In November 1999, the report To Err Is Human: Building a Safer Health System issued by the U.S. Institute of Medicine was launched. The report was based upon an analysis of multiple studies by a variety of organisations and concluded that between 44,000 to 98,000 people die each year as a result of preventable medical errors. This is more than those who die from motor vehicle accidents, breast cancer, AIDS, or Alzheimer disease, all causes that receive far more public attention. The report asserts that the problem is not bad people in healthcare. Instead, it is that good people are working in bad systems that need to be made safer. The report called for a comprehensive effort by healthcare providers, government, consumers, and others.

The present contribution will primarily focus on patient safety issues during the perioperative period with emphasis on the challenges encountered during surgery and anaesthesia.

Patient safety in the perioperative period

Adverse events during hospital admission affect nearly one out of 10 patients. A substantial part of these events is preventable. It has been shown that about half of all adverse events in hospitals are related to surgical procedures in the operating theatre. Interestingly, research into the occurrence of adverse events related to surgery and anaesthesia has started only relatively late. In 1957, the First Report on Confidential Enquiries into Maternal Deaths in England and Wales was published, and only in 1987, the First Confidential Enquiry into Perioperative Deaths Report was published. Commissioned jointly by the Association of Anaesthetists of Great Britain and Ireland and the Association of Surgeons of Great Britain and Ireland, 4,000 deaths occurring within 30 days of surgery during 1986 were analysed.

Although it is generally assumed that the introduction and widespread use of advanced monitoring technology such as end-tidal carbon dioxide monitoring and pulse oximetry has greatly contributed to improved patient safety, data seem to indicate that their routine use has resulted only in limited steps in improvement of perioperative patient safety. Indeed, monitoring tools are simply a tool and we now know that technical and non-technical skills and attitudes alike are necessary to reduce perioperative patient risks and improve patient safety by preventing avoidable mistakes. The use of checklists, communication, simulation and universal skills such as advanced life support etc., increase the likelihood of optimal outcomes.

The global need for quality of care and patient safety was first discussed during the World Health Assembly in 2002, and resolution WHA55.18 on “Quality of care: patient safety” at the 55th World Health Assembly that urged Member States to “pay the closest possible attention to the problem of patient safety”. Since then, there have been several international initiatives, which have brought the importance of the matter to the attention of policy-makers in many countries, including:

1. Development of global norms and standards;

2. Promotion of evidenced-based policies;

3. Promotion of mechanisms to recognise excellence in patient safety internationally;

4. Encouragement of research; and

5. Provision of assistance to countries in key areas.

The World Health Organization (WHO) has also undertaken a number of global and regional initiatives to address surgical safety. Safety of surgical care was the problem area selected for the second Global Patient Safety Challenge, in 2007–2008. This has resulted in the publication in 2009 of the WHO guidelines for safe surgery with the title: “Safe Surgery Saves Lives”. This document included a 19-items Surgical Safety Checklist, which was developed after extensive consultation aiming to decrease errors and adverse events and increase teamwork and communication in surgery. It is a simple tool designed to improve the safety of surgical procedures by bringing together the whole operating team (surgeons, anaesthesia providers and nurses) to perform key safety checks during vital phases of perioperative care: prior to the induction of anaesthesia, prior to skin incision and before the team leaves the operating room. The checklist has been implemented worldwide and its routine use has been associated with a significant reduction in perioperative morbidity and mortality.

Since its very beginning, the specialty of Anaesthesiology has been active in systemic attempts to improve patient safety. In 1992, the World Federation of Societies of Anaesthesiologists (WFSA) first published Standards for a Safe Practice of Anaesthesia. As part of the WHO’s Safe Surgery Saves Lives initiative in 2008, a work-group reviewed, revised, and updated the Standards, which were then endorsed by all national anaesthesia societies and published in 2010. The Standards were once again updated recently in 2018. While the fundamental Standards remained largely unchanged, an attempt has been made to reconcile these recommendations with those that have come from other entities writing about safe surgery, such as The Lancet Commission on Global Surgery and the Disease Control Priorities, 3rd edition. These standards are not intended to supersede the established national standards of any country. Instead they should primarily be considered as a resource for those countries that do not already have national standards and define minimum standards for any facility where anaesthesia is administered. To facilitate evaluation of facilities against these standards, a parallel Anaesthetic Capacity Checklist has been derived to allow anaesthetic departments, regions, or countries to assess their compliance and their needs (available on the World Federation of Societies of Anaesthesiologists’ [WFSA] website).

The International Standards for a Safe Practice of Anaesthesia were presented to the General Assembly of the WFSA in 2016 and unanimously endorsed by all national society members present. The document was also reviewed by the WHO Emergency and Essential Surgical Care Program and the Policy, Access and Use, Essential Medicines and Health Products Department.

Role of the European Society of Anaesthesiology in perioperative patient safety

Following the production of the International Standards for Safe Practice of Anaesthesia by the WFSA in 1992, the European Society of Anaesthesiologists (ESA) and the European Board of Anaesthesiology (EBA) launched the Helsinki Declaration on Patient Safety in Anaesthesiology. This declaration emphasises the role of anaesthesiology in promoting safe perioperative care. The ESA promotes this by providing access via their website to the Patient Safety Starter Kit.

The ESA Patient Safety and Quality Committee is very active in organising European Patient Safety and Quality Courses and Masterclasses and in promoting the Patient Safety Expert Network. The interest for the ESA patient safety initiatives extends far beyond Europe as can be observed on the Helsinki Declaration map. Many countries all over the world have signed the Helsinki Declaration. For instance, Australia, New Zealand and Canada have supported the Declaration since 2010; Latin America since 2012; the U.S. since 2014; and China and Japan since 2015. Many other countries have followed.

Signing a declaration is one thing; another issue is to really implement the principles of that declaration in daily clinical practice. In 2012, the ESA launched a survey among its council members and national anaesthesiology societies interrogating how three main aspects of the Helsinki Declaration were implemented in their national daily practices. The response rate was impressive, with more than 90 per cent of the member countries providing feedback. Interestingly, monitoring standards seemed to have been very well implemented in the majority of countries; however, the WHO guidelines and organisation of patient safety teaching and training facilities were significantly less well implemented in the various national practices. These data indicated that there is still a huge amount of work to be done to get all different aspects of perioperative patient safety implemented in our daily clinical practice.

Future challenges

What are main challenges for Europe in organising similar efficient and effective high-level standards for patient safety in all of its member countries? Although many problems will be similar to those in other places worldwide, Europe faces a major challenge because of its specific political composition of a conglomerate of individual nations with specific languages and healthcare system organisations. Indeed, the European Union consists of 28 member countries in which 24 different languages are spoken. As a mirror of this, the ESA, with its approximately 10,000 active members and more than 35,000 associate members, encompasses more than 40 different nationalities.

A 2012 report from the European Commission investigated the topic of Europeans and their languages. Some interesting observations were made. First, in accordance with the population, the most widely spoken mother tongue seems to be German (16 per cent), followed by Italian and English (13 per cent each), French (12 per cent) and then Spanish and Polish (8 per cent each). Interestingly, at a national level English is the most widely spoken foreign language in 19 of the 25 Member States where it is not the official language. The five most widely spoken foreign languages are English (38 per cent), French (12 per cent), German (11 per cent), Spanish (7 per cent) and Russian (5 per cent). It is to be underscored that only just over half of Europeans (54 per cent) are able to hold a conversation in at least one additional language, one-quarter (25 per cent) are able to speak at least two additional languages and only one in 10 (10 per cent) is conversant in at least three languages. It is obvious that the issue of diversity of language creates a huge challenge in terms of implementing common European initiatives such as patient safety directives in individual national daily practices.

Other problems are related to the differences in financial and human resources in the various European countries and the different organisation of the healthcare systems, all of which can influence standard of care. In 2012, the European Surgical Outcomes Study (EuSOS) group published the results of seven-day mortality after surgery in Europe. Astonishingly, a mean of 4 per cent, seven-day mortality was observed, ranging from 1.2 per cent to as much as 21.5 per cent depending on the country. This excess mortality seemed to be related to what the authors referred to as “failure to rescue”. In other words, patients died because of lack of identification and prompt treatment of adverse perioperative events. This failure to rescue seemed to be related to a lack of adequate resources, suggesting a direct relationship between improved patient outcome, patient safety and available human and financial resources.

This problem deserves further attention. One of the basic principles of the European Union is free movement of students, patients and doctors across borders. If one takes a closer look at the monthly salaries for board-certified anaesthesiologists in Europe, a greater than 10-fold difference can be observed between low-income and high-income countries. The result is a brain drain of board-certified anaesthesiologists from low-income (mainly Eastern and Southern Europe) to high-income countries (North-western Europe). The consequence is a lack of trained and skilled professionals in those areas suffering from the brain drain.

How is the ESA dealing with all of these challenges? Several projects are ongoing. Yearly, two or three guidelines are produced on various topics in anaesthesiology and intensive care, critical emergency medicine, pain and perioperative medicine. These guidelines are meant to provide recommendations for standard of care, which should help to bring practices all over Europe to the same level. In addition, they may help local care providers convince hospital administrations and healthcare officials about the specific needs to achieve these European standards of care.

The European Diploma in Anaesthesiology and Intensive Care (EDAIC) undoubtedly contributes to setting a universal high standard with regard to the knowledge and skills of anaesthesiologists worldwide. Programmes such as ‘mentor/mentee’ and ‘train abroad return home’ aim to allow professionals in low-income countries to develop their skills with the help of foreign colleagues/centres with specific expertise.

In line with the Helsinki Declaration Heads of Agreement 7 (need for research), ESA-supported research contributes to provide necessary data to update the situation on current perioperative morbidity and mortality issues and identify potential areas of improvement.

The Helsinki Declaration calls for routine measurement of safety in all anaesthesia departments. Because no generally accepted and sufficiently evidence-based set of anaesthesia quality/safety indicators exists, the ESA Patient Safety and Quality Committee has started the ESA Quality Indicators Project (EQUIP).

EQUIP is surveying national anaesthesia societies to establish an overview of anaesthesia quality indices used in Europe. This approach is complementing formal research about quality indices by describing commonly and successfully used indices, the suitability of quality indices in routine practice of different countries in Europe and common obstacles to and requirements needed for implementation of quality indices.

A major challenge is consistent implementation of the Helsinki Declaration principles such as patient safety programmes across Europe. To meet this challenge, the ESA has started the Helsinki Declaration Follow Up (HD-FU) Project. This research project is designed to better understand the local and regional/national differences in anaesthesia departments that help or hinder implementation of the Helsinki Declaration requirements. Based on the results, strategies will be developed that improve implementation and adoption nationwide.

Patient safety is a concern of every person and society dealing with patient care. The ESA is committed to close cooperation with all anaesthesiology and other specialist societies involved in perioperative patient care. A good example of such cooperation is the International Forum on Perioperative Safety and Quality. This is a meeting jointly organised by the ESA and the American Society of Anaesthesiologists at their yearly scientific meeting. By attending meetings such as this, anaesthesiologists can take the opportunity to meet colleagues and gain new knowledge about fatigue risk management and about for instance the role of simulation for improving patient outcomes.

Finally, caregivers are not the only stakeholders when thinking about perioperative patient safety. Our industry partners and the different patient societies and movements are also important key players. In the end, major advances in patient safety can be achieved only when all stakeholders work together to achieve a safer patient environment.

References available on request.

Transforming a healthcare organisation from good to excellent is not easy. If it were easy, every organisation would be great for treating all patients’ population, and as we know, few are. Most healthcare organisations are very good, but very good isn’t good enough. We don’t accept airlines being 99.99 per cent accident free in their landings, and we can’t accept that in healthcare either. The Institute of Medicine’s To Error Is Human report estimated as many as 98,000 people die in U.S. hospitals each year as a result of medical errors. The Centers for Disease Control and Prevention (CDC) has estimated for every person who dies from a hospital error or an infection, five to 10 others suffer a non-fatal infection. The Institute estimated the cost of all these medical errors at over US$20 billion annually. “With approximately 33.3 million hospitalisations in the U.S. each year, that means as many as 88 people out of every 1,000 will suffer injury or illness, and perhaps six of them will die as a result.”

Healthcare safety expert Lucian Leape compares the risk of entering an American hospital to that of parachuting off a building or bridge. The costs and frequency of the unintended harm and unnecessary death are unacceptable. The good news is analysis of the consistent application of best practices demonstrates that if the best science based medical practices were consistently followed, 80 to 90 per cent of these adverse events could be prevented. In my personal training practicum attended in Singapore in 2008 conducted by the Joint Commission International (JCI), the reality of healthcare was viewed to be a culture of low expectation due to many reasons such as wasting about 40 cents of each healthcare dollar spent, and being an environment that supports the tolerance of deviant behaviour. This kind of culture will not be tolerated when an organisation commits itself to excellence.

In a study quoted by JCI surveyor, Al Attal Z. in the quality and patent safety congress in Abu Dhabi in 2013, about what leaders in accredited facilities don’t hear about patient safety culture, he echoed the global anxiety of safe healthcare delivery where 56 per cent of 1,600 participants feel that their mistakes are held against them, and 71 per cent of staff are worried that mistakes are kept in their file despite that 74 per cent of hospital management show that patient safety is a top priority. On the contrary of stringent monitoring to errors reporting in order to meet accreditation requirements, in excellence environment, staff are empowered to practice correctly and report errors transparently. In my opinion, different types of national and international accreditations in the Middle East region have helped in improving healthcare practice and outcomes. It succeeded in emphasising on the necessity of reducing hospital acquired infections, raising awareness on international patient safety goals, reporting near misses, and addressing major medical errors that occurs at sharp end but still many years to come to see the impact on fixing broken processes and systems at blunt end, structuring realistic key performance indices, progressing toward value-based healthcare and following sustainable medical best practice to save lives and money.

The Institute of Medicine which was established in 1970 to provide independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public in the U.S. has produced two reports demonstrating healthcare has serious patient safety and quality problems and is in need of fundamental change (Institute of Medicine, 2000 and 2001). Care processes are poorly designed and characterised by unnecessary duplication of services and long waiting times and delays. Costs are exploding and waste is identified as an important contributor to the increase in healthcare expenditures. As a result, healthcare consistently does not succeed to meet patient’s needs. To better serve the needs of patients, healthcare systems have to be redesigned. By issuing the reports, the Institute of Medicine has put quality management strongly on the agenda of healthcare organisations. Delivering low quality of care was considered unacceptable. This obligation may cause more (financial) stress because, for example in The Netherlands, the hospital funding system pays fixed prices per patient regardless of the quality of care delivered. Hence, delivering high quality does not generate more income. However, the observations of the Institute of Medicine with respect to process optimisation and waste reduction offered opportunities for healthcare organisations with respect to cost containment.

Worldwide the cost of medical care is also increasing at an alarming and unsustainable rate. Admittedly, a significant percentage of these cost increases can be attributed to ageing populations and technological advances. Those two causes are inevitable facts of the technological and demographical developments of modern society. As such, they are largely beyond our control. However, another significant source of healthcare cost increases can broadly be characterised as unnecessary operational inefficiency. This we have more control over. Inefficiency we can change. If we do, we can provide more affordable and better healthcare for a large percentage of the population. Some operational inefficiencies are associated with the direct medical service delivery process. Others are associated with the administrative, logistical and operational side of the healthcare delivery system. I strongly believe that both areas in the Middle East healthcare delivery system can benefit from systematic process innovation activities that are offered by the excellence concepts and model.

The link between Total Quality Management (TQM) and Business Excellence (BE)

I would not be surprised if some object to the concept of industrialised healthcare delivery.

However, industrialisation is essentially a conversion of artisan methods to more efficient, cost effective, streamlined systems for the delivery of products or services (Levitt, 1976; Heskett, Sasser, and Schlesinger, 1997). During the past century, industry deployed a large arsenal of tools and innovation approaches to achieve high levels of operational efficiency. Economic history indicates that efficiencies in industry were obtained primarily as the cumulative effect of a large number of incremental improvements (Rosenberg, 1982 and Bisgaard, 2006). What sets apart Total Quality Management (TQM) and Business Excellence (BE) models from other performance management models is that TQM/BE models are designed to address the whole management philosophy of an organisation and the activities it uses to pursue it. TQM/BE models aim to guide organisations to consistently exceed the current and future expectations of all stakeholders (i.e., customers, employees, shareholders and the community) through “continuous improvement in all processes, goods and services” (Sitkin, Sutcliffe, and Schroeder, 1994). Central to this realisation is the creation of a working culture (by the senior leadership) that uses data information and knowledge for every sphere of organisational activity, and evolution of a managerial system that fulfils the intrinsic and extrinsic needs of the organisation’s employees (Dean and Bowen, 1994; Hackman and Wageman, 1995; Kanji and Wallace, 2000). When an organisation applies for a national BE Award, the key areas of organisational capability are assessed against the model and points are allocated to each measurement item by a panel of trained independent evaluators using a scoring guideline based upon the level of evidence of actual performance. In my opinion, having quality experts in the external assessment and jury processes are vital to the success of any national quality award model because it will lead to healthy and transparent economy. Furthermore, those organisations with leadership that seed excellence culture in its daily performance, conduct vigorous self-assessment and grow internal assessors with quality values, behaviours and integrity that would defiantly with time contribute not just to its business growth but its national economy footprint and have evident proposition at the global market. Quality in healthcare like any other industry is an integral part of it and shall benefit from the excellence approach.

The concept of quality in healthcare and how regional healthcare delivery would benefit from the organisational excellence philosophy?

Quality in healthcare delivery has always been a primary aim for clinical physicians. But since the beginning of recorded medical history, physicians have always aimed to provide the best outcomes possible for each patient, a goal consistent with medical codes of ethics since at least the time of Hippocrates. This emphasis on quality of healthcare delivery forms the first and oldest part of a useful triad of concepts that cover much of what we mean by good healthcare delivery. The second part of the triad, access, and the third part, cost, reflect two additional goals of healthcare delivery that are manifesting increasingly today in medicine’s interaction with society as a whole. Quality of care (good outcomes for each patient, within the limitations of current medical knowledge) at the level of individual patients or small groups of patients has been the focus of medical research and publication since a long time, although in the last two decades new emphasis has been placed on measuring quality at the level of the practitioner (individual practitioner or hospital). The U.S. government has devoted much attention to healthcare delivery initiatives since the 2008 general presidential election, and one state (Massachusetts) has already enacted significant healthcare reform, making this topic a particularly appropriate one for discussion. The branch of the U.S. government most directly tasked with ensuring quality in healthcare delivery, the Agency for Healthcare Research and Quality (AHRQ), uses 19 distinct criteria to define successful healthcare delivery: (1) effectiveness, (2) safety, (3) timeliness, (4) patient-centeredness, (5) equity, and (6) efficiency, (7) acceptability (8) accessibility, (9) appropriateness, (10) care environment & amenities, (11) competency, (12) capability, (13) continuity, (14) improving health, (15) clinical focus, (16) expenditure or cost, (17) governance, (18) focus or responsiveness, and (19) sustainability.

In the Middle East, different accreditations models and bodies were introduced in the last two decades as a remedial approach to improve quality of care in healthcare services by local authorities. Recently, different countries in the region including the Kingdom of Saudi Arabia, Jordan and UAE created their national accreditation scheme and started mandating it to foster national standards of quality of care. Similar to AHRQ, each hospital, authority or accreditation scheme adopted different dimensions to measure and assess its quality. In my personal opinion, as a lesson learned from the sole adaptation of the accreditation approach of any size of healthcare institution is that “structuring healthcare delivery algorithm on safety and quality is way beyond complying with the accrediting bodies’ requirements.”

 I strongly believe that what determines how great a healthcare organisation will become is how well its leadership system creates a culture of excellence and safety, improves the enterprise system and effectively implements best practices. I look forward to the day where quality, infection control and safety become the DNA of healthcare services in the Middle East region and the quality department becomes just a facilitation arm that helps leadership make informative decisions. The day shall come where every healthcare provider is morally engaged in the delivery system without monitoring.

What are the excellence models available worldwide and regionally… which model works for you?

There are two well recognised excellence award models worldwide, the Business Excellence Model which was launched in 1991 by the European Foundation of Quality Management (EFQM) and the Malcolm Baldrige National Quality Award, which was introduced in the early and mid-1980s recognises U.S. organisations in the business, healthcare, education, and non-profit sectors for performance excellence. The EFQM is an innovative approach that is currently popular in all industries, whether manufacturing or services, based on a belief of leaders from 14 companies, based in Europe, who were convinced that a new membership organisation (EFQM) was necessary to promote higher standards of management through knowledge sharing and recognition. Both awards provide a platform for systematic approach to facilitate leadership, culture, systems, and incremental process innovations. The models help organisations in building robust enablers to achieve sustainable results, which can be self-assessed internally or by peers externally using the RADAR (Results, Approach, Deployment and Assessment and Review) philosophy. Each model has excellence concepts that renewed emphasis on quality as necessary for doing business in an expanding and competitive world market. The EFQM just recently launched its 2020 Excellence model in Helsinki. The model takes a complete view of the organisation, which emphasises the role continuous improvement has in creating sustainable success. In the Middle East, the EFQM has made stronger footprint since the majority of governmental awarding bodies have adopted its approach while the Baldrige award remained within the boundaries of U.S.

Since early 2002, many quality awards were established and launched in the Middle East region including the Dubai Quality Award, followed by the King Abdullah Excellence Award of Jordan, King Abdulaziz Quality Award of the Kingdom of Saudi Arabia, and Abu Dhabi Excellence Award. It is not the aim of this paper to compare between the national or international quality/excellence awards but to emphasise on the benefit of adopting the business excellence approach in healthcare performance. For example, the Baldrige criteria asks about healthcare processes, support processes and innovation. The examiners look for the use of best practices in the application and during a site visit. In today’s competitive environment, Baldrige award recipients and others that have chosen performance excellence are reaping the benefits of financial stability, staff retention, prevention-based culture, safe and quality care, and a compassionate, ethical environment where staff, patients and physicians thrive. In 2005, 33 healthcare organisations applied for the Baldrige award, making healthcare the fastest growing segment. Even though the excellence awards in the region were targeting the private sector, it has recently expanded to the public sector with strong focus on customers’, stakeholders’ and community needs and expectations. I strongly believe that quality awards are instrumental in deploying the smart government vision when it comes to quality improvement in public services.

In conclusion, the senior leadership team in any healthcare organisation shall create the strategies, systems and methods for reaching performance excellence by seeding excellence culture, stimulating innovation, building knowledge and capabilities and ensuring organisational sustainability. Every organisation has the potential to achieve performance excellence, and there are several ways to get started: first, a good step is to learn about the excellence concepts and criteria whether national or international, which are based on world-class practices and provide a model for integrating clinical and business processes to drive performance excellence throughout the organisation. This shall enable the organisation to improve productivity and profitability while increasing patient, employee and community satisfaction. Second, conducting an annual assessment using the excellence criteria is an excellent way to measure your organisation’s pace of improvement.

References available on request.

As early as in 1956, John McCarthy and his colleagues, Marvin Minskly, Claude Shannon and Nathaniel Rochester coined the term ‘Artificial Intelligence’ (AI). More commonly, AI is defined as, “the science and engineering of making intelligent machines. Artificial Intelligence refers to the computer programmes that execute a task like that of human intelligence, especially intelligently and independently. The main objective of AI is to develop a machine that can exhibit human intelligence. It is also a promising tool for supporting the healthcare administration. Several studies have shown that AI algorithms are capable of managing patient flow and thus augmenting clinical care by reducing the administrative demands on clinicians. Artificial intelligence is not about robots completing the jobs and rendering people obsolete. AI in healthcare is set to help healthcare works and stakeholders manage the vast data and transform them into potentially life-saving information.

Concepts in AI

Intelligence is defined by learning and reasoning. Learning is an essential element in AI and is realised through machine learning. Reasoning is another component of AI, which encompasses data manipulation to produce actions. The AI is designed to work through two ways – symbolic-based and data-based (machine learning). Human’s process information through the eyes and that could be equated to the computer vision. In AI it includes methods for acquiring, processing, analysing, and understanding images.

Predictive modelling AI in healthcare

Artificial Intelligence has several applications in medicine including hospitals, clinical laboratories, and research facilities. Healthcare administration and operations; clinical decision support; predictions in healthcare; patient monitoring; and healthcare interventions are key domains where AI is applied.

Predictive modelling in healthcare is a proactive step towards identifying patients at risk of disease or adverse outcomes. One of the most common AI predictive model is the patient inflow into emergency department; re-admissions into emergency departments; disease or other outcomes; and in-patient mortality.

AI for improving operational efficiency

Resource optimisation and patient crowding in the emergency department is a challenging issue. Resource requirement forecasting is essential to reduce the rising healthcare cost by optimising the use and availability of healthcare resources. Yousefi et al., utilised machine learning and the genetic algorithm (GA) to determine optimal resource allocation in emergency departments. Yousefi et al., constructed a meta-model, with three power machine learning approaches (adaptive neuro-fuzzy inference system, feed forward neural network and recurrent neural network) using the bootstrap aggregating (bagging) and adaptive boosting (AdaBoost) ensemble algorithm. When applied to an emergency department, the GA algorithm was able to reduce the average length of stay by 15 per cent. Predicting the waiting time and appointment delays can help in optimising hospital resources and increasing patient satisfaction.

Curtis et al. utilised several machine learning algorithms to predict waiting times at a walk-in radiology centres or delay times at scheduled radiology facilities across all four modalities (computed tomography, MRI, ultrasound, and radiography). Several variables were extracted from the radiology information system. Nine machine learning algorithms (neural network, random forest, support vector machine (SVM), elastic net, multivariate adaptive regression splines, kth nearest neighbour, gradient boosting machine, bagging, and classification and regression tree) were used to fine-tune their parameters into the best possible training data fit. The root mean square error metric was used to determine the predictive accuracy of the algorithms. Among the nine machine learning algorithms, the elastic net was found to be better than other algorithms in accurately and efficiently predict the waiting time and delay time.

Automated diagnostic decision support applications can fast track diagnostic decisions in the emergency department as well as within the hospital departments and wards. Feature-rich AI models with several predictor variables were found to recognise patients at risk of experiencing an unplanned intensive care unit transfer. AI algorithms are capable of predicting hospital readmissions within a specified duration of time and that indeed can reduce the cost in the healthcare system.

Discussion

Early identification of patients in the emergency department requiring admission may perhaps help in optimising the hospital resources. Hong et al used triage information and patient history to predict hospital admission at the time of emergency triage. In general, the prediction of patient admission to ward from the emergency department was based solely on the triage (demographics, vital signs, chief complaint, nursing notes, and early diagnostics). Triage-based prediction models include the Sydney Triage to Admission Risk Tool and the Glasgow Admission Prediction Score. Hong et al. used 972 variables extracted per visit from the electronic health records. Logistic regression (LR), gradient boosting (XGBoost), and DNN were trained on three dataset types (only triage, only patient history and full set (both triage and patient history). The addition of historical information to triage information significantly improved predictive performance significantly vs. triage information alone. Moreover, XGBoost and DNN were better than LR in predicting hospital admission when the full dataset was used. The predictive value of XGBoost and DNN across all three dataset types was similar. Hong et al showed that the addition of patient history to the triage information could enable machine learning to strongly predict hospital mission.

Conclusion

The application of AI ranges from hospital administration to therapeutic decisions. It is changing the medical landscape. AI is designed to work through symbolic-based and data-based (machine learning). Computer vision and robotics uses symbolic- based data to process the information. Artificial neural network is a data-based AI that is enabled with cognitive capabilities of a human. Healthcare generates big data, which may be structured, unstructured and semi-structured. These data will be redundant unless it is interpreted and integrated into various algorithms, especially to predict outcomes.

In AI, the algorithms are created in such a way that they can not only modify themselves in response to patterns in data set, they can also derive inferences when applied to new data. In lieu of availability of humongous data, several predictive models have been developed in the context of healthcare administration and operations; clinical decision support; predictions in healthcare; patient monitoring; and healthcare interventions.

AI has been applied to predicting the flow of patients into the emergency department; streamlining patient flow to hospital; monitoring patients in ward and emergency department and predicting the availability of bed in in-patients. Various forecasting methods that have been employed in predicting patient flow include linear regression, exponential smoothing, time series regression, and artificial neural network.

AI seems to be an ideal tool for optimising patient management in hospitals. A wide range of AI algorithms are available for managing and predicting patient flow into the various departments of a hospital. 

References available on request.

The Dubai Health Authority (DHA) recently launched the Doctor for Every Citizen initiative to achieve Article Five of the Fifty-Year Charter, in line with the directives of His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai.

This initiative will further empower DHA’s drive towards the use of latest digital technology to better patient care, enhance efficiencies in the health sector and better support medical professionals as well as provide patients with added convenience and comfort.

HE Humaid Al Qutami, Director-General of the DHA and HE Abdulla Al Basti, Secretary-General of the Executive Council of Dubai launched the initiative. Several senior officials including HE Sami Al Qamzi, Director General of the Department of Economic Development, HE Khalifa Bin Drai, Executive Director of the Dubai Corporation for Ambulance Services (DCAS), Dr. Azad Moopen, Founder, Chairman and Managing Director of Aster DM Healthcare, Dr. Mohaymen Abdelghany, CEO of Al Zahra Hospital and Dr. Sara Alom, Chief Strategy Officer at Kings College Hospital in Dubai attended the event.

The 24/7 telehealth consultation programme is currently available for UAE nationals. For patients registered with the DHA, their complete electronic medical record will be available to the doctor at the time of consultation.

The telehealth consultation is presently available for the family medicine specialty. In the first phase, it will include consultation for diabetes, allergies, hypertension and dermatological issues as these are the most common health concerns. In the future, services that are more specialised will be added.

To book a consultation, the patient can download the DHA app or the patient can call the DHA toll free number 800 342 and book an appointment. The doctor and patient have an option of video calling or the patient can opt for a voice call only.

The telehealth consultation includes initial diagnosis, the patient can be referred to specialised centres and post the consultation, doctors can provide an e-prescription for certain conditions; they can even request for lab tests, which will be registered online through the electronic patient medical record system for DHA patients for added convenience. The telehealth consultation does not include any emergency care.

Al Qutami said that this initiative is one of the DHA’s strategic goals as directed by His Highness Sheikh Mohammed.

He said that the Authority has mobilised all its efforts and capabilities to achieve an integrated health system and through telemedicine it will provide immediate consultations around the clock, in accordance with the highest standards. 

Al Qutami said that the DHA has recently signed a number of MoUs with key private health sector entities in the UAE that were keen on taking part in this initiative.

He added that the Doctor for Every Citizen initiative has made a notable impact and a major shift in the concept of integrated healthcare. “DHA strives towards the provision of a healthier future for its community members, in line with the directives of our leaders and aspirations of our beloved city, Dubai. The Doctor for Every Citizen initiative, which is derived from the vision of His Highness Sheikh Mohammed bin Rashid aims to build a world-class health model and improve quality of life. It is our new beginning to achieve “2020: Towards the next 50”, which was announced by His Highness.”

Al Qutami thanked all those who have contributed to the success of this initiative. He thanked H.E. Abdulla Al Basti, Secretary-General of the Executive Council of Dubai and all members of the council for their support.

He also thanked DHA’s strategic partners and the DHA teams working on the project for their effort and dedication in making the Doctor for Every Citizen initiative a reality.

Dr. Marwan Al Mulla, CEO of Health Regulation Sector and Team Leader of the Doctor for Every Citizen initiative said the initiative further enhances DHA’s goals to strive towards the use of digital technology in healthcare to empower both health professionals and patients. He said the initiative also reflects the deep commitment towards collaboration between the public and private health sector in the Emirate with a common goal of striving towards excellence in care and enhancing quality of life and happiness.

For years, the sandwich generation has had to straddle the onerous burden of late working hours to prove its commitment on the work front along with taking care of family – from raising kids to tending to elderly parents. It’s no surprise that the stress levels of this generation are at an all-time high. And while this double-edged sword can sometimes be a motivator, more often than not, it can destabilise mental and physical health to the point of becoming harmful.

Stress – A silent menace

The World Health Organization (WHO) estimates that chronic diseases will account for almost three-quarters of all deaths by 2020. The UAE economy is growing at a swift pace, creating a conducive business environment and lucrative job opportunities. Yet, while all this sounds encouraging, it also comes at a cost – high stress levels. According to the findings of the Cigna’s 360-degree Well-Being Survey 2019, an astonishing 91 per cent of the country’s population is stressed, of which 22 per cent face unmanageable levels of stress.

Stress has a powerful impact on various aspects of people’s lives. In addition to affecting mood, energy levels, relationships, and work performance, chronic stress is a risk factor for developing health issues such as high blood pressure, heart disease, diabetes and depression. In fact, stress has put a serious burden on the UAE healthcare system. According to a study conducted by Asia Care Group, the cost of select stress-related illnesses on the healthcare system is estimated at US$698 million per annum. In 2018, healthcare expenditure in the country hit US$13.7 billion (AED50.3 billion) and is estimated to reach US$14.4 billion (AED53 billion) by end-2019.

Insurance is key to managing stress

With chronic diseases on the rise, the UAE is witnessing a growing demand for comprehensive healthcare solutions. The good news is that the country has made world-class healthcare a national priority under the UAE Vision 2021. In a bid to ensure the availability of quality health services, the UAE is on a mission to attract some of the world’s most reputable medical services providers to the country.

Driving this growth is a robust healthcare regulatory environment and the introduction of mandatory employer provided health insurance in Dubai and Abu Dhabi that is set to expand across the seven emirates. In 2019, the number of people in Dubai covered by health insurance reached 4.7 million – a whopping increase compared to 1.8 million in 2013. Sharjah and the Northern Emirates are expected to follow suit on the healthcare reforms, giving a further boost to the health insurance industry in the UAE and improving access to healthcare for its population.

The UAE government is also keen to collaborate with the healthcare sector, especially in areas that impact the overall well-being of the population. Together, they work towards a healthier nation – physically and mentally – whether through raising public awareness or promoting the adoption of structured wellness programmes at work.

Leading health insurance companies are jumping on the bandwagon and expanding their offerings to include preventive care, wellness packages, and even stress management classes that go a long way in enhancing the well-being of employees and helping them cope with the demands of the workplace.

Numbers speak louder than words

Stress is not to be taken lightly, and looking at this epidemic globally, the findings are quite shocking. Ten per cent of hospital admissions, six per cent of emergency department attendances, 10 per cent of primary care visits, and six per cent of outpatient appointments are likely to be the result of stress-related illnesses. It’s clear that action needs to be taken to address the causes of stress and to provide the right support systems for those who are experiencing its side effects.

How can we see the impact of stress?

Given the alarming growth of the stress epidemic worldwide, in September 2019, Cigna Insurance Middle East launched the first-of-its-kind Stress Care initiative in the UAE to encourage residents to ‘See Stress Differently’ and to raise awareness about the long-term impact of stress as a known contributor to chronic diseases.

In line with the UAE’s National Strategy for Wellbeing 2031, the new campaign seeks to empower people to take control of their overall health and wellness. For the first time ever, the Stress Care platform helped people visualise the impact of stress on their body and mind through computing physical readings of their brainwaves, heart rate and skin response to produce a Stress Portrait – a real-time rendering of the collected data into a stunning motion graphic artwork.

UAE residents were also given the chance to experience Cigna’s stress visualisations at a Cigna activation in Dubai, aimed at empowering people to take control of their overall health and well-being. After completing the stress visualisation assessment, people could create a personal Stress Care P.L.A.N. – a simple four-step actionable plan to help them proactively manage their stress.

“We all know that chronic stress has a major impact on people’s ability to perform in their jobs and engage with society,” said Jerome Droesch, CEO of Cigna MENA. “What is not so well known is that stress often manifests itself through physical symptoms, such as insomnia, hypertension, and diabetes. This means that in many instances, people are trying to find cures for the symptoms without recognising the root cause.”

In fact, according to Cigna’s research, the top four clinical manifestations in order of severity in the UAE are: heart disease (includes heart disease, high blood pressure, abnormal heart rhythms, heart attacks, and stroke), mental health problems (includes depression), gastrointestinal problems such as GERD, gastritis, ulcerative colitis and irritable colon, and obesity (includes all other eating disorders).

Renowned digital artist Sean Sullivan has applied his data visualisation expertise to help transform live stress readings from the human body into stunning motion graphic artwork to produce the Cigna Stress Portraits. The stress visualisation experience is a real-time rendering of the physical readings of a person’s brainwaves, heart rate, and skin response. While this innovative solution provides insights into how stress is affecting people physically at that very moment, it is not a medical or diagnostic tool.

Warmer colours, such as red and orange, suggest a rather high level of stress, while cooler colours, such as blue, indicate a lower level. Meanwhile, green and purple represent moderate stress. The intensity of stress is also captured in the speed at which the animation moves: a high-stress visualisation moves more rapidly, whereas calmer movements are typical for a low-stress visualisation.

The stress visualisation experience confirms a key suspicion that healthcare stakeholders in the country, added personal care. As consumer expectations continue to evolve, this niche segment presents companies with a unique opportunity to upgrade their services and join the fight against the stress epidemic.

The King Faisal Specialist Hospital and Research Centre (KFSH&RC) in Saudi Arabia was the first hospital in the Middle East to implement medication management via Automated Dispensing Cabinets (ADCs) and has continued to lead the way with deploying the solution in challenging environments where the predictability of activity and medication turnover, risk of stock-outs, and opportunities for station replenishment are difficult to predict and to realise effectively.

The load managed by the Pharmaceutical Care Division of the hospital is huge. KFSH&RC has 1,852 inpatient beds, receives 1.3 million outpatient visits and 12,601 inpatient admissions yearly, and its Emergency Department and Admissions Ward serves the heart of metropolitan Riyadh.

The hospital has successfully integrated over 100 ADCs in inpatient areas. These units streamline medication distribution, link nursing and pharmacy workflows, help support regulatory compliance efforts and reduce preventable medication errors.

One of the advantages of ADCs is that because they can be integrated into Computerised Practitioner Order Entry (CPOE) systems and to the patient’s Electronic Medication Administration Record and Electronic Medical Record, they can help reduce the risk of harm to patients by reducing preventable medication errors before they reach the bedside, and importantly for acute care areas they can help clinicians to start patients’ therapies faster by reducing time to first dose as medications are accessed by entering the patient’s ID number and the ADC then opens the correct compartment where the medication is held – this reduces the need for searching through cupboards and shelves, and hunting for medications – a very time consuming activity that takes clinicians away from their primary role of caring for the patient. On average it takes about four steps, and only five seconds to find and take the correct medication from an ADC.

ADCs at KFSH&RC are Enterprise Server connected; this means that via one database the Pharmaceutical Care Division can apply the hospital’s formulary across the entire organisation and can manage user information and user privileges across multiple units. Ideally this information should be web-based with unlimited access to the system and reports for authorised users.

KFSH&RC has successfully extended ADC usage to the Emergency Department. This is an area that has always been a challenge for hospital pharmacies due to the unpredictability of patient load, the variety of disease states and patient issues likely to present and the lack of a ‘fixed’ census in an environment, which may have patients on trolleys as well as beds and also employ virtual beds to manage patient location before formal admission to the hospital. All of this makes forecasting for which line-medications need to be stocked extremely challenging, and furthermore, makes maintaining adequate stock levels in the unit difficult due to the unpredictable patient census and acuity level.

The KFSH&RC Pharmaceutical Care Division placed 27 ADCs in the Emergency Department. As ADCs utilise space and can carry multiple small items in single dose pockets, the Emergency Department has approximately 1,600 line-item medications at its immediate disposal for treatment. Of course, powerful analgesia is commonly required in the Emergency Department for trauma or emergent surgical and medical conditions. These require secure storage, and documented usage trails. ADCs allow securement of narcotics and other controlled drugs through clinician access codes, two clinician electronic documentation or ‘sign-outs’ for controlled medications, and fingerprint recognition for authentication. The KFSH&RC Emergency Department carries over 200 controlled drugs in its ADCs, and premixed narcotics are managed in a locked refrigerator, which is integrated into the main ADC unit for user access.

Another pressing need in the Emergency Department is for first dose antibiotics to be given as soon as possible, also Emergency Department clinicians commonly administer rapid therapy bundles rather than single-medication treatments. The KFSH&RC Pharmaceutical Care Division manage this process through the deployment of ‘virtual-kits’ and ‘treatment-bundles’ for specific therapies. These are stored in ‘Cubies’ which allow access to either a complete mixing set for IV medications (for example antibiotic vial, water for injections, normal saline bag for dilution), or open several Cubies during only one station visit to allow the clinician to gather all the parts of the treatment-bundle quickly and efficiently.

Therefore, the physical medication needs of clinicians and patients in the Emergency Department can be met through ADCs, but as noted earlier the real challenge of this environment and that of Emergency Virtual Wards and Admission Units for medication management is the unpredictability of the patient workload. Differing needs, acuity and simple numbers of patients are all hard to predict. ADCs, and their related hardware such as Cubies and specialist-integrated refrigerators are all powerful aids, but it is the readily usable data that Enterprise Server networked ADCs create that make all the difference to ensuring the right types of medication are always available in sufficient volumes. In KFSH&RC ‘stock-outs’ of medications are avoided through a replenishment strategy based on activity in ED rather than on the more simple forecasting that might be used to plan for stock replenishment in more conventional care areas. Indeed, traditional planning for location and number of dispensing units also cannot be applied in the Emergency Department, instead new metrics based on medicine stock items, drug utilisation, doses dispensed, and patient turnover help manage stock and optimise ADC location.

In conclusion, the role of automation continues to grow and evolve in acute care as it does in other areas such as outpatients and beyond the main hospital environment. The challenges for each of these areas is different but the ability to gather data, and to turn that data into readily useable information to predict, plan, implement and evaluate medication management strategies (see Figure 1 for an example of how trends are reported from ADCs) is the real key to improvements in safety and in efficiency.

Effective hardware can take care of a lot of the everyday issues of access to, control of, and safeguarding of medications but it is the connecting together of networked devices through Enterprise Servers that makes the role of automation so central to modern healthcare delivery.

Healthcare data has long been one of the favourite targets for cyber attackers. A set of medical records can provide a wealth of data for criminals to conduct fraud or launch more effective targeted attacks. Ironically there have been so many healthcare breaches that the value of an individual data set has dropped significantly in recent years, but medical data is still a basic commodity in the underground cybercriminal economy.

Low hanging fruit

The healthcare industry has an unfortunately well-founded reputation as a softer target. A combination of factors including legacy equipment, stretched resources, and funding constraints mean the industry often falls behind when it comes to keeping systems up-to-date and secure.

Organisations on the front-end of healthcare also face unique security challenges due to the fact their main priority is treating patients and saving lives. This makes it far more difficult to manage the downtime required to keep systems updated and secured, even a few hours of downtime can impact lives, so it’s common to find systems running outdated software and lagging behind on patches that would address common exploits.

The connectivity dichotomy

Ironically, healthcare providers are also under pressure to invest in the latest smart medical technologies. These connected devices can help to deliver a more efficient and responsible environment that helps provide a higher level of clinical care while also reducing costs.

However, connected devices also present an easy target for cyber-attacks. Clinical imperatives often trump technical security consideration. It’s common to find that smart medical devices have been deployed without any IT or security planning, and their network behaviours, update capabilities, and vulnerabilities are often not well understood. These concerns are common in every industry where Internet of Things (IoT) devices are used, but the issue is especially pressing in the medical field, where patient’s lives may be directly at stake. A recent report found that a widely used series of connected anaesthetic machines could be vulnerable to attack, enabling a threat actor to inject overdoses or disable warning alarms among other potentially fatal activity.

Any new device added to the network – whether it’s a smart MRI machine or a Wi-Fi enabled infusion pump – also increases the potential attack surface. This is exacerbated by the large number of visiting devices that are connected to the typical hospital’s networks. Patients and their visitors, visiting physicians and specialists working at multiple sites, medical students and many other third parties will constantly be connecting to the network. Every connection will potentially expose the healthcare system to outside networks with limited security controls.

What are the risks?

One of the biggest challenges in security is the rapid evolution of the threat landscape. To keep track of the latest threats and challenges, Vectra’s Cognito platform uses AI to analyse attacker data. The latest trends were showcased in the Attacker Behaviour Industry Report 2019, which draws on a sample of 354 Vectra Cognito AI deployments covering more than 3m devices.

The primary focus was behaviours that indicate threats across all phases of an attack, particularly advanced, targeted attacks that include activity such as command and control, internal reconnaissance, lateral movement and privilege escalation, and data exfiltration.

Is ransomware still on the radar?

Public awareness of ransomware skyrocketed in 2017 after the WannaCry outbreak locked down millions of machines around the world. The NHS in the UK inadvertently became one of the most prominent victims, with the attack causing the cancellation of almost 7,000 NHS appointments and impacting an estimated 19,000 follow-ups. The NHS racked up costs of more than £20m dealing with the outbreak in a single week, with more than £72m being spent on subsequent clean up and upgrade activity.

Nevertheless, we have found ransomware to now be a less prominent threat, with the number of incidents dropping significantly from July-December 2018. That doesn’t mean organisations should let their guard down, as the approach is still used by many attackers, and increasingly in a more targeted manner. The key to defence is catching an infection early in its lifecycle and stopping it from spreading, as this can prevent files from being encrypted and stop the attack from disrupting essential services.

Progressing the attack

Achieving persistence on a compromised device usually just represents the very beginning of an attack. After securing a foothold, intruders will begin to probe the operating environment, using their captured machine to perform scans of networks and file stores to identify useful resources and information.

As attackers learn more and gain enhanced privileges they will move laterally through the network towards their targets. The most common sign of lateral movement in healthcare that we detected was the use of Kerberos authentication services and SMB file share account brute-force attacks, which aim to grant the attacker more privileges in the network and access to higher value systems and assets.

These moves are remotely orchestrated by the attacker using stealthy Command and Control (C&C) signalling. However, C&C behaviours that indicate these malicious actions can also be very similar to the result of ordinary network activity, making attacker activity hard to detect. Detecting the use of a remote access tool, for example, could be a sign of a criminal using C&C communications, but could also be perfectly legitimate activity. Common legitimate reasons for this behaviour in healthcare include communication with independent labs, imaging centres and other service providers such as IT support. Among the most widespread types of C&C behaviour we detected in the healthcare sector was the use of hidden HTTPS tunnels to hide command-and-control communications (C&C).

Completing the data heist

With patient records representing a reliable and lucrative payday for a cybercriminal, data exfiltration is usually the main priority for an intruder in the network. We most commonly see this being carried out through the use of hidden DNS tunnels, and allowing the intruder to covertly extract data over time hidden inside the legitimate everyday communications used to resolve domain names.

Alternatively, attackers may opt for the more overt “smash and grab” approach and extract a large quantity of data in a short period of time. This will result in an obvious spike in traffic to an external destination, making it easier to detect. However, there are once again legitimate reasons for similar data spikes, such as an IP CCTV uploading recordings to a cloud host.

More connectivity, more risk

Medical IoT-enabled devices with weak security controls can present attackers with many opportunities to find a way in and jump across subsystems. Connected devices also often provide ideal cover for malicious activity. Many healthcare devices will perform actions such as automatically logging into the network and will continuously attempt to login if they fail to connect. This generates a lot of noise that can conceal the intruder’s activity.

No organisation is totally attack proof, and those in healthcare suffer from more challenges than most as they deal with tight budgets, legacy technology, and difficulty in managing downtime.

Once an intruder has successfully infiltrated the network, detecting them effectively relies on contextual understanding. Most of the behaviours that indicate an attacker at work can just as easily be the result of perfectly legitimate behaviour.

Prescribing visibility and automation

Understanding the most common attack paths and achieving visibility into the traffic and behaviours used to identify them is crucial if healthcare security teams are to prevent intruders from running amok in their systems. Solutions powered by AI have become increasingly powerful tools in providing this capability thanks to their ability to automate much of the analytical and detection activity and produce results at a speed and scope much greater than the best human analyst test could.

These AI capabilities, however, are optimised for their individual tasks and so augment human security teams by doing the heavily lifting; freeing teams to perform high value security tasks. This results in improved threat awareness and incident response agility for the healthcare organisation.

Speed is of the essence when a threat actor is loose in the network, and the ability to identify suspicious activity quickly can prevent an intrusion from becoming a breach impacting millions of customers or essential clinical services. With so many attackers holding medical data in their sights, any edge healthcare organisations can achieve will make a difference.

For the first time, Arab Health is hosting ‘From Prevention to Innovation: A SEHA-Mayo Clinic Collaboration’, a new addition to this year’s much-anticipated event. The conference, which will offer 13.75 CME credits, will highlight the relationship between the two institutions and cover topics from prevention of disease to recent innovations in the care of the complex patient, with the added value of artificial intelligence (AI) and connected care. It will feature prominent speakers from SEHA who will open each session, followed by Mayo’s perspective on each of those topics presented by Mayo Clinic experts in those fields.

Ahead of the show, Omnia Health Magazine caught up with Dr. Gareth Goodier, Group CEO SEHA, to find out more about the collaboration between the two entities. He said: “2020 is a special and exciting year for SEHA. We have had a number of game-changing announcements recently, which will improve and change the quality of health services in Abu Dhabi. Arab Health 2020 will be unique for us because of our new venture with the Mayo Clinic. We are putting on a medical conference within Arab Health and will have some excellent speakers coming in from Mayo Clinic.”

These latest developments include the opening of the Sheikh Shakhbout Medical City (SSMC), which is a joint venture agreement with Mayo Clinic. Moreover, the Mohammed bin Zayed University of Artificial Intelligence (MBZUAI) and a comprehensive genomics program, were also recently announced.

Innovation cluster

Dr. Goodier highlighted that the relationship between SEHA and Mayo Clinic is that of a joint venture and not just an operating contract. “By its very nature this means that this is a strategic partnership that is long-term,” he said. “The ambition of both parties is to establish a destination medical center, equivalent to Mayo Clinic, Rochester, in the next five to six years. The ambition is huge.”

Mayo Clinic has successfully established its outposts in Arizona and Florida, which took them well over 10 years to get it to Rochester levels, the CEO shared. “They feel they have learnt from those experiences and can, therefore, short circuit the timeframe. This won’t happen overnight but the commitment from both parties is to raise the level of healthcare services in the UAE so that there is no need to travel overseas for healthcare provision. More than that, the goal for it is to become a hub not only for the GCC but also possibly a much broader community for the MENA.”

He stressed that the aim is to develop SSMC as a biomedical innovation cluster, so it can become a true innovation cluster, centered around excellent patient care. The objective is to not only attract medical tourists but also work with universities in the UAE to develop biomedically related intellectual property, which can be commercially developed.

Sheikh Shakhbout Medical City’s CEO, who joined from Mayo Clinic, Dr. Naser Ammash, said: “The collaboration between Mayo Clinic and SEHA was formed on a shared goal – advancing excellence in healthcare and meeting the complex needs of patients across the globe. We are building on SEHA’s legacy for excellence by incorporating Mayo Clinic knowledge and expertise to enable enhanced quality of care and patient experience. By bringing the Mayo Clinic model of care to the region, we will also have the opportunity to attract the best healthcare talent to Sheikh Shakhbout Medical City while also developing local expertise.”

Digital transformation

When asked about the emerging trends being seen in the healthcare industry, Dr. Goodier said that automation has a key role to play, as it takes some of the routine work from humans. “In pharmacy, we have robots that are relying on barcodes to deliver the right medication to the right patient at the right time. Similarly, AI is being applied to routine chest X-rays and CT scans and so on. All of the evidence these days is that latest AI in very routine cases is as good as, if not better, than humans. It can’t replace doctors but provides a baseline to which humans can add value. We are currently out for tender for AI to be applied to our radiology systems, where it is appropriate and has been proven to add value. In SSMC and the new Al Ain Hospital, which will be opened in 2021, we will have robotic pharmacies.”

Another exciting trend the CEO emphasized on was the prospect of a personalized approach to healthcare, particularly for Emiratis. He explained: “Most of the clinical trials on medications are conducted in Europe, America, Australia or China. We do not fully understand what differences this local population has in terms of genomics. Therefore, the announcement of the MBZUAI and the genomics program will ultimately lead down to the path of personalized healthcare across the board.”

He said that such initiatives would lead to a much better understanding of the morbidity and the disease patterns that exist in the local community. “We all know that there is a high-level of diabetes and renal disease and we need to do local research to better understand that so we can adopt lifestyle changes and if needed adopt therapies to keep people healthy,” he concluded.

Very recently, researchers from the University of Otago in New Zealand announced that the DNA they had collected from water samples could uncover the truth behind the Loch Ness Monster ─ the fabled creature that is said to inhabit the waters of Loch Ness in the Scottish Highlands. While the efficacy of the research is a debate for another day, it does go to show just how far and wide our scientific understanding of deoxyribonucleic acid, otherwise known as DNA, now reaches.

This tiny double-helix structure has had an enormous impact across a wide range of fields, with advances meaning that DNA testing is now routinely used in criminal investigations, paternity cases, agriculture, archaeology, forensics and, of course, healthcare.

Medically speaking, innovation in DNA analysis has opened up a wealth of different options for early intervention, from new-born screening to diagnostic assessment to testing specifically for particular conditions, such as cystic fibrosis.

However, over and above this, perhaps one of the most exciting things DNA testing offers healthcare is the opportunity to effect positive behavioural change on a much larger scale, by tackling issues one person at a time.

In order to understand how what sounds like an oxymoron can work – and why this is such an exciting prospect – we need to start by looking at the bigger picture.

A positive influence

While we know that there are certain components that will have a positive influence on everyone’s health and well-being – a balanced diet, a good night’s sleep or regular exercise – what we’re not always aware of is exactly how these things personally affect us. You might be able to drink caffeine directly before bed without any ill effect, for example, whereas it could keep me up all night.

Just as precision medicine (focusing on the approaches that are most effective for individuals based on genetic, environmental and lifestyle factors) brings tangible benefits, so does understanding your own body’s responses to certain foods or cardio exercise over weight-training. It can offer both insight and reassurance that you’re on the right path to wellness and tailoring your approach to health in a way that makes most sense to you. And if these insights can be accompanied by the option of a follow-up consultation with a nutrition or fitness expert, so much the better.

A growing market

The huge rise of popularity when it comes to genetic testing market is an ascent that shows no signs of slowing — a simple Google search will pull up several organisations in the UAE offering DNA testing. It should come as no surprise then that the sector is projected to be worth US$22 billion by 2024, according to a report from Global Market Insights. So, it’s incumbent on medical insurers to keep on top of how developments might affect both the industry and their members’ quest for a healthy life.

Of course, the type of information a health and lifestyle DNA test can confer is only the tip of the iceberg – it’s what individuals do with it that counts. But there is evidence to suggest that the positive impact from finding out more about your genetics can be truly life changing.

For example, one study in Finland tracked 7,300 people over an 18-month period, after they had received their genetic risk information. It found that 88 per cent of participants were inspired to take better care of their health and around a fifth of those who smoked managed to give up. This compares well with a control group of the general population, where only 4 per cent gave up smoking.

It goes to show that knowledge can be truly empowering – whether it’s the truth about a mythical creature or staying engaged in your own health journey. 

References available on request.

In 2017, the Organization for Economic Cooperation and Development (OECD) estimated that approximately 20 per cent of healthcare spending was effectively wasted in developing nations. Amplifying the issue further, the World Economic Forum Global Coalition for Value in Healthcare puts this number between 30-50 per cent globally. Wasteful spending is identified from three sources:

• Patients harmed in the course of care delivery requiring further treatment, or provided unnecessary procedures that do not improve their outcomes
• Care could be provided using fewer resources (via better utilisation of primary healthcare centres, generic pharmaceuticals, etc.)
• Non-value-adding clinical services and administrative processes, as well as other losses to corruption/fraud

Waste in healthcare is twice the sin. Not only are we misusing resources; we are also adversely affecting the well-being of our population (e.g. harmful procedures, long-waiting times, high costs, and unavailability of services).

Delivering accessible, high-quality healthcare services on a national level in an economically optimal and socially responsible way requires thorough planning and continuous resource management such as specialists, facilities or equipment. This is further compounded by the complexity of resources required in healthcare compared to other industries and the lead-time required to add capacity, such as a decade to prepare a specialist or the years required to build a hospital.

Globally, and especially in the Middle East, despite the rapid professionalisation of the industry, the challenge of optimising patient services remains. Several contextual factors exacerbate it further:

• Inadequate data healthcare planners often do not have robust and accurate data about current demand, future demand or even current capacity.
• Misaligned incentive systems many provider organisations do not have the incentives to optimise patient services, especially those that are funded using budgets. Such funding mechanisms strip the providers from the incentive to plan adequately, to optimise demand capture, or to even ensure patient satisfaction.
• Fragmented regulatory environment in many countries in the region, healthcare is regulated by multiple bodies with often contradicting agendas. This leads to a lack of coordination, inefficient allocation of resources and little accountability to optimise patient services.

This has led to (1) considerable waste through duplication of services; and (2) insufficient access to care in some regions, leading to costly medical transport and poor patient experience.

Clinical economics

Optimising patient services can be simplified as ‘enabling supply to meet the demand for services where and when required’. The fundamental logic of a capacity planning model is relatively simple: measure and compare the supply of resources against the demand, identify the gaps (positives or negatives), and find ways to bridge these gaps, while maintaining the quality of care. In healthcare, bridging gaps and surpluses often requires the intervention of numerous public and private stakeholders.

Healthcare resources are highly specialised and often bespoke in nature. This means the traditional approaches to capacity planning, as in infrastructure or industry, do not translate effectively — making resource definition the first critical step. Diversity of resource categories and granularity of data both dictate the need for a detailed model without it being overly complex. As Jorge Luis Borges famously illustrated via the complexity overkill in his ‘On Exactitude in Science’; “an empire where the science of cartography becomes so exact that only a map on the same scale as the empire itself will suffice”.

Economically clinical

The fundamental tenet of Value Based Health Care (VBHC) is measuring outcomes that patients experience relative to the cost of delivering those outcomes. The VBHC model rewards healthcare providers for providing quality care to patients. Under this approach, providers seek to achieve the triple aim of providing better care for patients and better health for populations at a lower cost.

For the VBHC concept to be successful, defining standardised outcomes is critical. Internationally, there exist several useful repositories (The Decision Institute, ICHOM, NHS, Sweden’s model) of medical outcomes from a rich source of disseminating experiences. Specifically, The International Consortium for Health Outcomes Measurement’s (ICHOM) co-founded by the Harvard Business School, The Boston Consulting Group, and Karolinska Institutet, works to unlock the potential of VBHC by defining global Standard Sets of outcome measures that really matter to patients for the most relevant medical conditions and by driving adoption and reporting of these measures worldwide.

The other aspect of VBHC is cost, which in turn, will be highly correlated to resource optimisation in terms of healthcare infrastructure, beds, clinical and admin teams, and equipment.

This optimisation of resources relies around four key dimensions of understanding your supply, forecasting your demand, governance, and finally developing a model, which is able to generate accurate results to drive change.

From a supply and demand perspective, key resources of a healthcare system must be accounted for, such as manpower, beds, equipment and operating rooms. Experience has shown that international benchmarking for supply and demand parameters of developed nations could be misleading for developing economies. Additionally, hospitals and primary healthcare centres serving specific population catchment areas, in particular for extended periods, often adapt to their communities’ specific needs. After a sufficient amount of time, a given hospital will have naturally tailored its services to the population it serves, or the population would have found alternate services (including reducing demand, which is detrimental). This means that when it comes to identifying the resources needed, individual hospitals are a preferable source of information, versus international benchmarks. On the other hand, for the model components that are concerned with efficient operation of a hospital, and the healthcare system as a whole, best-practice benchmarks can be more appropriate. For example, the number of biomedical technicians required with a specific skillset can be factored based on the number of machines installed, which in turn is determined by the actual utilisation of the machines based on actual admission numbers rather than on benchmarks.

Key stakeholder engagement through a robust governance mechanism is essential to ensure that model recommendations for capacity planning can be actioned. The welfare of the healthcare system as a whole must come before individual healthcare personnel needs.

Finally, there needs to be a capacity-planning model that is data-driven, accurate, yet easy to use. Such a model must inform decision makers on the existing healthcare situation as well as a reasonably precise future projection of demand, supply and gaps therein. Hence, the model has to be dynamic, with ability to show real time changes. The model should allow for scenario analysis, which will enable decision makers to plan for future healthcare scenarios such as changes to model of care, medical and technological innovations, changes in disease prevalence and incidence rates, and demographic shifts. Ultimately, the model should have the capability to support decision making on investments and strategic initiatives.

Ecosystem-level impact: National optimisation

A European country’s national hospital system is lagging behind its counterparts in terms of several key metrics, including higher hospitalisation rates, longer average lengths of stay, lower bed occupancy, poorer accessibility, etc. The national regulator decided to restructure the national hospital system to improve results. A dedicated team started with modelling and projecting the supply and demand of healthcare at the micro-regional level, benchmarked selected KPIs, and set targets to improve the system.

Based on the results of the capacity-planning model, the regulator started licensing hospitals for specialisations aligned with their population’s forecasted needs. An incentive structure was also introduced to promote investment in underserved areas and specialisations. Finally, for select specialisations, cooperation between providers was encouraged to optimise the overall network efficiency.

Ecosystem-level impact: Provider optimisation

A hospital located alongside a busy highway was originally conceived as a general hospital to serve the local community. Its proximity to the highway led it to receive an inordinate number of trauma patients involved in road-traffic accidents (RTAs). This has resulted in a diminished quality for other non-emergency patients such as long waiting times, high referral rates to other facilities, and crowded wards. All of this is driven by a noticeable “shortage” of beds, OR time, and anaesthesiologists.

The cost of adding capacity is prohibitive as there is little space for expansion. The hospital considered adapting its mission and its service portfolio — focusing on being a trauma centre. In addition to the capital costs associated with such a change, some of the local community needs will have to be offered by distant hospitals.

Before pursuing this plan, the hospital leadership wanted to explore if it would be possible to reduce RTAs (i.e. reduce supply rather than to increase capacity). An integrated capacity planning model allowed them to simulate a reduction in RTA admissions over a multi-year horizon and the impact on capacity as well as service levels to the community.

The previously perceived gaps requiring investment could be mitigated by a multi-government agency initiative to tackle RTAs. Armed with this analysis, the hospital leadership was able to change direction and engage with relevant stakeholders.

Fine-tuning the engine

Healthcare should be planned and managed like any public utility; it begins with accurate capacity planning and, more specifically, shifting the focus from adding capacity to optimising capacity and finally preventing waste. Our experience has shown estimated savings amount up to 16 per cent of annual budget across an entire healthcare system. Savings realised are through optimisation of resource allocation and trimming of surplus. These are savings that can be redirected to focus on a coordinated prevention effort. 

A healthcare capacity-planning model is critical in enabling leadership to make informed investment decisions in a dynamic market facing new technologies, shifting demographics, and changing disease patterns. It drives efficient operations and strategy execution by offering a differentiated view of the workforce and facilities. It supports the long-term management of public health by providing a platform for testing future scenarios. And perhaps most significantly, as an investment in public well-being it is an investment in a society’s stability and competitive advantage. 

References available on request.