

In today’s connected world, where data is everywhere and the perimeter can be anywhere, protecting information assets from sophisticated hacking techniques is an extremely dif-fi cult challenge. Driven by the rising tide of organised cyber-crime, targeted attacks are

increasingly aimed at stealing information for the purpose of identity theft . More than 90 percent of records breached in 2008 involved

groups identifi ed by law enforcement as or-ganised crime. Such attacks are oft en auto-mated using malicious code that can penetrate into an organisation undetected and export data to hacker sites.

Malicious insiders constitute a growing segment of breach drivers, and a proportion-ately greater portion of the cost to business of data breaches. Th e Ponemon study found that data breaches involving negligence cost €138 per record while those caused by malicious acts cost €156 per record.

With the regularity of data breaches making news headlines, it might seem reason-able to regard data breaches as an inevitable by-product of our connected world, a cost of doing business that we must simply learn to live with. A closer view of the facts, however, suggests that this is not necessarily the case. Symantec’s security expertise, global intel-ligence network and real-world experience with customers combine to inform a more confi dent perspective.

How to stop breachesBy following a risk-based and content-

aware information security strategy that incor-porates multiple solutions working together in concert, data breaches are preventable. Th e six steps that any organisation can take to signifi -cantly reduce the risk of a data breach using proven solutions are to proactively protect in-formation with a unifi ed data loss prevention solution, automate the review of entitlements to sensitive data, identify threats by correlat-ing real-time alerts with global security intel-ligence, deploy a multi-layered combination of security solutions to stop incursion by targeted attacks, establish network defences to detect and block data exfi ltration and to integrate prevention and response strategies into secu-rity operations.

Getting startedFor many organisations, the process begins

with a data breach workshop. Th e Symantec Data Breach Workshop helps organisations quickly identify their confi dential information and accurately identify and quantify their risk of a data breach.

The anatomy of a data breach

To schedule a Data Breach Workshop or to see a full copy of the Anatomy of a Data Breach whitepaper, contact Symantec at http://go.symantec.com/one-breach

ASK THEEXPERT

Sarah Whipp is VP of marketing for EMEA at Symantec. She joined Symantec in July 2009 after nine years at McAfee, most recently as VP of EMEA Marketing. Symantec is the world’s fourth-largest software company and a global leader in providing security, storage and systems management solutions.

Sarah Whipp on why breaches happen and how to prevent them occurring.

Symantec.indd 92Symantec.indd 92 7/4/10 16:31:127/4/10 16:31:12

Symantec AD.indd 1Symantec AD.indd 1 23/3/10 17:03:2023/3/10 17:03:20


A number of requirements were added under HITECH, which was part of the stimulus bill. One of these is to create in the US a federal breach notifi cation provision if protected health information becomes improperly accessed or compromised. Hospitals must notify the indi-vidual whose information has been compromised, whether the informa-tion is in electronic form or paper form. Th ey must also notify Health and Human Services, who will list the breaches on a website; the state attorney generals if there are more than 500 people in a particular state that have been compromised; and the local media.

“Th is new notifi cation provision is stronger than any state require-ment,” Koenig points out. “Providers are quickly focusing on this for three reasons. One, most of the state breach notifi cation laws that existed before didn’t include health information; now health information under HITECH is included.

“Second, providers had a strong programme around HIPPA but HIPPA security only applied to electronic protected health information.

There are challenges within the hospital IT environment: legacy applications may not support modern authentica-tion controls; there is a need to share access to equipment and patient care areas across multiple users who require access to medication records; the open nature of hospital

fl oors causes problems of physical security; and regulatory compliance requirements are increasing.

If that’s not bad enough, there is the additional, oft en underestimated, risk of improper access and even medical identity theft by knowledgeable insiders James Koenig, Practice Leader, Privacy & Identity Th eft , and Prac-tice Leader, HIT Privacy & Security for PricewaterhouseCoopers, explains: “Knowledgeable insiders have surpassed outsiders and hackers as the leading cause for identity theft within companies. Within hospitals, the main areas that have been vulnerable have been within collections, within patient enrol-ment, with physical security, with IT and even the janitorial crew. Th ere are a lot of risks within the environment to electronic health records.

“Th ere are many reasons for which information is improperly ac-cessed. Some of the more notable ones have been when healthcare provid-ers and staff have accessed the medical records of celebrities; that’s one type of improper access that is still relatively common. Th e other type is for gaining information that can be used for medical identity theft , to get a health insurance ID number or other information that could allow someone else to access medical care, or to even obtain prescription drugs that are commodities that can be used on the street.

“Th at’s one of the new major underestimated risks within an environment, and within hospitals you have so much change, so much vulnerability, so many people, that this is naturally starting to grow.”

In the US, hospital IT depart-ments are also now faced with the challenges of complying with the requirements of HITECH, which has expanded on those originally set out by HIPPA. Koenig recommends that healthcare providers there focus on the changes to HIPPA under HITECH, specifi cally on the protected health information breach noti-fi cation requirement.

Staying safeJames Koenig tells Marie Shields about the role played by single sign-on in identity access management for healthcare IT.

“Th e return on investment

depends on the profi le of your workforce and how many log-

ins they average in a given day”

DATASECURITY

KOENIG ED.indd Sec1:94KOENIG ED.indd Sec1:94 7/4/10 15:52:207/4/10 15:52:20


Single sign-onDespite the rising concerns about security and the need to comply

with increased regulatory requirements, the adoption of single sign-on in healthcare has been slower versus other industries, oft en due to the inability of older specialised medical equipment to talk and to accom-modate some of the new identity management and single sign-on tools.

According to Koenig, this is becoming less of an issue as technol-ogy matures and hospitals continue to upgrade their systems, especially around electronic health records. “Vendor consolidation has reduced the number of tools in the market,’” he says. “It has also consolidated some of the developer talent, and the remaining tools tend to be a little more consistent so that there’s no longer a reducing number of platforms and standards and options that healthcare can focus around. It’s probably behind other industries, but it’s maturing and getting better.”

Th e use of single sign-on does confer a number of benefi ts, includ-ing fewer passwords to remember, lower support costs, more ability to push secure authentication standards and controls across the enterprise,

at one time, centralised support, centralised logging and monitoring, and fewer accounts to maintain each year.

In general, Koenig says, organisations using single sign-on will spend less time look-ing into many diff erent types of applications; instead, they can track it across the single sign-on. “Th e return on investment depends on the profi le of your workforce and how many log-ins they average in a given day, and with this reduced time and cost of the people entering in passwords repetitively it allows more time to focus on healthcare delivery.

“Resetting of passwords will fall if you have fewer passwords to remember. You will also fi nd people writing them down less, and writing passwords down is what makes them insecure; this is how some of the security in-cidents at hospitals have occurred. Also, be-cause of the new technology, many payers in the US are upgrading their electronic health records and related systems and architecture in preparation for certifi cation to get stimu-lus funds for the meaningful use of electronic health records.”

As part of this overall update of the sys-tems and investment in the infrastructure at

hospitals, single sign-on will also be accompanied by self-service resets as opposed to a manual call to a help desk. Th ese new systems oft en have features that allow users to go to an intranet site and through self-service and answering challenge questions, they can reset the password them-selves.

Th e benefi ts can be summarised as: reduced cost for the enterprise, quicker response time for people who need to get their passwords, fewer instances of passwords being forgotten because people remember a single sign-on better, and less need to write passwords down.

HITECH now includes paper-based pro-tected health information, which provid-ers may not have focused on before.

“And third, HITECH now requires that all business associates comply completely with the HIPPA privacy and security rules. Previously they only had to agree to provide adequate safeguards in a contract. Now, when en-trusting protected health information to a third party – which could be a lab or another vendor – the focus around protected health information is growing.”

Koenig says that the types of information that can be compromised, not just healthcare information, but employee information and the requirements under other privacy laws, including the state breach no-tifi cation laws, have changed the environment and made it much more complicated for healthcare providers to comply.

James Koenig is Practice Leader, Privacy & Identity Theft, and Practice Leader, HIT Privacy & Security, for PricewaterhouseCoopers.



ImplementationAs with any new technology implementation, there are challenges

involved in bringing single sign-on into a hospital or healthcare setting. Koenig believes the main challenge is cost. “Return on investment is based upon building a core framework and then adding additional ap-plications over time. Part of the challenge is adding that to our legacy applications that aren’t quickly compatible. You can always build them in, you can always address it, but the question is, at what cost?

“Th e second challenge is that by having a single sign-on, people will potentially have access to a wider group of systems, applications and information with each sign-on across this system of single sign-on ap-plications.

“Th is means it will be more diffi cult for providers to make sure that access control rights and authorisations given to employees, doctors and staff are limited to the areas that they need for legitimate business and healthcare purposes.

“For example, there may be a staff person who used to have a log-on for the practice management application, which would do scheduling and billing for patients. Th ere was another application for the electronic health records that needed a diff erent sign-on. Th ere’s another sign-on for the laboratory, and for the blood work. Th ere’s another sign-on for radiology data.

“Four diff erent sign-ons, just in this one example. If they’re all part of a single sign-on, hospitals have the challenge to make sure that the right person can only go into where they need to. If there’s a staff member who doesn’t need radiology data, maybe they’re improperly looking at a patient’s data or multiple patients’ data in radiology.”

Koenig says the challenge will be to limit controls and adjust them when people get promoted or terminated, or at a minimum review them each year. “With single sign-on, you can do a lot more and seamlessly move across areas. Th at’s great unless you haven’t checked to make sure that the areas are appropriate.

“Right now the management is done because there isn’t single sign-on, it’s all manual. When somebody says, ‘I need another sign-on,’ you ask, ‘Is it appropriate for that person?’ Now, when you’ve seen them all together someone may have too much access to information that they don’t need.”

AuthenticationAnother method of ensuring only the right people are allowed access

to the correct areas is authentication. Strong authentication centre around one type of authentication, such as a password: how many characters are there, are they letters and numbers? Do you need a special character like an asterisk or an exclamation point? How hard is the password to crack? Multi-factor authentication involves the number of questions you need to answer to get in. For example, single-factor authentication could be just a user ID. If someone had a user ID 123, and someone else knew that ID number, they would be able to access that system.

Two-factor or multi-factor authentication adds other information to the equation, related to ‘something you have’ or ‘something you are’. “When you’re logging in to your bank or calling up, they may ask you challenge questions about your mother’s maiden name or other things, that’s multi-factor,” says Koenig. “It goes beyond the simple stuff .

“How does single sign-on work with two-factor authentication? Strong authentication or strong passwords should always be part of the equation. Two-factor authentication, using a name plus a password, is currently industry common practice. Th e fi nancial services industry addressed this issue several years ago, requiring it for online fi nancial information.

“Since then, fi nancial institutions and frankly most large and me-dium-sized organisations have used two-factor authentication to allow access to any system. Th at would be a sub-requirement for a single sign-on. Sometimes, for example, if you’re going from a simple access into the radiology system, where a limited number of people have access, you might just have someone’s user ID number and not necessarily a pass-word, and maybe the password requirements aren’t that hard.

“But when you’re going to a single sign-on environment, you want to make sure that the person who is entering, who now has access to a lot more information, actually is that person. It’s very common, when you’re moving from a smaller environment that may not have these controls to single sign-on, that people will need to have more complex passwords in addition to what might previously have just been a user ID.

“Part of that goes to the success of the single sign-on. People need to be trained and they need to get used to the fact that instead of having multiple IDs to remember, they may now have only one, but a more com-plicated one that would truly make sure that it’s them.”

Identity managementKoenig points out that typically, single sign-on is part of an organi-

sation’s identity management programme, or it could be thought of as

GlossarySingle sign-on (SSO) is a property of access control of multiple, related, but independent software systems. With this property, a user logs in once and gains access to all systems without being prompted to log in again at each of them.

Identity access management (IAM) encapsulates people, processes and products to identify and manage the data used in an information system to authenticate users and grant or deny access rights to data and system resources. The goal of IAM is to provide appropriate access to enterprise resources.

Strong authentication centres around the strength of the information needed to access a system, such as the type of password and how diffi cult it is to crack.

Multi-factor authentication brings other information into the equation, based on questions related to ‘something you have’ or ‘something you are’. Federal Financial Institutions Examination Council guidelines state that true multi-factor authentication requires the use of solutions from two or more of the three categories of factors.



Koenig’s forecast for the use of SSO and identity access management tools in the healthcare sector is bright: continued deployment in the in-dustry will occur as US providers mature their systems and applications to prepare for certifi cation to get the stimulus funds for the meaningful use. Th ere will be increased purchasing and use of some of these single sign-on and identity management tools to help grow secure access from beyond the areas in which it now exists.

“A big stimulus or driver for that will be the stimulus funds and the meaningful use of certifi cations over the next couple of years,” he con-cludes. “It’s a great opportunity to use those funds and those existing ef-forts around enhancing your technology, plus the need to certify around privacy and security when you apply for the meaningful use funds. Th at’s an important part that a lot of people who are just focusing on the tech-nology are potentially missing.”

a component or a benefi t of some of these identity management tools. Organisations’ websites will very oft en already have single sign-on and some of these identity management access control solutions built in, but other areas are not so secure.

“Very oft en it’s the internal intranet connections between the labo-ratory, radiology, billing and the practice management system’s elec-tronic health records that aren’t connected,” Koenig says. “Th at’s the area where there needs to be work and oft en a separate investment focusing on extending what might be an existing identity management approach, which covers certain applications to some of these older legacy systems and applications.

“For example, many organisations have a wide variety of applica-tions that leverage what’s called an active directory, which is like a single vault of ID. Every time someone enters the system, they check against this active directory. But typically right now, it’s only covering email and a couple of other applications. It doesn’t always get out to those separate ancillary, important healthcare delivery applications. Extending identity management beyond the existing areas that are covered – email, web and some basic applications – will take a separate investment.

“It’s part of regular authentication of controls, but when people buy these systems in these diff erent departments, they don’t always integrate them with the existing identity management controls and functionality that already exists elsewhere. Th at’s the connection that needs to be done now.”

“Return on investment is based upon building a core framework and then adding additional applications over time”


The great


SPECIALREPORT

April 27, 2009The WHO raises its pandemicwarning to phase 4, meaningit has discovered human-to-human transmission of thevirus in at least one country

April 17, 2009A high-tech laboratory atthe Centers for DiseaseControl identifies a newinfluenza virus

March 2009First swine flu infection

April 30, 2009Egypt begins killing alldomestic pigs in the country,despite protests from animalrights activist and Frenchactress Brigette Bardot tostop the mass slaughter

It was almost exactly a year ago that an outbreak of H1N1, orswine flu, began in the state of Veracruz in Mexico. There wasevidence that there had been an ongoing epidemic formonths before it was officially recognised as such and theMexican government closed most of Mexico City’s publicand private facilities in an attempt to contain the spread of

the virus. Unfortunately, it spread globally as clinics became over-whelmed with infected patients. In fact, the World HealthOrganisation (WHO) and the US Centers for Disease Control (CDC)stopped counting cases over the coming months and in June 2009 de-clared the outbreak a pandemic.

The news sparked near-constant media focus on the condition asdeath on a mass scale was expected. Over one billion people around theworld were expected to fall victim to the disease with millions more get-ting sick as parallels were drawn with the Spanish Influenza of 1918, inwhich 40 million people died in just 18 months. In Britain alone healthauthorities worst-case scenarios predicted as many as 65,000 peoplecould die over the winter season, while Germany ordered 50 milliondoses of a swine flu vaccine and the Netherlands 34 million. MeanwhileFrance and Portugal announced major orders for vaccines against thevirus, soon after Latin American countries expressed concern that theirpoorer region could miss out.

Billed as a pandemic of devastating proportions, it was predicted to cause a globalstandstill as hundreds of thousands of people around the world died and millionsmore got sick. So what happened to swine flu?

By Rebecca Goozee

The Outbreak

swindle?swine flu

Swine flu swindle_mar10 07/04/2010 15:55 Page 98


June 11, 2009The WHO declares aswine flu pandemic

November 2009Poland decides not to buyany vaccine

July 24, 2009German states order 50 million vialsof swine flu vaccine

August 2009By the end of the southern winter,fewer people than usual have diedfor an average flu season

February 11, 2010The National Pandemic FluService in England is closed


A cautionary taleScientists claim that while the virus is mild, it can still kill –

and in fact is still responsible for deaths and that the low fatalitiesare down to the fast-acting response to official advice. FredHayden, influenza research coordinator at the Wellcome Trustand a former WHO expert, told Reuters back in November 2009that early planning paid off because the original predictions hadbeen revised. “I wouldn’t characterise this as a ‘mild’ pandemicat all,” he said. “We are seeing some very unfortunate loss of life.I think it’s a bit early to make that judgement.”

But five months later and after the dreaded flu season inEurope has passed, it seems Hayden could be wrong in his eval-uation and that the pandemic is indeed ‘mild’ – particularly as ithas been used so frequently to describe a patient’s condition.Accusations of overreaction were flying as early as October andNovember last year when both British and French media suggest-ed that the pandemic had been ‘hyped’. Sceptics across the conti-nent are asking what are the hype was all about – in November forexample, France’s Le Parisien newspaper ran the headline ‘Swineflu: why the French distrust the vaccine’, and remarked upon the“dangerous liaisons between certain experts, the labs and the gov-ernment, with the obscurity of the contracts between the state andthe pharma firms adding to the doubt.”

Scientists claim they are stuck in the middle and can’t win; thatthey were unable to avoid the advice from organisations like WHO,because it would have caused public outrage and widespread panicto simply ignore the global guidelines. And it appears that the WHOhas yet to learn its lesson – indeed, the organisation has been urgingcountries to prepare for a flu pandemic since 1997, when H5N1

(avian flu) infected 18 people in Hong Kong and the re-emergence of the infec-tion occurred in China and South Korea in 2003.

Mike Fumento, a writer and blogger based in the US, believes that the hypeis all down to the way WHO has dealt with the situation, particularly in theway it dealt with changing the definition of ‘pandemic’, which occurred justbefore swine flu was announced as such. “The definition previously required‘enormous numbers of deaths’, but the agency desperately wanted a pandemicand with swine flu vastly milder than ordinary flu, it clearly didn’t fit. So theysimply penned a new definition to match swine flu, making deaths irrelevant

Films like Danny Boyle’s 28 Days Later suddenly became a daunting re-ality as people around the world were convinced a devastating plague was onits way: trade was predicted to slow to a crawl, economies were sure to crum-ble, schools would be empty, food supplies would dwindle and power supplieswere going down.

But by March 2010, swine flu had claimed just 16,713 lives – nowherenear the millions suggested – which barely registers on the annual death tollfrom seasonal flu, estimated at between 250,000-500,000. So just what hap-pened to swine flu?


Spot the differenceOriginal definition of a pandemic, according to the WHO: An influenza pandemic is a worldwide epidemic caused by anew strain of virus which leads to infection rates andmortality rates which exceed seasonal but similarly heavywaves of influenza by several orders of magnitude. Aprecondition for an influenza pandemic is the appearance of aviral subtype which had not yet circulated amongst thehuman population or which had occurred so long ago that noresidual immunity remains amongst the population, andwhich is capable of provoking severe illness and of

Swine flu deaths in europe

A-Z List of countries and total number of swine flu deaths

6 Albania24 Austria20 Belarus17 Belgium10 Bosnia35 Bulgaria26 Croatia77 Czech Republic30 Denmark13 Estonia

41 Finland258 France178 Germany21 Georgia93 Greece57 Hungary2 Iceland210 Italy31 Latvia21 Lithuania

3 Luxemborg13 Macedonia35 Moldova54 Netherlands29 Norway138 Poland83 Portugal107 Romania71 Serbia38 Slovakia

15 Slovenia271 Spain16 Switzerland25 Sweden415 Turkey202 Ukraine362 United Kingdom

Below 100

Above 100

Figures from 21 January 2010

50 deaths

disseminating effectively from one human to another.

New definition of a pandemic, according to the WHO: An influenza pandemic may occur when a new influenza virusappears against which the human population has no immunity.WHO has defined the phases of a pandemic to provide a globalframework to aid countries in pandemic preparedness andresponse planning. Pandemics can be either mild or severe inthe illness and death they cause, and the severity of a pandemiccan change over the course of that pandemic.


GREMED AD.indd 55GREMED AD.indd 55 24/3/10 09:53:3424/3/10 09:53:34

and explicitly declaring ‘mild’ strains would qualify,” says Fumento.“However, the change cannot be justified medically – a flu pandemic simplyhas to include severity or it’s meaningless, which is unlike non-flu or othervirus pandemics, because flu hits almost every single country around the globeevery single year.”

Fumento goes on to explain that because the WHO described swine fluas a pandemic, the media jumped on the story focusing on the fact that thiswas the first pandemic in 41 years and therefore putting it in the same cate-gory as Spanish Flu and Asian Flu. Experts like John M. Barry wrote a piecefor influential newspaper The Washington Post claiming that because it is apandemic the US alone could expect between 89,000 to 279,000 deaths. Andrather than look at the severity of the infection, Fumento proposes that fig-ures were extrapolated from the last pandemic in 1957/58, which makes thedata meaningless when the mildness of the infection is taken into account.

Tom Jefferson, a physician and epidemiologist who for the last 15 yearshas been conducting extensive reviews of seasonal influenza vaccines, believesthat one of the extraordinary features of the whole influenza saga is that there arepeople who make predictions year after year, seeing it getting worse and worse.

“Sometimes you get the feeling that there is a whole industry almost waiting fora pandemic to occur,” says Jefferson. “The WHO and public officials, virologistsand the pharmaceutical companies – they’ve built this machine around the im-pending pandemic. And there’s a lot of money involved, and influence and ca-reers, and entire institutions. And all it took was one of these influenza viruses tomutate to start the machine grinding.”

Jefferson goes on to explain that influenza is a big money maker for thepharma companies, because of the vaccines and drugs that are sold to com-bat it. He says that the strict focus on flu is not only misguided, but extreme-ly dangerous. Indeed, many cynics are pointing the finger at pharmaceuticalcompanies as being the mastermind behind the swine flu pandemic. It does-n’t help matters that in the US, for example, the government has decided tomake sure that the pharmaceutical companies producing vaccines are pro-tected from legal action by any patients who suffer from adverse affects of thevaccines such as pain, suffering or death should it occur. Secretary of Healthand Human Services Kathleen Sebelius signed a document back in June 2009granting immunity to those making swine flu vaccines under the provisionsof a 2006 law for public health emergencies that allows for a compensationfund if needed. Federal officials will also be immune from lawsuits, conve-niently granting themselves impunity from their actions.

Unfortunately for the public, vaccines have been rushed to market beforemany of the tests to discover potential side effects become known, whichcould prove extremely dangerous. Back in February 1976, when an out-break of swine flu struck New Jersey’s Fort Dix army base in the US, killinga 19-year-old and infecting hundreds of soldiers, President Gerald Ford –believing the US was on the brink of a devastating epidemic – ordered a


“The WHO basically held atrigger for the implementation of the pandemic preparednessplans and with this highrevenues for the involvedproducers of pandemic vaccinesand some antiviral drugs”

DR WODARG WOLFGANG


nationwide vaccination programme at a cost of US$135 million. Within amonth, reports of Guillain-Barre syndrome – a paralysing nerve disease –surfaced and by April more than 30 people had died of the crippling con-dition. Facing protests, federal officials abruptly halted, and then can-celled, the vaccination programme in December of that year. The swineflu epidemic failed to materialise.

This all rings true of the past year. And in fact the WHO is currently defend-ing itself against charges from the Parliamentary Assembly of the Council ofEurope (PACE) in relation to the pandemic. Dr Wolfgang Wodarg, Head ofHealth for the Council, has accused the makers of flu drugs and vaccines of influ-encing the WHO’s decision to declare a pandemic, claiming that pharmaceuticalcompanies made “enormous” gains, while countries around the world “squan-dered” their health budgets and saw millions vaccinated against a relatively milddisease. Wodarg branded the swine flu outbreak as “one of the greatest medicalscandals of the century”, adding that the seeds of the scare were thrown five yearsago when it was thought the lethal bird flu virus would mutate into a human form.

“Associated Press reported on May 19, 2009, that China, Britain, Japanand a dozen other countries had urged the WHO not to use the pro-posed new definition of a ‘pandemic’ and to ‘be very cautiousabout declaring the arrival of a swine flu pandemic’, fearingthat a premature announcement could cause worldwidepanic and confusion,” says Wodarg in the hearing on thehandling of the H1N1 pandemic on 26th January 2010. Hegoes on to explain that there were already doubts over theWHO’s alarm on avian flu in 2005/2006, which in fact wasnever transmitted between humans. Given that the WHOofficially stated in panic-stricken terms that avian flu couldthreaten mankind it was unsurprising that medication worth bil-lions of dollars was bought up quickly. “From a scientific view, this med-ication had never been clinically tested for the disease for which it was marketed,given that avian flu had never become contagious among human beings and thusthose medicines could not be tested because the disease they had been pro-vided for did not exist.”

As a consequence of the avian flu situation, contracts between nationalstates and pharmaceutical manufacturers were signed in order to ensure thatthere would be a certain availability of vaccines in case of a real future pandem-ic. “These contracts and marketing commitments were to take effect when aglobal flu pandemic was declared by the WHO,” says Wodarg. “So the WHO ba-sically held a trigger for the implementation of the pandemic preparedness plansand with this high revenues for the involved producers of pandemic vaccines andsome antiviral drugs.” Wodarg reveals that the contracts signed between statesand pharmaceutical companies were, for the majority, kept secret until somewere recently made public by whistleblowers.

“We can see that the WHO undertook an incomprehensible action, whichup to now was never justified by any scientific evidence. WHO ‘gambled away’public confidence. It does therefore seem right that we investigate this matterwithin the Council of Europe to find out how the WHO could undertake suchrisky action in spite of lots of warning and protest from scientists and nationalgovernments. It did so in the case of the avian flu and again for swine flu,” saysWodarg. “The main questions to investigate are: Why has this been done, whois behind this, what is the core of the public-private-partnership that was intro-duced 10 years ago, what is at the role of the enterprises, who participates in rel-evant decision-making processes and who takes overall responsibility?”

At the same hearing back in January, Dr Keiji Fukuda, Special Advisoron Pandemic Influenza to the Director-General at the WHO, admitted thatthere is still much to learn about flu to improve the handling of such events,mainly due to the fact that it has been impossible historically to predict an in-fluenza pandemic’s impact. He explains that swine flu spread with unprece-dented speed, reaching 120 countries and territories in about eight weeks, andthat it also occurred outside the usual season for influenza causing a strikingand unusual pattern of severe illness and death in younger people.

Regarding the accusations from PACE, Fukada says that the WHO takesthe issue of providing independent advice very seriously. “The flu pandemicpolicies and responses were not improperly influenced by the pharmaceuti-cal industry. Cooperation with a range of partners, including the private sec-tor, is necessary, but numerous safeguards are in place to avoid conflict ofinterest. WHO is confident of the scientific validity of it recommendations.The labelling of the pandemic as ‘fake’ is to ignore recent history and scienceand to trivialise the deaths of over 14,000 people and the many additional se-

rious illnesses experienced by others.”Meanwhile, Luc Hessel, Chairperson of the PandemicInfluenza working group for the European Vaccine

Manufacturers, rejects the fake pandemic motion, claimingthat the vaccine industry did what it was asked to do –which was to produce safe vaccines in a timely mannerand respond to government requests. He says that the in-dustry is governed by stringent health regulations andrigorous safeguards against conflict of interest. “The in-

dustry responded quickly and effectively and was able todeliver the vaccines ordered by governments. “Our industry

responded to requests from WHO and governments who want-ed to have fast access to a large quantity of vaccines – it’s too early to

speculate on the overall return for the industry, but in my view the industryhas been a responsible and reliable partner. Pandemic vaccines were proper-ly tested and for the first time in history, vaccines were available shortly afterthe declaration of a pandemic – this was only possible thanks to a decade ofresearch and development and 60 years of experience.”

However, the vaccine-makers’ profit margins speak for themselves: pro-ducers such as GlaxoSmithKline saw their profit margins soar by 30 percentduring 2009 and Roche made a whopping 12 times its profit during the sec-ond quarter of 2009 compared to the same period in 2008.

Admittedly, hindsight is a wonderful thing; it’s easy to be wise after theevent. But the fact remains that there is a lot of unused swine flu vaccine – theUK government for example ordered 90 million doses of the H1N1 vaccinewith an option to buy 30 million more and only around 5.25 million peoplewere vaccinated in Britain; and if this situation has occurred in other coun-tries it’s likely there are tens of millions of doses going spare around the world.And unless there is a fresh pandemic in the next couple of years, these are like-ly to pass their sell-by date.

Whether the swine flu epidemic was exaggerated in order to boost thebottom line of the big pharmaceutical companies or the WHO was justi-fied in being cautious – despite changing the definition of a pandemic tofit with the swine flu situation – is yet to be seen. With the PACE reporton the poor practice of the WHO not due until the end of April – with apossible plenary debate in June – it’s impossible to say where the finger ofblame will point just yet. n


The UK government ordered90 MILLIONdoses of the H1N1vaccine, but onlyvaccinated 5.25million people


Swine Flu: All hype and exaggeration?

Flu pandemic death tolls

50 million Spanish Flu 1918

3 million Hong Kong Flu 1968

1 million Asian Flu 1957

14,000 Swine Flu 2009

Geographical spread was rapid

9 countries29 April 2009

74 countries11 June 2009

120 countries1 July 2009

Sources: WHO, ECDC, BBC, Financial Times

United States

113,690 cases // 3068 deaths

Canada

25,339 cases // 426 deaths United Kingdom

28,456 cases // 392 deaths

Brazil


Turkey


India


China


Russia


Argentina


Mexico


The 10 countries with the highest number of swine flu deaths(confirmed cases // confirmed deaths)

Estimates vs. the actual number of deaths

The United States The United Kingdom

Actual3068

Actual392

Est.90,000

Est.50,000 It was estimated that up to 30-40%

of both the UK and US would become ill

within six months of a pandemic being

announced. Official figures of confirmed

cases were much lower.

Vaccine orders and consumption

Number of cases have slowly been declining, resulting in governments having a huge surplus of the vaccineand cutting their initially large orders from the pharmaceutical companies.

FranceOrdered 90 million // used 5 million

United KingdomOrdered 90 million // used 23 million

United StatesOrdered 251 million // used 160 million

Hospitalised swine flu patients

Less than 5 years 5-15 years 16-44 years 45-64 years 65+ years

With an underlying condition

Without an underlying condition

By age



to suggest that all parts of the worldhave experienced peak transmission ofthe H1N1 virus – adding that additionaltime and information was needed toprovide expert advice on the “status ofthe pandemic”.

The ruling by the committee, which wasaddressed in an email from WHOspokesman Gregory Hartl, is of particularsignificance as it comes from a committeecomprised of 15 experts that makesconfidential recommendations to theDirector-General. From here, Chan is thenrequired to inform the health ministries ofWHO’s 192 member states and the Vaticanof her decision.

WHO has already confirmed thevirus has killed 16,000 people, thoughstresses that this is a grossunderestimate as patients often goundiagnosed or untested. In fact,according to WHO, it may take a year ortwo after the pandemic is over before

the truth can really be established aboutthe death toll.

Ultimately though the messagecoming out of the WHO camp seems tobe a complex one. The mixed messages,which have been highlighted by the factthat as a direct result of the H1N1pandemic and the resulting demand forvaccines the pharmaceutical industryhas seen a massive rise in profits, havealso been maintained by the‘unpredictability’ of the influenza.

According to Dr. Nancy Cox of the USCenters for Disease Control andPrevention (CDC) and a member ofWHO’s emergency committee, the grouphas long been struggling to make sure itgets the issue across correctly. “It is very,very difficult to get the wording exactlyright,” Cox said in a telephone interview.“We expect the 2009 H1N1 virus to bearound for a long time. It is a complexkind of message.”

As such, analysts are anticipatingthat WHO and other public healthagencies will be keen to make clear thatthe influenza has a ferocious anduncertain future.

What’s more, doubts remain overthe reliability of vaccines, largelyassociated with the fact that drugmakers rushed to get vaccines to marketas the pandemic spread. In fact,following the outbreak last June thepharmaceutical industry's biggestplayers literally raced to develop newvaccines, with drug makersGlaxoSmithKline (GSK) and Rocheleading the way – but, as the pandemicappeared to be less severe thananticipated, nations who purchased thevaccines are now being left with asurplus of the drugs.

Switzerland, Spain and Britain, forinstance, are now considering giving awayor selling the millions of doses that theyhave received or have on order, while the US– which so far has only distributed 160million of the 251 million doses it purchasedfor doctors, hospitals and other healthcareproviders – is yet to make a decision onwhether it will have an overflow and whatit will do with any surplus.


WHO: ‘pandemic yet to peak’The Director-General of the World Health Organisation (WHO)announced last month that it is too early to say the peak of theglobal swine flu pandemic is over. WHO chief Margaret Chan

has decided that it was “appropriate not to make any changesin the current pandemic phases right now”.

The decision came a day after the WHO’semergency committee of expertsrecommended against the UN healthagency declaring that the peak of thepandemic is over. A committee of expertshad warned that the pandemic of H1N1 flu isyet to peak, advising that it would bepremature to suggest otherwise.

The warning came despite recentreports speculating that WHO’s ties withthe pharmaceutical industry meant thethreat of H1N1 had been exaggerated.

Last June, the World HealthOrganization declared the new virushad caused the first influenza in morethan 40 years, after it spread aroundthe world from Mexico and the US inless than six weeks. Since then,however, the impact of the influenzapandemic has failed to reach the levelsexpected by experts.

But the expert committee has nowadvised WHO that it would be too soon


within a multimodal strategic context that has been tried and tested as part of ‘Clean Care is Safer Care’. Th is multimodal strategy ad-dresses: system change, healthcare workers’ education and training, monitoring and performance feedback, reminders in the workplace, and institutional safety climate. Healthcare-associated infection (HAI) occurs in

every country and aff ects millions of patients annually worldwide. As a global issue, HAI has received much attention from healthcare set-tings and governments, as well as the public and media. Th e World Health Organisation (WHO)

made the commitment to address this problem through the successful activities of the First Global Patient Safety Challenge: ‘Clean Care is Safer Care’ launched in 2005.

Hand hygiene has been recognised as the single most important measure in these attempts and is the basis of actions promoted by ‘Clean Care is Safer Care’. As part of this challenge, over 120 ministries of health have pledged their commitment to tackle HAI. Healthcare facilities in many countries will be paying particular attention to taking action at the point of patient care on and around May 5, 2010, as participants in the WHO SAVE LIVES: Clean Your Hands initia-tive (the next phase of the First Global Patient Challenge dedicated to promoting hand hygiene sustainability).

More than 6000 healthcare settings from 126 countries have already registered for the SAVE LIVES: Clean Your Hands global annual initiative, representing over two million beds and fi ve million healthcare workers.

What can you do? We ask you to support the call for action by: registering your facility

to demonstrate a commitment to SAVE LIVES: Clean Your Hands and/or asking fi ve others to do the same; sharing your plans and successes with others through local and national publications, as well as with WHO; fi nding out if there is an existing hand hygiene campaign in your country and seeing what you can do to support it; listing fi ve areas for improvement in your facility and discussing these with your man-agers and staff ; using and promoting a multimodal strategy to ensure sustained hand hygiene improvement; 3, 4, 5 including the WHO’s ‘My 5 Moments for Hand Hygiene’ approach; 6 and participating in the in-augural WHO infection control webinar series as an additional way to improve knowledge. During the week of May 3, 2010, fi ve live webinars will take place, including one by me on May 5.

Where is your institution placed in the crusade for optimising and sustaining hand hygiene performance and safe patient care? As-sessing the level of your own institution, using a specifi cally designed approach, and working towards achieving the status of a hand hygiene excellence centre should be paramount. Using a framework to support such an approach will assess the level and improvements required,

SAVE LIVES: CLEAN YOUR HANDSA call to action from Professor Didier Pittet, University Hospitals Geneva, Expert Lead for the

WHO First Global Patient Safety Challenge.

WHO initiativeThe SAVE LIVES: Clean Your Hands annual initiative is part of a major global effort led by the World Health Organisation (WHO) to support healthcare workers to improve hand hygiene in healthcare and thus support the prevention of often life threatening HAIs.

This initiative is part of the WHO Patient Safety First Global Patient Safety Challenge, ‘Clean Care is Safer Care’ programme aimed at reducing HAI worldwide, which was launched in October 2005. The clear and central feature of Clean Care is Safer Care thus far has been to target efforts on the importance of clean hands in healthcare. The program has galvanised action at many levels including, as at November 2009, Ministers of Health from 121 countries having pledged commitment to reducing HAI and support the work of WHO. Thirty-eight nations/sub-nations have also started hand hygiene campaigns during this time.

SAVE LIVES: Clean Your Hands was deemed a natural next phase of the Clean Care is Safer Care programme, moving the call to action from a country pledge of commitment to the point of patient care. The central core of SAVE LIVES: Clean Your Hands is that all healthcare workers should clean their hands at the right time and in the right way.

SAVE LIVES: Clean Your Hands incorporates a global annual day to focus on the importance of improving hand hygiene in healthcare as well as WHO providing information and materials to support these efforts and sharing information on the activities of the many others who take action at local, national and regional level.

A suite of tools and materials have been created from a base of existing research and evidence and from rigorous testing as well as working closely with a range of experts in the fi eld. The tools aim to help the translation into practice of a multimodal strategy for improving and sustaining hand hygiene in healthcare.

Source: www.who.int/gpsc/5may/background/en/index.html

HANDHYGIENE


Pittet.indd 106Pittet.indd 106 7/4/10 16:22:067/4/10 16:22:06

Clean care is safer care

The recent global concerns about infl uenza A (H1N1) are an important reminder to everyone that hand hygiene is critical. Professor Didier Pittet, lead of the WHO First Global Patient Safety Challenge: Clean Care is Safer Care, said:

“To prevent infl uenza virus spread, cleaning hands with soap and water or an alcohol-based handrub is imperative both at community level, and in healthcare settings. Although droplets spread through coughing or sneezing is considered a major route of infl uenza transmission, hand contamination is also a critical contributing factor.

Persons suffering from fl u-like symptoms should clean their hands with soap and water or by using an alcohol-based handrub, particularly after touching their nose or mouth, and before contact with another individual or patient. The simple act of hand hygiene will contribute to reducing spread of infection. It is also particularly vital when caring for a vulnerable population, including the elderly and the very young, receiving care in hospitals and other healthcare or social-care environments.”

Source: http://www.who.int/gpsc/pittet_message/en/index.html

To truly protect patients, it will take leadership, commitment, a range of actions, continuous assessment, experience-sharing, and time. Be part of a large cohort of observers and participate in monitoring of practices; we encourage healthcare institutions to consider this as part of their May 5, 2010 activities. Th e power of such an action can ultimately change behavior, improve care and reduce patient harm.

Have you considered what the patient safety/infection control re-search priorities are in your healthcare setting and have you considered publishing your work? WHO identifi ed that studies addressing the cost eff ectiveness of patient safety activities are important in both developed and developing countries. In developed countries, studies on enhancing communications and safety culture were deemed priority areas.

Th e WHO Guidelines on Hand Hygiene in Healthcare 3 clearly highlight where specifi c gaps still exist on this topic and welcome fur-ther studies and evidence of improving practices. Th e WHO First Pa-tient Safety Challenge team is actively facilitating sharing of knowledge between nations/sub-nations running formal hand hygiene campaigns through a dedicated network of campaigning countries.

As lead for this exciting and powerful global movement, I fi rmly be-lieve that we must not forget that hand hygiene is a global issue. Patients are infected in healthcare environments everywhere. It is our fi rm resolve to make hand hygiene improvement tools readily available so that healthcare workers regardless of their environment can access and utilise them.

For more information, please see www.who.int/gpsc/, [email protected], www.who.int/gpsc/5may/news/webinars/en/index.html, www.who.int/gpsc/national_campaigns/en/

“We must not forget that hand hygiene is a global issue. Patients are infected in healthcare environments everywhere”

Professor Didier Pittet


Pittet.indd 107Pittet.indd 107 7/4/10 16:22:067/4/10 16:22:06

108 www.nghealthcareeurope.com108 www.nghealthcareeurope.com

In the European Union, approximately four million illnesses and 37,000 deaths per year are attributable to healthcare acquired infec-tions (HCAI). Th is results in 16 million extra days of hospital stay at a cost of €5.5 billion per year. HCAI seems to increase the risk

of death three times, compared to the mortality rate of uninfected patients with the same pathology. Hand washing and hand sanitizing seriously reduce the risk of HCAI as well as reduce the cost. One study showed that a 10 percent reduction in HCAI cases in hospitals would save fi ve times the cost of prevention eff orts.

Since 2008, when NHS trusts across England and Wales began promoting hand hygiene to reduce HCAI, there has been a signifi cant decrease in episodes of HCAI: 57 percent less of reported multi-drug resistant Staphylococcus aureus (MRSA) episodes, 61 percent less of Clostridium diffi cile (C. diffi cile), and 40 percent less of all other reported episodes. Nonetheless, infection incidence and the resultant suff ering, disability and death still are too high. Even one careless person can wreak havoc. French researchers recently found that one non-compliant staff member who sees every patient daily can lower the overall compliance rate by as much 23 percent.

Self-monitoring vastly overestimates compliance. One study showed that self-reporting doctors had a perceived rate of 73 percent (range of 50 to 95 percent). Observed reports showed a compliance rate of only nine percent. Because of these concerns, a monitoring system for hand washing that uses radio frequency ID (RFID) technology is now available for hospitals and other healthcare centres throughout the European Union.

Th e HandGiene RFID system gives administrators the ability to track, improve and meet staff hand-wash-ing goals of up to 100 percent. Th e monitoring system can also be set to remind individual healthcare workers that they have not washed or sanitized their hands. “We have to look at everyone to fi nd the one person who isn’t compliant,” says John Wu, HandGiene Corporation’s scientifi c advisory board member.

Each staff member is issued a nametag or wristband that is read by the RFID-enabled system upon entering and leaving a designated area as well as at a dispensing unit for soap or hand-sanitizer. Every instance is logged into a database that can be read in real-time. Th e system

The importance of hand washingRichard J. Verdiramo reveals why HCAI rates are decreasing, and why they need to keep going down.

For more information, please call 00 353 87 635 2787 or visit www.handgienecorp.com

NEXT BIGTHING

Richard J. Verdiramo is Vice President and a board member of HandGiene Corp. Since graduating from Providence College in 1986, he has served as a senior executive, board member for, and brought public, a range of companies specialising in internet and new media marketing, healthcare and organic food products.

works with soap or hand-sanitizers for restrooms, lava-tories, patient areas and treatment rooms.

“We realised that RFID technology could be used to reduce the incidence of HCAIs, saving lives – and costs – in the healthcare system,” says Vincent Verdiramo, HandGiene President. Th e most oft en cited reason for lack of hand washing is easy access. Soaps and hand-sani-tizers are simply not located conveniently. Th is is why the HandGiene inventor, Vincent Verdiramo, included soap and hand-sanitizer dispensers with the system.

“We wanted it to be a complete solution to the prob-lem, not just a monitoring device,” explains Verdiramo. Whether soap or hand-sanitizer, the gel in the dispensers takes 15 seconds of friction to dissipate, making sure that hands are clean. Because C. diffi cile spores are frequently resistant to alcohol, HandGiene off ers a propriety sani-tizer that is not alcohol-based. Th e sanitizers kill MRSA, C. diffi cile and other bacteria as well as viruses and fungi.

Unlike alcohol, the sanitizer solution does not dry out the hands when used continually, as alcohol-based prod-ucts do, thereby reducing the hand-washing rate. “Many healthcare workers complain that alcohol-based sanitizers dry out their hands when used continuously,” says Ver-diramo. “We tried to eliminate as many obstacles as pos-sible to hand-washing without compromising effi cacy.”

Th e patented system integrates with existing legacy systems for fast installation and ease-of-use. Web-based soft ware allows administrators to monitor specifi c em-ployees, teams, departments and shift s in complete or multiple locations.

“In the European Union, approximately four million illnesses and 37,000 deaths per year are attributable to healthcare acquired infections (HCAI)”

HandGeine_NBT.indd 108HandGeine_NBT.indd 108 7/4/10 16:26:427/4/10 16:26:42

HANDGIENE AD.indd 1HANDGIENE AD.indd 1 23/3/10 17:01:3023/3/10 17:01:30

MIRACLE CURE?


miracle cure.indd 110miracle cure.indd 110 7/4/10 16:27:457/4/10 16:27:45

In an ailing industry desperately casting about for a way to save itself, the rapidly emerging fi eld of pharmacogenomics could provide a life-saving tonic.

By Marie Shields

There can be no denying the fact that the pharmaceutical world is in fl ux, if not downright turmoil. Th e old blockbust-er model has fallen by the wayside, and even the big players are seeking a cure, with some gobbling up their rivals in an attempt to boost fl agging pipelines. But there is another option that could be a lifesaver for the industry – pharma-cogenomics, also known as personalised medicine.

Personalised medicine in healthcare is defi ned as the need to consider an individual patient’s unique lifestyle and medical history, and how this impacts on his or her response to treatment. In pharmaceuticals, however, per-sonalised medicine aims to develop drug therapies that have effi cacy within narrowly targeted groups of patients, based on each person’s genetically programmed reaction to the drugs.

Th e foundation of this type of personalised medicine is the fact that two people can take the same medication and have completely diff erent responses: one may have severe side eff ects, and the other none at all. Or the treatment may lead to remission in one person, and seem to have no eff ect in the other.

One reason for these diff erent outcomes is the variation in our inherited genetic make-up. Genetic variations can determine how we respond to treatment, similarly to the way they cause diff erences in eye or hair colour. For example, if you have a genetic variation that causes a drug to stay in your body longer than normal, this may cause unwanted side eff ects.

Researchers are working to identify these genetic variations and match them with responses to medications, so that physicians can take this into account when prescrib-ing drugs. In addition to the usual information such as weight, age, medical history and how any relatives may have reacted to the same medication, doctors in the future may be able to take into account your own personal genetic make-up.

Th e fi eld of personalised therapies – and the diagnostics used to develop them – is growing so rapidly that at the end of last year PricewaterhouseCoopers released Diagnostics 2009, the fi rst in a series of annual reviews of signifi cant events for per-sonalised medicine.

According to Tony Pillari, PwC’s Director, Healthcare Advisory Services, the report was developed for three key reasons. First, the level of deal activity in the in vitro diagnostics sector, which PwC feels is signifi cant and likely to increase in the coming years, creating a multitude of business opportunities.

Second, the growing importance of diagnostics in the practice of medicine and in the emergence of personalised medicine. And third, the many exciting advances that have been made in recent months in the fi eld of personalised medicine, including those related to diagnostics.

Reaping the benefi ts

The potential benefi ts of pharmacogenomics could include:

The ability to make better medication choices: In the UK, 10,000 people a year die from adverse reactions to medications. Pharmacogenomics may be able to reduce the number of adverse reactions by predicting who is most likely to react badly to a particular drug.

Safer dosing options: Standard doses used today can prove toxic to those with certain genetic make-ups. Using pharmacogenomics, doctors may be able to predict which dose will work for which patients.

Improvements in drug development:Pharmacogenomics may help drug companies better focus their drug development programmes, by predicting in advance which people will have adverse reactions to a drug before it is tested. These people can then be excluded from clinical trials.

Source: www.mayoclinic.com




Jan Lundberg, formerly AstraZeneca’s EVP for Discovery Research and now Head of R&D at Lilly, says that even in the last couple of years there have been major developments in personalised healthcare and com-bined diagnostics. He highlights the CNS area of Alzheimer’s disease, where the pathophysiology is increasingly known, based to a large extent on genetic analysis of patients with hereditary Alzheimer’s. “Here we have a PET ligand as a new diagnostic tool,” he says, “and you can see if patients have accumulated amyloid in the brain, which is a strong signal that the risk of developing Alzheimer’s is high. You can follow the accumulation of amyloid and potentially prevent amyloid deposits or reduce them if they are already there, which is likely to infl uence the disease.

“Th ere are some new agents coming in, which are tested to prevent accumulation of or to deplete amyloid, which off er a way of combining diagnosis and potentially following the eff ects of anti-amyloid treatments and correlating that with improvement in cognition, again taking a per-sonalised healthcare treatment approach.”

Lundberg believes treatments developed for specifi c patient popula-tions will become more common within the pharmaceutical industry, as traditional business models change and as progress in technology and sci-ence make this possible.

Th is applies particularly in oncology, as he explains: “In oncology we have the ability to analyse tumour biopsies or blood samples for their respective tumours. We can let science drive the benefi ts for patients both in relation to maximising the potential for clinical eff ect and also reducing risk. It’s still an evolution, but the trend is very clear.”

Earlier analysisLundberg does point out, however, that ideally R&D organisations

should work out beforehand which groups of patients are likely to benefi t, rather than waiting until the drug has been developed and then looking for people it can help.

“A key aspect will be to identify these opportunities early enough. With Iressa, we only established which patients would respond when the drug was already on the market. It would be better if we could do this at the time of, or even before, nominating compounds to the clinic in a new area. We could analyse this tumour population to see if there are specifi c path-ways that are particularly prone to be more responsive, and then design the compounds against these pathways and select patients in early clinical trials that could be maximally responsive, based for instance on genetic analysis of tumour biopsies.”

PwC’s Pillari believes specialised therapies can help pharmaceutical companies improve their bottom line. “Th e blockbuster model has been the predominant model in the pharmaceutical industry for some time and until recently, it has been very successful. However, the poor return on R&D investment realised by that model over the past few years, in terms of new drugs developed and introduced into the marketplace, has been well documented, as has the number of drugs coming off patent in the next few years.

“As a result, and quite understandably, pharmaceutical companies are very concerned about pipelines and future revenues. In this context, the

In PwC’s defi nition, a personalised medicine diagnostic is any tool that allows for the generation of data that are then used to tailor prevention and care strategies to the needs of the individual. Such tools would include companion diagnostics, early diagnostics and prognostics.

More accuracyTailoring the treatment to the patient is not an entirely new idea.

What’s diff erent about this new defi nition, says Pillari, is the specifi city and accuracy that advances in genomics and proteomics and a whole host of related technologies now make possible.

“We now have a much deeper understanding of many diseases, includ-ing complex diseases like cancer, at the molecular level, and our knowledge continues to grow,” he says. “Th at kind of understanding simply wasn’t possible before. As a result, the way we treat disease, including how we design treatment options for patients, has changed to a point where trial and error will hopefully be replaced by trial and success.”

Pharmaceutical companies looking to maximise success rates will be able to determine which subsets of patients would be more likely to re-spond positively to their drugs. Th is happens to some extent already, with companies oft en targeting subsets of patients if initial trials with larger groups don’t yield the expected results. AstraZeneca, for example, did this with its anti-cancer drug Iressa. In 2004, a large randomised study failed to demonstrate a survival advantage for the drug in the treatment of non-small cell lung cancer, but it has since been shown to be eff ective in patients with mutations relating to epidermal growth factor receptor.

Testing timeThe following genetic tests are currently in use. They help guide dosing and prevent toxic levels of medication from building up in patients who lack certain enzymes.

Cytochrome P450 test: This group of enzymes are responsible for metabolising more than 30 types of medications. The test can determine dosing and effect of some antidepressants, anticoagulants, proton pump inhibitors and a number of others.

Thiopurine methyltransferase test: This enzyme breaks down the chemotherapy drug thiopurine, which is used to treat leukaemia and autoimmune disorders.

UGT1A1 TA repeat genotype test: This test detects a variation in a gene that affects the UGT1A1 enzyme, which determines how the body breaks down irinotecan, a drug used to treat colorectal cancer.

Dihydropyrimidine dehydrogenase test: This enzyme breaks down the drug 5-fl uorouracil, commonly used chemotherapy medication.

Source: www.mayoclinic.com


move to specialised therapies is relevant to the pharmaceutical industry for two reasons. First is the potential to reduce drug development time and costs and increase success rates through enriched clinical trials.

“Th ese are trials that only include those people who, based on the analysis of their make-up at the molecular level, are most likely to respond to a given drug. Second is the opportunity to move to a ‘niche buster’ model, that is, one that generates revenue because of the value a specialised therapy delivers to a specifi c subset of patients.”

Th ere are some within the industry who see a potential downside to the advent of personalised medicine. David Lathbury, AstraZeneca’s Director of Process Chemistry, believes it will only help big pharma im-prove its business models if it translates to a much more reduced cost of development. If it doesn’t do this, he says, the simple net present value calculation means that companies won’t make money. “If you can very quickly identify the target groups, if you can get through phase III with, for example, 200 patients, then absolutely it will be a benefi t. But if you’ve got to go through the same process before you identify that population, it could be very diffi cult.”

Lathbury says that where personalised medicine could make a diff er-ence is in dosing regimens, which could help drive through a better result. “We tend to give everyone an average dose, that’s the way most clinical programmes are designed. If better titration of dose will reduce adverse events, increase compliance and get a better return on the drug, those steps I think we can take.”

Th en there’s the view we could go much further. Dorman Followwill, Partner and VP, Healthcare EIA for Frost & Sullivan, describes his idea of the ultimate version of personalised medicine. “If you’re talking about the holy grail of personalised medicine, it would be walking into a physician’s offi ce, pulling out a smart card that has your genotype on it, and having them plug it into their system and then diagnose you or dispense medica-tion for your genotype.

“Estimates of when we might achieve that vary from 10 to 15 years, to as long as 100 years. However long it takes, we will see increased per-sonalisation over time because that is a mega trend in the world today. In my role, I get to look at some of the 360-degree views of many industries produced by our team, and the topic of personalisation comes up big time

Biomarkers can be a sign of a normal/abnormal process, or of a condition or disease. For example, blood pressure is widely accepted as a biomarker because large epidemiologic databases exist demonstrating a correlation between elevated blood pressures and adverse cardiovascular outcomes. This has been supported by the numerous placebo-controlled studies showing an effect on stroke and coronary heart disease outcomes from lowering blood pressure.

US FDA Pharmacogenomics Guidance further defi nes three categories of biomarkers: exploratory, probable and known valid. Markers are included in these categories based upon available scientifi c information.

in healthcare, in automotive and transportation, and in environment and building technologies.”

PopularityTh e version of personalised medicine as it exists today has proven

popular with regulators. In some cases, they now insist on biomarker test-ing to guide drug prescribing. Tony Pillari believes their main concern is effi cacy. He points out the testing for infection by a specifi c HIV subtype that is required prior to the use of Pfi zer’s Selzentry treatment, which he says is based on the fact that Selzentry blocks the specifi c receptor that HIV subtype uses to attach to and infect white blood cells.

“Similarly,” he says, “testing for epidermal growth factor receptor (EGFR) expression is required prior to the use of Erbitux because Er-bitux binds to EGFR and blocks certain growth factors that ultimately promote the expansion and spread of tumours. We believe this practice will become more common, as everyone in the healthcare value chain, from regulators to pharma to providers to patients to payers, appreciates the benefi ts of improving drug effi cacy as well as reducing the frequency of adverse events.

Yet despite the fact that the clinical case for developing companion diagnostics is strong, the PwC report points out that there has yet to be signifi cant deal-fl ow between the pharmaceutical and diagnostics indus-tries, because while the existing pathway for drug approval and reim-bursement is clear and well-established, this is less so for diagnostics and even less so for drugs and diagnostics developed in tandem.

Pillari does point out that there are a number of encouraging initia-tives underway, including by the FDA and the Critical Path Institute, to better defi ne the pathway for drug and companion diagnostics develop-ment. As this pathway becomes clearer, and the risks associated with such strategy are mitigated, he expects deal-fl ow between the two to increase.

However you look at it, and even with its potential downsides, there is no backing away from pharmacogenomics, with its potential to bring once-dead drugs back to life by allowing them to be repurposed for new populations. In a beleaguered industry suff ering from the twin ills of dry pipelines and no blockbusters, personalised medicine could provide a life-saving shot in the arm.


Biomarkers can be further divided into the categories of predictive or prognostic. A prognostic biomarker is associated with the likelihood of an outcome (eg. survival, response, recurrence) in a population that is untreated or on ‘standard’ (non-targeted) treatment.

A predictive biomarker can predict differential effect of treatment on outcome. A predictive biomarker is a biomarker that is present prior to an event occurring and which predicts that outcome. For example, the KRAS oncogene can be considered a negative predictive biomarker for response to treatment with the EGFr (epidermal growth factor receptor) class of drugs since it can identify which patients are unlikely to respond to treatment with an EGFr inhibitor.

What are biomarkers? Source: www.c-path.org



What are the current limitations of the clas-sical assays for respiratory tract infections? How is your technology paving a new way to detect respiratory tract infections? Guus Simons. Numerous viruses and bacteria are involved in acute respiratory tract infec-tions (RTIs) and the clinical presentation is generally not indicative of a specifi c pathogen. Up to now, many laboratories still use classi-cal assays to diagnose respiratory pathogens. Th ese assays can be divided into cell culture, immunofl uorescence/antigen detection and nucleic acid/PCR-based tests. Cell culture is still the golden standard for detection of respi-ratory pathogens. However, cell culture is time consuming and has a low sensitivity. Rapid antigen tests are available for some respiratory pathogens but have been shown to be less sen-sitive and less specifi c than cell culture-based approaches. Nucleic acid amplifi cation tests

have proven to be rapid, sensitive and spe-cifi c alternatives that can be used in either a monoplex or a multiplex (up to fi ve pathogens) format. PathoFinder’s MultiFinder technology has overcome the limitations of conventional multiplex PCR. Detection and identifi cation of up to 25 pathogens in a single assay is now possible, enabling the introduction of com-prehensive molecular diagnostics in the daily clinical routine.

Can you explain the advantages of multi-parameter tests compared to monoplex assays? Why are these advantages so im-portant?GS. Th e golden standard in nucleic acid based diagnostics is monoplex real-time PCR. How-ever, multiparameter assays allow for the co-

amplifi cation of more than one target enabling the comprehensive detection of (multiple) infectious disease agents in a single assay. Up to now, multiplex real-time PCR assays have been suff ering from a reduced sensitivity compared to monoplex assays. Th e sensitivity of PathoFinder’s RespiFinder assay has been extensively compared to monoplex real-time PCR assays and an identical sensitivity was observed. Th is is also refl ected in the good results obtained during independent quality control studies like the Quality Control for Molecular Diagnostics (QCMD) initiative. Multiparameter assays save time and reduce costs compared to sequentially performing multiple monoplex assays. Since diagnostics of infectious diseases is driven by costs and a fast turn around time, multiparameter tests have a great advantage on monoplex assays as long as sensitivity and specifi city are not aff ected.

Why is it important to test all relevant patho-gens for a certain disease in one assay? GS. Multiparameter assays off er laboratories the ability to detect a wide range of patho-gens in a single assay. Additionally, multiple infections (also know as co-infections) are poorly detected by classical assays whereas dual and triple infections are easily detected by multiparameter assays. Th e ability to detect multiple infections provides the possibility to investigate the clinical importance of these infections and to see whether they result in a poorer outcome of the patient. Finally, mul-tiparameter assays will also contribute to our understanding of the epidemiology of respira-tory infections and provide new information on seasonality, geographical distribution and risk groups.

Can you give an insight into the future development of the molecular diagnostics sector? GS. Molecular testing has greatly improved the laboratory’s ability to diagnose infectious diseases. I believe that the future of molecular diagnostics is comprehensive diagnostics. Th is means the molecular diagnostics of all relevant pathogens in a single assay. Th e in-creased sensitivity of molecular tests means that infected patients will be diagnosed more accurately and more oft en, especially at times when they are shedding low levels of patho-gens that would be missed by non-molecular tests. Comprehensive diagnostics will set a new standard in diagnosis of panel diseases and will provide clinicians with important information to assist in better patient man-agement decisions. RespiFinder was the fi rst assay we launched and several RespiFinder products are now on the market in Europe. Currently we are validating multiparameter assays against viral meningitis and sexually transmitted diseases. We hope to launch these new products in the coming year.

Comprehensive diagnosticsGuus Simons reveals where the molecular diagnostics sector in Europe is heading.

After obtaining his PhD in molecular biology at the University of Nijmegen, The Netherlands, Guus Simons performed his post-doc period at the University of Ghent, Belgium. Before founding PathoFinder, he held several research and management positions at Dutch biotechnology companies. He has written over 50 scientifi c publications and 15 patent applications.

EXECUTIVEINTERVIEW

“Finally, multiparameter assays will also contribute to our understanding of the epidemiology of respiratory infections”

Pathofinder.indd 114Pathofinder.indd 114 7/4/10 16:28:327/4/10 16:28:32

PATHOFINDER OPP ED AD.indd 1PATHOFINDER OPP ED AD.indd 1 23/3/10 17:03:0123/3/10 17:03:01


The healthcare sector is insulated from the eff ects of the economic crisis as a result of its ability to generate cash and the attractive liquidity that this provides. People still get sick in a recession.

But we are living in an economy of half-dead-half-alive banks, governments, consumers and companies. Th is downturn in the economy and the continuing growth in demand for healthcare will have a major, negative impact on healthcare payers’ willing-ness to pay high prices for new therapeutics. Th is will accelerate a move towards new business models in the sector, according to a new book published by PA Consulting Group entitled Th e Zombie Economy: Leadership in Times of Uncertainty.

Th e eff ect of this zombie economy may be indirect and follow on the tail of the current crisis, but the impact of the zombies cannot be understated. In the zombie economy the banks, which fi nance healthcare companies, are too weak to support lending, government fi nances are too stretched to support expanding healthcare policies, consumer wealth is too depleted to allow them to pay from their own pockets, and companies are saddled with debt they cannot service. Th ese organisations all have roles as payers in the healthcare economy and are increasingly unable or unwilling to pay the prices suppliers seek. Th e zombie economy is forcing prices and re-imbursement prices – set by zombie governments and insurers – down.

Emerging budget pressures mean that healthcare payers must all spend less and prioritise in the zombie world. At the same time, the demand for care is growing because of an ageing population, rising expectations of care, signifi cant increases in the prevalence of lifestyle diseases across all regions, and the development of new treatments. Th is downward pressure on prices is set to intensify thanks to a windfall the payers are about to receive: many companies face imminent patent expi-ries on the biggest brands. And while this will bring savings to healthcare budgets, it will also mean healthcare companies will lose a large share of their revenues.

Many companies are exploring new elements to their products; pre-dictive tests and approaches that support the correct usage of new drugs, together promise to provide better value for money. However, these new, more complex products bring complex pricing systems. We are seeing a

trend towards payment by results, with perceived value for money defi n-ing prices and reimbursement levels that may be variable over time.

Today, healthcare companies are paid for providing inputs – di-agnostics, drugs, medical devices and some related services. In the future, the healthcare payer could pay companies for delivering an outcome for the patient. Th is has the potential to open the industry up to a diff erent set of players providing a new wave of information technology innova-tions, products and services converging, and new business models appearing.

“While the healthcare industry ap-pears buoyant relative to other industries, the combination of the recession and the dynamics of the sector will have a big impact in the fi rst half of the next decade,” says Ken Fyvie, Healthcare Specialist at PA Consulting Group. “If they are to avoid the eff ects of the zombie economy, health-care companies must prepare for lasting and fundamental change in how they source and develop the next generation of

products, and how they engage with their more diverse and demanding customers. Payment by results could become more a part of how compa-nies are compensated for their products and services.”

The new zombie healthcare modelHealthcare may be buoyant now but a zombie economy is driving the sector to a

new model of payment by results.

How will the sector survive the zombie economy? The branded healthcare companies need to focus on developing innovative products and cost reduction initiatives, and take radical action to survive, including:

• Developing propositions that are more aligned to the demands of all customers – physicians, payers and patients

• Exploring new elements to products with perceived value for money

• Increasing associations with external sources of new technologies and potential products to realise greater cost-effi ciency

• Defensive mergers, which are already in evidence; the fi rst among the major players has been Pfi zer’s acquisition of Wyeth in late 2009

ECONOMIC CRISIS

Zombie Healthcare.indd 116Zombie Healthcare.indd 116 7/4/10 16:32:327/4/10 16:32:32

AcrometrixCorp Ad.indd 1AcrometrixCorp Ad.indd 1 23/3/10 16:58:3523/3/10 16:58:35


winnerAnd the

HEALTHCAREREFORM

Healthcare Reform ed_16 nov 07/04/2010 15:51 Page 118

It was, remarked one observer, like a scene from the civil rights erahalf-a-century ago. Rallies outside the Capitol are typically order-ly affairs, with speeches and well-behaved crowds; this one hadbaton-wielding police separating furious demonstrators from themembers of Congress making their way to vote on the divisiveissue of healthcare reform. Racist and homophobic slurswere repeatedly hurled at pro-reform lawmakers

walking by; another was spat upon. Democratic Whip JimClyburn, who led fellow black students in integrating SouthCarolina’s public facilities a half century ago, called the be-haviour shocking. “I heard people saying things todaythat I have not heard since March 15, 1960, when I wasmarching to try to get off the back of the bus,” Clyburntold reporters. Clearly, the issue of healthcare reform isbringing out the nastier side of American politics.

Indeed, such venomous exchanges have been sympto-matic of President Obama’s attempts to push through the health-care restructuring plans that provided his presidential campaign withsuch a strong and popular platform. The debate should have been about doc-tors, patients, insurance, drug companies and coverage; instead, much of theattention has been focused on the legal and constitutional processes requiredto get any potential reform bill passed into law.

Make no mistake: this has been an exhausting campaign for people onboth sides of the political divide. Back in December it had only seemed a mat-ter of time before comprehensive healthcare reform became a reality. But


After months of sparring between Democrats and Republicans overhealthcare reform, it is the American public that is set to emergevictorious following President Obama’s controversial restructuring ofthe health sector. By Ben Thompson

is...Republican Scott Brown’s defeat of Democratic candidate Martha Coakley in aSenate special election in Massachusetts – one of the Democrats’ safest seats –sent shockwaves through Washington and re-energized GOP activists. Almostovernight, the passage of healthcare reform had gone from being a mereCongressional formality to a mathematical uncertainty as the Democrats lost the

all-important 60-vote super-majority that would have virtually guaranteedthe bill’s success. And while polls demonstrated overwhelming bi-

partisan support for individual components of reform, theRepublicans seized upon Brown’s victory as being represen-

tative of public unease with the process by which the argu-ments were being won.

The result has been months of wrangling, snipingand political maneuvering. But in the last few weeks,

Obama has taken strong action to bring what has been ayear-long legislative showdown over his top domestic pri-

ority to a close. “Everything there is to say about healthcarehas been said, and just about everybody has said it,” he asserted

at a recent briefing. “Now is the time to make a decision about how tofinally reform healthcare so that it works, not just for the insurance compa-nies, but for America’s families and America’s businesses.”

And on March 21, he finally got his wish. The healthcare reform legisla-tion passed by the House of Representatives by a vote of 219-212, effectivelyends a year’s worth of political horse trading and lobbying, and gives an ad-ditional 32 million Americans access to basic health insurance by 2019. Andeven though it is projected to cost US$938 billion over the next decade, it is

The US spends about US$2.2 TRILLIONa year on its healthcaresystem, which includes

private, federal and employer schemes


also set to reduce the budget deficit by US$138 billion over the same period,according to the Congressional Budget Office.

It is the first major revamp of America’s costly and unwieldy health in-surance system in decades, and Obama has been keen to stress that the victo-ry is one for America as a whole rather than one for him and his party. “I’vegot a whole bunch of portraits of presidents around here, starting with TeddyRoosevelt, who tried to do this and didn’t get it done,” the President said dur-ing a televised inquisition by Fox News in the Blue Room of the White Houseas the campaign neared its climax. “But the reason that it needs to be done isnot its effect on the presidency. It has to do with how it’s going to affect ordi-nary people who right now are desperately in need of help.”

Indeed, the true winners of the reform process could be the Americanpublic. Over 94 percent of all non-elderly Americans will have access to healthinsurance by 2016, versus just 83 percent now. Health insurers won’t be ableto deny coverage based on pre-existing conditions. And generous subsidieswill be available to lower-income families to help them get cover. The bill alsoexpands eligibility for Medicaid as part of its coverage mechanism, as well asincreasing Medicaid reimbursements, which will make it easier for patientson Medicaid to find doctors who take their insurance. The so-called ‘donuthole’ coverage gap in Medicare Part D plans is also set to be closed.

The influential American Public Health Association (APHA), for one,congratulated the House of Representatives on its historic decision. “For near-ly a century, providing quality, affordable care to all Americans has eluded ourgrasp; today’s vote, however, changes all that,” said Georges C. Benjamin,Executive Director of APHA. “Passing this measure will strengthen our pub-lic health system, invest in prevention, improve the health of the Americanpeople and move us closer to providing comprehensive and affordable healthcoverage for all Americans.”


1 One in every six dollars in the USeconomy is spent on healthcaretoday

8 The number of people every minute who are denied coverage,charged a higher rate or otherwisediscriminated against because of apre-existing condition

41The percentage of adults under theage of 65 who accumulatedmedical debt, had difficulty payingmedical bills or struggled with bothduring a recent one-year period

50If you’re an American under theage of 65, there’s a 50/50 chancethat you will find yourself withoutcoverage at some point in thenext decade

$115 The average monthlypremium for employer-sponsored family coveragein 2009

The case for healthcare reform

President Barack Obama and Vice President Joseph Biden leaveafter making a statement at the White House after the US Houseof Representatives passed healthcare reform legislation

625 The number of people wholost their health insuranceEVERY HOUR in 2009


There was support from the private sector, too. Gary Lauer, Chairman andCEO of eHealth, Inc., also sees the bill’s passage as significant. “With final legis-lation awaiting the President’s signature, strategies for implementation of reformand enrollment of Americans in health insurance coverage will be the next andmost important order of business,” he says. “We believe that the technologiesthat have been developed by private sector players are key to ensuring Americansfind and receive the coverage this legislation would mandate.”

Of course, the bill as it stands today is far from perfect. And according toMichael Cannon, Director of Health Policy Studies at the Cato Institute, it isunlikely that the health legislation signed into law by President Obama willlook the same when it takes effect in four years’ time. “It creates too many un-stable situations that Congress will have to address,” he says. For instance,under the new law, insurance companies will have to offer coverage to chil-dren with pre-existing conditions within the next six months. But it is notclear how much they will charge. And, Cannon says, young people andhealthy individuals will have an incentive to drop their coverage now, know-ing that they will be offered a cheaper alternative in the future. That couldcause private health insurance markets to implode.

Such ambiguities mean the debate on the merits of the healthcare planlook set to run on well into the second half of Obama’s term – and possiblydecades into the future. Insurance companies – despite gaining access to an ad-ditional 32 million taxpayer-subsidised customers (Forbes called the new legis-lation a “cash for clunkers programme for HMOs”) – are amongst thosedisenchanted with the move. “WellPoint is disappointed that after more than ayear of debate, Congress has approved healthcare legislation that does little to re-duce cost and improve quality – two important elements to building a sustain-able healthcare system that provides affordable coverage for all Americans,”stated Kristin Binns, a spokeswoman for Wellpoint, in the aftermath of the vote.“We will continue to advocate what we believe is in the best interest of our cus-tomers and the country – affordable, quality healthcare that is accessible to all.”Likewise Jeffrey Kang, Chief Medical Officer at health insurance giant Cigna, be-lieves the legislation only addresses part of the problems facing the healthcaresystem. “The bill really only deals with the coverage issues or the expanded ac-cess issues, and doesn’t deal with the cost or quality issues,” he says. “So you findthe expanded coverage is financed by lots of increased taxes.”

There is certainly a case to be made that reforms are going to prove cost-ly. The overhaul will largely be paid for by cuts in Medicare, new taxes on in-vestment income and fees on various industry participants that will almostcertainly be passed along to the general public. And while government subsi-dies for people who cannot afford insurance and insurance exchanges to helppeople get coverage will not be operational before 2014, the increased costswill begin next year.

But despite continued opposition to the programme of changes, theDemocrats are entitled to feel that a significant victory has been achieved. Anew Associated Press-GfK Poll finds a widespread hunger for improvements

to the healthcare system amongst the American people, which suggests thatObama has a political opening through which to push his plan. Half of allAmericans say healthcare should be changed a lot or ‘a great deal’, and onlyfour percent say they are happy with the status quo. Democrats hope that sucha groundswell of support for change will be enough to counter the fact thatmore than 80 percent of Americans say it’s important that any healthcare planhave support from both parties, and that two-thirds believe the President andcongressional Democrats should keep trying to cut a deal with Republicansrather than pass a bill with no GOP support.

Such a scenario means the opinion polls over the next few weeks willmake for interesting reading. Can success breed further success and enablethe President to steam ahead with difficult laws on immigration and the en-vironment? Or will the protracted nature of the healthcare battle leave hisparty feeling burnt out, beaten up and short on favours to call in?

If the President himself is in any doubt, he’s not showing it, preferring in-stead to concentrate on the historic significance of an achievement that hasproven too great for every American leader before him. “At a time when thepundits said it was no longer possible, we rose above the weight of our poli-tics,” he said, shortly after the bill was passed. “We pushed back on the undueinfluence of special interests. We didn’t give in to mistrust or to cynicism orto fear. Instead, we proved that we are still a people capable of doing big thingsand tackling our biggest challenges. We proved that this government – a gov-ernment of the people and by the people – still works for the people.” n


Breakdown of US federal healthexpenditure, 2007

Other

Military (serving)Veterans

Medicaid(Low-income families)

Medicare(Elderly 65+)

9.5%4.2%4.5%

24.7%

57.2%

Total US$754 billion

“We proved that this government – agovernment of the people and by thepeople – still works for the people”


DESIGN122

One of Britain’s most famous architects, Lord Norman Foster – and the man who has brought us the Gherkin in London and Bei-jing Airport – may have changed the future of hospital design and architecture with his very fi rst hospital, Circle Bath. More of a fi ve-star hotel than a hospital, the clean-

lined, light-fi lled, stone-paved modern interior is quite diff erent to the traditional NHS building. Th e smell of coff ee and leather seating greets you as opposed to the usual disinfectant, and the plate glass windows give way to views of the green fi elds surrounding the city of Bath. And rather than signs at the entrance, people are ready to guide you to the right place.

Upstairs, each patient who stays in overnight has their own room: the fl oor is made of oak, the windowsill has a herbarium and there’s a view. In fact, even the typically windowless operating theatre has a view of the countryside. Th e equipment is all hidden away and there are no dark, endless corridors to be found anywhere in this building, in fact everything is designed to make patients and visitors calm and relaxed.

However, these ideas are nothing new. Research has long proven that patients get better in calm environments with natural light. And surgeons have reported that the calmer the patient the less anaesthetic they have to use and in turn the faster people are back on their feet, plus patients are proven to bleed less in operations and are more likely to re-spond well to treatment.

And while Circle Bath is a private hospital, it will off er operations to NHS patients at the fi xed NHS rate, so there’s hope that the nationwide healthcare system will learn a thing or two from this brand new hospital. And while the NHS has already won praise for the new children’s wing at Moorfi elds, Newton Abbot’s Community Hospital and the Norfolk and Norwich, it has yet to fully embrace the light and cheer that are so obviously required. Margaret Hodge, the minister responsible for archi-tecture, spoke last year about the dark rooms and miles of corridors of the new Queens building in Romford.

So we’re not there just yet. In fact, the Commission for Architec-ture and the Built Environment says there is still a long way to go if the NHS wants to make more hospitals welcoming and attractive. While the government has embarked on a billion-pound programme of rebuilding

More fi ve-star hotel than traditional healthcare institution, NGH reveals why Circle may have just redefi ned the expectation of what a hospital should look like and how it should function. Welcome to the hospital of the future.

Hospital 2.0

Hospital future_back.indd 122Hospital future_back.indd 122 7/4/10 16:26:587/4/10 16:26:58

DESIGN 123

hospitals it’s yet to be seen whether it will continue churning out the same kind of buildings, with some updated styling, or will take on board some of the principals of Circle’s design.

Ali Parsa – a former investment banker with Goldman Sachs – the Chief Executive of Circle, and Spencer de Grey, a Foster partner, both believe that the cost and scale issues won’t be a problem, insisting that they have worked to a budget similar to those of NHS hospitals. Th ey also believe that future projects will be cheaper now that they’ve learnt from the experience of their fi rst hospital.

“Th e Circle partnership has the most extensive programme of hospital building across the country, designed by leading architects with the am-bition to redefi ne patients’ experience of healthcare,” explains Parsa, the managing partner of Europe’s largest clinician partnership. “Each hospital is controlled and managed by the professionals who provide the services to their patients. Our newly opened hospital in Bath, built by Foster & Part-ners, with service designed by the team who brought Mandarin Oriental into the UK, and organic-only food from Daylesford, is already redefi ning the expectation of what a hospital can be.”

Bath Circle in numbers

Construction cost: £21 millionSite area: 10,103 m2Building area: 6400 m2Total height: 13.2mCar parking spaces: 155 incl. 2 disabledOutpatient consultation rooms: 9Inpatient bedrooms: 26 single, 2 twin/familyOperating theatres: 4Imaging Equipment including: MRI, CT-Scan, X-ray, UltrasoundStructure: Concrete, fl at slabsMaterials: Brick, glass/rainscreen panel system and Mill fi nish aluminium

Hospital future_back.indd 123Hospital future_back.indd 123 7/4/10 16:27:027/4/10 16:27:02

REGIONAL FOCUS124

provision. Article 41 of the 1993 constitution confi rmed a citizen’s right to healthcare and medical assistance free of charge, achieved through compulsory medical insurance rather than just tax funding. Th is and the introduction of new free market providers were intended to promote both effi ciency and patient choice.

Unfortunately, none of this has worked out as planned, and the reforms have in many respects made the system worse. Despite the fact that Russia has more physicians, hospitals and healthcare workers than any other country in the world, the health of the population has signifi cantly declined sine the collapse of the Soviet Union.

In contrast to the wealth and prosperity of those who live in cities such as Moscow and St. Petersburg, life in the rest of the country re-

The Russian Federation encompasses 83 federal subjects. At 6,592,800 sq miles, Russia is by far the largest country in the world, covering more than a ninth of the Earth’s land area. Russia is also the ninth most populous nation in the world with 142 million people.

Pre-1990s Soviet Russia had a totally socialist model of healthcare with a centralised, integrated, hierarchically organised structure with the government providing free healthcare to all citizens. Despite weak-nesses, the integrated model achieved considerable success in dealing with infectious diseases such as tuberculosis, typhoid fever and typhus.

Th e new Russia has changed to a mixed model of healthcare with private fi nancing and provision running alongside state fi nancing and

The battle to provide good healthcare in post-Soviet Russia continues.

Fighting a new Cold War

Regional Focus.indd 124Regional Focus.indd 124 7/4/10 16:22:407/4/10 16:22:40

mains harsh and short. Life expectancy for males is 61.5 years, which is considerably lower than the fi gures for the European Union. Th e reason for this is thought to lie mainly in the high mortality rate of working-age males, who succumb to preventable conditions such as alcohol poison-ing, stress and smoking.

Heart disease accounts for 56.7 percent of total deaths, with approxi-mately 30 percent involving people still of working age. About 16 million Russians suff er from cardiovascular diseases, placing Russia second in the world, aft er Ukraine, in this respect. HIV/AIDS, which was virtu-ally non-existent in the Soviet era, rapidly spread following the collapse, mainly through the explosive growth of intravenous drug use. Cases of and deaths from tuberculosis have also increased.

REGIONAL FOCUS125

Bridge of Great Peter, St. Petersburg

PharmaceuticalsThe Russian government’s drug reimbursement programme encouraged an increase in drug consumption and medicine sales and this trend is expected to continue in 2010, according to a report from Frost & Sullivan. The healthcare industry will also benefi t from the country’s ageing population as well as an increase in disposable income, consumer spending, demand for healthcare products, and government funding for drugs through a new health insurance system.

As imports account for nearly 60 percent of the total volume of the Russian pharmaceuticals market, the government has been trying to lower the reliance on western drugs by giving an impetus to the local production, mostly of generic drugs, which is a market with tremendous potential.

The government is also actively encouraging the biotechnology sector, as part of the country’s economic modernisation plan.

MoscowMoscow is Russia’s capital and is the largest city in the country. It is also the largest metropolitan area in Europe and ranks among the largest urban areas in the world. Moscow

plays host to a large number of the world’s billionaires; the emergence of a market economy has produced

an explosion of Western-style retailing, architecture and lifestyle. It is rich in culture,

most notable is the Tretyakov Gallery, The Bolshoi Theatre and Moscow International House of Music. It also encompasses 96 parks, the world-renowned Saint Basil’s Cathedral and the Tsytsin main Botanical Garden of Academy of Sciences.

Male life expectancy in Russia is 61.5 years

Regional Focus.indd 125Regional Focus.indd 125 7/4/10 16:22:427/4/10 16:22:42

IN REVIEW126

On the shelfFrom Lean principles to environmental infrastructure and improving research methods, NGH uncovers the best of this quarter’s healthcare book releases.

Applying Lean in Healthcare: A Collection of International Case StudiesBy Joe Aherne and John Whelton

Covering healthcare all the way through clinical applications to nutritional services, this book provides a collection of case studies to demonstrate how Lean thinking can be applied to the industry. Off ering an international perspec-tive, the text introduces key concepts and provides real-life examples to illustrate the practical benefi ts – including more effi cient processes, increased patient satisfaction and cost savings – that can result from a Lean philosophy. Th e book also features a number of expert contributors who off er practical tips.

NGH SAYS: A must for any professional looking at delivering improvement opportunities and the insightful examples from other healthcare organisations are particularly useful at seeing how to implement Lean strate-gies and solutions.

A

t

b

N

Testing Treatments: Better Research for Better HealthcareBy Imogen Evans, Hazel Thornton and Iain Chalmers

How do we know whether a particular drug, therapy or operation really works, and how well? Such timely and pressing questions are raised and addressed in this probing enquiry into modern clinical research, with far-reaching implications for daily medical practice and patient care. Aimed at both patients and professionals, this book builds a lively and thought-provoking argument for better, more reliable and more relevant research, with unbiased or ‘fair’ trials, and explains how patients can work with doctors to achieve this vital goal.

NGH SAYS: A great guide to the methods, uses and value of fair testing as well as describing how bad research can slip through the net and what to do about it. A genuine and thoughtfully critical look at the issue of pub-lished medical research.

Improving Healthcare Through the Built Environment InfrastructureBy Mike Kagioglou and Patricia Tzortzopoulos

Looking at the crucial issues of healthcare delivery from a built environment perspective, this book addresses the key issues related to healthcare delivery in relation to capital investment and infrastructure, design and operations management theories and their application to healthcare. Bringing together key industrialists and academics – all heavily involved in the formulation and delivery of new practices – the case studies highlight how policies and healthcare models are implemented in practice and help identify the key challenges for the future.

NGH SAYS: With the delivery of healthcare continuing to develop and change as new technologies and modalities of care are brought to the market, this book helps academic researchers as well as practitioners understand how the healthcare infrastructure sector works. A great guide for all those in the fi elds of planning, delivering, maintain-ing and operating healthcare environments.

Lkmhh

Noh

Book Reviews.indd 126Book Reviews.indd 126 7/4/10 16:18:487/4/10 16:18:48

From the people you hire to the products you sell, if you’re in business, we’ve got it covered...

Your World. COVERED

Find out more: www.nghealthcareeurope.com

Next Generation HealthThe healthcare industry is changing. Understanding how to improve clinical processes, meet industry standards and merge the maze of disparate systems is vital. NGH EU combines unbiased industry news with thought leadership from the most respected executives in healthcare, providing a platform for strategy and learning.

NextGen Power & EnergyA poll of 4000 utility executives posed the simple question: what keeps you up at night? The answers were costs, new technologies, ageing infrastructure, congested transmission and distribution, viable renewables and inadequate generation capacity. NextGen P&E covers them all.Available for: EU, Africa

Find out more:

www.ngpowereu.com

InfrastructureInfrastructure provides insight on how developers can achieve critical objectives by integrating leading-edge solutions across their operations – helping them to make informed decisions about technology and operations solutions for all of their areas of responsibility.Available for: US, MENA

Find out more:

www.euinfrastructure.com

Business ManagementWhat business processes work? What are the proven, successful strategies for taking advantage of domestic and international markets? Business Management is about real, daily management challenges. It is a targeted blend of leadership and learning for key decision-makers in government and private enterprise.Available for: US, Middle East, Europe

Find out more:

www.bme.eu.com

CXOTechnology leadership is merging with strategic and fi nancial leadership, and senior management is being called into a partnership for the future. CXO brings together a range of voices with one shared vision: to develop a strategy that considers business needs and technology’s role in moving your company forward.Available for: EU

Find out more:

www.cxo.eu.com

CataloguePage.indd 127CataloguePage.indd 127 7/4/10 16:36:447/4/10 16:36:44

PHOTOFINISH128128

German Health Minister Philipp Roesler addresses a press conference at the health ministry in Berlin on March 26, 2010. Roesler and members of the health department of the coalition fractions pre-sented the corner points for the long lasting reform of the pharmaceutical market.

Photo Finish_P128.indd 128Photo Finish_P128.indd 128 7/4/10 16:26:047/4/10 16:26:04

PATHOFINDER IBC AD.indd 1PATHOFINDER IBC AD.indd 1 23/3/10 17:02:4723/3/10 17:02:47

Ziehm Imaging AD2.indd 1Ziehm Imaging AD2.indd 1 23/3/10 17:05:0223/3/10 17:05:02

ngh eu 1

Documents

health systems

nnit ad

bracco ad q7a

different systems

theatre systems

basic health insurance

europewide health system

theuks national health