Diabetes is a global epidemic affecting an estimated 422 million people worldwide. Type 2 diabetes can be caused by genetic inheritance, but by far the obesity epidemic has created massive increases in the occurrence of Type 2 diabetes. This is due to the major insulin resistance that is created by obesity.

In an interview with Omnia Health Magazine, Dr Mohamad Sohil, Specialist – Endocrinology, Medcare Hospital, Sharjah, emphasised that people with diabetes are being hit hard by COVID-19. According to a Lancet Diabetes & Endocrinology study mining 61 million medical records in the UK, 30 per cent of COVID-19 deaths occurred in people with diabetes. After accounting for potentially relevant risk factors such as social deprivation, ethnicity, and other chronic medical conditions, the risk of dying from COVID-19 was still almost three times higher for people with type 1 diabetes and almost twice as high for type 2, versus those without diabetes.

The doctor also shared data from the U.S. Centers for Disease Control and Prevention that showed that more than three-quarters of people who died from COVID-19 had at least one pre-existing condition. Overall, diabetes was noted as an underlying condition for approximately four in 10 patients. Among people younger than 65 who died from the infection, about half had diabetes. Clinicians and scientists have said that there is no question that unless people with diabetes have their glucose under control, COVID-19 poses much more danger to them than to other people.

“Over a lifetime, problems with too much or too little glucose inflict widespread damage in the kidney, heart, and liver, as well as around nerves,” explained Dr Sohil. “Stroke, heart attack, kidney failure, eye disease, and limb amputations can be the legacy of poor glucose control. The linings of blood vessels throughout the body become so fragile they can’t ferry needed nutrients, as well as they, should. Inflammation rises and the immune system does not perform well.”

He stressed that obesity, which is more common in type 2 diabetes but can also occur in type 1, makes all these conditions worse. Once someone with diabetes or obesity became infected with COVID-19, then their outcomes were generally not as good. They were more likely to be hospitalised, intubated, and have higher rates of death. People with obesity, as a rule, have lower cardiorespiratory fitness, meaning they can’t move as well due to poorer lung function, severe sleep apnoea, and blood vessel disease. “Also, downstream hypertension and other cardiovascular diseases pose a greater risk. It’s those comorbidities that seem to be affecting the increased risk or poor outcomes,” he added.

What causes diabetes?

Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood. Insulin produced by the pancreas lowers blood glucose. Absence or insufficient production of insulin, or an inability of the body to properly use insulin causes diabetes.

Risk factors for type 2 diabetes and pre-diabetes are many. Dr Sohil shares the below factors that can raise the risk of developing type 2 diabetes:

• Being obese or overweight
• High blood pressure
• Elevated levels of triglycerides and low levels of “good” cholesterol (HDL)
• Sedentary lifestyle
• Family history
• Increasing age
• Polycystic ovary syndrome
• Impaired glucose tolerance
• Insulin resistance
• Gestational diabetes during a pregnancy

Dr Mohamad Sohil

Diabetes management in the UAE

The number of people with diabetes in the UAE has increased dramatically during the last five decades and with the further development of the country, more people are being diagnosed with diabetes.

The doctor said that in 2000, the prevalence of diabetes in the UAE was the second-highest in the entire world. In order to reduce the prevalence of diabetes and improve the quality of life and reduce the long term diabetes complications, especially, cardiovascular, renal and ophthalmic complications of diabetes, the National Diabetes Committee (NDC) encouraged and supported by Ministry of Health developed guidelines to ensure optimal diabetes management, which every person with diabetes deserves. These guidelines use the evidence and analysis of the International Diabetes Federation (IDF) and the American Diabetes Association (ADA) guidelines as well as local experience obtained over the years.

“Thus, the guidelines are customised to suit the culture and the style of living in the UAE, ensuring a reliable and efficient method of the management of diabetes, and as result, there was a reduction of the prevalence of diabetes in UAE. In 2014, the UAE become the fifth highest in the GCC in diabetes after being the second-highest in 2000,” he highlighted.

Future of diabetes care

Dr Sohil said that clinicians are often asked how will an individual respond to a specific medication? Who will develop diabetic retinopathy? How can we generate a personalised glucose control algorithm to help develop a safe closed-loop system? Of the millions with pre-diabetes, who are most likely to develop diabetes and thus benefit from preventive regimens? This is where Artificial intelligence (AI) could become an important tool, he said.

“AI can be defined as a means for computers to do tasks that would normally require human intelligence. While diabetes mellitus is a chronic, pervasive condition that is data-rich and with a variety of potential outcomes. Thus, diabetes is fertile ground for incorporating AI,” he concluded.

Can diabetes be prevented?

Dr Sohil shares a few measures that could help prevent type 2 diabetes:

• Cut sugar from your diet.
• Performing physical activity regularly can increase insulin action and sensitivity, which may help prevent the progression from pre-diabetes to diabetes.
• Drinking water instead of other beverages may help control blood sugar and insulin levels.
• Carrying excess weight, particularly in the abdominal area, increases the likelihood of developing diabetes. Losing weight may significantly reduce the risk of diabetes.
• Quit smoking.
• Following a very-low-carb diet can help keep blood sugar and insulin levels under control, which may protect against diabetes.
• Avoiding large portion sizes can help reduce insulin and blood sugar levels and decrease the risk of diabetes.
• Avoid sedentary behaviours.
• Consuming a good fibre source at each meal can help prevent spikes in blood sugar and insulin.
• Optimise Vitamin D levels.
• Minimise intake of processed foods.

Recently, Mayo Clinic researchers have discovered how to manufacture cells capable of generating a hormone that regulates low blood sugar. In an interview with Omnia Health Magazine, Quinn Peterson, Ph.D., discusses how he and his team have developed a new method of mass-producing a cell product containing the hormone glucagon that is capable of protecting against hypoglycemia in animal models. Excerpts:

How does generating pancreatic cell types from renewable sources hold promise for cell replacement therapies for diabetes?

Diabetes is the result of damage or dysfunction of the cells of the pancreas that regulate blood glucose. Researchers (including those in our lab) have been working to develop methods to generate pancreatic cells that can be transplanted into patients and restore the ability to regulate blood glucose. One of those cell types, the pancreatic alpha cell is responsible for preventing low blood sugar. In patients with diabetes, these alpha cells often do not work adequately. In this study, we report a method to produce large quantities of these alpha cells and demonstrate that when transplanted into animals these cells are capable of preventing low blood sugar.

How does the hormone glucagon work?

One of the most acute dangers associated with diabetes is uncontrolled hypoglycemia or low blood sugar. If blood sugar levels fall too low, patients can experience coma or even death. The natural mechanism in the body to prevent low blood sugar is regulation by the hormone glucagon. It is secreted from alpha cells that signal the body to release glucose stores in response to hypoglycemia (low blood sugar). When blood sugars are low, alpha cells secrete glucagon into the bloodstream. The glucagon travels to the liver where glucose stores are released into the bloodstream in response to rising glucagon levels thus bringing blood glucose levels up to normal.

Dr Quinn Peterson

How successful were the trials on animals? Were there any important lessons learnt?

Animals that received transplanted alpha cells were protected from hypoglycemia and spent less time with low blood sugar levels than animals that did not receive the transplanted cells. These studies demonstrate the promise of these cells to prevent hypoglycemia.

What quality checks need to be met before mass manufacturing starts? When would the treatment become widely available?

Stringent quality, safety and manufacturing evaluations are required prior to clinical evaluation including stability, toxicity and long-term survival studies. In addition to these studies, testing in large animals is planned to evaluate the required dosing of the cell product. These studies will support the ultimate clinical evaluation of this therapy. Although this therapy is still under development, we aim to start these clinical studies by 2022 and if successful this treatment could be widely available to patients by the end of the decade.

What does the term “living medicine” mean?

The cell replacement therapy envisioned here represents a new way of thinking about medicine where treatment does not just impact the living organism, but the treatment itself is living—in this case, a living alpha cell. Transplanted alpha cells are not inert. They have the ability to sense conditions and adapt their response in reaction to changing condition in the patient. In this way, we think of this future therapy as a living medicine that functions autonomously to improve patient health.

This work was supported in part by benefactor gifts to the Mayo Clinic Center for Regenerative Medicine, which included the Khalifa Bin Zayed Al Nahyan Foundation.

COVID-19 has negatively impacted every sector of the global economy often resulting in job losses. With global travel restrictions only now easing and hotels reopening, the travel and tourism sector and consequently hospitality, are two of most affected sectors.

Based on the latest report issued by The World Tourism Organization (UNWTO) in May 2020, “Impact Assessment of the COVID-19 Outbreak on the International Tourism”, the COVID-19 pandemic has cut international tourist arrivals in the first quarter of 2020 to a fraction of what they were in 2019. International tourist arrivals dropped by 22 per cent in Q1 2020, potentially declining by 60-80 per cent for the whole year. This translates into a loss of 67 million international arrivals and about US$ 80 billion in receipts globally.

Based on the UNWTO report, the expected forecast for the overall international tourist arrivals for 2020 is projected to decline between 58 per cent to 78 per cent by year-end, assuming the lifting of travel restrictions and opening of borders by July and December 2020, respectively. This project’s a potential 100 million to 120 million direct tourism jobs at risk.

This places 2020 as the worst performance for international tourism since 1950 and puts an abrupt end to a 10-year period of sustained growth.

Based on the survey conducted by Colliers MENA Hotels team in April 2020, 79 per cent of hotel owners in the MENA region decided to partially or fully close their hotels due to low occupancy rates and 54 per cent of respondents expect the market to take about six to 12 months (from the start of recovery), for the hotel market to return to 2019 occupancy levels.

Even once the travel restrictions are lifted, the travellers will have to adopt to new “normal”, which will require COVID-19 testing, social distancing and many other ‘new normal’ practices and policies.

In this article, we highlight how the health and wellness sector can act as a catalyst to revive travel, tourism and hospitality sectors in the MENA (especially, UAE, Kingdom of Saudi Arabia (KSA), Egypt) region.

Introduction of health and wellness offerings are expected to not only revive travel, tourism and hospitality sectors but are also expected to provide sustainability to the sector by offering concepts identified in the report, which require both domestic and international tourists to stay from few weeks to months in hotels instead of few days.

Global Medical & Wellness Tourism Market

An important factor is to understand that wellness tourism is different from and larger than, medical tourism as presented below:

Global Tourism: US$ 5.3 trillion in size and 11.9 billion total trips

Global Medical Tourism: US$ 70 – US$ 80 billion in size and 14 – 16 million total patients/trips

Global Wellness Tourism: US$ 639 billion in size (projected to increase to US$ 919 billion by 2022) and 830 million total trips

Based on the latest available data, the Global Market Size reached US$4.22 trillion by 2017, representing a growth of 12.8 per cent from 2015-2017. To revive MENA travel, tourism and hospitality sectors, governments, private investors and operators will need to focus on beyond traditional medical tourism and spas and offer a wide range of services that encompass healthcare and wellness services highlighted below to achieve sustainable recovery and growth attracting local, regional and international tourists.

Back to basics

On 28 May 2020, UNWTO released a set of guidelines to help the tourism (and hospitality) sector to emerge stronger and more sustainably from COVID-19. The UNWTO guidelines highlight “the need to act decisively to restore confidence and, as UNWTO strengthens its partnership with Google, to embrace innovation and the digital transformation of global tourism.

“The guidelines provide both governments and businesses with a comprehensive set of measures designed to help them open tourism up again in a safe, seamless and responsible manner”.

Highlighting the importance of restoring the confidence of travellers through safety and security, the UNWTO protocols are designed to reduce risks in each step of the tourism value chain. These protocols include the “implementation of check procedures where appropriate, including temperature scans, testing, physical distancing, enhanced frequency of cleaning and the provision of hygiene kits for safer air travel, hospitality services or events”.

Based on an intimate experience in MENA, Colliers believes that provision of tertiary care healthcare facilities offering minimal care in case of emergencies will further boost the confidence of travellers to visit.

For main cities, such as Dubai, Abu Dhabi, Riyadh, Jeddah and Cairo, tour and hotel operators can affiliate with local hospitals that are known to provide good quality of care.

For resorts outside the main cities, similar to the coastal resorts in Egypt, Jordan, Oman, the UAE and more recently in KSA (Red Sea Project, Qiddiya Entertainment City and Amaala Red Sea Riviera) hotel operators may have to combine to provide the support facilities. This may take the form of shared capital cost to establish a suitable healthcare facility; as with hotel branding consideration could be given to healthcare brands that would enhance the attraction of the overall destination. Once established, to improve profitability, the facility would also serve the permanent catchment population alongside tourists and those owning holiday homes.

Another option for establishment of healthcare facilities could be Public-Private Partnership (PPP), where such facilities are considered as “public good” and governments provide regulatory and financial incentives to attract private investors and operators.

To make the tertiary care hospitals more profitable and hence attractive to investors and operators, other health and wellness “packages” could be offered as part of “tourism packages”. These have the additional positive impact on tourism and hospitality sectors as wellness tourists can often extend the length of stay.

Typical wellness packages would include beauty, cosmetic, weight loss, fitness/skills treatments, diet and nutrition, rehabilitation treatment (trauma, accident and mental health) and other health-driven wellness treatments.

Conclusion

Health and wellness sector can act as a catalyst to revive travel, tourism and hospitality sectors in the MENA region.

Introduction of health and wellness offerings are expected to not only revive travel, tourism and hospitality sectors but are also expected to provide sustainability to the sector by offering concepts identified above, which require both domestic and international tourists to stay from few weeks to months in hotels instead of few days.

Mansoor Ahmed

The COVID-19 outbreak has put mental health at the forefront with the global surge in stress levels and anxiety caused by the pandemic.

While the world has now come to terms with the situation; carrying forward with a healthy state of mind is a priority. Dr. Khawla Ahmed Al Mir, Consultant Psychiatrist at Rashid Hospital says, “The initial shock period is over and we are clearly in the adjustment phase, which is extremely important as we need to learn to live with the current realities, we need to adapt in order to stay fit mentally. Adaptability is a key trait to help you navigate the ups and downs of life. At the same time, for a situation like COVID-19, it means that while you adapt to the new normal you also follow all precautions to ensure you are staying safe and protecting your loved ones to the best of your ability. This essentially means that you are not in denial of the situation and so you are doing everything you can while accepting that there is an ongoing pandemic.”

Mir added that in order to support your mental health, it is important to stick to routines and timetables without being too rigid but at the same time, not letting a very fluid routine get in the way of day-to-day tasks. “We have to learn to live with the new normal situation. It is best to stick to a routine as much as possible especially when it involves regular exercise, as exercise is a known and proven stress buster; it helps release endorphins, which are feel-good hormones.”

Mir adds, “Those who do not exercise, I strongly urge them to take up an activity, it could be simple exercises for 30 minutes on the mat or a walk outside now that the weather is cooler.

“Connecting with nature is therapeutic in many ways so combine spending time outdoors with exercise, but of course make sure you wear a mask and follow all precautionary measures in line with governmental regulations.”

Mir added that falling off the bandwagon and slacking when it comes to habits such as exercise is common in stressful times but that is when you need to commit the most, as you will reap maximum mental health benefits of a workout.

She also encouraged community members who are not able to cope with the stress to seek professional help. “Some level of stress is normal in a situation like this but if the stress reaches unmanageable levels for long periods of time where for instance you are not able to get out of bed or doing daily tasks seems like a problem or you are facing persistent negative thoughts, it is time to seek professional help and support.”

She also advised people to have realistic expectations and embrace the current situation to find solutions rather than trying to escape or fight it. “I understand that parents of young children, in particular, have a lot on their plate especially if they have opted for homeschooling. Working out a timetable where they probably wake up an hour earlier to finish their work or prepare for busy mornings might be helpful or dividing their tasks into specific time zones that work for the family might help too. Women in particular should make sure they do not take on too much and find time for themselves. They should share the tasks with their husbands and other house members. If their children are old-enough they should empower them by encouraging them to take charge of some home tasks but of course, they need to ensure it is safe and age-appropriate.

“On weekends while there are several things that need to be completed, parents should find some quiet time for themselves, even if it is for a short while.

“The current situation also poses stresses which cannot be changed such as job insecurities. It is important to remember that we should focus only on the things that we can change, and we should not stress about the things that are beyond our control. Although a certain amount of forward planning and strategising is important to prevent sudden setbacks, overthinking is definitely not helpful for the mind.”

“I strongly believe that our habits define us to a large extent so stick to habits and routines that will help you and your family and do those consistently. If you slack do not be hard on yourself, get back on track.

“Finally, it is important to adopt calming down activities such as yoga, meditation or journaling and practice it daily even if it is for 15 minutes. Your mind is the backbone to health and well-being, take time out to protect and nurture it.”

Stress management tips

Exercise: It is not only good for your physical health; it is great for your mental health too!

Deep breathing and meditation: Do not underestimate the power of breath to help calm your mind. Prioritise sleep: Lack of sleep increases stress hormones.

Reduce or eliminate caffeine: If caffeine makes you anxious, consider cutting it back.

Journal

• Accept that there are events you can’t control

• Set-realistic goals and be kind to yourself

• Seek social support

• Seek medical support if you are suffering from persistent stress  

Since early 2020, the world has witnessed radical changes to the policy, economic welfare, industry development and life itself. With the number of coronavirus infections recently surpassing over 43 million cases worldwide, we’re sailing uncharted waters. Naturally, healthcare has been heavily relied on to mitigate the pandemic’s burden on a macro level, with data-driven technologies adopted to make smart yet critical decisions more efficient. But what exactly has data rich Artificial Intelligence (AI) been doing behind the scenes to keep services afloat?

COVID-19 has accelerated healthcare’s already growing dependence on data-driven technologies. Data and analytics have been invaluable in instructing and tracking the supply chain distribution of PPE equipment, which has been in shortage throughout the pandemic. The financial crisis occurring as a consequence of the loss of elective procedures has impacted revenues and margins, whilst creating unprecedented risks for the health and safety of caregivers.

Perhaps the most significant area of transformation is the underlying clinical processes for patient engagement, diagnosis and post-discharge care, which are likewise, driven by AI and analytics. These factors have spurred the industry to pursue swift digital transformation and to innovate new kinds of patient engagement.

How healthcare providers already utilise and depend on data and analytics

Many healthcare organisations are looking to harness the vast potential of AI and its four components – machine learning (ML), natural language processing (NLP), deep learning and robotics, to transform their clinical and business processes. They seek to make sense of an ever-expanding wave of structured and unstructured data and to automate iterative operations that previously required manual processing. There is tremendous potential for analytics to deliver on the promise of better-quality care, at lower costs, by empowering staff to harness the power of predictive and prescriptive analytics.

Analytic Process Automation (APA) systems have optimised healthcare services in use cases such as transforming waiting list scheduling. Online waiting lists can automate the analysis of recent data across a hospital to visualise the number of referrals and median waiting lists for new appointments.

Regionally, the Saudi Arabia Ministry of Health manages local government hospital and medical activities with the assistance of automation platforms, allowing various administrative tasks such as collecting COVID-19 test results to determining quarantine durations automatically.

This network analysis has allowed the government to understand the virus reproductions rate and track its spread.

Crucially, this information has informed decisions, which have assisted in reducing the spread of the virus and ultimately, saving lives. Through insight analysis, the Saudi Arabia Health Ministry could target where, who and when they were required to respond to COVID-19 cases and inform quarantining regulation.

Democratising data and analytics in healthcare

Data-driven technologies are beginning to empower every human decision, thus liberating workers from the monotony of basic tasks, such as temperature checks when entering a hospital. As more organisations evolve towards a data-led culture, the rate at which smart systems can be scaled across all parts of a business has emerged as the true measurement of success.

However, there remains a data-literacy gap across the healthcare sector globally. As the amount of data collected surges exponentially, the sheer quantity can overwhelm businesses. Consequently, many organisations have little choice but to focus on narrow portions of data – an incomplete fraction when solutions demand a greater percentage of the whole.

The emergent category of APA could be the key to capturing the best of man and machine at scale. APA automates business processes and grants even novice-level knowledge workers direct self-service access to business-critical data insights at speed. In practice, this means more employees can adopt and benefit from data with minimal training – reducing reliance on data specialists and democratising data analytics.

On the horizon

There is little doubt, that 2020 has proved to be the most pivotal landmark across all industries, and particularly for the healthcare world. As the industry painfully realised the importance of data and analytics in harsh circumstances, this allows the opportunity for technology to spearhead a new frontier for healthcare. As the complexity of data increases, it is imperative to adopt both descriptive and predictive analysis, while embracing ML and NLP to obtain the necessary information. Nonetheless, the healthcare sector must remain inquisitive and progressive. By asking the right questions and applying the right technologies, data and analytics can help solve some of our toughest, shared challenges.

On day one of Omnia Health Live Americas, Kaveh Safavi, Senior Managing Director, Global Health Practice, Accenture, gave the keynote speech on ‘What does the consumer think about digital health?’

He focused on consumers and digital health and a recent research that shows a very interesting phenomenon, which is that digital health while very appealing to consumers has shown some stalling in its adoption.

We are all counting on digital health to making healthcare more accessible, affordable and effective. But simply the availability of digital health by itself isn’t going to be enough. It is important to understand why and how people use digital tools and what is necessary to fulfil that promise.

In a research conducted at the end of 2019, it was found that there appears to be a plateauing in consumers use of digital health overall. There are three drivers of this plateau:

1. If an individual has a bad experience, they are less likely to come back the second time.
2. If you don’t trust who has your information or what they are going to do with the data.
3. If the providers don’t recommend the use of technology, consumers won’t use it.

Safavi said that but when COVID-19 showed up it accelerated digital healthcare. He shared that in the U.S. around the end of 2019-start of 2020, around 5 per cent of all patient encounters was being done over a virtual platform. By May, this had reached almost 50 per cent of all visits being conducted virtually.

“There were a lot of reasons for this but one of the most important is that it was forced adoption, there were no alternatives,” said Safavi. “Other factors for the increase included the healthcare insurers decision to pay for virtual visits. Also, license laws were liberalised. Clinics opened in June and there has already been a reduction in virtual visits and the number of physical visits has increased. The real question is where will that number stabilise? Our research suggests it might be 30 per cent.”

He concluded by saying that today it is not just a physical or digital world but a blended physical and virtual world and recognising that it is a blending and not a transition is a critical part of the overall process.

Digital first

At the ‘Leveraging digital health to predict and manage future health crises’ session, Carlos Otero, CIO - Hospital Italiano de Bueno Aires, highlighted that COVID-19 completely transformed the way people were seeking consultations at his hospital. Telehealth is not only important for physicians and patients, he stressed, but also for other departments within a hospital. “Therefore, we need to change our infrastructure, and the way we provide systems to operate in the new normal,” he added.

While Nick Guldemond, Professor of Integrated Care and Technology, Sechenov First Moscow State Medical University, said the digital uptake in healthcare during COVID-19 skyrocketed. Currently, there are interesting applications in digital health in different disease areas such as mental health, cardiovascular risk management and diabetes, among others. But these are usually standalone solutions.

“If you are thinking about efficiency and quality of care, it’s more a matter of how you plan and organise and work together, rather than having only a one-to-one context with the patient or with a colleague,” he stressed. “This would involve health communication with primary care providers and social care providers and work together as a team. While the perception is that digital might contribute to better outcomes and quality of care, in many countries that is still not the case. We still have a long way to go in order to make digital work for people with complex diseases.”

However, he emphasised that there are some promising developments in store. There are various platforms combining different elements of the healthcare system such as diagnosis, triage, patient navigation etc.

The 1st Middle East Advisory Board Meeting for Medication Management and Safety took place in Dubai in February. The Board for Medication Management and Safety set itself the following objectives during its first meeting:

• Review the region’s current medication management landscape, identify specific challenges, and propose solutions.
• Assess the impact of tools that may add transparency, and safety to the medication chain.
• Discuss opportunities to create a regional data consortium, to publish findings, and create educational materials for dissemination across the region.

The Board is composed of individuals with a wide scope of experience, and we quickly found that there are common themes running through our current interests and areas that we feel will be important for Medication Management and Safety in the near future.

Common themes important for medication management

A broader definition of medication error

The group adopted a working position that the most useful definition of medication error for our examination of end-to-end medication management and safety in the region is that of the National Coordinating Council for Medication Error Reporting and Prevention, which defines a medication error as, ‘any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer… including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use’.

This definition is felt to be particularly useful as it has a taxonomy of error type and categorisation of error cause.

The group reached a consensus that medication errors can occur throughout the whole of the process, from supply issues requiring substitution medications through to administration, and that any change in the process allows an opportunity for deviation from administration practice and for medication error. Deep integration of medication management processes with the Electronic Health Record (EHR) and the use of ‘exceptions’ or medication ‘enrolment’ first on the EHR core system (to act as the true reference for the change) and only then on the Computerised Prescriber Order Entry (CPOE) system’s formulary, and the formularies of Automated Dispensing Cabinets (ADC) and Smart Pumps is suggested by the group as the optimum option for managing substitutions and dose unit changes.

Participants at the first Middle East Advisory Board Meeting for Medication Management and Safety

‘To err is human’ and bridging the gap

Medication Management, despite technology application, remains a human process and we recognise that unsanctioned workarounds to established processes from anyone in the medication chain can very quickly become a potentially dangerous and unauthorised ‘standard practice’.

With this in mind, ‘transparency’, and how systems we create for Medication Safety and Management can both uncover and catch discrepancies between what is prescribed, dispensed and administered, was reviewed. Key features of a transparent system are:

• Verification of all prescription orders in the pharmacy.
• Control and tracking of high-value and high-risk medications via the EHR.
• For opiates, it is suggested that system-wide order sets and EHR protocols that use morphine-equivalency measures during prescription and reassessment of pharmacotherapy regimens are of value, with an integrated ADC’s single unit-dose dispensing facility, and low-dose single administration units (e.g Morphine 5mg prefilled syringe) acting as controls on administration.
• Employment of the technology of GTIN/GS1 barcoding in tracking medication usage allows serial, batch, and lot numbers to be identified throughout the medication chain, down to administration to the patient. Integration of medication inventory systems into the EHR also allows accurate tracking of medications entering ng the organisation, and whilst not all medications sourced in the Middle East are GTIN/GS1, it is our experience that over 70 per cent and up to 100 per cent of the medications entering our facilities are. The potential impact this has for reducing expired medication waste in a facility is very large.

Engaging the patient

Returning to the theme that Medication Safety and Management is ‘human’, the Board recommends reaching out to patients via personal health records held in part by the patient, such as Malaffi in Abu Dhabi’s Health Authority, and through other patient applications to improve reporting of issues by patients and to help our understanding of Adverse Drug Events in outpatients and outside of the hospital. Patient engagement is a key aspect of medication safety and has the potential for making a significant contribution to improving compliance with medication regimens and with medication reconciliation processes. In terms of patient compliance and satisfaction, we suggest the following as useful initial strategies drawn on the experience in our facilities:

• Reducing times between refills by reducing the dispensed amounts at each visit.
• Texts to remind patients for medication self-administration, appointments, and tests.
• Delivery of medications to homes.

The engine room of the hospital

Turning to IV Medication Safety and Management, we first reviewed compounding, and the pressure faced by pharmacies supplying up to 600 batches of IV medications daily in larger facilities. Batching is commonly undertaken by technicians supervised by a cleanroom pharmacist, and the technician follows a ‘recipe’ from the EHR. The pharmacist checks the ingredients, and the technicians proceed to create a batch of doses with these ingredients. We feel the weakness here is that the technicians may not achieve the correct dose in each batch, with under/overdosing possibly occurring in each individual dose made.

It was a common experience among board members that batching forces multi-tasking pharmacists into a position of witnessing only complex steps and accepting that simple steps will not be witnessed for lack of time. In terms of cost/waste, any error made in batch preparation, even if found in only one prepared medication, requires that the entire batch be destroyed and started over.

We recognise that physical and mental fatigue among pharmacy technicians is a very real reason for medication error; again medication management is a human process. With this in mind it is vital that technology we deploy in the cleanroom, as in all medication safety systems right down to the bedside, must help the user but also STOP the user from continuing in a dangerous manner. Lack of knowledge is not commonly the cause of medication error, most errors are ‘performance slips.’ Technology generated Hard Stops are, therefore, vital.

IV medication administration safety

Moving out of the central pharmacy, we believe it is possible for senior pharmacists to continue to influence medication safety across the facility through technology and through human systems such as planning and therapeutics committees, with specialist groups for specific areas such as neonatology, oncology, paediatrics, and elderly care. Engaging with physicians, nursing staff, and clinical pharmacists and the sharing of results and achievements in medication safety across the organisation through these inter-disciplinary alliances is vital.

In terms of IV medication safety, we strongly advocate a cascade of medication safety from the core EHR IV formulary acting again as the central reference. This requires rapid update and alignment with the central formulary of smart pump medication libraries, and the use of dosing Hard Limits that cannot be overridden, rather than Soft Limits by the end-user for IV medication dosing. We suggest that the use of Soft Limits should be restricted, to avoid nuisance alarms, as a reduction in extra alarms that are not of value to the end-user increases compliance across the organisation in our experience.

The cascade from the core EHR formulary to the patient’s bedside should also include IV medication labelling, with appropriate warnings for high-risk medications that match the same medication’s alerts on the ADC, with the clinical advisory on the IV smart pump, and on the patient’s EHR medication administration record.

Even in a ‘joined-up’ and well-integrated IV medication safety system, it is important to recognise that new errors can be introduced into the medication safeguarding chain by these same systems; an example being the non-separation of active treatment in some EHR medication records from medication regimens that have been discontinued. It is, therefore, vital, at all times, to:

• Consistently ascertain if the system is functioning correctly and responding rapidly to changes in treatment and medication supply needs in the facility.
• Review how partial, or unfinished integration may be causing more problems than having stand-alone systems with other safety gates.

It is also important to look at how other systemic processes operating within the facility may give us information on how well our medication safety and management system is functioning. By example:

• Financial and charge systems operating within EHRs can, for example, act as an effective double-check on administration and as a discrepancy check – as the charges in the patient record would be less than expected if the drug has been dispensed but not administered.

Looking to the future

Looking forward to areas that we feel will be important for Medication Management and Safety in the near future, we feel that Artificial Intelligence (AI) systems that constantly check the system’s effectiveness against parallel data may be a ‘real-time’ solution for discovering gaps in medication safety systems, and that these should include review at any point in time of antimicrobial usage, prescribing trends, availability within the hospital group and region of medications, and the total stock available within the facility.

Enactment of the ICT Law

On 6 February 2019, His Highness Sheikh Khalifa bin Zayed Al Nahyan, President of the UAE and Ruler of Abu Dhabi signed the UAE Federal Law No. 2 of 2019, “On the Use of Information and Communications Technology in the Health Fields” (the ICT Law) which came into effect three months later. The ICT Law provides a robust framework for the protection of personal health information and data, under the auspices of the UAE Ministry of Health and Prevention (MOHAP). The ICT Law further raises some issues of consideration, particularly under COVID-19. The ICT Law applies to all methods and uses of health information within the UAE, including those pertaining to the various free zones within the UAE.

Objectives of the ICT Law

Among the stated objectives of the ICT Law are to ensure the use, security and safety of such information in the various health fields; and to permit MOHAP to collect, analyse, and keep health information at UAE-level (Article 3 of the ICT Law). The ICT Law further calls for the creation of a centralised system for the collecting and exchange of information between MOHAP, other various federal and Emirate-level health authorities, and other relevant governmental entities (Article 5).

While these Articles are broad-reaching in their wording, they indicate that MOHAP and other concerned governmental entities have the right to review and examine any health-related information which is collected and stored throughout the UAE. This has some interesting implications in the current pandemic, as it seems to support the theory that MOHAP is empowered by the ICT Law to review health data and information to better manage COVID. This view is further bolstered by Article 16(3); which says personal health information could be accessed if it is done to take preventative or curative measures directed at public health or to preserve the health and safety of a patient and any person in contact with him.

Use of the ICT law under COVID-19

This would include the power to coordinate with other governmental authorities regarding the collection of health information on citizens, residents, and tourists, and the authority to issue directives, rules, or orders relating to the frequency of testing, quarantining, and the monitoring of movements of persons or group congregation throughout the UAE. All of the measures that the UAE has undertaken to combat COVID-19 have been done with the support of the ICT Law (in addition to other laws, regulations, and orders).

As a result of the powers granted the authorities under the ICT Law and other legislation, the response of the UAE to the COVID-19 pandemic has been recognised globally. It has been ranked as one of 11 countries with the best responses to COVID-19, with a low death count resulting from its proactive measures.

Protection of personal health information

Article 13 codifies the long-standing (but largely informal) healthcare practices in the UAE. Article 13 states that health information relating to health services provided inside the UAE cannot be stored, processed, generated, or transferred outside of the UAE. An exception is made where the relevant health authority has issued a decree in coordination with MOHAP.

Virtually all the electronically generated, stored, or archived health records across the UAE are password protected.  It is quite difficult—if not impossible—to transfer health information recorded on CD-ROM or other formats to a recipient via electronic mail.

Potential ramifications and solutions

However, Article 13 raises some potential questions and concerns. For example, cloud-based healthcare solutions that are hosted outside of the UAE, outsourcing of IT or network solution abroad may be implicated by Article 13—as well as healthcare apps or medical devices which monitor a variety of healthcare information of patients in the UAE (e.g., heart rate, blood pressure, arousals in sleep) and transmit such information to servers overseas. While much of this technology is readily available in the UAE, device manufacturers and app creators are likely to request greater clarity and detail—which may come in the form of future executive regulations (as contemplated by Article 29 of the ICT Law).

Furthermore, it is unclear if Article 13 is intended to affect the provision of telemedicine services. These would include acts such as a videoconference between a specialist doctor abroad and a patient in the UAE discussing a diagnosis or a protocol to treat an existing disease—or the review of a medical report generated in the UAE by a non-resident doctor for purposes of providing a second opinion. In the past few years, telemedicine services have been introduced into Abu Dhabi and Dubai—and have been limited, suspended, and modified since then (with the current trend being the licensing of a full spectrum of telemedicine services) As a nascent area of medicine (and law), all of the issues surrounding the provision of telemedicine services are still unclear.

Accordingly, there have been Emirate-level telemedicine laws and regulations issued by various health authorities (e.g., Dubai Healthcare City, and the Health Authority of Abu Dhabi). The various legislation enacted by the authorities has emphasised personal consent in the transmission of personal health information and data to specialist clinics and doctors outside of the UAE. However, the ICT Law is federal legislation and would supersede any telemedicine laws of the various Emirates in case of a conflict (assuming there is one).

A holistic approach to treating COVID-19 and other diseases

In the current climate, it seems more likely that the ICT Law will not interfere with the diagnosis or treatment of patients by competent and qualified doctors who practice overseas—and this may likely be bolstered by executive regulations to this law. The UAE’s continuous and progressive focus on smart technology and applications will likely see Emirate-level telemedicine laws and regulations as ratified or incorporated into a future legislative framework under the direction of the UAE federal government. Currently, this may help give COVID-19 patients here in the UAE access to cutting-edge drug therapies or protocols from doctors around the world (assuming, additionally, no effective or safe vaccine will be created in the near future). These patients can then work with their doctors in the UAE on effective treatment strategies.

Saladin Aljurf

Telehealth is nothing new. Derived from the Greek word for “far”, telehealth has been around since the invention of the telephone. Since then, thousands of innovative technology-enabled remote-care solutions have been invented and registered around the world, with national healthcare systems and large providers starting to develop targeted digital strategies in the early 2000s.

This strategic shift toward telehealth approaches saw providers move 5-10 per cent of their consultations to virtual platforms. Early adopters were quick to recognise the benefits of telehealth solutions: an immediate improvement in patient access, particularly in rural areas; a reduced burden on hospitals; and greater multi-disciplinary cooperation between remote healthcare professionals.

However, up until 2020, the speed of technology uptake was held back by several factors, such as the slow development of reimbursement solutions, and the lack of research into the safety and efficacy of telehealth interventions. Uptake was limited by slow provider adoption, the nascent regulatory framework, and by the significant investment required to make telehealth solutions work. In addition, patients themselves were still unfamiliar with telehealth, and many lacked the access to the infrastructure needed to support it.

Now, 2020 marks a critical turning point for the telecare industry. As the COVID-19 pandemic has spread around the world, telehealth has come to the fore as an intuitive solution for outpatient care. Providers, payers, and regulators have joined forces to ramp up capacity, expand the range of services they offer, and deliver them to the population. Many providers have even set up fully remote treatment pathways for chronic conditions, covering the entire healthcare journey from teleconsultation, to home visits by a phlebotomist, to e-prescription and home delivery of medication and home care interventions.

The benefits and risks of telehealth

Healthcare systems around the world are working hard to improve access to high-quality care for everybody—no matter where they live. Telehealth has unrivalled potential to deliver on this goal—a patient with a smartphone can access the right specialist in the right time. By using the latest digitally enabled solutions, providers can build remote treatment pathways for all major conditions, admitting the patient to healthcare facilities for hospital interventions alone, like surgery or complex diagnostics.

Another key benefit of telehealth is its potential to reduce overall care costs by enabling early diagnosis and prevention; faster discharge of patients as they can receive their continuous care at home, e.g. remote physiotherapy; and better utilisation of specialists. But scaling up telehealth solutions too rapidly can represent a tangible risk if it’s not supported by the appropriate evaluation of outcomes and the creation of evidence-based care telehealth pathways. Without robust clinical studies, we can’t know for sure if remote interventions are safe and of the same quality as face-to-face ones. The efficacy of traditional pathways is backed by decades of research, but when it comes to telehealth, that evidence is only just beginning to emerge. In 2020, the forced ramp-up of remote healthcare during the COVID-19 pandemic will shift that balance.

Another major risk comes from the patient side: after all, the significant effort expended in rolling out telehealth services would go to waste if patients lacked confidence in their safety or lacked access to the right devices and tools to use those services in the first place. And this would jeopardise adherence to treatment regimes, putting successful outcomes under threat as a result.

Building a sustainable telehealth ecosystem

In order to be truly sustainable, telehealth systems should be based on five key pillars:

1. Evidence-based telehealth pathways. Existing clinical guidelines and treatment standards have been written with traditional care in mind. Providers need to optimise digital interventions and define their role in treatment pathways. This means they must pinpoint which procedures need to be digitalised, identify the patients that this applies to, and determine the best way to achieve this goal. This approach would also help to increase the adoption of telehealth solutions by medical professionals.
2. Robust regulatory framework. Telehealth is still evolving, so an open dialogue between providers and regulators is paramount. For some of the decisions, multiple authorities need to be involved; for example, around healthcare professional certification, e-prescription, home medication delivery. Therefore, it’s very important to have a comprehensive legal framework to ensure telehealth services are both safe and effective. In addition, countries may consider a set of policies encouraging innovation and entrepreneurship to facilitate the development of local solutions.
3. Reimbursement of telehealth services. For most countries, the majority of healthcare costs are paid for by national payers and insurance companies, with out-of-pocket spend ranging from 10-20 per cent. This means that patient demand is often curbed by the extent to which telehealth solutions are covered by their insurance.
4. Investment in infrastructure. Successfully ramping up virtual care infrastructure takes significant investment. Providers have been seeking additional government funding from initiatives like the Telehealth Network Grant Program in the U.S., which was granted US$29 million under the administration’s Coronavirus Aid, Relief, and Economic Security (CARES) Act.
5. Patient adoption. Patient experience has a significant impact on adoption, so it’s vital to ensure that designs are user-friendly, compatible with different types of technology, and backed up by qualified customer support.

What’s next for telehealth in the GCC?

The telehealth journey was already well underway in the GCC long before COVID-19 came into the equation. For example, KSA had developed an e-Health Strategy in 2010; in 2017, Dubai Healthcare Authority issued Administrative Decision Number 30 to regulate the provision of telehealth services. Since then, both the KSA and UAE have seen an increase in telehealth services. The fundamental ecosystem—including legal frameworks, essential regulations, and key solutions—was in place by the time the pandemic started. But telehealth solutions often covered just select interventions rather than full pathways, with some still in the development phase. Meanwhile, reimbursement models were still in the refinement stage—in common with those of other developed health systems at the time. The COVID-19 pandemic has led to a spike in the adoption of the technology, and an increased focus by providers and regulators on fast-tracking the shift from traditional care to telehealth.

As communities are settling into the “new normal”, GCC countries are reflecting on the future of virtual care. The results achieved to date have been very positive. But to capture the full potential of telehealth, we’ve identified some immediate actions that would enable transformation and accelerate adoption:

National public providers in the GCC, supported by government authorities, could establish a process of knowledge-sharing related to the development of digitally enabled treatment pathways for the key conditions. Ideally, Centres of Excellence should be created, with a remit to focus on researching the outcomes and publishing the supporting evidence. Patient education and patient-centred telehealth pathway design would accelerate the rate of adoption and encourage patients to stick with telehealth, rather than going back to a traditional care model in the future.

To ensure maximum coordination between authorities, providers and tech firms, National Committees and non-government organisations could take a coordination role, ensuring safety and efficacy of care and encouraging local tech entrepreneurship.

Using the latest scientific evidence, healthcare systems could facilitate the inclusion of digital interventions for the most common medical conditions into the national treatment guidelines.

National payers and private insurance companies should continue working closely with providers to identify economically viable technologies, evaluate their true financial value, and develop permanent payment models.

We are now entering a new era for telehealth—one that will create fresh challenges and opportunities for healthcare systems and patients around the world. And we have every reason to believe that new technology will help bring safe, equitable, value-based care to the population. Based on its positive progress so far, the GCC region is well placed to claim a strong leadership position at the forefront of this growing movement.

While we continue to manage through the COVID-19 pandemic, it is important to reflect on the lessons learned. The response to COVID-19 has shown us that organisations with a commitment to- and competence in- quality, patient safety and accreditation are better prepared to effectively manage through a crisis. Published reports from around the globe continue to demonstrate the value of quality, safety and accreditation, providing a framework to guide healthcare facilities as they recover and rebuild. This pandemic should be a catalyst for innovation, to move into the next generation of quality and safety.

Role of quality and accreditation during a pandemic

Emergency management frameworks are based on the cycle of PREPARE, RESPOND, RECOVER and MITIGATE. Health systems that applied quality improvement and patient safety principles managed successfully through each of these phases.

For example, during the prepare phase, the use of prioritisation matrices such as the hazard vulnerability analysis provides a systematic approach to plan for potential hazards. South Korea illustrated this by using the lessons learned from their experience with MERS in 2015, implementing updated emergency plans when COVID-19 arrived.

When responding to disasters, organisations need to prioritise safety, to address threatening conditions and reduce risks of harm. COVID-19 made very visible the risks to both patients and healthcare workers from communicable diseases. A September 2020 World Health Organization (WHO) report identified that 14 per cent of COVID-19 cases are amongst healthcare workers, as high as 35 per cent in some countries. Hospitals with effective infrastructures and procedures for infection prevention and control were able to pivot their attention toward managing this novel virus.

The purpose of the recover phase is to learn from the organisation’s initial response to the emergency, then strengthen their processes to enhance organisational performance during the next emergency. By applying quality tools such as listening to the voice of the customer (patients and staff), conducting root cause analyses, collecting data, implementing corrective actions, organisations can improve their processes to be more effective. Multiple examples of process improvement – for patients, staff and organisations – have been published, including cohorting COVID-19 patients, reuse of Personal Protective Equipment (PPE), and collaborative communication.

Mitigation activities reduce the likelihood of occurrence or reduce the damaging effects of unavoidable hazards. The use of telehealth services and plexiglass separations are mitigating actions that use human factors engineering to remove or reduce the risk of viral transmission.

How has accreditation supported organisations during this pandemic?

Joint Commission International (JCI) standards provide healthcare organisations with an evidence-based framework, a toolkit of best practices that support and guide organisations to provide high quality, safe care during crises as well as ‘normal’ times. For example, the JCI Accreditation Standards for Hospitals, 7th Edition, require hospitals to have an emergency management plan that is maintained and tested, including plans for communicable disease outbreaks. The Quality Improvement and Patient Safety chapter define the components of a quality management programme, including the use of a standardised approach to improvement and management of safety events. In the Governance, Leadership and Direction chapter, hospitals are required to monitor their supply chains, to assure available, effective equipment and products. The importance of supply chain management has been painfully obvious during the COVID-19 pandemic, as health systems struggled with unavailable (or counterfeit) PPE, medications and ventilators.

Data from a JCI ‘voice of the customer’ survey identified the top challenge for hospitals has been managing ‘Resources and Assets’, including PPE. The physical, psychological and emotional toll on healthcare workers during the pandemic has been overwhelming. JCI standards include requirements for healthcare facilities to support the physical and mental health of their staff. Through these and many other standards, accreditation supports organisational readiness to effectively manage the challenges of a disaster.

The future is now

COVID-19 has exposed strengths yet revealed weaknesses within our healthcare systems globally. Changes that have been in development for decades, such as telehealth, were accelerated in implementation. But failures in our system – such as racial inequities, healthcare insurance coverage gaps, lack of single-source data centres – have been accentuated. It is time to reframe quality, safety and accreditation.

With the digital transformation, we are all experiencing through the expansion of technology, the next generation of quality – Quality 4.0 – has arrived for healthcare, as it has for other industries. COVID-19 has reinforced the criticality of quality and the need to incorporate technology, including the use of available data sources and advanced analytics. The literature on Quality 4.0 focuses on understanding and managing context when approaching a problem: leadership, culture, diversity, adoption and implementation. The quality professional needs both technical skills as well as the ‘soft’ skills of change management, communication and teamwork.

Over the past decades, healthcare has made significant improvements in patient safety. But our progress has been limited; harm still occurs globally at a high rate. According to the WHO, one in 10 patients are harmed while admitted to hospitals. Now is the time for a cultural transformation across the globe, to move healthcare toward high reliability and zero patient harm. Joint Commission has studied high reliability in healthcare, and identified three necessary pillars:

• Leadership that is committed to safety, setting the strategy and providing resources;
• Organisational culture focused on safety – for patients AND healthcare workers – as the priority;
• Performance Improvement, a data-driven approach to problem-solving, with all staff trained in the science of improvement

Now is also the time to revaluate accreditation, to recognise its multifaceted roles. COVID-19 has demonstrated the value of accreditation – to our patients, our communities and our healthcare staff. The JCI standards provide healthcare organisations with evidence-based guidance for continuous improvement. The accreditation process itself provides an assessment of performance, identifies opportunities for improvement, offers best practice recommendations, and inspires change. In our current crisis, accreditation offers the support that healthcare organisations need.

Conclusion

The risk of a global pandemic such as COVID-19 has been anticipated for decades. Healthcare has more tools available now than ever including advancements in clinical medicine, public health, technology, quality- and accreditation. There is evidence that this pandemic can be successfully managed with the application of quality tools and principles. Navigating into our changed world will require a renewed commitment to accreditation. These are the safeguards for the future of our global health.

Dr Leonhardt will be speaking at the ‘Quality, safety and accreditation in our changed world’ session on Saturday, 7 November, at the virtual Patient Safety