The April classified advertisement is a little scary, seeking a “systems engineer,” listing a dozen profoundly technical skills an applicant should have in order to gain the $65,000-$77,000 position at the Health Services Authority.
Managing patient and doctor records; databases; pharmacies and labs; an inventory of assets from furnishings to equipment and medicines; financial accounting; labor; scheduling; kitchens; laundry; a vehicle pool; repair and maintenance of an enormous physical plant and ensuring uninterrupted power supplies – and doing it for not just the Cayman Islands Hospital, but also the Brac’s Faith Hospital, the Little Cayman Clinic, five district health centers, a dental clinic and an eye clinic, means an HSA “systems engineer” has to navigate a host of complex technologies.
The ad mandates an “in-depth technical knowledge of managing server computing in an enterprise environment of at least 400 PCs,” and requires a candidate to have a university degree, eight years’ post-graduate experience and industry certification in at least two areas: “Cisco networking, Microsoft systems, IP telephony and storage systems engineering.”
And lest applicants take these antecedents too lightly, the ad says they “must have above-average interpersonal skills.”
The technology making modern medicine possible is not just systems management, but, of course, encompasses continually evolving, increasingly sophisticated and often wildly expensive equipment – for diagnostics, for operating theaters, for critical treatments like dialysis, and for relatively standard procedures like imaging, IV infusions and blood pressure.
Dr. Yaron Rado, radiologist and chairman of the board at CTMH Doctors Hospital, says it costs “millions” annually to stay abreast of the technology driving both healthcare and marketplace competition.
“We do a lot of everything to stay abreast,” he says. For example, when he and his group of doctors and independent investors bought the hospital for approximately $30 million in mid-March 2016 – after four years of due diligence and planning – “every patient file was on paper, and we invested more than $1 million in ‘Medworx,’” a high-speed server infrastructure for patient and materials management.
“It was a lot of work, not just in terms of money, but the time of staff. We are planning to upgrade to a 10-gigabit network,” he says, adding “we run a full antivirus and high-security firewall system to protect our patient’s data,” acknowledging that “hospitals are in focus to phish data from and we have a proactive program to undermine the threat.”
To upgrade accounting systems, Dr. Rado says, required a team of accountants working “double time” for “over a month.”
The task, he says, was “immense, to change the infrastructure and focus.”
At East End’s Health City Cayman Islands, Director of Business Development Shomari Scott says “the hospital is run by several systems in various areas. There are bespoke technological solutions that run the medical records and billing departments, for example, as well as appointments and other administrative functions.”
He pointed to computer control systems making the hospital itself a “smart building with regard to energy consumption, and several conservation features,” offering a broad concept of integrated networks: “The vision of Health City is to become a medical ecosystem, in that we will have many integrated touch points.”
Looking specifically at medical technology is an entirely separate job, largely handled at Doctors Hospital by an eight-member Digital Transformation Committee. The panel’s decisions determine not only levels of investment, but – for years into the future – the direction the hospital will take.
“We are looking at where we are and what is right for us,” Dr. Rado says, from the 2015 $5 million purchase of a 3 Tesla, 3-D magnetic resonance imaging machine to a ”Genius” 3-D digital mammography machine – costing between $400,000 and $450,000 and using half of the radiation of more traditional machines – to simply ensuring stable online connections between patients, their doctors and hospital administration.
Health City clinical director, chief cardiothoracic and vascular surgeon Dr. Binoy Chattuparambil says, “It is vital that every hospital stays up-to-date in all of the medical specialties that they offer. It is very much the same for us.
“Major expansions and acquisitions are built into our capital-expenditure budget, which is developed via a process with the senior executive team and the doctors in which they project which new technology and procedures they intend on offering in the coming year based on our strategic plans.”
Those plans are shaped by Health City’s mission as an advanced tertiary-care center, designed for multinational medical tourism “so we have always had to have the technology and medical expertise on board to meet that expectation,” Dr. Chattuparambil says.
While the CTMH Doctors Hospital committee reviews purchases of equipment, Dr. Rado goes out and finds it. As a radiologist, his focus is mammography, both 2D and digital 3-D, CT scanning, MRI and interventional radiology; though, according to his Doctors Hospital profile, “he strives to implement the latest and most advanced state-of-the-art technology in the hospital.”
“Conventions,” he says. “I’m a radiologist, and I attend conventions.” Annually, he goes to “one big one in Vienna,” the European Congress of Radiology, and “the biggest one” in Chicago.
“I see 50,000 radiologists, and 250,000 others” in Chicago, he says, studying computed radiography, computed tomography, magnetic resonance imaging, ultrasound, nuclear medicine and angiography – and newer technologies such as PET/CT, diffusion weighted MR, cardiac CT, and virtual colonoscopy.
In East End, the roster of equipment and technology is startling, an April 24 press release, marking the hospital’s fourth anniversary, offers an indicative list.
Last year, it says, “the hospital became the Caribbean’s only regional center for an advanced form of life support called extra corporeal membrane oxygenation,” essentially an artificial respiratory and circulatory machine, “allowing the patient’s organs to rest while natural healing of the affected area takes place.”
Health City doctors performed the Caribbean’s first “cryoablation,” treating atrial fibrillation by “introduc[ing] a deflated cryoballoon into the heart,” then circulating a liquid, which cools and dilates the balloon, and then freezes whichever structure it is put into.
Also in 2017, the release said, Health City was the first healthcare facility in the Caribbean, Central and South America to implant a cardiac contractility modulation device for heart failure.
“Currently offered in the U.S. on a clinical-trial basis only, CCM does not affect cardiac rhythm directly. Rather, the aim is to enhance the heart’s natural contraction sustainably over long periods of time,” the release says.
“This is the first time we have introduced this device in the entire Caribbean,” said interventional cardiologist and electrophysiologist Dr. Ravi Kishore. “In the U.S., it’s an investigational device so it’s not routinely implanted in patients in the U.S. and none has been implanted in Central America and South America.” Shomari Scott adds that the procedure is approved in Europe and Australia, so is not “experimental.”
Elsewhere, he says, Health City orthopaedic surgeons used a telescoping magnetic nail device in the region’s first limb-lengthening surgery, making it “less invasive and painful for the patient.”
“We are continually striving to improve both the outcomes and the experience for our patients through medical innovation and technology,” Scott says.
CTMH Doctors Hospital’s 20-plus doctors and medical staff also keep up with industry journals as “part of their continuing medical education, something we need to be part of,” Dr. Rado says.
But it all requires “a lot of investment.” He is reluctant to specify what the hospital spends annually, saying only “it’s millions.”
“Medicine,” he says, is relentless, “and if you stop investing, you go nowhere. Capital investments are huge if you want to do first-class medicine and we are looking at every financial model to raise more money.”
At last month’s board meeting, he says, “it was all we discussed.”
Scott laments how difficult it is “to describe how Health City remains current and on the leading edge in healthcare, as it is just a core aspect of what we do. If you are committed to providing high-quality care and excellent outcomes, it is just something you have to do.”
Like Dr. Rado, Scott hesitates to reveal investment figures or equipment budgets, saying only that Health City’s financing from its Bangalore, India, parent company Narayana Health “has been substantial,” reflecting “the confidence” of founder Dr. Devi Shetty.
“Of course,” Dr. Chattuparambil says, “Health City has an annual budget for equipment and acquisitions, as well as further developments to the hospital complex. For example, one major project currently on the horizon is the development of a cancer center to include radiation therapy – which we do not currently offer. The cancer center is perhaps one-and-a-half to two-and-a-half years off.”
Most of CTMH Doctors Hospital’s equipment is supplied out of the U.S. According to www.medicaldesignandoutsourcing.com, a leading chronicler of medical-device manufacturing, eight of the globe’s top 10 medical-equipment manufacturers are American, led by joint Ireland-Minnesota Medtronic, with divisions addressing cardiovascular disorders, diabetes, spinal and biologics, neuromodulation, surgery and cardiac-rhythm disease.
No. 2 is New Jersey’s consumer-goods and medical-device giant Johnson and Johnson, which manufactures orthopaedic, cardiovascular, diabetes, vision-care and surgery products.
No. 3 is joint Netherlands-Massachusetts-based Philips (Healthcare), which creates medical lighting and products for anaesthesia, oncology and cardiology.
No. 4 is Chicago-based GE Healthcare which makes diagnostic equipment – including CT image machines – and makes patient-monitoring systems and biopharmaceuticals.
The No. 5 and 6 spots belong to Germany’s Fresenius Medical Care and Siemens Healthcare.
No. 7 is Ohio-based Cardinal Health, which supplies pharmaceutical and medical-device products directly to hospitals internationally, specializing in wound care, surgical, laboratory, over-the-counter and home-healthcare products.
No. 8 is New Jersey’s Becton Dickinson, which makes medical devices, laboratory instruments and diagnostic products for hospitals, laboratories and clinics globally.
No. 9 is Illinois-based Baxter International, a Fortune 500 healthcare company specializing in renal diseases, haemophilia and immune disorders, complemented by IV and irrigation products, surgical care, blood-purification therapies and infusion pumps.
Finally, No. 10 is Michigan-based Stryker Corporation, another Fortune 500 company, and specializing in medical technologies, marketed directly to doctors and hospitals. The company started manufacturing hospital beds 60 years ago, ultimately expanding into medical, surgical, neurotechnology and spine products, including implants for joint replacement and trauma surgeries; surgical equipment and surgical-navigation systems; endoscopic and communications systems; patient handling and emergency medical equipment; neurosurgical, neurovascular and spinal devices.
Dr. Rado says equipment is procured in two ways – and both through the hospital board, which also works in two ways: As part of a regular procurement program, a sort of “recurring investment, just to keep up-to-date,” he says, citing new software as an example; or as a “one-off” whereby the hospital takes advantage of spot markets in fresh technology.
The board’s two options play into the tandem choices for procurement itself: standing arrangements with a single manufacturer – such as software updates for existing equipment – or on a sort of freelance basis, a “best of breed,” Dr. Rado says, as the hospital seeks “top-of-the-line equipment.”
CTMH Doctors Hospital’s 3-D digital mammography system, for example, comes from Massachusetts-based Hologic, ranked at 33 among global med-tech suppliers, and its MRI machine comes from GE Healthcare, No. 4 on the global list.
By going through #33 Hologic for its mammography system, however, instead of, for example, GE Healthcare, Dr. Rado says the hospital procured the machine “two years ahead” of everyone else.
The hospital’s top-ranked ultrasound machine is GE’s “LOGIQ E9 with XDclear,” which claims to “deliver extraordinary image quality on a broad spectrum of patient body types,” enabling doctors to “visualize blood flow without the limitations of Doppler,” to “enhance work flows,” and to “integrate real-time ultrasound with previously acquired CT, MR, PET or ultrasound images.”
Health City appears largely to embrace the “freelance basis” and “best of breed” option employed by CTMH Doctors Hospital.
“There is no one region, country or company that supplies most of Health City’s medical equipment,” Scott says. “We maintain good relationships with global suppliers of medical equipment and work with them to acquire the best of available new technology.”
Companies from Switzerland, the U.K., France, Sweden, Spain, Germany and Japan comprise 14 of the world’s 35 largest medical-technology manufacturers.
And, again, Scott says, “the training and expertise of the doctors and surgeons involved is vital in these partnerships.”
Dr. Rado says financing the acquisitions, that “millions annually to remain up-to-date,” is funded by the hospital itself.
“We are investing all the profits back into the hospital,” he says, rebuffing rumors of financial problems: “The word on the street is that we are in trouble,” he says. “We are not.
“We bought the hospital in a profitable state and it’s making money.”
He is tight-lipped about plans, saying only that “we are investing heavily in all products and are looking into different services that are not yet on the island.”
Both he and Scott reject fears that equipment and technology investments are among the chief drivers of rising costs for healthcare – estimated at 10 percent per year. Dr. Rado pointed to his $5 million MRI machine.
“I would say it makes it a little more difficult,” he says, “but, for example, with this MRI, we get paid through insurance fees, so we really don’t charge any more than with the old equipment.”
The hospital is aware of a free market for medical services, both next door and in East End, so controls its patient fees, hoping that state-of-the-art equipment will draw consumers, and that, he says, “gives us an edge over the competition.”
“And that, “he says, “is why we do it. In the end, it’s all about patient safety.”
Scott refers to one of Dr. Shetty’s founding aphorisms: “It’s not a solution if it isn’t affordable.”
One of Health City’s principles, he says, “is to make world-class healthcare both accessible and affordable. To increase our costs would run contrary to that mission. Rather than pass our costs on arbitrarily to patients, we employ several methods to keep our services affordable.
“For example, we use the economies of scale at our disposal due to being a part of the Narayana Health chain of hospitals. Over 30 hospitals have far more purchasing power than one small facility in the Caribbean, and this works to our advantage.”
Broadly speaking, Dr. Chattuparambil says, in the next decade Health City hopes to become “the dominant brand and player in the Caribbean from a medical perspective. We want to work with our brothers and sisters in medicine to fill all existing medical gaps from an accessibility and affordability standpoint.”
He cites another Shetty aphorism, this regarding cost controls: “In healthcare, you can’t do one big thing and reduce the price. We have to do 1,000 small things.”