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The Challenge

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Investment in Healthcare for the Prosperity of People and the
Economic Wealth of Nations




Real Life Examples – from Prevention to Therapy

o   DIAGNOSIS and THERAPY – Medication process
o   SCREENING – Cardiovascular Risks
o   DIAGNOSIS – Cardiovascular Diseases
o   TREATMENT - Cardiovascular Diseases
o   INFORMATION MANAGEMENT – Cardiovascular Diseases
o   PREVENTION – Cancer
o   SCREENING – Cancer
o   DIAGNOSIS – Cancer
o   TREATMENT – Cancer
o   TREATMENT – Long Term Care
o   TREATMENT – Intensive Care


Conclusions

Looking forward (Annexes” Molecular Medicine”) (KJS?)

o   DIAGNOSIS – Cardiovascular Diseases (Annex 1)
o   SCREENING – Cancer (Annex 3)
o   INFORMATION MANAGEMENT – Patient-centric processes




                                                                1
Investment in Healthcare for the Prosperity of People
and the Economic Wealth of Nations




The Challenge – Health and the Economy

Health is important to the economy. According to a study by the World
Health Organization, conducted in 2001, 50 percent of the difference in
economic growth between rich and poor countries is connected to poor health
and lower life expectancy of the population.1 Adding an average increase in
life expectancy of 10 years generates 0.35 percent to the growth of the
Gross Domestic Product (GDP) of a country.1 A society in good health leads
to higher productivity, increased labor supply, better education and
contributes to sustainable long term growth. A society in bad health leads to
economic loss, which threatens growth, competitiveness and employment.

Healthcare represents one of the most important economic sectors in the
European Union, currently accounting for 9 percent of GDP in the EU member
states. It is vital, therefore, that Europe reduces its health burden and
compensates for negative economic influences, such as the ageing
population, the decline of human capital and increasing global competition. It
must forever relinquish the view of health expenditure as a burden and
increase its focus on investing for the future. Putting the health of society as
a whole at the heart of health policy and investing appropriately will increase
the personal well-being of the population and improve economic prosperity.

Healthcare –Vital to a Country’s Infrastructure

The Member States of the EU are connected by motorways, rail links and
airways. People are moving around the Union for purposes of travel, study,
work and retirement. As the borders across regions and countries disappear
so must those that currently exist within healthcare. Shared infrastructures
that improve health and support the strategic objectives of prosperity,
solidarity and security will also be needed. Social and economic cohesion
depends on both economic development and similar living conditions.

A modern healthcare system, delivering high quality care, is one of the major
building blocks for the economic development of a region, a country and
Europe as a whole. While the economic argument for investing in health in
low income countries might differ in detail from high income countries, recent

1
 1. Macroeconomics and Health: Investing in Health for Economic Development,
Report on the Commission on Macroeconomics and Health, Jeffrey D. Sachs, WHO,
20 December 2001



                                                                                2
evidence show that significant benefits can be achieved by improving health
infrastructure in both developing and developed countries.2 There is a strong
case for policy makers interested in improving economic outcomes to
consider investment in health infrastructure as an option by which to meet
their economic objectives.

The EU Structural Funds provide the opportunity for new Member States,
Accession Countries and all Regions of Europe to speed up the process of
development.

Healthcare – The Need for a Holistic Process-oriented Approach
It is essential to understand modern healthcare as a continuous and
interlinked process. The complete care pathway consists of prevention,
diagnosis, therapy, rehabilitation and long term care. Each of these steps, as
well as the continuum of care as a whole, needs to be optimized and citizen-
patients placed at the centre of all efforts. The goal is to help citizens
increase their healthy life years and to help patients get better as quickly as
possible. To do so, medical professionals and decision makers need all the
relevant information and knowledge available in the right form at the right
point in time and the right point of care. Working towards such a process-
oriented healthcare system requires a joint effort by all stakeholders. This
will ensure that the limited resources available are used in the most efficient
way and without compromising the well-being of individual citizens.




2
 Surckhe M, McKee M, Sauto Arce R, et al. Investment in health could be good for
Europe’s economies. BMJ 2006;333:1017-1019


                                                                                   3
Improving Healthcare Quickly – Delivery Quality of Care

In order to identify the quick wins, it is important to understand and analyze
the enormous positive contribution of standardized care processes and
clinical pathways to the improvement of quality and efficiency of healthcare.
A study performed by the US Institutes of Medicine in 2000 estimated that
`adverse events’ during patient treatment are responsible for approximately
90,000 deaths per year.3 [ONE MORE 2006 Study] A second report in 2001
revealed a wide `chasm’ between the quality of care the health system
should be delivering today and the quality of care that most people receive.4
It is widely believed that the situation in many, if not all European health
delivery contexts, is characterized by similar, if not the same deficiencies.




The Agency for Healthcare Research and Quality confirms these findings,
identifying more deaths per encounter with the healthcare system than for
activities such as driving or traveling by scheduled airline or European
railroad.




3
    To Err is Human” (2000)
4
    “Quality Chasm” (2001)


                                                                            4
   Source: AHRQ, Commission on Systematic Interoperability, USA,
                             2005

It is obvious, therefore, that investment into the safety, quality and efficiency
of healthcare services will be highly beneficial to individual citizen-patients as
well as to the social and financial wellness of society as a whole.


Medical Technology - Essential to the Solution

Innovative medical technologies offer a range of solutions to address the
early detection and diagnosis and the efficient treatment of many diseases.
Today, almost all widespread chronic illnesses can be treated successfully if
detected and diagnosed early enough. Despite differences between the
healthcare systems within Member States of the EU, the disease burden and
problems associated with these diseases are almost identical. After well
organized, preventive measures, a process-oriented, efficient collaboration of
medical professionals and other healthcare staff ensures the best healthcare
process.

Regular preventive examinations, for example, those for cardiovascular risks
or specific types of cancer, can save lives! Reliable diagnosis with up to date
imaging equipment improves treatment decisions by medical staff. It helps to
avoid unnecessary medical procedures and generates benefits for both
patients and society as a whole. For example, highly efficient therapies such
as linear accelerators in radiotherapy can kill cancer tumors quickly, leaving
healthy tissue undamaged. Researchers in life sciences and industry are
constantly looking for new solutions to detect and treat diseases earlier and
more reliably.




                                                                                5
Health ICT – Connecting Stakeholders

Modern health Information and Communication Technology (sometimes
referred to as eHealth or connected health) increases the accessibility of
individual citizen-patient information and supports clinical decision-making. It
enhances clinical knowledge and improves both patient outcomes and
effectiveness of clinical services. Networked IT systems in hospitals, doctors’
offices and at home improve working practice and permit a seamless flow of
information.

Health ICT and the shared eHealth infrastructure support and enable all the
steps in the patient-centered care process: from examination to electronic
prescription in primary care, from admission to discharge in hospital. They
also facilitate rehabilitation and long term care. In this way, all steps along
the patient care pathway become transparent to all stakeholders, including
citizen-patients. In doing so, they help avoid possibly fatal mistakes, improve
the quality of care and reduce healthcare costs.




                                                                              6
Real Life Examples – From Prevention to Therapy

The following real life examples illustrate opportunities to improve efficiency
and quality in healthcare. They show the benefits to the patient and, at the
same time, demonstrate cost efficiency for society. All complete care
processes are included, from prevention to therapy, and their role in
generating continuous health improvement is highlighted.




                                                                             7
DIAGNOSIS and THERAPY - Medication Process

The study performed by the US Institutes of Medicine in 2000 on the
hazards of healthcare has prompted a number of similar studies in
European countries. The European Commission estimates that as much as
10 percent of all hospital admissions may be due to medication errors,
making them one of the leading causes of death worldwide, even more
relevant than traffic accidents, breast cancer or HIV/AIDS.

Computerized Order Entry Systems in hospitals can significantly reduce
these errors as the next illustration indicates.



    Medikationsmanagement im Krankenhaus

            Durch IT-gestützten Medikationsprozess
            gehen fehlerhafte und unklare
            Verschreibungen um bis zu 73% zurück *                                            Stockholm, Schweden



            Zeit von der Verschreibung bis zur
            Verabreichung einer Medikation konnte
            um 64% verringert werden **
                                                                                                    Ohio, USA



            Geschätzte Kosteneinsparung von 840.000 USD
            durch Verringerung der Medikationsfehlerrate *
                                                                                                   Virginia, USA




 Quellen:   *W. Baldauf-Sobez, et. al., How Siemens computerized order entry systems helps prevent the human error,
            electromedica 71 (2003) no. 1, 2-10
            ** HIMSS Analytics, EMR Sophistication Correlates to Hospital Quality Data, 2006




Establish a similar system in doctors’ offices and pharmacies would allow
any new prescription to be checked against information in an Electronic
Health Record (EHR). The EHR would contain the medication history of this
patient, including allergies and chronic diseases, which could influence the
choice of prescription. Such a system could only support decision making,
and not replace the decision taken by a qualified medical professional.

Healthcare stakeholders are increasingly aware of the potential benefits of
such a system and many countries are working on its implementation.




                                                                                                                      8
    SCREENING – Cardiovascular Risks


Cardiac infarctions and strokes are common in European countries. Both
can have fatal consequences or lead to permanent disabilities and the need
for long term care. High blood pressure, high levels of cholesterol and/or
diabetes are among the key triggers of both diseases. All these risk factors
are very often unnoticed and can lead to infarctions or strokes after only a
few years.

A computer-aided analysis of an image of the background of the human
eye can help to detect and evaluate these risk factors early. This
preventative procedure combines the use of a dedicated camera for the
acquisition of an image of the background of the eye with elements of
telemedicine. The procedure takes only a few minutes, is non-invasive and
free of pain. All images are transmitted through a secure communication
link to a central server, which is connected to a diagnostic centre, where
qualified specialists evaluate the images. Arteriosclerotic changes in the
background of the eye indicate an increased risk for cardiac infarctions and
stroke.

The procedure can also be used to indicate changes that could lead to a
glaucoma or a diabetic retinopathy. Preventing any of these diseases
through early detection and preventive treatment will not only improve the
quality of life of the patient, but also reduce future health expenditures.




                                                                               9
     DIAGNOSIS – Cardiovascular diseases


Multislice Computed Tomography

Cardiovascular disease is increasing in prevalence on a daily basis, making
early diagnosis more and more important.              Multislice Computed
Tomography (MSCT) can provide precise, non-invasive, high-quality
images of moving parts of the body, such as the heart, without the need
for invasive techniques.

Unlike classical X-Ray examinations, computed tomography (CT) shows
cross-sectional images of the body. The X-ray source and detector rotate
together around the body of the patient, resulting in a large number of
high-resolution, cross-sectional images with high resolution, which are
assembled into 3D impressions of the body. Technological innovation is
now allowing MSCT to take images of the complete cardiovascular system.
It delivers images of the moving heart and its vessels in real-time,
enabling a four-dimensional, dynamic evaluation of the health status of the
patient.

This technology offers a number of advantages to the patient. It reduces
both the examination time and the number of appointments needed.
Medical professionals acquire the images in a shorter time frame and with
the higher quality and reliability required for diagnosis, resulting in shorter
waiting times for the patient between examination and diagnosis. MSCT
has the potential to replace the current standard procedure, the invasive
diagnostic catheter, and therefore increasing patient comfort and at the
same time reducing the healthcare expenditure

The whole heart in a few seconds

Multislice Computed Tomography (MSCT) has advanced rapidly over the past
decade. Its spatial and temporal resolution has improved and its application
has expanded to include coronary angiography. There is growing evidence
that the newer systems have the ability to rule-out haemodynamically
significant stenoses and replace invasive, catheter-based coronary
angiograms in selected clinical settings. For example, in post-myocardial
infarction (MI) risk factor assessment. In some cases, thrombi formed in a
patent artery as a result of atherosclerotic plaque rupture during an MI, can
remain unnoticed and undetected. Due to a number of self-repair
mechanisms, these thrombi will be remodeled and the plaque will grow. Such
remodeling has no initial impact on lumen diameter but the outer diameter of
the vessel is increased - a process known as vessel remodeling. Despite a
large plaque burden, blood supply to the heart is preserved and the patient
remains symptom-free. If, at some point in the future, a thrombus (derived



                                                                                  10
from a so-called `vulnerable plaque’) grows rapidly and acutely interrupts
blood flow over a long period of time, the patient will experience another MI.
While standard risk factor assessment provides a statistical estimate of risk,
imaging-derived parameters allow direct visualization of plaque formation
within the arterial wall. They provide insight into plaque development,
progression and individual risk of major cardiovascular events.

Vulnerable plaque research is advancing rapidly with the development of
invasive, catheter-based imaging procedures such as intravascular
ultrasound (IVUS), optical coherence tomography (OCT), intravascular
magnetic resonance imaging (MRI) and nuclear probes. However, in the case
of susceptible patients, diagnosis should focus on non-invasive assessment of
plaque burden and plaque characteristics.

CT is a cross-sectional imaging technique with the potential to show not only
the contrast-enhanced lumen of the vessel but also characterize the vessel
wall and the severity of atherosclerotic burden.




                                                                           11
    TREATMENT – Cardiovascular diseases

3-Dimensional Presentation of Coronary Vessels

Calcifications in arteries can limit the capacity of the vessel or even block
the vessel completely, creating a stenosis. This deprives the heart muscle
of sufficient oxygen and other essentials, resulting in a cardiac infarction.
The situation can be corrected with the use of a minimally invasive
procedure called angioplasty. In this procedure, a balloon catheter is used
to reopen the blocked vessel. The catheter is advanced from the hernia
through the larger blood vessels of the body to the heart and the site of
the stenosis. This process is supervised with the use of dedicated X-ray
systems. When the catheter reaches the stenosis, a small balloon at the tip
of the catheter is inflated, widening and reopening the vessel. This process
is called dilatation and, in order to prevent the vessel blocking again, a
stent is often placed in the vessel. A stent is a small tube made of wire
introduced into the vessel together with the catheter. It is pressed against
the walls of the vessel from the inside and stabilizes the walls of the
vessel.

Determining the degree and length of the stenosis is difficult if only
conventional two-dimensional (2D) images are available. This information
is important to the decision about treatment. The length of the stenosis is
particularly important as it indicates the size of stent is required.

Three-dimensional (3D) presentations of the relevant blood vessels
contribute significantly to the decision–making of medical professionals.
Approximately 25 to 30 percent of patients suffer from a reblocking of the
vessel after the placing of a stent. However, correct calculation of the
required length of the stent can reduce this incidence considerably. Modern
angiography systems can show precisely the location and size of the
stenosis and provide other information concerning the blockage. Dedicated
software combines the information from 2D images of the area and
calculates a 3D presentation of the vessel in question. To do so, only two
images from different angles are required. The 3D presentation is then
displayed on a monitor. The presentation is `virtual’ and can be accessed
from all angles and perspectives. In contrast, a 2D presentation may lead
to incorrect calculations regarding the length of a stenosis, because a
stenosis that follows the view angle looks shorter than it is in reality.
Presentations in 3D remove this risk.

This procedure helps reduce the need for additional interventions, for
example, placing another stent, therefore, benefiting the patient and
reducing costs.




                                                                                12
Presentation of the opening of a blocked vessel by angioplasty




                                                                 13
INFORMATION MANAGEMENT – Cardiovascular diseases


The glue in the process - Comprehensive cardiovascular IT solutions

Over the past few years, digitization has contributed greatly to rapid
improvements in efficiency, quality and patient outcomes. Information
technology-based disease management helps provide physicians with the
most complete set of data within the shortest possible time, facilitating better
and faster decision making. An Electronic Patient Record (EPR) provides
imaging and vital signs data as well as patient history.

The future will show even many more advances, all aiming at further clinical
utility and procedural efficiency. For example, images from multiple
modalities such as cardiac X-ray, CT, MR, IVUS and ICE (intracardiac
echocardiography) will be seamlessly integrated in the interventional suite to
improve the efficiency and outcomes of complex procedures such as
ablations and biventricular lead placement.

Imaging, information technology and device technology will converge to
provide optimized device visualization or automated information flow to guide
implant procedures.




An electronic patient record




                                                                             14
        PREVENTION - Cancer

Virtual Examination with new non-invasive technologies

Bowel cancer is the second most frequent type of cancer behind lung
cancer. Incidence varies across the European Union, for example, as many
as 65,000 patients in Germany and 5,500 patients in Greece are diagnosed
with this cancer each year.5 Prevention and early detection can save lives.
If the disease is diagnosed in an early stage, there is a 90 percent chance
of survival. However, many patients refrain from a preventive endoscopic
examination because it is an unpleasant procedure.

Virtual colonoscopy is a non-invasive procedure based on Computed
Tomographic (CT) technology that is capable of detecting both polyps and
lesions in the colon. Examination takes less time, is much more
comfortable for the patient and the quality and reliability of the results are
comparable with endoscopy.




    Images from a Virtual Colonoscopy

With the help of a CT system, several cross-sectional images of the
abdomen are taken. Using specially designed software, the medical
professional can then view a three-dimensional (3D) presentation of the
complete bowel. He can take a virtual `flight’ through the whole organ,
accessing areas that cannot even be reached by endoscope. The time from
the CT examination to diagnosis is only 10 minutes, therefore, virtual
colonoscopy important alternative preventive measure.




5
    Estimated data, Robert-Koch-Institut [date]


                                                                                 15
        SCREENING - Cancer

Mammography

Breast cancer is the most frequent cause of death for women aged
between 40 and 60. The World Health Organization estimates that quality-
controlled mammography screening could reduce mortality by 35 percent.6
Many medical professionals and politicians in Europe are therefore
advocating the introduction of mammography screening programs based
on European guidelines.

Mammography is an X-ray examination that can be performed using either
analogue or digital systems. Digital systems use a digital detector instead
of the X-ray film needed with analogue systems. This detector transforms
the X-rays into electrical signals, which are then used to display and store
the images. Digital systems offer a number of advantages over analogue
systems:

        They can perform the examination with up to 40 percent less
         radiation without compromising the quality of the examination.
        They can detect more breast cancers at an earlier stage. In a group
         of 500,000 women screened for breast cancer, approximately 1500
         additional cancers would potentially be detected earlier.7
        Medical professionals have immediate access to the images and can
         provide an instant diagnosis. The images can be transferred
         electronically for a second opinion if required.
        Digital images can be enhanced electronically, reducing the need for
         repeat examinations.
        The images can be archived easily and efficiently.
        Digital images can detect even the smallest changes in the breast,
         raising the possibility of breast cancer being detected early enough
         for successful therapy.




6
 reference needed.
7
 Oslo Study, Radiology n° 232, July 2004, p. 192-204, RSNA 2004, abstract
SSG01-3



                                                                                16
Image acquired on a digital mammography system, and reviewed
directly on a review workstation. A dedicated image processing is
applied to enhance lesion visibility.




                                                               17
    DIAGNOSIS - Cancer


Hybrid-Systems for Diagnosis: PET-CT

Computed Tomography (CT) systems provide detailed presentations of all
the structures in the human body. They may detect a tumour but are
unable to determine whether it is a benign or cancerous (malignant) mass.
Positron Emission Tomography (PET) is able to make this distinction. In a
PET examination, a radioactively marked substance is introduced into the
patient’s circulatory system. The radioactive substance is not dangerous to
the patient, but sufficient to be used for diagnosis.

In the majority of cases, radioactively marked sugar, such as glucose, is
used. Since cancer cells require especially high amounts of energy for their
rapid growth, the marked glucose is concentrated in these tumours. As the
sugars are broken down, the highly sensitive detectors in the PET system
detect the radiation and locate the tumour. The PET system then uses this
information to calculate an image, which can be used by medical
professionals to determine the nature of the tumour. PET systems are
often used to stage a primary tumour and check for potential metastasis.

The functional data generated by a PET examination can be improved if
they are combined with the structural or morphological information from a
CT examination. Ideally, this is done in a single examination using a
combined PET-CT system. Using the combination of simultaneously
generated images from both systems, a medical professional can
determine the size and location of a malignant tumor down to fractions of
a millimeter. This information is essential to the planning and
implementation of cancer therapies and can save the life of a patient.




CT image of the lung (left); PET image of the same area (centre).
Combination of both images, allowing exact localization of the


                                                                               18
tumor and determination of size (right). Arrows in the images
indicate the tumor location.




     TREATMENT - Cancer


Radiotherapy – Linear Accelerators and Imaging Equipment

Cancer cells are greedy. They grow extremely quickly and consume a great
deal of energy within the body. The aim of cancer treatment is to stop the
cancer cells from growing and requires specific therapies. Radiotherapy has
been established as an effective therapy in more than 60 percent of all
cancer cases.
The principle behind radiotherapy is to destroy tumour cells using targeted,
high energy radiation and affect the surrounding healthy tissue and
neighbouring organs as little as possible. To do so, oncologists need
accurate information about the location of the tumour and the surrounding
organs. They gather this information using a range of modern imaging
procedures. These include: Magnetic Resonance Imaging (MRI), Computed
Tomography (CT) or the combination of CT with other examinations such
as Positron Emission Tomography (PET) or Single Photon Emission
Computed Tomography (SPECT). With the help of these procedures,
malignant tissue becomes visible and can be targeted precisely with
radiation. The amount of radiation required for therapy is calculated
individually and applied to the patient in several sessions with the help of a
linear accelerator, a specific radiotherapy device.

Radiotherapy addresses cell replication, a natural process in the body. The
human body constantly replicates cells with the help of cell division, but
tumour cells divide more quickly and more aggressively than healthy cells.
The energy of the radiation, applied through radiotherapy, changes the
core of the cancer cell in such a way that it is no longer able to divide and
replicate. If radiation reaches healthy tissue, it usually regenerates via
self-repairing mechanisms, which are better developed than those of the
cancer cells.




                                                                                 19
Radiotherapy Treatment Planning

Multislice Large Bore Computed Tomography

Within the last decade, there have been enormous clinical and
technological innovations in radiotherapy. Three-dimensional (3D) dose
planning, Intensity Modulated Radiotherapy (IMRT) and Image Guided
Radiotherapy (IGRT) are all new techniques aimed at improving local
control to achieve superior mapping of dose distribution and avoid organs
at risk. To achieve this therapeutic goal, precise geometric knowledge of
the target is required. Therefore all these new techniques have moved
from two-dimensional (2D) treatment planning, using X-ray radiographs
systems known as X-ray simulators, to 3D and even four-dimensional (4D)
treatment planning based on Computed Tomography (CT) images.




                                                                            20
Unlike classic X-ray examinations, CT provides cross-sectional images of
the body. These are generated by rotating both the X-ray source and the
detector around the body of the patient. The result is a large number of
high resolution images composed of 3D impressions of the body plus data
required for treatment simulation and accurate calculation of dose
distribution within the patient.

Many radiotherapy treatment techniques demand specific patient
positioning in order to avoid irradiation of organs at risk, for example,
during breast treatments. As radiotherapy treatment is sometimes
required daily for five to eight weeks, patients have to be precisely
repositioned with great reproducibility using specific immobilization
accessories.

Multislice Computed Tomography (MSCT) provides high-quality images
which allow radiotherapy physicians to accurately pinpoint the treatment
target. Both the patient position and the accessories required can be
difficult to accommodate in a standard diagnostic MSCT tunnel (70 cm).
Therefore, radiotherapy MSCT is now designed with a larger bore (> or =
80 cm) to cope with patient treatment requirements.

Recent technological innovation allows MSCT to acquire a 4D data set
showing potential tumour movements due to patient respiration. These
images which can help define the local limits (gating) of treatment in
difficult localisations.




                                                                            21
          TREATMENT – Long Term Care

IT-Supported Disease Management – Efficient Treatment of Chronic
Patients

According to the World Health Organization (WHO), 60 percent of
healthcare expenditures go toward the chronically ill.8 The number of
patients suffering from these chronic conditions will increase in the next
few years. For example, the number of diabetic patients is expected to
double, reaching almost 340 million worldwide, by the year 2025.9 These
illnesses require that the patient sufficiently understands the disease,
coordinates treatment with the treating physicians and monitors the course
of the illness and compliance. Disease monitoring simply requires frequent,
regular checks of a few simple parameters to predict the near-term
progression of the disease. Asthmatics, for example, blow into a tube to
measure peak flow; patients with chronic heart failure check their weight
daily. These values, monitored over time, indicate whether the patient
needs to be admitted to the hospital or whether he can continue to lead a
largely normal life. If the values point to hospitalization in the near future,
a simple intervention with medication may prevent it. This results in a
higher quality of life for the patient and lower costs for the healthcare
system.



       Medication Management in the Hospital

              Up to 73 % reduction of wrong and unclear
              prescription due to IT supported medication
              process.                                                                           Stockholm, Schweden



              Up to 64 % shorter time between
              prescriping and administering of a
              medication
                                                                                                      Ohio, USA



              Estimated cost reduction of 840.000 USD due to
              decrease of error rate in medication
                                                                                                     Virginia, USA




    Source:   ** HIMSS Analytics, EMR Sophistication Correlates to Hospital Quality Data, 2006




8
    Reference needed
9
    Reference needed


                                                                                                                       22
IT-supported processes keep the chronically ill out of the hospital

Therefore, the goal must be to monitor these values at short intervals with
the patient and respond quickly to changing circumstances. Figures from the
US support the fact that appropriate care plans for patients with chronic
heart failure can reduce hospitalizations by up to 50 percent.10 Although this
sounds easy in principle, it doesn't always serve the interests of the
healthcare system. Hospitals are reimbursed for patients treated, as are
physicians' practices, and no one is paid if an acute case never happens.

An example from the US shows, however, that under-financing a disease
such as chronic heart failure, generates a business model that results in
better quality patient care and lower costs.11 As a hospitalization for chronic
heart failure involves on average of six and a half days in an ICU, the costs
are approximately $8000; however, the hospital is only reimbursed $4000.
Therefore, the hospital isn't really interested in treating these patients and
only does so because it is contractually obligated.

The familiar patients are trained and supported via appropriate IT systems.
They receive individual treatment plans and their own personal electronic
patient record, into which they regular enter the values they monitor. The
physician, in turn, checks the figures and can intervene if they cause
concern. This avoids a stay in hospital and, as a result, the patient enjoys a
higher quality of life and the hospital preserves its financial resources. More
of these `win-win’ situations which benefit the patients and the healthcare
system, need to be identified in the future.

There is an increasing desire within healthcare organizations to treat
critical patients as quickly as possible in order to limit the time spent in
intensive care units, as treatment in such units is exceedingly costly for
providers and patients alike. The proliferation of monitoring requirements
that have resulted from this need to move patients out to lower acuity
hospital settings, earlier than was previously the case, has triggered
growth in the area of low and mid acuity patient monitoring equipment in
the healthcare market. Today, there is a significant demand for high-level
monitoring equipment that reduces the need for direct physician care,
particularly as there is a shortage of healthcare providers in the industry.

Information and communication technologies have already proven that
they can improve the quality and efficiency of treatment of chronic
conditions significantly. In addition to educational and preventive measures
for the population as a whole, it is essential to establish new procedures
for the treatment of patients with chronic health conditions. These
procedures need to optimize the treatment of patients in their daily


10
     Reference needed
11
     Reference needed


                                                                               23
environment and help avoid complications and deterioration of their health
status.

For diabetics, asthmatics and patients suffering from cardiovascular
conditions, the monitoring of vital parameters like blood sugar level, peak
flow value or body weight, may contribute significantly to the early
detection of changes in health status. If this monitoring is done in the
patient’s daily environment, it avoids costly stays in hospital. Trials have
shown that use of electronic patient records (EPRs), call centres and the
increased participation of patients can help reduce by half the number of
hospital admissions of patients with cardiovascular conditions.

IT solutions can also contribute to the effective organization of measures
for secondary prevention. For example, diabetic retinopathy is a
complication that can affect up to 60 percent of all diabetics and can lead
to permanent blindness. However, 90 percent of cases can be treated
successfully, if diagnosed early enough. IT solutions can help organize the
prevention process and ensure the quality of preventive measures.

In addition to the improvement in the quality of life for patients with
chronic conditions, IT supported disease management also helps
significantly in the of control healthcare expenditure.




A promising project for disease management with IT in Scotland




                                                                               24
    TREATMENT – Critical Care

Integrated Workplaces in Critical Care and Operating Room

Peri-operative medicine is the biggest single cost factor in the care process
in hospitals. It consumes considerable resources both in the operating
room (OR) and in the intensive care unit (ICU), accounting for
approximately 90 percent of staff costs. The medical devices used for
monitoring and supporting life-critical organs are subject to continuous
innovation and improvement. In the OR and ICU, the coherent use of
technology for the improvement of clinical work places can also contribute
to more efficient processes and cost reductions.

Virtual local area networks (Virtual LAN) can connect all the systems used
for therapy, monitoring and documentation without the need to install a
separate, dedicated network of its own. Virtual LAN can use the existing
network in the hospital or wireless technologies. Integrated work places
also use a uniform user interface for all medical devices, supporting and
facilitating the safe use of equipment as well as staff training.

Integrated work places connect all the sub-systems within a particular
work place. This enables plausibility checks between different devices that
help avoid false alarms, i.e. where alarms sound but there is no critical
patient situation. This is particularly relevant as, in stand-alone
conventional devices, 80 percent of all alarms are false, resulting in a
major burden for staff and consumption of considerable resources.
Integrated work places also facilitate new therapeutic procedures. For
example, combining measurements from monitoring equipment with the
control of therapy systems improves the effectiveness of life support
equipment compared to manually controlled therapy devices.

A fully integrated work place provides medical professionals with the
relevant patient information for optimal therapy decisions. It can be
supported by automatic recommendations for specific procedures or clinical
pathways and allows comparison with data stored in the Electronic Health
Record (EHR) of the patient.

One example of a solution making use of this technology is automated
controls for clinical respirators (devices supporting the breathing of
unconscious patients). Automatic control of the respirator reduces the
artificial interference with the patient’s breathing system to a minimum. It
also speeds up the `weaning’ of the patient from artificial breathing
support back to natural breathing. This not only reduces potential adverse
effects for the patient, but also reduces the length of stay in the ICU and
frees staff to perform other care tasks. Integrated systems also provide
closed-loop, feedback control mechanisms for the exact dosage of




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medicines during intensive care and surgical interventions, reducing the
consumption of pharmaceuticals.

It is crucial for hospital administrators to have a transparent overview of all
hospital processes. They must have the tools available to adapt and
optimize these processes. This is particularly relevant to the changing
reimbursement system, which has moved from reimbursing individual cases
towards average cost reimbursement (Diagnosis Related Groups) i.e. in the
language of the modern industry, full Cost Accounting.

In order to secure the information, an appropriate IT environment has to be
in place, with all the variables available to manage optimal process flow in
the hospital. At the same time equipment should be flexible and equipped
with an easy and uniform user interface. These developments are the
responsibility of the healthcare industries of today and tomorrow.

Finally, as most technologies make use of a web-based software
environment, there is the possibility for remote service of the equipment.
Through the use of telematic services, a service centre can control the
performance of the equipment and initiate preventive inspections when
necessary. Service centres can diagnose failure or malfunction and ensure
that the appropriate service technician with the correct spare parts is
dispatched to fix the system as quickly as possible. Alternatively, the
remote service may help the technician on site to find the source of the
failure and correct it without the need for a service technician to visit the
hospital.




                                                                                26
The duration of inadequate ventilation (length of bar graphs) on ICU
is significantly reduced by automatic and seamless adaptation of
ventilator support compared to adaptation in clinical routine
procedure by medical staff.




Example of intuitive and unified graphical user interface (GUI):
Touch control for all workplace components (cockpit design
approach). Example shows the effect of stepwise automatic
adaptation of ventilation support. The stepwise adaptation over time
(s. lower diagram) results in the desired patient status of normal
ventilation (s. trend graph in the middle).

CONCLUSIONS



Partnerships in the Interests of People

New and existing Member States and Regions are increasingly directing their
health policies to subscribe to citizen-centered services. These activities
support the need to improve patient safety along the full continuum of care
and assist healthcare professionals in their daily work. They provide citizens
with tools that enable them to become both well-informed and self-assured
patients and gather, analyze and disseminate relevant quality information for
policy-making.

The examples included here demonstrate that innovation in medicine and
medical information and communication technology can improve the different
stages of the care process. Prevention, screening, diagnosis and therapy
would become less burdensome to the citizen. Care would be of a higher


                                                                           27
quality and more cost-efficient through avoidance of errors and medical
complications, easier examinations and therapies, easier access and sharing
of information and fewer unnecessary procedures.

With changes in the locations in which healthcare is provided, developments
in medical, communication and information technologies allow those services
previously restricted to hospitals to be offered in community clinics, mobile
health units and in patients’ own homes.

To achieve this vision, health, social care and other providers must work as a
team to deliver a coherent continuum of care. If necessary, this care must
extend beyond national and linguistic borders and medical, information and
communication technologies again can facilitate this co-operation. It is vital
that all parties have access to, and the ability to share securely, up-to-date
information on a citizen’s health status.

Connected health (or eHealth) has the means to tackle rising costs, improve
productivity and patient care and provide better clinical outcomes. According
to the Institute of Medicine,4 moving from a paper to an electronic based
patient record system is the single step that would improve quality of care
and patient safety. However, the quality of an Electronic Health Record (EHR)
is largely dependent on the basic patient records from which it is abstracted.
In this respect, there is still much to be done in terms of effective
implementation of an EHR solution on a large scale at the point of care.
Policy makers and care providers that want to successfully meet the future of
healthcare, therefore, have compelling reasons to embrace leading-edge
technology such as advanced electronic patient record (EPR) systems; order
entry    systems;     medical    documents      management     systems;     and
knowledge/decision support systems. EPRs alone have significant cost-saving
potential. In a survey conducted for the European Commission,12 $81 billion
or more could be saved annually through improvements in healthcare
delivery efficiencies. Transaction efficiencies could add another $10 billion or
more in annual savings.

All stakeholders in healthcare need to work together to combine the
individual procedures into an efficient and coherent care process of high
quality. The medical industry will contribute its technology, together with its
experience and skills, to this healthcare transformation process. It will use
ITC and the EHR to make all relevant health data available where and when
it is needed. Only well informed patients and medical professionals can make
the correct decisions in critical situations and they need diagnostic and
therapeutic tools to implement these decisions. Transparency in the results of
prevention and screening programs, as well as different treatment paths, will
facilitate continuous improvement of the process.




12
     Empirica for EC DG INFSO, 2006


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Industry and medical professionals have already begun optimizing the
processes and using technology in designated areas. The `Integrating the
Healthcare Enterprise’ (IHE) initiative is developing integration profiles that
address eHealth interoperability problems across different standards,
technologies and manufacturers. IHE describes and tests solutions for
specific clinical situations in clinical laboratories and cardiology or radiology
departments. These clinical processes are being defined by medical
professionals and implemented by industry and, as more and more are
addressed successfully, so the short term gains seen by medical
professionals increase. However, without system intra-operability between
countries, these clinical processes will be more costly to deploy and maintain
and will create additional healthcare burden in an environment already
stretched to its limits.

However, there is one technology now emerging that will have a greater
impact on the diagnosis and treatment of disease than anything that has
gone before. By detecting the precursors of disease at the molecular level in
the body, the new technology of molecular medicine will allow many diseases
to be detected and cured well before the patient suffers any symptoms. It
poses some significant challenges, not least of which is the development of
ultra-sensitive bio-sensors that can detect specific molecules in a patient’s
blood at concentrations equivalent to a grain of salt in an Olympic swimming
pool. Molecular medicine is, however, a prize worth pursuing as it promises a
paradigm shift in the care cycle that will both eliminate patient suffering and
the cost and societal impact of late-stage medical intervention

(NEW TEXT IN IMAGE BROUGHT IN LINE WITH NEW TXT OF CONCLUSION)




In summary, a healthcare system centered on the citizen which builds on
efficient, high-quality health systems, services and processes can only be



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achieved if all stakeholders work together. Citizens, medical professionals,
health insurance companies, politicians and industry must all be involved. A
sustainable investment in good health is not just good for people; it is also
an increasingly important sector of most economies. It is the source and the
driver for innovation.


Acknowledgement

The following members of COCIR have contributed to the development of this
brochure:

AGFA -Healthcare
Dräger Medical
GE Healthcare
KODAK
Philips Medical Systems
Siemens Medical Solutions
Toshiba Medical Systems Europe


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