Bangalore Doctors Perform a Rare Bloodless Liver Transplant on a Nigerian Patient

Doctors at the Aster CMI Hospital in Bangalore have performed India’s first bloodless liver transplant on Jehovah’s Witnesses from Nigeria. The surgery was challenging compared to a normal liver transplant due to patient’s religious beliefs. The doctors could not use blood or blood products such as platelets, fresh frozen plasma, Cryoprecipitate and more. Few such surgeries have been conducted worldwide and were successful.

The patient named – Jehozadak from Nigeria was suffering from end-stage liver disease. Without a liver transplant, his chances of survival were less than 10% in the next 2 years.

The team of liver specialists – Dr. Rajiv Lochan, Dr. Sonal Asthana, Dr. Mallikarjun Sakpal, Dr. Arun V – Anesthesiologist and Dr. Prakash Doraiswamy – Intensivist, reviewed the patient’s medical history before recommending surgery and charted out a feasible pathway.

“During a liver surgery, patients lose a lot of blood which needs to be replaced for the patient’s survival. Generally, doctors keep 3-4 units of blood and a similar quantity of platelets/plasma on reserve for the patient. In this case, we had to figure out and alternative,” said Dr. Mallikarjun Sakpal, Hepatologist at Aster CMI.

The doctors used ‘Normo-volemic hemodilution’ technique where doctors took two units each of both patient and donor’s blood and were connected to the system throughout the surgery using special equipment so there is no break in the blood circulation loop. This procedure was discussed with the patient before surgery and it was in line with their beliefs.

During the surgery, the patient lost about 2 units of blood which were compensated with the use of ‘cell-salvage’ technique to collect and reuse the blood. The surgery lasts for 12-hours and two teams of specialists with close to 25 doctors were involved in this surgery.

In a period of two weeks, the patient and his brother, who was a donor, were discharged from the hospital.   

Source : Gulfnews.com

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Cyber Attacks and Approaches to Protecting Health Data

Over the last few years, technological advances have gained a massive entry into the healthcare scene with tech companies revolutionizing health with digitalized healthcare innovations, telemedicine services, wearable health devices, and other AI-driven tech initiatives.

More investments are being channeled into healthcare as healthcare providers and insurers are beginning to see how effective tech makes healthcare delivery and how much it saves employers in administrative costs. Expenditure in healthcare technology is, therefore, growing significantly and in 2017, it rose to $100 billion.

As a result of these tech initiatives, patients share information through telemedicine platforms on their smartphones, and in healthcare facilities, patient data is made easily accessible to their providers via connected medical devices. No doubt, as technology expands, it will create new frontiers in healthcare, however, there is a growing concern for the security of the enormous amount of patient information these tech innovations contain – Big data.

Factors Responsible for Healthcare Cyber Attacks

According to findings by FortiGuard Labs, the number of cyberattacks in healthcare organizations was two times more than the average number in other organizations in the vertical market and these cyber security issues take different dimensions. According to the Identity Theft Resource Center (ITRC), data breaches in the healthcare industry accounted for 22.6 percent of the total reported cases in 2017.

Mergers and Acquisitions (M&A) in health care is one of the most important factors predisposing to cyber attacks. M&A creates vulnerabilities that often promote breaches of health cybersecurity. These M&A activities have been growing stronger in recent years and are expected to gain more strength as healthcare providers expand their services.

Mergers and Acquisitions involve the use of a wide range of medical technologies and digitalized platforms through which vital information about healthcare services, providers, and patients are transferred between the newly merged organizations, and this creates an easy target for cybercriminals.

Furthermore, health data is vulnerable for a number of reasons. First, health data tends to be of more value than financial services and medical identity theft usually takes a longer time to detect than any other type of fraud. Coupled with this is that fact that cybersecurity is still in an early stage of maturation and cybercriminals have developed more sophisticated ways of breaching this security.

In 2017, for instance, FortiGuard Labs reported that healthcare data experienced an average of almost 32,000 cyber attacks every day per healthcare organization as compared to an average of over 14,300 per organization in other industries.

Another important factor influencing the rapid rise in cases of cyber attacks in healthcare is the growing increase in development and number of malware families. According to Fortinet’s Q4 2017 Global Threat Landscape Report, the number of existing malware families increased by 25% while the number of unique malware units rose by 19%, the volume of which triggers an increase in cyber attacks.

Data encryption has also seen widespread incorporation in health systems. Although encryption protects data, it also triggers cyber criminals to hide malware using encryption. This, in turn, increases the need for inspection of encrypted data which in itself may cause certain mishaps and create weak points through which cyber attacks could be carried out.

Approaches to Protecting Health Data

Software and hardware make up the channels through which most transactions in healthcare are conducted, and these channels are vulnerable. Therefore, it’s vital for providers and insurers to fortify their cyber security to safeguard these health data. Some of the recommendations made by cyber security experts are as noted below;

Update HIPAA : The Health Insurance Portability and Accountability Act of 1966 (HIPAA) has provided guidelines or information constituting the HIPAA security rule which protects the privacy of certain health data. The security rule provides national standards of implementing appropriate physical, administrative, and technical security measures to safeguard the integrity of electronically held health information.

Many healthcare organizations are already aware of the framework for the HIPPA safety rule, however, it’s key to update these safety measures, as recommended by HIPPA, for protection of data against new and more sophisticated cyber attacks.

Promoting Good Cyber Hygiene : Healthcare organizations need to improve their update and software patching processes routinely. These organizations need to employ threat intelligence and automation in the software patching process.

Excellent cyber hygiene also includes keeping an inventory of all medical devices used in collecting health data and transferring them. This enables them to track these devices and check for vulnerabilities. Hospitals should ensure strict monitoring of searches and downloads on their IT devices. This provides information for extraction of patient data, financial information, or even research data.

Personnel Training : Training of personnel plays a key role in preventing cyber attacks. Some phishing attacks have succeeded in breakdown cyber security systems because certain personnel was ill-informed.

Regular training of staff on best practices for data security is essential to keep them aware of security threats, what dimensions cyber attacks manifest in, and strategies to prevent such attacks.

Best Practices : There are a number of forums in which organizations can share best practices and successful strategies for preventing cyber attacks. Financial Services Information Sharing and Analysis Center (FS-ISAC) provides a forum for collaboration between organizations in the financial services sector to share best practices on cyber security.

Also, the National Health-ISAC plays a key role in converging organizations and experts in the healthcare industry to discuss strategies for combating cyber attacks.

One of such strategies is using a strong authentication. The Multifactor authentication, for instance, is a form of cybersecurity used in many financial service companies. This technology provides a strong security system to protect vital data.

Cyber Insurance : Cyber insurance is used by many financial organizations to improve the security of financial data. This form of cyber security is still novel and has not been widely used in the healthcare sector. However, the main challenge with cyber insurance is the source of payment and the coverage of security. With regards to the security coverage, the dilemma remains who is to be protected, the institution or the patient.

Advanced Threat Intelligence : With the growing sophistication of cyber attacks, the conventional methods of patching vulnerabilities and correcting intrusions are becoming inadequate. Therefore, advanced intelligence systems are required.

The conventional approaches include using signature-based detection and isolated security devices. However, advanced intelligence not only detects cyber attacks but diagnoses the techniques used in breaching vulnerabilities. Furthermore, certain artificial intelligence-based algorithms can detect anomalies and instantly communicate detected malware and shrink the attack.

In the healthcare industry within the last few years, technology has created a new paradigm. In the future, digitalized healthcare and AI-based models of care will redefine healthcare. However, this growth comes with a risk of data security intrusion. With these measures in place, cyber attacks can be curbed so that technology can be used to its full potential in healthcare.

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Five Factors to Consider before Foreign Investments in Medical Tourism

In recent times, millions of patients have been traveling from home countries to other destinations to seek health care. In 2017, for example, an estimate of 1,400,000 Americans was noted to have traveled out of the country for health purposes, with approximately 16 million international patients worldwide.

Top procedures medical tourists travel for include cosmetic surgery, dental care, cardiac surgical procedures, cancer care, and orthopedic procedures. Countries at the forefront of medical tourism today include Asian countries including UAE, India, Thailand, and Singapore, and Malaysia, as well as European countries including Turkey and Hungary. The drivers for this cross-border healthcare are the affordability and quality of care in the destination country, and access to exotic trips and a congenial ambiance during the travel period.

The medical tourism market has recorded tremendous growth over the last few years, as countries are starting to expand their healthcare systems and investments are being channeled into technology advancements and healthcare infrastructure developments to attract international patients.

Some of these investments are made by independent foreign companies and government of other countries. Investments channeled into establishing or funding healthcare facilities equipped for international medical tourists, provision of hotel services which will partner with these hospitals, investing in the country’s medical equipment and technology manufacturing industry, and investment in the airline industry for transport of the massive inflow of medical tourists into a nation.

With investments come risks, and the considerable investment needed to facilitate success in the medical tourism industry requires that stakeholders do thorough research in two key areas – the services to provided by the proposed investment project and the viability of the destination site for the investment. Experts recommend considering the following factors in assessing the appropriateness of a medical tourist destination before investing.

Safety

International patients will rarely visit a country for medical treatment if there are reports of political unrest or social upheavals in the country or if such visits will pose a threat to their personal security. Investors, therefore, should seek adequate consultations regarding the security risks and trends in the destination.

Investors are also advised to check the destination sites for adherence to the CPTED principles of environmental design and national surveillance strategies. Destinations with CPTED-compliant urban environment and building planners are associated with low-security risks and are suitable for investments in health tourism.

Reception at the Project Destination

Having the government and locals of a potential destination site support the project is a very vital factor in deciding to invest. Some undeveloped destinations may establish special economic zones (SEZs) which may offer investors duty-free import of building materials, medical equipment, and furniture, as well as offer tax incentives.

A medical tourism project should be beneficial to the community members and must ensure environmental sustenance. The project, during construction and full operation, must provide job opportunities for members of the local community, and must provide useful healthcare services for locals as it does for international travelers.

If the project doesn’t provide benefits to the community and has negative impacts on environmental preservation, the public may regard such projects as against their interests and the community members may retaliate by being inhospitable to foreigners and medical travelers which, in turn, will reduce the attractiveness of the destination.

Supportive Regulations

In the face of unsupportive legislation and government regulations, health tourism projects will not thrive. In countries with weak regulations for medical tourism, the market may be flooded with unregulated and rogue competitors which will damage the medical tourism brand and reputation for all stakeholders in that country.

In a country with poor policies and standards regarding healthcare and health tourism, and an inadequate framework for health tourism, health tourism investments have a high risk of failure. The proposed destination country must have strict active legislation on handling legal matters regarding international healthcare, fraud, and safety and pricing violations, for it to be regarded as appropriate for investments.

Investors should also ensure that there are laws regarding health informatics and health records systems in the destination country. In the same vein, legislation over telemedicine, physician mobility, and medical records transfer to patients’ home countries should be well noted.

The Right Equipment

Providing healthcare services for health tourists is beyond delivering beds and surgical equipment, it involves tailoring healthcare infrastructure and hotel inventory to the specific needs of the target patient.

For example, investing in carpeted floors during construction of a project may pose risks and challenges of the target patient are those with neurological or orthopedic disorders who may be using walkers or crutches, and who may be on wheelchairs.

Hotel facilities should suit the type of patients targeted. A facility which aims to attract obese patients for bariatric surgery must partner with a hotel that provides rooms with sturdy furniture and bed for such patients. Additionally, patients who undergo breast cancer surgery are not advised to sleep in a bed for a few days after surgery, therefore, a facility intending to specialize in breast cancer surgery must provide accommodation that has recliners in the room for the patient to sleep on during the early recovery period.

Marketing

Investing and establishing the health tourism project is one step, the other is the communication strategies to seize the target market. These strategies should include useful language translation and leveraging technology through website development and a strong social media presence.

An effective marketing strategy must center on amplifying the brand as a destination and not just a clinic, to appeal to the international community presenting it as a health tourist brand. This requires an active collaboration with local and national tourism boards, the Ministry of Tourism, and chambers of commerce. If these agencies do not provide adequate support and brand amplification, the project may fail.

These factors are essential in building a viable health tourist brand and securing a good return on investment for every investor. The health tourism industry is a growing and delicate market and factors leading to success in the business are multifaceted. A careful examination of the key areas, including the viability of the project in the destination site, operational logistics, and effective marketing and communication will guide investors on the right path to success.

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Ethics and Medical Tourism

Cross-border travel for healthcare is not immune from ethical considerations. Apart from obvious concerns of costs, risks and quality of care, a very real issue emerging in research is the ethical consequences of medical tourism. The Simon Fraser University Medical Tourism Research Group consists of a team of five researchers who have published many academic papers addressing this subject. They have indicated that patients may not be aware of these ethical concerns and ongoing education is important. These ethical concerns revolve around effects on the home country, on the patient and on the destination country.

When discussing medical ethics and the medical tourism industry we must first discard the sensational and the absurd. Horror stories of illegal organ donors and non-licensed surgery in questionable facilities are atrocities and are obviously unethical, illegal and universally condemned. The issues that need to be explored are the legitimate questions that can arise from any medical service and how they affect both the patient specifically and healthcare in general.

The physician’s ethical obligation to the patient is usually obvious to do no harm and do their best for the patient. The other partners in healthcare also have obligations. The patient has the theoretical social responsibility to maintain health and reduce burden on society to a minimum. This concept is emphasized to a greater degree in a socialized health system. Finally, society and government carry the obligation to care for the sick and reduce public health risks. These three facets of ethics need to be considered in the medical tourism model.

The Potential of Burden on the Patient’s Home Country

In a recent publication in the British Medical Journal, a Canadian-based team conducted a focus group with health professionals dealing with the ethical concerns of medical tourism. Because Canada has socialized medicine and a national health insurance system, it is not surprising that some of the major questions posed were the effect of late-arising complications burdening the national health system and the risk of introducing new antibiotic resistance infections to the home country. Further concerns identified regarded the potential for discontinuity of medical records for the medical traveller and the legitimacy of informed consent at a distance if the patient does not have complete information about the host country before arrival.

“Medical tourism for the classes, but missionary care for the masses.”

The Patients Ethical Perception

The ethical arguments over medical tourism can also have a bearing on the patient’s decision to seek care overseas. Each patient has his or her own ethical considerations justifying health travel. Patients often find it necessary to seek healthcare elsewhere because of the unethical situation in their home health system; be it inflated costs, the inability to obtain insurance or prolonged waiting lists for procedures.

Effects of Medical Tourism on Local Healthcare

Another frequent issue discussed in medical ethical research is the effect of medical tourism on the host nation. A paper in the World Hospital Health Service journal of 2011 discussed that limited expenditures in local healthcare infrastructure and development with concurrent investment targeted for medical tourism can lead to unequal access of health resources in developing nations.

“By contractual arrangement, a portion of earnings from medical tourism contribute to the national health plan’s revenues and healthcare programs of this small nation.”

The Harvard Pilgrim Health Ethics Advisory Group spoke about “brain drain” diverting medical talent way from the local population toward medical tourism markets. These issues have been summarized with the often spoken axiom, “Medical tourism for the classes, but missionary care for the masses.”

An Incommensurable Justice System

The legal system in the destination country can also be a significant concern. The lack of malpractice insurance or difficulty in initiating civil action in some destination countries may lead to an undesirable situation for the travelling patient.

An Industry Responds

The best solution in avoiding these dilemmas is information. There is a wealth of information available. Both the patient and the facilitator need to ask questions to avoid these ethical impediments. Providers need to furnish answers to these issues with absolute transparency.

Many international hospitals are accredited through agencies, such as the Joint Commission and Accreditation Canada. This is a great first step. Other information that should be available and sought including outcome data, such as complication rate, infection rate (including antibiotic resistance patterns), medical record-keeping and language, malpractice insurance and health professional licensing. An ideal medical tourism product should offer complication and infection rates lower than the patient’s home country. In addition, they should be able to provide a complete medical record in the language of the patient’s choice. The medical tourism operator in addition to accreditation should hold malpractice and liability insurance and have in place policies and procedures to ensure qualifications of staff.

Recognizing the uniqueness of medical tourism, a separate accreditation system ensuring transparency and standards is now in the development phase. These initiatives could incorporate an ethical assessment, which is already seen in other sectors, such as in some mutual funds and in some consumer-imported products that have approval for social responsibility and sustainable merit, such as Fair Trade and other such programs for products originating from developing nations.

Finally not all developing nations are seen as draining from the local healthcare assets to the medical tourism sector. In some cases, the medical tourism initiatives contribute to local healthcare by providing expertise, economic stimulation and resources that might not be available.

In the Turks and Caicos Islands located south of the Bahamas, medical tourism services are provided in a state-of- the-art accredited facility operated in a private-public partnership between the local government and InterHealth Canada since 2010. In addition to private care, such as medical tourism, this project also functions as the hospital to provide local residents comprehensive emergency, primary and secondary care as part of a national health insurance plan. By contractual arrangement, a portion of earnings from medical tourism contribute to the national health plan’s revenues and healthcare programs of this small nation, providing services that would otherwise be unavailable locally.

Singapore has evolved into an important medical hub of the Southeast Asia and Asia-Pacific regions. With a relatively small population, the surge in medical tourism has allowed the healthcare system to exploit economies of scale and obtain equipment and expertise that benefit the local population as well. It can be argued that the medical tourism prevents loss of medical experts moving to other developed nations.

Indonesia has also initiated medical tourism in an effort to improve local hospitals. Medical tourism is argued to improve infrastructure, increase competition and decrease outbound medical tourism of the nation.

As the medical tourism industry continues to grow, new challenges, such as the ethics of cross-border health arise, and the industry continues to respond to these issues with research, information and initiatives.

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