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

Airtel Insurance

In an effort to bring more value to you: our customer, Airtel has partnered with Pan Africa Life Assurance Limited and MicroEnsure

to create a FREE (yes, 100% free) insurance product which offers Airtel customers in Kenya access to FREE life, accident and

hospitalization insurance based simply by how much you spend on our network.

his product is the first in Kenya to allow Kenyans to register and benefit from insurance from the comfort of their mobile phone. It is

also the most accessible insurance cover- all you require is your mobile phone and your Airtel sim-card

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.