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1
PUBLIC LECTUREKENYATTA UNIVERSITY
  • CHANGING MEDICAL ETHICS IN ICT ERA AND
    PATIENT-DOCTOR-COMMUNITY RELATIONSHIP
  • DR JOSEPH ALUOCH F.R.C.P. E.B.S.
  • SEPTEMBER 25th 2014
  • NAIROBI

2
A Brief History and Overview Of Biomedical
Ethics
3
WHAT IS BIOMEDICAL ETHICS?
4
MEDICAL ETHICS
  • Ethics expresses the ways in which we examine,
    explore and attempt to understand the moral life.
  • What are the moral obligations of health
    professionals in a world of advancing technology
    and promise.
  • Allows us to reflect on the relationship between
    the professional and the patient.

5
MEDICAL ETHICS
  • Ethics a generic term for the various ways of
    understanding and examining the moral life
  • Moral Choices
  • what values, what reasons and what language

6
MEDICAL ETHICS
  • Applied Ethics a practical discipline
  • Investigates ethical issues which arise in
    medicine and healthcare by applying the
    principles and methods of moral philosophy to
    these problems

7
MEDICAL ETHICS
  • The doctor patient relationship
  • What makes a good doctor / professional?
  • What choices, values and traits

8
HOW SHOULD ONE LIVE?(SOCRATES)
  • How doctors should treat patients rests on
    general moral principles about how a person
    should treat another person
  • Thus
  • Biomedical ethics grounded firmly in the study of
    moral philosophy

9
WHAT IS BIOMEDICAL ETHICS?
  • Species of practical normative ethics
  • Norms standards of right and wrong action
    behaviour
  • Normative ethics is concerned with how people
    ought to act, what sort of person one ought to be
    or what sort of policies ought tot be implemented.

10
WHAT IS BIOMEDICAL ETHICS?
  • Species of practical normative ethics
  • What one is obligated or permitted to do, or
    prohibited from doing, in different contexts of
    biotechnology, medical practice and research.
  • So we employ principles and theories of normative
    ethics to motivate and justify actions and
    policies in biomedicine.

11
WHAT IS BIOMEDICAL ETHICS?
  • Species of practical normative ethics.
  • Objectivity
  • Impartiality

12
WHAT IS BIOMEDICAL ETHICS?
  • Descriptive ethics
  • Descriptive ethics is concerned with how people
    actually behave, not how they ought to behave.

13
WHAT IS BIOMEDICAL ETHICS?
  • Metaethics
  • Metaethics is focussed on the nature of morality
    concerned with the point of ethics, i.e. what do
    the terms good, bad, wrong, right mean..

14
CONTEMPORARY MEDICAL ETHICS
  • ...the student begins with the patient,
    continues with the patient, and ends his studies
    with the patient, using books and lectures as
    tools...
  • Sir William Osler, Canadian Physician(1906)
  • As quoted in Singer, P, Viens, AM, Cambridge
    Textbook of Bioethics (2008)

15
ETHICAL REASONING
  • Clinical Ethics is learnt in the same way as
    clinical medicine is learnt, at the coalface,
    through meeting patients and their families,
    being involved in their cases. It is a practical
    discipline.
  • The doctor must learn to recognise the ethical
    aspects of his/her clinical (and scientific
    research work), and to make reasoned decisions
    about this work within the framework of the law
    and medical council guidelines.

16
CONTEMPORARY MEDICAL ETHICS
  • Society allows doctors a degree of personal
    freedom in making decisions and in their
    interactions with patients. But in giving doctors
    that freedom society expects them to be able to
    defend their decisions and actions with
    reasons...Doctors must be able to show how their
    decisions and actions relate to the law and to
    the relevant guidelines.1
  • 1Hope, Savulescu, Hendrik, Medical Ethics and Law
    (2008)

17
ETHICAL REASONING LEARNING TO REASON
  • Scientific Reasoning
  • The skill of evaluating the scientific evidence
    available and applying it, using clinical
    judgement to the clinical scenario at hand. This
    is a fundamental part of your medical education
    and later practice.
  • Ethical Reasoning
  • In the same way, ethical reasoning is a skill
    required to allow you to identify and negotiate
    ethical problems, using an organized framework of
    ethical methods or tools in the clinical setting.

Ethical reasoning must stand up to scrutiny, (in
court if necessary) in the same way as the
scientific aspects of decision-making.
18
  • Traditional Medical Ethics

19
2500 YEARS OF MEDICAL ETHICSA BRIEF HISTORY
  • Timeline

460 BC
2009 AD
Hippocrates
20
THE SCHOOL OF HIPPOCRATES5TH CENTURY BC
  • Hippocrates The Father of Medicine
  • Medical School (Greek Island of Cos)

460 377 BC
21
THE HIPPOCRATIC OATH
c.1595
22
HIPPOCRATIC OATH I
  • I swear by Apollo, the healer, Asclepius,
    Hygieia, and Panacea, and I take to witness all
    the gods, all the goddesses, to keep according to
    my ability and my judgment, the following Oath
    and agreement
  • To consider dear to me, as my parents, him who
    taught me this art to live in common with him
    and, if necessary, to share my goods with him
  • To look upon his children as my own brothers, to
    teach them this art.

23

HIPPOCRATIC OATH II
  • I will prescribe regimens for the good of my
    patients according to my ability and my judgment
    and never do harm to anyone.
  • I will not give a lethal drug to anyone if I am
    asked, nor will I advise such a plan and
    similarly I will not give a woman a pessary to
    cause an abortion
  • But I will preserve the purity of my life and my
    arts.

24

HIPPOCRATIC OATH III
  • I will not cut for stone, even for patients in
    whom the disease is manifest I will leave this
    operation to be performed by practitioners,
    specialists in this art.
  • In every house where I come I will enter only for
    the good of my patients, keeping myself far from
    all intentional ill-doing and all seduction and
    especially from the pleasures of love with women
    or with men, be they free or slaves.

25

HIPPOCRATIC OATH IV
  • All that may come to my knowledge in the exercise
    of my profession or in daily commerce with men,
    which ought not to be spread abroad, I will keep
    secret and will never reveal.
  • If I keep this oath faithfully, may I enjoy my
    life and practice my art, respected by all men
    and in all times but if I swerve from it or
    violate it, may the reverse be my lot.

26
BENEFICENCE AND NONMALEFICENCE
  • Hippocratic Oath
  • Established the principles of Beneficence and
    Non-maleficence
  • Prohibited poisons and potions for abortion or
    euthanasia
  • Maintain confidentiality
  • Avoid exploitation
  • Pursue best interests of patient

27
THE HIPPOCRATIC OATH
  • However no acknowledgement of the patients
    rights (e.g. truth telling or consent)
  • Does not deal with welfare of society or of others

28
THE HIPPOCRATIC OATH
  • The Oath of a closed, self-protecting guild1
  • an old boys club?
  • Tradition of altruistic doctors practising
    paternalistic medicine...?

1Harris, J, Bioethics (2001) OUP
29
THOMAS PERCIVAL, ENGLISH PHYSICIAN
  • Beginning of modern professional ethics
  • First used the term Medical Ethics in his book
    on the subject (1803)
  • Somewhat of a misnomer at this point conflicts
    between practitioners were endemic at this time
  • c.f. Manchester doctors dispute
  • Tripartite structure of medicine at the time
  • Physicians, Surgeons and Apothecaries

30
THOMAS PERCIVAL
  • Expanded the Hippocratic focus on the
    doctor-patient relationship to a broader social
    ethic of medicine emphasizing the professional
    responsibility of the physician.
  • Influenced the early ethical codes of AMA, BMA
    and the WMA up until 1940s

31
MEDICO-ETHICAL ASSOC. 1800S
  • Manchester Medico-ethical Assoc.
  • BMA medico-ethical committee 1853
  • The attempt to produce codes of professional
    ethics to deal with certain recurrent problems
    they faced in the practice of their profession.
  • Colleague control

32
AMA CODE OF MEDICAL ETHICS 1849
  • Revised to AMA Principles of Medical Ethics 1903
  • Leading with revised editions to a code embodying
    a set of principles that in the spirit of
    Percival, emphasize not only nonmaleficence and
    beneficence but also doctors responsibility to
    the medical profession and to society at large.

33
MEDICAL ETHICSFOUNDATIONS I
  • Traditional codes of ethics
  • Doctors as independent, self-sufficient
    philanthropists, whose beneficence is analogous
    to generous acts of giving.

34
  • MODERN /BIOMEDICAL ETHICS

35
20TH C NAZI GERMANY AND US
  • Experimentation on Humans
  • Without their consent
  • Perverse extension of the authoritarian nature
    of paternalism (Glannon)

36
NUREMBERG CODE (1947)
  • The judgment by the war crimes tribunal at
    Nuremberg laid down 10 standards to which
    physicians must conform when carrying out
    experiments on human subjects.
  • 1. The voluntary consent of the human subject is
    absolutely essential

37
NUREMBURG CODE (1947)
  • Informed Consent enshrined in Medical Ethics Code
  • Patient oriented approach for the first time
  • Medical ethics ceased to be the sole domain of
    doctors now tested against the principles of
    society (Kennedy, 1981)

38
CHANGING SOCIETY 1960S
  • Less deference to authority
  • Anti-war movements, Vietnam, Cuban Missile
    crisis, CND, hippies, public demonstrations for
    rights, civil rights movements, feminism
  • Generally more assertive attitudes to individual
    rights and self-determination

39
CHANGING MEDICINE
  • Technology progressing to offer more expensive
    treatments, life-prolonging, scarcity of
    resources with increasing costs (Dialysis, Organ
    transplant, Artificial ventilation)
  • Reproductive control with contraception and
    abortion concept of reproductive rights

40
BIOETHICS (1971)
  • a new discipline that combines biological
    knowledge with knowledge of human value systems
    (Potter, 1971)
  • The study of the ethical dimensions of medicine
    and the biological sciences

Medicine

Science
Ethics
41
BIOETHICS
  • A growth in Academic comment with a shift in
    Moral philosophy increasingly from metaethics to
    applied ethics
  • Increasing ethical issues for society as a whole,
    prompted by the new technologies (IVF, Genetics,
    Stem cell technologies, etc.)
  • Non-medical commentary (philosopher, sociologist,
    ...) on how medicine and science should be
    regulated and how doctors and scientists should
    behave

42
MODERN MEDICAL ETHICSFOUNDATIONS II
  • Moral Philosophy
  • Contemporary Medical ethics
  • 1960s Moral problems of modern society
  • CND, Vietnam, ...
  • Personal and public responsibility for happens to
    the world
  • Patients have rights and entitlements

43
BENEFICENCE AND NONMALEFICENCE
  • Early interpretations
  • excessively paternalistic
  • Now tempered with the recognition of other
    principles

44
AUTONOMY
  • Gradual shift in decisional authority from doctor
    to patient
  • Introduced the patient based principle of
  • AUTONOMY
  • To sit alongside and complement physician based
    principles of beneficence and non-maleficence

45
AUTONOMY
  • auto self
  • nomos law
  • Moral Self Rule
  • Having the capacity and the right to
    self-determination to formulate and follow a
    life plan of ones own making

46
Sovereign over own mind and body Individual
freedom can be restricted only if risk of harm
to others
Respect for persons as autonomous
ends-in-themselves Capacity to Reason Apply the
moral law unto ourselves
47
JUSTICE
  • In context of a changing society,
  • equality involves the concept of equal access
    to society's goods,
  • i.e. scarce and expensive healthcare resources
  • How can these be justly allocated?

48
ETHICAL CHALLENGES OF THE ICT IN HEALTHCARE IN
A CHANGING SOCIETY
49
INTRODUCTION
  • The primary objective of the medical profession
    is to render service to humanity reward or
    financial gain is a subordinate consideration.
  • AMA Principles of Medical Ethics
  • Codes of Medical Ethics Current Opinions with
    Annotations, 1997.

50
ETHICS MEDICINE - PART 1
  • Ethics can be viewed as a prerequisite for the
    success of medical practice, much the same way
    that safety is a prerequisite for the success of
    airline travel.
  • Dyer, KA. JMIR 20013(2)e23

51
Modern Biomedical Ethics
  • Modern bioethics reformulates the fundamental
    moral problems as a problems for society, rather
    than merely ones of professional self-regulation.
  • Takes the patients perspective as its starting
    point.1

52
ETHICS MEDICINE - PART 2
  • In both cases, if the prerequisites are not in
    place to ensure trust in the product or services
    provided, consumers will not utilize the product
    or service.
  • Dyer, KA. JMIR 20013(2)e23

53
MEDICAL ETHICS
  • Most physicians are governed by their own
    internal code of ethics.
  • The commitment to help and serve others has
    traditionally taken precedence over economic
    interests.
  • Medicines code of ethics is considered to be far
    more stringent than the law.
  • Professional organizations have more formalized
    codes to ensure that their members behave
    ethically.

54
MEDICAL ETHICS ON THE INTERNET
  • Online entrepreneurs, business medical,
    rushed to cash in on the Internet bonanza, with
    its promise of great potential wealth.
  • Investor shareholder interests are often
    placed above the welfare of patients.
  • These actions are in direct conflict with many
    of the existing medical codes of conduct.

55
MAJOR AREAS NEEDING GUIDELINES IN MEDICAL
INTERNET ETHICS
  • Doctor-patient, provider-patient,
    therapist-client relationships
  • Online medicine, online therapy
  • Online research
  • Quality of information on medical and healthcare
    Web sites
  • Ethical conduct of medical and healthcare Web
    sites
  • Privacy and security

56
QUESTIONS RAISED BY PROVIDING HEALTHCARE SERVICES
ON THE INTERNET
  • Does a physician, provider or therapist
    consultant to a website have an ethical
    obligation to site visitors?
  • At what point does the a patient-provider
    relationship begin?
  • Does an online relationship require that an
    off-line one exists?

57
MORE QUESTIONS RAISED
  • Do any of the ethical guidelines that guide and
    protect the patient-provider relationship apply
    in cyberspace?
  • Is the relationship reduced to a medical or
    healthcare provider-consumer one?
  • What are the limits of online medicine or online
    therapy?
  • What is the ethical obligation of dealing with
    unsolicited e-mail?

58
WHOS TRAVELING OVER THE INTERNET?
Patient
Clinician
59
MEDICINE HEALTHCARE ON THE INTERNET
  • Medical websites, more than any other type of
    site on the Internet, should ensure visitors
    personal privacy and prevent personal medical
    information, including patterns of use and
    interests, from being sold, purchased, or
    inadvertently entering the hands of marketers,
    employers, and insurers.
  • Principles Governing AMA Web Sites
  • Winker MA JAMA 20002831600-1606

60
GUIDELINES FOR QUALITY MEDICAL AND HEALTH WEBSITES
  • 1996 - Health on the Net Foundation Code of
    Conduct
  • 1999 - Medscape The Ethics of the Medical
    Internet
  • 2000 - AMAs Guidelines for Medical and Health
    Information Sites on the Internet
  • - Internet Healthcare Coalitions
    International Code of Ethics
  • - MedCERTAIN development of an trustmark
  • 2001 - URAC Hiethics Fee-based Health Website
    Accreditation program

61
ETHICAL CONDUCT OF MEDICAL AND HEALTHCARE WEB
SITES
  • Medical website designers, writers, backers,
    consultants, e-health marketers, healthcare
    providers and physicians must understand the
    unique position they are in with online
    healthcare consumers.
  • Online entrepreneurs and non-medical
    professionals should be educated not to exploit
    online patients or clients and follow a Medical
    Internet professional code of conduct.

62
PRIVACY SECURITY
  • Without enforceable guidelines for creating
    healthcare sites and ensuring privacy, and
    standards for conducting online research,
    Internet users risk their private life
    unexpectedly becoming public and face potential
    repercussions if insurance companies, employers,
    friends or family discover confidential
    information about their health.

63
CONCLUSIONS - PART 1
  • The major areas identified for further
    examination study in this paper include
  • How privacy, security, confidentiality should
    be ensured when visiting a website or conducting
    transactions over the Internet.
  • How website visitors can determine the quality of
    information at a website.
  • How the doctor-patient, patient-provider, and
    therapist-client relationships should be
    translated into practicing online medicine and
    online therapy.

64
Conclusions - Part 2
  • How website designers, developers, sponsors
    managers should develop maintain ethical
    medical and healthcare websites.
  • How online medical and healthcare businesses
    should be ethically conducted.
  • How online research should be ethically
    conducted.
  • How all the professions involved in the medical
    or healthcare Internet should ethically comport
    themselves.

65
  • INFORMATION COMMUNICATION TECHNOLOGY IN HEALTH
    CARE

66
PILLARS OF HEALTH INDUSTRY
Chemistry
19th Century
Physics
20th Century
ICT
21st Century
67
ICT IN MEDICINE
68
ICT IN HEALTH CARE DELIVERY
Growing
  • Globalisation
  • Health care economics
  • Patient process
  • Medical profession
  • New technologies (mobile videophone, mobile
    networks)

2000 2010
68
69
  • Impacts ICT include-
  • Medical informatics
  • Telemedicine
  • Medical Information
  • E-Learning

Functions of Internet
70
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71
MEDICAL INFORMATICS
  • This is a term used to describe how medical
    information is handled, accessed, manipulated and
    retrieved.

72
WHAT IS HEALTH INFORMATICS?
  • Healthcare informatics is a combination of
    computer science, healthcare science, information
    science and cognitive science

73
TELEMEDICINE
  • This is the delivery of healthcare where
    distance is a critical factor by all health care
    professionals using information and communication
    for the exchange of valid information for
    diagnosis treatment and prevention of disease and
    injuries, research and evaluation and for the
    continuing education of healthcare providers, all
    in the interest of advancing the healthcare of
    individuals and their communities. 2

74
HEALTH INFORMATION
  • Medical professionals are better informed
    implying that information can get to them faster
    and from anywhere using internet.

75
THE IMPORTANCE OF INFORMATION
  • The healthcare of our clients is largely
    dependant on information.
  • Every action taken depends on previous
    information and knowledge.
  • The delivery of health care requires information
    about
  • Science of type of care (nursing)
  • Patient or client
  • Provider
  • Outcomes
  • Process and systems for delivery of care

76
THE IMPORTANCE OF INFORMATION
  • Patient or client
  • Information on the client is required for his/her
    individual care.
  • The assessment process consists of gathering
    information.
  • The use of technology can assist in collecting
    this information.
  • Information on the client can be found in the
    patient record, the patients history, lab
    results.
  • Information on the client changes and grows over
    time.

77
E LEARNING
  • ICT has also presented innovative educational
    delivery methods which have overcome the
    traditional barriers to continuous medical
    education.
  • The virtual campus
  • Podcasts
  • Video conferencing

78
GENERAL BENEFITS
  • Elimination of chart-pulling, chart-filing, chart
    loss.
  • Easy electronic review of patient information
    before visits.
  • Notification of completed diagnostics and labs to
    review.
  • Notification of required follow-ups, tests, etc.
  • Potential reduction in medical errors with
    decision support and easier access to relevant
    information.
  • Reduction in prescription errors and subsequent
    time lost communicating with pharmacies.

79
GENERAL BENEFITS
  • Easy communication with patients other providers
    specialists, hospital visits, etc.
  • More complete and detailed information available
    for claims, malpractice suits, etc.
  • Potential reduced costs for labor and supplies
    related to charts and chart maintenance.
  • Improved flow of information between staff
    members.
  • Accountability

80
E-HEALTH
Quality of care
Access to care
  • Image assistant by computers
  • Continuos education
  • E-prescription
  • Telemedicine
  • Teleconsultation
  • Home care
  • Monitoring
  • Electronic health record
  • Digitalized health system
  • Hospital information systems
  • Regional networks
  • e-reimbursement/procurement
  • Smart cards

Economy of care
80
81
E-HEALTH INCLUDES
  • Health/hospital information systems
  • Health surveillance
  • e-learning for health care professionals (medical
    continuing education)
  • Remote patient monitoring
  • Telehealth/Telecare
  • Telemedicine

82
GET YOUR ICT STRAIGHT
83
DIGITAL TECHNOLOGY
  • DIGITS( NUMBERS)
  • DIGITS( LATIN- FINGERS)
  • HISTORICALLY BEACONS
  • SMOKES (analogue)
  • DRUM SOUNDS
  • INFORMATION HANDLED IN NUMBERS
  • DIGITAL SIGNALS NOT VISIBLE
  • RECOGNIZE( images sounds and words)
  • DIGITAL Vs ANALOGUE

84
A BIT ABOUT BYTES
bit bit 0 or 1
byte B 8 bits
Kilobyte KB 1,000 bytes
Megabyte MB 1,000 Kilobytes
Gigabyte GB 1,000Megabytes
85
WHAT IS FIBER OPTICS?
  • Transmitting communications signals over
    hair thin strands of glass or plastics

86
FIBER OPTIC APPLICATIONS
  • Fiber is the least expensive, most reliable
    methods for high speed and/or long distance
    communications
  • Fiber optic systems transmit using infrared
    light, invisible to the human eye, because it
    goes further in the optical fiber at those
    wavelengths

87
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88
PATIENT RECORDS
  • One obvious use of ICT in medicine is the
    introduction of databases to store patient
    records

89
. . the future of the library is that there is
no library -- at least not as we know it today
90
THE INFINITE LIBRARY
If youre over 50, todays libraries are
probably nothing like the ones you remember ...
Enter any major library today and youll find an
armory of computers and ,,,,,,,,,,,,,,,,
91
ICT NURSING
  • Improves ability to efficiently and accurately
    assess treat their patient
  • Nurses largest group of health care worker,
    leading edge of transformation or health care
  • Diminishing professional nurses
  • Use of lower cadre nurses in e-nursing

92
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93
WHAT IS TELEMEDICINE?
  • . . . the use of electronic information and
    communication technologies to provide and support
    health care when distance separates the
    participants . . .

94
TELEMEDICINE AND THE FUTURE
  • Education (Virtual University)
  • Clinically in everyday practice, education,
    remote
  • Patient oriented, in practise, education and
    monitoring at home
  • Network, between doctor ,pt., pharmacy and all
    health personnel
  • Disasters, catastrophes,e.g.earth quake
  • Telesurgery

95
TELEMEDICINE APPLICATIONS
  • The main application areas of telemedicine
    systems are
  • telehomecare and telecardiology,
  • teleradiology,
  • telepathology
  • ...
  • (There are other specialties that use
    telemedicine services, as teledermatology,
    teleophthalmology, telesurgery, telepsychiatry
    etc., but these are poor of applications at the
    moment).

96
TELERADIOLOGY
  • Radiology is one of the fields where telemedicine
    has been more developed
  • Teleradiology is the most widely used
    telemedicine service at present
  • Teleconsoluting
  • TeleDiagnosis
  • E-Learning

97
KEEP YOUR ICT COOL
98
EMERGING APPLICATIONS
  • Telepharmacy
  • Teledentistry
  • Broader Home Health
  • Remote Surgery

99
TYPES OF TELEMEDICINE
  • Synchronous-Describes interactive video
    connections because the transmission of
    information in both directions is occurring at
    exactly the same period. (Live Telemedicine)
  • Asynchronous-Describes store and forward
    transmission of medical images or information
    because the transmission typically occurs in one
    direction in time. (Store and forward
    telemedicine)

100
LIVE TELEMEDICINE
ADVANTAGES DISADVANTAGES
  • Multiple specialty use.
  • Interactive.
  • High quality video and audio.
  • Patient provider relationship.
  • Scheduling constraints.
  • High equipment costs.
  • Expensive line charges.

101
DONT LET ICT PULL YOU DOWN
102
STORE AND FORWARD
ADVANTAGES DISADVANTAGES
  • No scheduling constraints.
  • Less burdensome technical requirements.
  • Low connection and equipment costs. (POTS)
  • Information stored centrally, more secure.
  • Limited Specialties.
  • Delay in getting feedback.
  • No patient provider interaction.
  • Incomplete view of the case.

103
CORE PRINCIPLES OF TELEMEDICINE
  • Is only a tool (like a stethoscope)
  • Must be physician directed
  • Must be integrated into established clinical
    operations and routines
  • Physician-patient relationships must be preserved

104
TELECARE
  • Tele-Home Care allows to offer medical assistance
    to the patients directly to their home
  • Tele-Home Care may improve the quality of life of
    patients
  • Home-care and community based health service are
    becoming an increasingly important part of the
    healthcare services, allowing the so called
    Continuity of care

104
105
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106
TELE - PATHOLOGY
107
TELE - MONITORING
108
TELEMONITORING DEVICES
109
DEVICE FOR GLUCOSE MONITORING


110
MEDICAL PERIPHERALS
111
CHALLENGES OF HEALTHCARE PROVIDERS (PUBLIC AND/OR
PRIVATE)
  • To improve quality and treatment and care of
    patient and of life of the citizens.
  • To reduce costs (expenditure control).
  • To use advanced diagnostic and therapeutical
    technologies (CT,MRI, etc.) for a large number of
    patients/citizens.

112
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113
Rabbit, where are you going?I am going to
kill the Elephant Can you do that?Well, Ill
try, and try again. Tanzanian, ProverbThank
you
114
WHAT IS E-HEALTH??
  • ICT in healthcare
  • Mostly Iinternet
  • Healthcare telematics
  • Medical records
  • Telemedicine
  • Digital imaging
  • In fact re-organising healthcare

115
EXAMPLES
  • Electronic medical records
  • eHealth platform portal site
  • Register for physiotherapy and nursing
  • Electronic medical prescriptions

116
EXAMPLES EMP
  • Electronic Medical Prescription
  • Avoid erroneous interpretation
  • Possibly concurrently with paper
  • Avoiding fraud, theft, forging
  • Over-medication can be discovered
  • Diverse added values possible, requiring law
    changes

117
THANK YOU IF YOU HAVE BEEN LISTENING
118
WHAT IS TELEMEDICINE?
  • . . . the use of electronic information and
    communication technologies to provide and support
    health care when distance separates the
    participants . . .

119
TELEMEDICINE AND THE FUTURE
  • Education (Virtual University)
  • Clinically in everyday practice, education,
    remote
  • Patient oriented, in practise, education and
    monitoring at home
  • Network, between doctor ,pt., pharmacy and all
    health personnel
  • Disasters, catastrophes,e.g.earth quake
  • Telesurgery

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EMERGING APPLICATIONS
  • Telepharmacy
  • Teledentistry
  • Broader Home Health
  • Remote Surgery

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TYPES OF TELEMEDICINE
  • Synchronous-Describes interactive video
    connections because the transmission of
    information in both directions is occurring at
    exactly the same period. (Live Telemedicine)
  • Asynchronous-Describes store and forward
    transmission of medical images or information
    because the transmission typically occurs in one
    direction in time. (Store and forward
    telemedicine)

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LIVE TELEMEDICINE
ADVANTAGES DISADVANTAGES
  • Scheduling constraints.
  • High equipment costs.
  • Expensive line charges.
  • Multiple specialty use.
  • Interactive.
  • High quality video and audio.
  • Patient provider relationship.

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STORE AND FORWARD
ADVANTAGES DISADVANTAGES
  • Limited Specialties.
  • Delay in getting feedback.
  • No patient provider interaction.
  • Incomplete view of the case.
  • No scheduling constraints.
  • Less burdensome technical requirements.
  • Low connection and equipment costs. (POTS)
  • Information stored centrally, more secure.

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TELEMEDICINE EQUIPMENT
Power Zoom Push-button 1-50x zoom allows both
close focus and wide angle images. Auto Focus
The camera automatically stays in focus for ease
of use. Freeze Frame Freeze frame produces the
clearest possible image, making it ideal for both
low- and high-bandwidth solutions. Accurate
Colors One button white balance sets highly
accurate colors quickly and easily. Polarization
Elimination of surface skin reflection allows
camera to see into epidermal layers. Touch and
View The AMD-2500 includes manual or automatic
iris control to maximize image brightness.
AMD 2500 General Examination Camera
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QUALITY IMAGES
Pictures taken by AMD 2500 General Examination
Camera
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HOW IT WORKS
  • Video conference system
  • Cameras each end
  • TV screens/computers each end
  • Various medical peripherals
  • Video connection
  • T-1 line
  • Satellite
  • Phone line (POTS)
  • Internet

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) ) ) ) ) ) ) ) ) ) )
) ) ) ) ) ) ) ) ) ) ) ) )
Hub Site
Remote Site
T-1
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CORE PRINCIPLES OF TELEMEDICINE
  • Is only a tool (like a stethoscope)
  • Must be physician directed
  • Must be integrated into established clinical
    operations and routines
  • Physician-patient relationships must be preserved

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TELEMEDICINE APPLICATIONS
  • The main application areas of telemedicine
    systems are
  • telehomecare and telecardiology,
  • teleradiology,
  • telepathology

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TELECARE
  • Tele-Home Care allows to offer medical assistance
    to the patients directly to their home
  • Tele-Home Care may improve the quality of life of
    patients
  • Home-care and community based health service are
    becoming an increasingly important part of the
    healthcare services, allowing the so called
    Continuity of care

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PATHOLOGY
  • Histology slides can be transmitted to
    pathologists using a digital camera attached to a
    microscope

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LIVE TELEMEDICINE EQUIPMENT
  • General Examination Camera
  • E-Stethoscope
  • ENT Scope
  • Ophthalmoscope
  • X-Ray Digitizer
  • 12 lead ECG machine
  • Spirometer

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ECG WITH PERSISTENT MEMORY
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DEVICE FOR EMERGENCY


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OTHER DEVICES
Magnetic stirrer
Heat ramp pressure probe
Organ bath
Algae fluorometer
Negative pressure tank
Solar Powered Datalogger
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ADVANTAGES
  • Specialist advice without the patient having to
    travel to the central hospital
  • Cost saving in transport and patient
    accommodation
  • Better utilisation of specialist resources
  • Educational opportunities

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DISADVANTAGES
  • Incorrect diagnoses
  • Cost of hardware
  • Need good telecommunication network
  • Training of staff
  • Medicolegal concerns- patient confidentiality

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PITFALLS
  • Cost- digitizers are expensive
  • Telecommunications limited in many parts of
    Africa and Asia- satellite shows promise
  • Medicolegal issues- patient confidentiality
  • Training of physicians

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FUTURE DIRECTIONS
  • Digital cameras may replace digitizers and are
    much cheaper
  • Wireless communications are rapidly expanding in
    developing countries
  • Internet II may provide sufficient bandwidth for
    telemedicine
  • Offers many educational opportunities

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MOZAMBIQUE PROJECT
  • January 1998 First ITU Telemedicine project was
    implemented in Mozambique, connected two
    hospitals (one in Maputo, the capital of the
    country, and the second in Beira) for
    teleradiology.

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MOBILE EHEALTH IN RURAL AREAS
  • There are two solutions
  • Mobile phone can be used for management and
    consultations related to medical services.
  • Mobile eHealth care clinics/units traveling in
    rural areas from one village to another and
    connected to nearby hospital by wireless
    communication for consultations.

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MOBILE TELECOMMUNICATION IN DEVELOPING COUNTRIES
  • The number of mobile phones in many developing
    countries is drastically increased during the
    last five years offering technical platform for
    many mobile eHealth services to be organized.

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MOBILE NETWORK COVERAGE IN SELECTED COUNTRIES
(ITU, 2007)
  • Combodia 87, Gambia 85, Guinea 80, Kenya 77,
    Pakistan 90, Rwanda 90, Senegal 85, Togo 85,
    Uganda 80, Zimbabwe 75.

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GOALS OF TELEMEDICINE
  • To provide consultation and interpretation in
    regions of demonstrated need
  • To provide specialist services in hospitals
    without on site support
  • To promote educational opportunities for
    physicians

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Conclusion 1
  • Experience demonstrates that there is no single
    solution that will work in all settings. The
    complexity of technologies and the complexity of
    needs and demands of healthcare suggests the
    gradual introduction, testing and refining of new
    technologies.

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Telemedicine in Developing Countries
  • Telemedicine has the potential for offering to
    developing countries both qualitative and
    quantitative improvements.
  • Many developing countries have inadequate
    health-care and medical services. Developing
    countries suffer from a shortage of doctors and
    other health-care professionals.
  • Developing countries are inevitably short of high
    level hospital infrastructures. The geographical
    distribution of existing hospitals and health
    services is far from ideal usually they are
    limited to urban centres at county or district
    level.
  • For countries with limited medical expertise and
    resources, telecommunications services and
    network have the potential to provide a solution
    to some of many problems. Increasingly, there is
    a recognition that health services must be
    provided close to the people who need them and an
    integrated, cost-effective approach is necessary.

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  • The state of health of population is a direct
    determinant of development. Access to better
    health services reduces poverty and increases
    productivity. Investment in health is a
    prerequisite to economic and social progress.
  • Population growth and the emergence of new health
    problems are increasing the demand for health
    services and for more expensive treatments.
    However, increasing demand and rising health care
    costs have not been matched by the funding of the
    health sector in most developing countries.
  • About one billion people worldwide do not have
    regular access to local health services.

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MEDICAL ETHICS IN CHANGING SOCIETY
  • Society-complex
  • Individual Patients right awareness
  • Patients critical consumers

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MEDICAL ETHICS
  • Doctors V Patients
  • Doctors V Society
  • Medicine the art of healing
  • Service to humanity
  • Doctors as businessmen

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CHANGING FACE OF MEDICINE
  • ART To Science
  • Service To business
  • Patient To consumers
  • Lawyers Decision Makers

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WHAT IS ETHICS
  • Ethics or moral philosophy is the systematic
    endeavour to understand moral concepts and
    justify moral principles and theories
  • Ethics builds and scrutinizes arguments settings
    forth large-scale theories on how we ought to
    act, and it seeks to discover valid principles
    and the relationship between those principle

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MORALITY AND ETHICS
  • The terms moral and ethics come from latin and
    Greek respectively (mores and ethos). Deriving
    their meaning from the idea of custom.. There
    is also another Greek word ethos which denotes a
    character feature. Aristotle called his ethics a
    study of character traits, in sense of virtues
    and vices.

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MEDICAL ETHICS
  • Is based on philosophical ethics
  • It isnt any special ethics but rather ethics of
    special cases.
  • Medical ethics does not concern only doctors but
    also patients and society
  • The central question of medical ethics is the
    doctor- patient relationship

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THE NATURE OF MORALITY
  • Moral acts are acts done benefit others, they are
    altruistic and are not motivated by
    self-interest.
  • Morality makes reference to right/wrong/permissibl
    e behavior with regard to basic values

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THE ORIGINS
  • The Beginnings
  • The Nuremburg Code, 1948
  • Earlier Points of Origin
  • Babylonian codes
  • Hippocratic Code/Oath
  • Islamic Codes
  • Jewish Codes

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SOME HISTORICAL POINTS
  • Privacy and confidentiality
  • Abortion/status of the fetus
  • Allocation of scarce resources
  • Definition of death

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SOME HISTORICAL POINTS
  • Genetics issues
  • Reproductive issues
  • AIDS
  • Animal rights
  • Relationship with pharmaceutical industries

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HIPPOCRATIC OATH5-4 CENTURIES B.C
  • An obligation of nonmaleficence and an obligation
    of beneficence are both expressed in the
    Hippocratic oath
  • I will use treatment to help the sick according
    to my ability and judgement, but I will never use
    it to injure or wrong them

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THE SOCIAL CONTEXT WHY IS MEDICAL ETHICS SO
PREVALENT?
  • Some factors
  • Womens Movement
  • - Male dominance of medicine
  • - Focus on cure rather than care and
    prevention
  • Legalization, legislation, and litigation
  • Social interest in freedom and autonomy decline
    in the status of medicine

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  • The moral duties of the doctor
  • The duty to help cure
  • The duty to promote and protect the patients
    health
  • The duty to confidentiality
  • The duty to protect the patients life
  • The duty to respect the patients autonomy
  • The duty to protect privacy
  • The duty to respect the patients dignity

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  • The moral rights of the patient
  • The right to high quality medical service
  • The right to autonomous choice
  • The right to decide
  • The right to be informed
  • The right to privacy
  • The right to health education
  • The right to dignity

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  1. Professionalism is a term which embodies numerous
    qualities of physicians as public servants
  2. Professionalism aspires to altruism,
    accountability, excellence, duty, honour, and
    respect fro other
  3. A commitment to the highest standards of
    excellence in the practice of medicine and in the
    generation and dissemination of knowledge

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  • The concept of professionalism includes the
    following values as
  • Honesty -Commitment to
  • Altruism excellence
  • Service - accountability
  • Commitment -Life-long learning
  • Communication

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Principles of Ethics
  • Beneficence
  • Non-Maleficence
  • Autonomy
  • Truth telling
  • Confidentiality
  • Preservation of life
  • Justice

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IMPORTANCE OF ETHICAL ISSUES
  • Increasing profile/Recent press headlines
  • Increase in technology
  • Better informed society
  • Doctors in Management
  • Public scrutiny

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AUTONOMY
  • Capacity to think, decide, take action
  • Mental incompetence no autonomy

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TRUTH TELLING
  • In much wisdom is much grief and he that
    increaseth knowledge increaseth sorrows
  • (Ecclesiastics 1,18)
  • Patients do not want the truth if the news is bad
  • At times there are good reasons for overriding
    truth telling principle

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CONFIDENTIALITY
  • Act against this principle and you destroy
    patients trust
  • Clash- when keeping confidentiality would harm
    others e.g child abuse
  • Should patients have access to their notes?

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PRESERVATION OF LIFE
  • At what stage does human life begin?
  • Can we assess another persons quality of life?-
    Jehovahs Witness

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EUTHANASIA
  • Active an active intervention end life
  • Passive deliberately withholding treatment that
    might help a patient live longer
  • Voluntary euthanasia is performed following a
    request from a patient
  • Doctor assisted suicide a doctor prescribes a
    lethal drug which is self administered by the
    patient
  • Non-voluntary ending the life of a patient who
    is not capable of giving permission
  • Involuntary ending life against a patients

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GIFTS TO PHYSICIANSFROM INDUSTRY
  • Is it ethically permissible to accept gifts from
    pharmaceutical representatives?
  • Any gift accepted by a physician should primarily
    entail a benefit to patients and should not be
    substantial value.
  • Individual gifts as long as they relate to the
    physicians work.

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ADVERTISING IN MEDICINE
  • Patient information and doctors advertising
    medicine
  • Commercialized health care marketing
  • Doctors website
  • Media coverage
  • Electronic medicine

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ADVERTISING AND PROFESSIONALMISCONDUCT
  • Information
  • Drawing attention to achievements
  • Attracting patients
  • Professional advantage
  • Financial benefits

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  • For sale an antique desk suitable for lady with
    thick legs drawers.
  • Now is your chance to have your ears pierced and
    get extra pair to take home, too
  • Wanted Unmarried girls to pick fresh fruit and
    produce at night.
  • Sheer stocking. Designed fro fancy dress, but so
    serviceable that lots of women wear nothing else
  • We build bodies that last a lifetime
  • Man, honest. Will take anything
  • Used Cars Why go elsewhere to be cheated? Come
    here first!

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  • TELEMEDICINE HAS THE POTENTIAL FOR OFFERING
    DEVELOPING COUNTRIES BOTH QUALITATIVE AND
    QUANTITATIVE IMPROVEMENTS.
  • These include
  • distance consultations, diagnosis and advice for
    treatment by medical specialists
  • education and training. Rural health-care staff
    can have regular access to lessons given by
    specialists in hospitals (e.g. on the management
    of common and special diseases)
  • access to international medical databases
  • increasing effectiveness and efficiency, for
    example in reducing waiting times for
    consultations, and in introducing medical
    information systems.
  • Health care network and telemedicine facilitate
    the provision of medical information distributed
    in health district and clinical centres and are
    useful for developing countries.

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TELEMEDICINE IN DEVELOPING COUNTRIES
  • CHALLENGES
  • 1.Poor technology infrastructure
  • 2. Lack of funding
  • 3. Lack of it education
  • 4. Insufficient training for health care workers
  • Resistance to change HCW patients

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TELEMEDICINE CHALLENGES
  • Ethical Resource allocation cost-effectiveness
  • Patient-Doctor relationship
  • Effect on healthcare network
  • Sustainability at Donor exit

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  • Telemedicine in developing countries not a
    panacea
  • Clinical Diagnostic Therapeutic
  • Educational Administrative
  • Excessive expectations
  • Unsustainable funding models
  • Lack of trials andevaluation data

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TELEMEDICINE IN RLC.
  • Why is telemedicine worth considering in
    developing countries
  • Telemedicine deserves consideration because of
    the real needs of developing countries for
    healthcare access.
  • There is also the ethical imperative of trying to
    obtain the best possible healthcare in a
    resource-constrained environment

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TELEMEDININE IN Dev.Count.
  • Now that worldwide satellite communication is
    available at reasonable cost, telemedicine can be
    used in many different ways such as improving
    healthcare access, supporting health workers in
    isolated settings or addressing the shortage of
    specialist doctors.
  • Telemedicine thus works toward the concept of
    only one class of medicine, which transcends
    boundaries

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CHANGING FACE OF MEDICINE
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PATIENTS DEMANDS
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IF YOU HAVE BEEN!
THANK YOU FOR LISTENING
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HEALTHCARE AS A BUSINESS
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ADVERTISE - DEFINITIONOxford English Dictionary
  • Make generally known
  • promote (goods or services)
  • physically to encourage people to buy or use
    them.
  • Ask or offer by public notice.

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  • Be demonstrably true in all respects
  • not be misleading, vulgar or sensational
  • seek to maintain the decorum and dignity of the
    profession
  • not contain any testimonial or endorsement of
    clinical skills
  • not claim that one doctor is superior to others
    nor contain endorsements for any particular
    doctor an
  • avoid aggressive forms of competitive persuasion,
    such as those that prevail in commerce and
    industry.

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CHANGING FACE OF MEDICINE
  • ART--------TO SCIENCE
  • SERVICE TO BUSINESS
  • PATIENT TO CONSUMERS

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HEALTHCARE TODAY
  • POLITICAL INFLUENCE
  • EXPANDING SERVICES
  • QUALITY CARE
  • PRIVATE CARE Vs PUBLIC SERVICE MEDICAL TOURISM

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QUALITY OF CARE
  • Quality is never an accident it is always the
    result of high intention, sincere effort,
    intelligent direction and skillful execution it
    represents the wise choice of many alternatives

  • William. A, Forster

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MEDICINE AS A BUSINESS
  • Medical care Economic transaction
  • Doctors Purchasing agents
  • Medical care Consumer good
  • Doctors skilled vendors
  • Market price/forces

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ADVERTISEMENT IN MEDICINE
  • Be demonstrably true in all aspects
  • Not be misleading, vulgar or sensational
  • Seek to maintaining the decorum and dignity of
    the profession
  • Not contain any testimonial or endorsement of
    clinical skills
  • Avoid aggressive forms of competitive persuasion
    ,m such as those that prevail in commerce

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HOSPITAL AS INVESTMENT
  • Selection of Area ( prosperous )
  • Selection of patient location ( insurance cover)
  • Procedure orientated
  • Price mark-ups
  • Avoiding low profit illness
  • Management MBA versus MPH

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HEALTHCARE
  • PRODUCTIVITY VERSUS PATIENT CARE
  • How many patients seen
  • Bed occupancy

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INFORMED CONSUMER
  • Ideal market situation range options
  • Healthcare and choice service of money health
    cover.
  • Customer Service in Hospitals
  • Hospitals are spending huge sums on customer
    service for competitive services
  • Patients simply Customers

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  • We all know that health care is big business
    these days, but did you know following?
  • It is six to 10 times more costly to attract a
    new customer than it is to retain an existing
    one.
  • A satisfied customer only tells five other
    people.
  • An unhappy customer tells approximately 20 other
    people.
  • It only takes 30 seconds for a customer to form
    an opinion.

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HOSPITAL REPORTS
  • Customers
  • Market shares
  • Cash Flow Problems
  • Product Vs Results
  • Bottom line results
  • Consumer Vs patient care needs
  • Marketing/ Advertising and consumer service.

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