In addition to designing and manufacturing a complete line of diagnostic cardiology and patient monitoring equipment, Mortara Instrument has always been recognized as a leader in the development of algorithms for safe and reliable ECG analysis. Now, Mortara has taken up a new challenge: Alarm Fatigue management.

Due to the increased number of monitored parameters available today and the need to reduce healthcare costs, algorithms must both be more sensitive and prevent more false alarms than in the past. Cardiac Care Units are always so busy that the large number of false alarms generated every day by monitoring systems can become a serious issue for healthcare personnel. This large number of false alarms induces so-called Alarm Fatigue’: in a nutshell, healthcare professionals, tired of wasting time in silencing false alarms, not only lose trust in their monitoring system, but tend to ignore possibly real alarms.

Mortara VERITAS^TM covers a large variety of diagnostic fields: from automatic resting ECG interpretation, to ambulatory Holter monitoring, to real-time algorithms specifically designed for bedside monitors and central stations, largely employed in Coronary Care and Intensive Care Units. Integrated in all Mortara product lines, VERITAS is constantly updated with new features and improved specificity and sensitivity.

Having obtained levels of sensitivity and specificity in line with major manufacturers is not enough to fight Alarm Fatigue. That is why much attention and investment have been devoted to reducing false alarm rates without affecting sensitivity. The updated VERITAS Arrhythmia algorithm defines a new standard in Alarm Fatigue management: up to 60percent less false alarms for lethal arrhythmias when compared to the most common algorithms available on the market, resulting in vast improvement of reliability of the systems on which it is installed.

The new version of VERITAS will be available on the Mortara monitoring line – Surveyor^TM Central, Surveyor S4 telemetry, Surveyor S12 and S19 bedside monitors – starting November 2016*.

For further information, click  here

Mortara, Surveyor^TM and VERITAS^TM are trademarks or registered trademarks of Mortara Instrument, Inc.

*Not available in the U.S.

Medical tourism refers to people who travel overseas for obtaining treatment. In the past, it referred to (wealthy/privileged) patients from developing countries who visited medical centres in industrialized countries to get treatment not available at home.
However, the situation has since reversed, in certain cases dramatically. Medical tourism now typically refers to patients from industrialized countries who travel to poorer countries for lower priced, or more quickly available (and in some cases, superior) treatment. Top medical tourist destinations in this respect include India and Thailand as well as Costa Rica, Mexico and the Gulf.

Medical tourism and health tourism
Some studies do not consider medical tourism to include cosmetic and wellness tourism – with dental treatment also viewed as a cosmetic procedure. This, larger group is often referred to as health tourism.
Market revenues for a major medical tourism destination, Thailand, include a relatively large number of cosmetic surgery procedures. This segment also includes a multitude of places in south America, with the industry’s maturity fed by bustling local demand. For example, according to the Sociedad Boliviana de Cirugia Plastica y Reconstructiva’, over 70percent of middle and upper class women in the country have had plastic surgery.

India leads in higher-end procedures
Conversely, at the other end, if only surgical procedures for overseas patients are included, India leads the global medical tourism market.
Consultants McKinsey estimated 180,000 medical tourists were treated at Indian facilities in 2004 (up from 10,000 just five years earlier). Arrivals have since been rising sharply and are estimated to have reached 250,000 in 2012, contributing 3 billion USD in revenues. This is effectively about 30percent of the global market, estimated for the year at 10.5 billion USD by Transparency Market Research.
India has proven to be a preferred destination for US and UK patients, in particular, because of the use of English in most professional interactions, as well as the fact that both countries have a large number of Indian-origin physicians. Indeed, the US government’s top medic, the Surgeon General, is Vivek Hallegere Murthy, a 40-year old Indian.
India stands out as an interesting destination in another respect. Its massive generic drugs industry provides post-operative medicinal treatment at prices well below the West.

Market drivers: cost, waiting times, accreditation
Key factors driving medical tourism from the West to developing countries include the high cost of healthcare and increasing waiting times for certain procedures. Insurance in several countries often does not cover 100percent of the costs of common age-related requirements such as a knee or hip replacement, or limits the choice of the prosthetics, or the surgeon and facility.
Accreditation of top hospitals in medical tourism destinations has also fuelled demand. The oldest international accrediting body is Accreditation Canada, which has accredited hospitals in about a dozen countries.
The best known accreditation group, however, is Joint Commission International (JCI) in the US. JCI was set up in 1994 to provide international clients education and consulting services, and several international hospitals now see accreditation as a way to attract American patients. JCI is an independent private, not-for-profit organization that seeks to develop nationally and internationally recognized procedures to help improve patient care and safety. It advises hospitals to meet standards for patient care and then accredits hospitals meeting the standards.
A British scheme, QHA Trent Accreditation, is an active independent holistic accreditation scheme. Another is GCR.org, which monitors success metrics and standards of almost 500,000 medical clinics worldwide.
These schemes vary in quality, size and cost to hospitals making use of them.
Increasingly, hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, and Accreditation Canada or QHA Trent for Canadian and British patients.

Indian price advantage boosted by quality, innovations
Practically all surgery procedures performed in medical tourism destinations cost a fraction of what they do in industrialized countries. For example, while a liver transplant in the US costs about 300,000 USD ( Euro 280,000), the figure in India is 50,000 USD ( Euro 47,000). Open heart surgery in India costs between 3,000 ( Euro 2,800) and 10,000 USD ( Euro 9,400), compared to 70,000 USD ( Euro 65,500) in the UK and 150,000 USD ( Euro 140,000) in the US.
Such figures acquire added value when one reviews the conclusions of a Harvard Business School (HBS) study in November 2013, comparing data on angioplasty in the US versus India. The study found that one in 200 US angioplasty patients required emergency surgery, with half of them dying, while only two of 40,000 angioplasty patients at India’s CARE Hospitals required emergency surgery, with just one death in the OR since the hospital’s inception in 1997.
The HBS study also studied other Indian hospitals and interventions, finding them to be on par or better than their US counterparts – for example, Apollo Hospitals with knee, coronary and prostate surgery as well as for infections related to the operating theatre and catheters, Narayana for coronary artery bypass procedures, Deccan for peritoneal dialysis and Aravind for ophthalmology.
The HBS review noted India was not simply an improver but an innovator too, for example Indian doctors pioneered the beating-heart method of surgery, where they operate without shutting patients’ hearts down via a heart-lung machine, leading to fewer complications, shorter hospital stays and quicker recovery.

New segment of intra-Third World medical tourism
While much attention remains on Western medical tourists, one of the fastest growing market segments consists of patients within the Third World, who travel to more advanced developing countries. India again is at the top of the list. In early Dec 2016 / Jan 2017, for instance, it was announced that Iman Abdulati, a 36-year old woman weighing half a tonne, was to be flown to India from her home in Egypt for bariatric surgery.
Such cases have drawn considerable attention for other, political reasons.
Pakistani patients with severe conditions requiring top-notch treatment are a routine media fixture in India. For example, in September 2016, Pakistan’s Express Tribune’ featured the case of Abdul Basit, an 11-year old boy who had been suffering from the rare condition known as Crigler-Najjar syndrome and went for a liver transplant to India. Two years previously, after complications, the wife of former Afghan President Hamid Karzai gave birth to a girl at Fortis Hospital in New Delhi.
In August 2016, The Diplomat’ reported India had emerged as one of the fastest growing global healthcare destinations, particularly for patients from conflict countries like Afghanistan, Iraq, Yemen, Sudan, the Democratic Republic of Congo (DRC), and Somalia, attracting close to 400,000 foreign patients a year, half from war-ravaged countries.
The selection of India as preferred medical tourism destination is being officially sanctioned. In 2004, BBC News’ reported that ‘India was chosen as the place’ for sending sick patients from Tanzania unable to be treated at home, after the Tanzanian government ‘did a comparative analysis of health facilities in South Africa, India and western European countries.’ In 2007, Companion Global Healthcare teamed up with hospitals in India (as well as Thailand and Singapore).

China lags India due to egalitarian healthcare model
Due to a variety of reasons, the other Asian behemoth, China, has a much less mature medical tourism sector. WHO figures show hospital bed densities far lower in India, at just 9 per 10,000 people (making a total of roughly 1 million beds) compared to 42 in China (about 5 million). However, the higher share of private beds in India (40percent against 6.5percent in China) means that India has slightly more private beds – about 400,000, against China’s 325,000.

More than anything, India’s lead over China in medical tourism symbolises its top-down approach to healthcare, in contrast to China’s bottom-up one which first aims at providing top quality healthcare to local Chinese. As a result, China does not provide good healthcare for its middle and upper class. For Britain’s Guardian’, poor rural Chinese were curiously’ better off than their city cousins.’ The Guardian’ contrasted this with India, where ‘many city-based healthcare facilities are excellent….’ This higher-end focus provides India with more medical tourists than China.

Hospital budgets: the sky’s the limit
There are now at least a dozen major private hospital groups in India. Leading groups (with 20-50 facilities, and 2,500-8,000 beds) include Apollo, Max Healthcare, Fortis, Escorts Healthcare, Wockhardt and the Manipal Group. Many of the above (as well as newcomers from cash-rich Indian conglomerates such as Reliance, the Hindujas, Sahara and ITC) are also pursuing the new concept of Medicities, involving suburban developments dedicated wholly to integrated hospital facilities.
The procurement budget of such groups is not insignificant. Apollo’s annual spending on medical equipment, for example, has been close to 200 million USD in recent years. Such budgets allows cash-rich Indian hospitals to procure state-of-the-art equipment – from Da Vinci robots and stereotactic laser surgery to wide-bore 3T Silent Scan MRIs.
Nevertheless, as far as spending is concerned, Indian hospital groups face several challenges in the coming years, especially from the cash-flush Gulf.

US hospitals lead Gulf partnerships
US hospitals are at the forefront of partnerships in the Gulf. One of the key reasons was the difficulty for medical tourists from the region to obtain US visas after 9/11, according to the American Hospital Association.
Key US partners of Gulf hospitals include Johns Hopkins Medicine, which has an agreement since 2006 to partner the General Health Authority for Health Services in the UAE. It also manages the 400-plus bed Tawam Hospital in Abu Dhabi and an affiliated centre offering state-of-the-art molecular imaging services. Johns Hopkins also has alliances with King Khaled Eye Specialist Hospital in Saudi Arabia.
Another example is the Cleveland Clinic, which is affiliated with the International Medical Centre in Jeddah, Saudi Arabia, and is a strategic partner at the 360-bed, multi-specialty Cleveland Clinic Abu Dhabi Hospital in the UAE.
Elsewhere in the UAE, Methodist International manages the operations of Burj Dubai Medical Centre as well as clinics in Dubai, while Partners Harvard Medical International is a key strategic collaborator with Dubai Healthcare City (which explicitly seeks to attract foreign medical tourists).

Education and training focus in Gulf
Many of these alliances are increasing their focus on education and training. For example, the Partners-Dubai Healthcare City has added a high profile unit called Harvard Medical School Dubai Center Institute for Postgraduate Education and Research, while in 2014 Johns Hopkins signed a partnership with oil major Aramco to provide medical education and training in Saudi Arabia.
Qatar, too, has sought US partners. The Weill Cornell Medical College was in fact one of the earliest ventures, established in 2001 as a partnership between Cornell University and the Qatar Foundation for Education, Science and Community Development. It aims to provide medical education and cutting-edge research.
Ironically, the focus on training might hit a traditional source of physicians in the Gulf especially hard, namely Indians who would be replaced by skilled locals.

New service and business models are challenging the traditional role of a hospital – as a place where sick people are taken to get better. Instead, a growing body of evidence suggests that the key mission of future hospitals will be to help people to avoid falling ill, and to manage those that do in fundamentally different ways than at present.  Such processes are principally driven by economic pressures and the promise of new technologies. However, patients are also playing a major role.


Patients more proactive
It has indeed been apparent for some time that patients are far less passive than they were in the past. In Britain, a study by the King’s Fund think-tank found patients wished to be far more involved in healthcare decisions. In addition, the study reported that patient satisfaction depended not just on medical outcomes, but also on being treated with dignity and respect.
Emerging technologies are seen as one way to enhance the patient experience, and several popular apps show how rapidly patients have moved to centre-stage. In the US, Heal, a smartphone app, lets patients search for physicians in a manner similar to Uber’s connecting passengers to drivers. Zocdoc, another tool for finding doctors, has added an artificial intelligence-powered Insurance Checker feature which lets patients select and verify insurance information as they are booking appointments.  An app called Welloh goes beyond doctors to give users information about hospitals, pharmacies, care centres and other facilities. Clinical trials are also opening up to volunteers, thanks to an app called TrialReach, which helps patients find open clinical trials for specific medical conditions.
These new health access paradigms resonate strongly with younger patients.  According to a report from Salesforce, over 70 percent want their physicians to adopt mobile health applications.

Apple integrating health apps
Evidence of the opportunities arising from enhanced patient participation comes from Apple, which plans to bring the current clutter of healthcare apps under one roof. Its new Health Records feature will allow users to see their records of allergies, immunizations, lab results, medications and other conditions in a single window and send notifications when any data is updated.
Big Data
One of the most promising and best known tools in the emerging technology arsenal is computing giant IBM’s Watson, which deploys artificial intelligence (AI) to collect and interpret vast amounts of data from medical literature in order to advise on best treatment options. Scores of other tools provide personalized treatment plans for cancer patients using the genetic background of their tumours, accompanied by analysis from tens of thousands of other, similar cases.
These kinds of innovations count on assimilating and interpreting what has come to be known as Big Data. The sources for this data, whose volume continues to grow by leaps and bounds, are many. They include clinical studies, prescriptions, radiological images and a host of other healthcare information.

The Internet of Things
One new source of data is from the Internet of Things. Connected medical devices such as insulin pumps and pacemakers pick up signals and automatically transmit information to networked computers, which allow physicians (and patients) to perform real-time monitoring.
An array of wearable devices to track vital signs are another fast-growing source of medical data. On an individual basis, this may not amount to much. However, when the data is provided by millions of users, its size becomes staggering, as does its potential for providing insights.

Cloud computing
Such a burgeoning mass of data is being generated asynchronously, processed and stored by different machines on multiple platforms. Making it usable is hardly simple.
One promising answer to such a challenge lies in cloud computing technology, which has dramatically reduced the cost of data storage, as well as the time required to process and transfer the data to multiple users at different locations. For patients needing to visit a lot of specialists, the accessibility of their data from a variety of locations can be indispensable.

The Electronic Health Record
One of cloud computing’s biggest areas of impact may be the electronic health record (EHR), one of whose goals was in fact to address the above challenge – patient data access in real time by different specialists.
The EHR has generally failed to meet expectations (and over-expectations). In both Europe and the US, the EHR’s key technical/operational limitation was that clinical and financial data could not be easily shared and exchanged among providers – as many had assumed or otherwise hoped for. In the US, EHRs have generally also failed to meet levels of reporting that support the ‘meaningful use’ requirements of pay-for-performance programmes.

Cloud computing seems likely to give a new lease of life to the EHR. Server-based EHRs always run the risk of system failure, which would prevent access to critical patient data until the server has been restored. Such a scenario does not concern cloud-based EHRs. In addition, cloud services are encrypted and provide security. Cloud-based EHRs also reduce entry barriers to adoption by transferring responsibility for confidential patient information to specialized vendors.

Design and hospital re-purposing
The impact of such developments are reaching into the very design of a hospital. Christopher Shaw, Chair of a professional organization called Architects for Health and founder of the design firm Medical Architecture, believes there is a growing mismatch between the physical infrastructure of a hospital and the nature of activities expected to be required over the coming decades.
One key question here is the future of hospital buildings – whether to renovate and incrementally redesign structures or start afresh. Indeed, even as popular imagination associates future hospitals with robotic doctors, another equally beguiling scenario consists of individualized medicine, extending to some forms of surgery, carried out at home.

Hub-and-spoke models
The reality may lie in between, at least in the foreseeable future. One of the most likely scenarios might be a hub-and-spoke hospital model. Its inside tier would consist of academic medical centres serving larger populations and focused on acute care. The middle tier would be an intermediate-care hospital, located in smaller cities or larger towns and providing longer-term rehabilitation and nursing support. The outer tier would be comprised of polyclinics for outpatient diagnostics and elective care, referred from primary care physicians.  At the periphery would be the patient’s home, with telemedicine treatment, and possibly some form of tele-surgery assisted by paramedical professionals on the scene. Some of the latter may well be robots.

Telehealth
After many false starts, telehealth technology is now on the edge of take-off – helping allocate care to patients more efficiently, by eliminating the need to visit hospitals, when they do not have a need to access concentrated multi-disciplinary expertise.
Telehealth is also seen as a means to bring patients back more quickly to their homes. Indeed, there is a considerable body of evidence which suggests that the sooner patients begin recovery at home, the more quickly they heal.
Telehealth is not only being pushed by technology but also pulled by economics. In the US, for example, healthcare providers of diabetic patient care have to contend with value-based measures. As a result, they are becoming increasingly dependent on real-time data from remote glucose monitors. Telehealth allows patients to be more engaged, and participate with physicians in ensuring better outcomes, by adhering to insulin or other medications.

Emerging models – examples
The challenge facing the emerging healthcare model lies in the best way to integrate resources, delivery and support mechanisms, and the need to avoid duplication. However, there are encouraging signs from several parts of the world.
In the US, Westchester Medical Center Health Network (WMC Health), is an example of the emerging hub-and-spoke hospital model. The core of the system consists of a 1,500-bed facility headquartered in Valhalla, New York, which is the only facility for complex interventions and procedures. Buttressing this are six (intermediate) hospitals, as well as several polyclinics and medical campuses. The system covers a population of more than 3 million people spread over 15,000 square kilometres.

In Europe, there are several efforts to redefine hospital design. In a variation of hub and spoke, Guy’s Hospital at London has developed its cancer centre as a stack of ‘villages’, one atop another, with each providing a different service (radiotherapy, chemotherapy, etc.).
Certain hospitals have sought to move in the opposite direction, bringing a full range of services to patients in one room or area. In Veldhoven, the Netherlands, a new Woman-Mother-Child Center at Maxima Hospital provides prenatal, delivery, postnatal and breastfeeding support services from one room.

UMC+ in Maastricht, NL
Some of the most radical efforts to address the redefinition of the hospital are being explored in the Netherlands, at Medical University Centre+ (UMC+) in Maastricht.
In late 2009, the departments of Dermatology and Orthopedics at UMC+ started out on separate tracks of what is called ‘design thinking’. Each department independently developed and implemented new care and financing systems, closely adapted to what they saw as the real needs of their patients, and combining specialities, which had been traditionally separated.
The key mission at UMC+ is to avoid pushing strategy down individual departments, which have highly specific patient groups, processes and technologies, and instead build strategy bottom up, involving inputs from across the staffing chain.
Nevertheless, the aim of design thinking is to also generate organizational change. Over time, several other departments began applying the methodologies pioneered by Dermatology and Orthopedics, creating a new hospital healthcare model.
Over time, the UMC+ model is transforming  healthcare focused on rehabilitation, to preventive public health and development. The shift has also changed the role of the Board. Directors no longer set out strategies, but make communication possible between different departments. The Board aims to ensure that different departments do not seek to reinvent the wheel, and instead continuously develop and implement internal best practices.

The challenge of demographics
Nevertheless, many challenges still lie ahead. While Internet- and smartphone-friendly millennials are clearly going to benefit from new hospital care models, the bulk of hospital and healthcare needs for the next decade or two lie in the elderly. According to a Partners HealthCare study in 2016, few seniors obtain information or accomplish healthcare-related tasks online. Only 16 percent of seniors said they used the Internet to obtain health information, while just 7 percent contacted physicians online.