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Healthcare Technology Management
Europe and Asia walking together
30-03-2015
Summary
- Mature vs emerging economies healthcare:A Bipolar disorder or can we walk
together? Some data
- Ageing populations: a unipolar world?
- Frugal Innovation & Uberization
- Conclusions?
Introducing TBS
Founded in Italy with a global turnover of €232m (£165 million - 2014) managing 900K devices worldwide (£3.5bn replacement value).
Resource and scale
215 UK based medical technology specialists, and 2,400 worldwide
Carry out 1.2m planned maintenance checks in 1,000+ healthcare facilities globally
Planned maintenance of 100,000 devices in the UK
43,000 Telehealth service users (technology at home)
Quality
Quality Management System (QMS) - ISO 9001:2008
Medical Devices QMS - ISO 13485:2003 –
Environmental MS - ISO 14001:2004
Information Security MS - ISO 27001:2005
Occupational Health and Safety MS - OHSAS 18001:2007
Assets and Technology
NHS N3 compliant platforms
‘Ansur’ software for automated testing of medical equipment
‘Medixine’ software for Telehealth
‘Governo’ software for managing 16,000 suppliers
Integrated asset management system - SI3C global database
‘Elelco’ transactional software
The world today: a bipolar disorder in healthcare
Healthcare
Technology Management
PPP Leasing/Rental/COMS Pay Per Use/Revenue
Sharing Risk Sharing
Developed Countries Emerging Markets
Cost Cutting
Crisis
Private failing
Public In Administration
Cut costs Manage technology as OPEX Better control of cash flow Improvement in productivity Improvement in safety Tax benefit
Value for money
Cost is King
Need fast growth Need partner to finance growth Share risks / rewards
Not enough acute care beds, doctors
No primary care
Healthcare global trends
Population
• By 2050 earth’s population will be 9 billion
• What are today developing countries will weight for almost
75% of entire world population
- 2/3 of world population will live in Africa, Southern Asia and
Eastern Asia
- Other 10% will live in LatAm
Healthcare Expenditures
• Healthcare expenditure is basically flat in developed
countries due to the financial crisis and an already high
quality level of healthcare services
• In developing countries, on the other hand, healthcare is still
far from standards
- Healthcare expenditure: Germany 4000 US$+, UK 3000 US$ +,
China 400US$+, India 100US$+
- Not enough hospital beds, doctors and nurses
• High speed growth of healthcare expenses are expected in
developing countries based on private investment
- Either as PPP, private with GVT as payer, private directly to
patient
- Biomedical equipment sales growth >10% in China, India
World Population 2050
Health workforce
Appleby J BMJ 2013;346:bmj.f1563
Fig 1 Hospital beds by type: English NHS: 1979-80 to 2011-124 5 6.
Appleby J BMJ 2013;346:bmj.f1563
Ageing
population
Lifestyle and
behaviours
impact on
health
Rapidly
rising
medical
inflation
Availability of
healthcare
professionals
Bipolar vs unipolar
Simultaneous existence of multiple medicinal practices
Ayurveda, Yoga, Unani, Sidda &
Homeopathy
Extensive use of modern
medicine
Co-existence of public & private healthcare delivery models
Public sector contributes to greater
capacity; 60% of total beds
Growing revenue share of private
hospitals; ~81% by 2015E
High diversity in healthcare supply
>60% populace in rural
Affordability huge concern
~65% hospitals in Urban with
~70% doctors
Balance in advances in primary and tertiary care
Emerging global provider of
quality tertiary care
Favorable primary care low cost
models
Sources: World Health Organization; World Bank; Central Bureau of Health Intelligence (CBHI)
Success
13
13% increase in
life expectancy to
66 years, 2012
50%
68%
reduction in
Infant mortality rate to
44 per ‘000 live births, 2012
reduction in
maternal mortality rate to
178 per ‘000 live births, 2012
Growth reported for the period 1990 till 2012
Sources: World Health Organization; World Bank; Central Bureau of Health Intelligence (CBHI)
Challenges…
Low public spending and high out-
of-pocket spending
Lack of standardization of
clinical protocols
Under supplied & under consumed
healthcare services
Regulatory framework evolving -
not holistic & partially defined
India ranks low on Clinicians per ‘000 & per capita
healthcare spend ~58% out-of –pocket spending in 2015E
Limited ability to measure outcomes Limited focus on quality & infrastructure
… are opportunities
need & room to “innovate” for
Reach &
affordability
Infrastructure
creation
Clinical process
innovation
Medical devices &
technology
A
B
C
D
Evolving regulations around
protocols, norms & quality
Sizeable market opportunity to
capitalize
Diversity provides for enough vectors
to test
High out-of-pocket spend leads to
balanced consumer expectations
Surge in investment & technology
has invited variety of players
Public health workers deployed across
rural areas for primary care
Performance based compensation
Increased access to quality maternity care
by training midwives
Outsourced inventory & lease rental
agreements
Subscription model to provide affordable
consults to low income families via
mobile phone
On-roll GPs with standard protocols
Improving reach & affordability
Creating more touch-
points through skilling
for rural outreach
Increase awareness
Affordability for rural &
the urban poor
~0.9 mn ASHA workers
deployed till date
~USD 60 for a normal child
delivery
Packages at less than 1
nickel per day
‘Assembly line’ approach to cardiac
surgeries with innovative strategy to cut
costs
‘Pay-per-use’ model for medical
equipment
Low-cost prefabricated structures
In-house manufacturing of OT
sheets
Engineered patient flow, coupled with
standardized clinical protocols to
manage high volumes
In-house manufacturing for lenses
(cost reduced from $70 to $2), sutures &
eye pharmaceuticals
Clinical process standardization to achieve scale
Dedicated focus on
specialty
Low cost delivery
through operational
efficiency
Standardization to
measure outcomes
By pass surgery at $1,500
against $144,000 (USA)
Over 1,00,000 surgeries &
2,75,000 cath-lab procedures
till date
World’s largest ophthalmology
service provider
~1000 procedures per day
C
Mobile based, non-invasive anemic
screening tool with
Significantly low cost per transaction
‘Zero’ threat of infection
No need for waste management
ecosystem
Cloud based, portable eye screening
device ensuring
Screening for 5 conditions within 5
minutes
1/5th the cost of conventional
screening
A portable resuscitation device to lower
prevalent incidents of infant mortality
Minimal training to operate
Single person handling
High success rate
Medical devices: low-cost solutions for emerging markets
Bridge the current skill
gap
Lower cost per
transaction
Integration with other
platforms
NeoBreathe
State-of-the-art
infrastructure
Latest medical equipment
Full suite of services
• ‘Bare shell’ infrastructure
• Leased or outsourced
medical equipment
• ‘No frills’ services
Address both extremes
of consumer groups -
highly affluent & bottom-
of-pyramid
Ensure value-for-money
& quality delivery
Infrastructure creation: Extending from state-of-the-art to low cost delivery formats
D
High-end
centers
Low-end
‘budget’
centers
This has helped India offer an ‘innovation buffet’ for developed markets…
Delivery
formats
Primary
clinics
Standalone Tertiary &
Quaternary Hospitals
Operating
model
Volume
(low-cost)
Value
(High capex)
Affordability Bottom-of-pyramid
(cross-subsidization)
Affluent
(full suite of services)
Medical
technology
Frugal engineering;
low-cost portable devices
State-of-the-art
Clinician
utilization Agnostic; redistributing
skills to nurses, paramedics
Technology to
aid accessibility
Gamma knife
Clear mandate to
scale PPP model
Growing insurance
penetration
Rise in share of
rural spending
Surge in capital
availability
+
Additional
1.8 million beds
and
700,000 doctors
required by
2025
Only
25% population
covered
27% CAGR
from 2007 to 2012
Increased
affordability.
Disproportionate
public spending 100% FDI
Sources: India Brand Equity Foundation – Healthcare report, 2012, Euromonitor, World Health Organization
Indian Healthcare sector needs to capitalize on structural changes to continue the growth story…
…However, sustainable innovation would be key to address divergent facets of growth
Facets of healthcare growth in India
• Rising demand across diverse
consumer segments
• Increased burden on supply -
infrastructure & talent
• Focus on preventive than curative
care
• Growing penetration of the internet
& mobile devices
• Optimized play of Govt. & private
sector
Elements for sustainable innovation
Sustainable innovation
Holistic
spanning
across the
value
chain
Cost-
effective
minimal
cost for
desired
outcomes
Affordable
optimal
prices
based on
target
group
Recognized
awareness
on
relevance
and usage
China….
Averages of 322 new hospitals were built each year during 1990 - 2007. This number is expected to go up to 400 annually in the next 10 years. About 30% of total investment in these new hospitals is used for purchasing of medical equipment.
The medical device market is estimated at just under US$17.1bn in 2013. This makes
China the fourth largest market in the world and the second largest in Asia behind
Japan. For the 2013-18 period, Espicom estimates market growth will continue to
average 20% per annum in local currency, equivalent to a US dollar CAGR of 18.7%,
making China one of the fastest growing markets in the world. High rates of growth
are not uncommon in the Asian region, but on the back of a huge market size, China's
growth is particularly pronounced.
Ageing
Chronic diseases
Kong Lingzhi, deputy director of the disease prevention and control bureau under the Ministry of Health, made the remarks on Saturday at the Forum of Prevention and Control of Chronic Disease. "China is facing a great challenge from chronic diseases, which has a serious impact on both the economy and society," said Kong.Each year, about 3.7 million people die before they reach 60 because of chronic diseases. There are currently 200 million hypertension patients and 90 million diabetics in China, official statistics show.To address the challenge, "the government is now drafting an inter-ministerial roadmap for chronic disease intervention, which will set targets, define responsibilities and distribute guidelines for the prevention and control of chronic diseases," she said.The initiative aims to strengthen national and global monitoring and surveillance; scale up the implementation of evidence-based measures to reduce risk factors, such as tobacco use, an unhealthy diet, physical inactivity and harmful alcohol use; and improve access to cost-effective healthcare to prevent complications, disabilities and premature death.
Diabetes
China is facing an epidemic of diabetes and of diseases for which diabetes is a major risk factor, including ischemic heart disease, stroke, and chronic kidney disease, according to a massive study of nearly 100,000 Chinese adults reported in the September 4 issue of the Journal of the American Medical Association. Among the key points reported by Yu Xu, PhD, from the Shanghai Jiao-Tong University School of Medicine, China, and colleagues for the 2010 China Noncommunicable Disease Surveillance Group:
Diabetes prevalence was 11.6% (12.1% in men, 11.0% in women).
Two-thirds of diabetes cases were undiagnosed.
Only 25.8% of diabetics were receiving treatment.
Among those treated, fewer than 40% had adequate glycemic control.
Over half of Chinese adults were prediabetic (no prior diagnosis, but fasting plasma glucose 100 to 125 mg/dL, 2-hour plasma glucose 140 to 199 mg/dL, or HbA1c 5.7% to 6.4%).
HTM for Home Care
Healthcare Technology management provide seamless support for
clinical teams to enable care pathways to be transitioned from the
hospital into the homecare environment.
With the goals of:
Reducing the need for hospital based care
Reducing condition management costs
Improving the quality of life for individuals with long term conditions
Sample outcomes
HTM for Home Care - technology platform, call center support and specialistic expertise for a broad range of projects in different areas of telemedicine:
- Diabetes
- Chronic Hearth Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Home rehabilitation after cardiac surgery
- Admission avoidance through home hospitalization
A common issue in telemedicine value propositions is providing proof of
clinical efficacy and cost reduction.
Sample outcomes: diabetes
T=0 1 year reduction
HbA1c 8,2 7,5
TC -7,3 mg/dl
TG -10,6
Ipoglicemia/month -50%
Face to face visits -300
1 healthcare organization - 120 patients
Sample outcomes: Chronic Hearth Failure (CHF) case 1
•CCFM has performed trial on 145 patients, mean 71,3 years old, with a
recent clinical admission for CHF with left ventricular ejection fraction
(LVEF)≤40% or diastolic dysfunction.
•Mean trial: 165 days/patient
•Mean LVEF at the beginning was 32.4% and after 6 months became
35.6%,
•After 6 months patients in NYHA Class IV underwent: 36% in III , 9% in II
and 46% remained stable in IV.
•Patients in NYHA Class III underwent: 46% in II, 1% in I and 46 % remained
stable.
•Mean MLHFQ score at the beginning was mean 38 and after 6 months
became mean 22.
Sample outcomes: Chronic Hearth Failure (CHF) case 2
Intervention Mean (SD)
Control Mean (SD)
∆% between means
∆ between medians
Number of
hospitalizations
1.33 (1.61) 1.54 (1.81) -13.64%
Number of
hospitalizations for CHF
(primary and secundary
diagnosys)
0.6 (1.08) 0.93 (1.35) -35.48%
Number of visits to A&E 1.36 (1.86) 1.79 (2.5) -24.02%
Number of visits and
exams
59.5 (47.53) 61.82 (45.6) -33.20%
Number of specialist
visits for CHF
1.11 (1.25) 1.83 (1.68) -39.34%
Number of visits and
exams for CHF
3.32 (3.55) 4.97 (4.49) -33.20%
8 hospitals - Intervention: 227 patients – Control: 112 patients
Sample outcomes: Chronic Obstructive Pulmonary Disease (COPD)
Intervention Mean (SD)
Control Mean (SD)
∆% between means
∆ between medians
Number of visits to A&E 1.21 (1.49) 1.31 (2.63) -7.63%
Number of specialist visit
for pathology
1.34 (1.00) 1.65 (1.56) -18.79%
Number of investigation
for pathology
4.22 (4.78) 5.12 (5.28) -17.58%
Number of
hospitalizations
0.7 (1.02) 0.8 (1.62) -12.50%
Number of
hospitalizations for
pathology
0.40 (0.76) 0.49 (1.21) -17.13%
Number of bed days for
hospitalised patient
23.6 (34.29) 25.5 (23.2) -7.45%
6 hospitals - Intervention: 229 patients – Control: 105 patients
Sample outcomes: Home rehabilitation after cardiac surgery
Daily reimbursement for
home rehabilitation
140 €
Daily reimbursement for
hospital rehabilitation
200 €
- 30 % cost
Population: 197 patients
Sex male - female 83% - 17 %
Mean age 60 years
Patients ultra - octogenarians 2 %
Associated diseases (hypertension, diabetes) 85 %
The project with Princess Alexandra Hospital (Harlow, GB)
Princess Alexandra Hospital (PAH) – 320 bed NHS hospital located in
Harlow, GB
ORLA Healthcare – Private provider of health services with a mission to offer
more healthcare at home rather than in hospitals
TBS GB – Technology solutions provider (logistics, maintenance and
decontamination of the devices, 24/7 call center), including CE marked cloud
software system (Medical Device according to EU regulations)
The devices used in the project are:
- Nonin pulse oxymeter
- A&D blood pressure monitor
- St Bernard GPS location system and alarm button
Operational model
Innovative Consultant-led acute medical Hospital at Home service
Princess Alexandra Hospital (PAH) – initially admitting adult A&E patients, plus ward in-
patients from November
Staffed by ORLA Consultants, Middle Grade Doctors, ANP, Registered Nurses, HCAs,
Therapists and Pharmacist - based at PAH 24/7
Triage assessment by ORLA clinical team to asses clinical suitability and risk. Then
patients transferred and managed at home
Equity of access and evidence-based clinical pathways. 15 mile radius of PAH
Social care pathways and trusted assessor responsibilities
Operational model
The Princess Alexandra Hospital, Harlow
ORLA Healthcare - consultancy in the A&E - home visiting nurses
TBS GB - Technology platform - E-Health Center support - Logistics management of devices - Telemedicine+Telecare
The technology solution
3G private connection
web application
Physician TBS call center
(24/7/365)
Patient’s home
(TBS manages
logistics, maintenance,
decontamination, etc.)
Easy plug-and-play hub installation
CE marked cloud software system (Medical Device)
2net Hub ecosystem
Achievements to date (since April 2014)
60 approx. conditions - COPD, Pneumonia, Skin Sepsis, Urinary Sepsis, Frail Elderly,
Fluid & Electrolyte Disorders, often with co-morbidities Patient profile: 18 – 97 years of age 700 approx. patient admissions 3,500 approx. bed-days saved for PAH. Only 18 transfer back to PAH - mostly for changes in clinical condition. Unavoidable re-admissions - Nil Very positive clinician and patient response, with patient satisfaction of 99%
(Family & Friends test) Proof of concept – proven with a safe and sustainable service model, and now extended
to wards
TRADITIONAL DELIVERY MODEL
Symptom Checkers
TRANSACTIONAL • Book Appts • Change details • Repeat Meds • Messaging • View records • EPS
Written/video self-help info
Sign-post content e.g. pharmacy
24/7 call back from 111 clinician
Secure e-consults with
own GP
NEW DELIVERY MODEL
Mobile low cost coverage
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LEGO: Standard 40 ft (12M) x 13 ft (4M) x 10ft (3M) Container
All Modules are based on standard 144 M3 and 72 M3 shipping containers.
Containers are Pre-fitted with all internal services at the “Factory”.
Sidewalls are 1000 mm demountable panels.
Containers are locked together on site.
Standard Modules (Lego Blocks)
13 Standard Units
Main core of 4 Containers.
Radiology & Minor Theatre of 2 Containers.
All other are single Container.
Minimal site works undertaken during manufacturing period.
Concept Lab A
Standard Lab /
Clinic
8 Exam Consult
Ophthalmic
rooms
X-Ray
Minor Theatre
Getting to the bottom: New thinking in healthcare financing
• Improving healthcare funding is crucial for poor countries. Insurance is often rare, with
patients using out-of-pocket payments for most healthcare. Many millions of people are
tipped into poverty every year when a family member falls seriously ill.
• Overall spending on health is tied closely to a country’s per-capita GDP and is
therefore difficult to increase. But the little money that is spent on health can be better
organised by converting out-of-pocket payments into health insurance premiums.
• Designing health insurance policies for the poor is challenging, given low incomes,
high illiteracy, and low awareness of how insurance works. But more and more micro
insurance schemes are appearing.
Back to basics: Innovation in medical technology
• New medical technology is often designed for rich countries, making it too expensive and
inappropriate for Asia’s millions of poor. But more and more organisations are focused on
“frugal engineering”.
• “Frugal engineering” aims to make healthcare technology that is cheap, uses local
materials, can withstand tough treatment and harsh environments, is easy to repair, and is
simple to use by healthcare professionals with limited skills or training.
• Innovating for the poor often means adapting existing technology to new uses rather then
developing new technology.
Doctor dilemmas: Innovative ways of delivering healthcare
• Running clinics and hospitals is hard in many Asian countries because so many
people live in rural areas where doctors are thin on the ground. That leaves millions
of poor relying on health workers with little or no training.
• Many promising models of healthcare delivery are emerging to overcome the skills
gaps in rural areas, from harnessing mobile phones to deliver telemedicine, to
building branded franchises of clinics to improving training.
• Alongside “horizontal” models of healthcare delivery—those that address the full
range of illnesses— innovative “vertical” models are also being used that tackle
specific diseases, such as tuberculosis.
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