Digital image management in a globalised world: opportunities and challenges
Department of Biomedical Imaging, Faculty of Medicine,
University of Malaya, Kuala Lumpur, Malaysia
Good health for all populations is an accepted
international goal , and there have been broad gains in life expectancy over
the past century. However, the perspectives of how health is best defined vary
considerably, and health inequalities between the rich and the poor persist. The
prospects for future health depend increasingly on the relatively complicated
process of globalisation . In 2001, the WHO Commission on Macroeconomics and
Health demonstrated that health is not only a benefit of development, but is
also indispensable to development . Illness all too often leads to
"medical poverty traps" , creating a vicious circle of poor
nutrition, forgone education, and still more illness. All of these then
undermine the economic growth that is necessary, although not sufficient, for
widespread improvements in health status.
The promotion of health equity is defined in the
literature as "the absence of disparities in health (and in its key social
determinants) that are systematically associated with social
advantage/disadvantage". The Social Determinants of Health (CSDH),
established by the WHO, are considered the fairest and most effective way to
improve health for all people and reduce inequalities. Social determinants of
health, broadly stated, are the conditions under which people live and work
which affect their opportunities to lead healthy lives. Good medical care is
vital, but unless the root social causes that undermine people's health are
addressed, the opportunity for well-being will not be achieved.
Globalisation is a term with multiple hotly contested
definitions and meanings. And it is generally an umbrella term for a complex
series of economic, social, technological, cultural and political changes
across the globe. The most appropriate definition of globalisation would be
"a process of greater integration within the world economy through
movements of goods and services, capital, technology and (to a lesser extent)
labour, which leads increasingly to economic decisions being influenced by
global conditions" . The outcome of globalisation is the increasing
interdependence and interaction among people, companies, and governments of
different nations, driven by international trade and made possible by
innovations in information technology.
Historically, companies in developed countries have led
globalisation by pushing products and services into developing countries and
emerging economies. Now, emerging countries are pushing their services into
developed countries with quality labour and services at low cost. In short,
globalisation has become a two-way street as both sides exploit each other's
markets and economies, creating a virtual world labour and market force. . Even
though globalisation is most often seen as an economic process, the current
view of globalisation is that of a more comprehensive phenomenon. This
phenomena is being shaped by a multitude of factors and events but at the same
time is reshaping our society rapidly [7-9].
Thus the emergence of the global marketplace has taken on
the following features :
- New global governance structure � Globalisation influences the
interdependence among nations as well as the nation state's sovereignty leading
to (a need for) new global governance structures.
- Global markets � Globalisation is characterised by worldwide changes in
economic infrastructures and the emergence of global markets and a global
- Global communication and diffusion of information � Globalisation makes
the sharing of information and the exchange of experiences around common
- Global mobility � Global mobility is characterised by a major increase
in the extensity, intensity and velocity of movement and by a wide variety in
'types' of mobility.
- Cross-cultural interaction � Globalising cultural flows result in
interactions between global and local cultural elements.
- Global environmental changes � Global environmental threats to
ecosystems include global climate change, loss of biodiversity, global ozone
depletion and the global decline in natural areas.
While some may argue that globalisation allows poor
countries and their citizens the opportunity to raise their standards of
living, encourage democracy and embrace multiculturalism, others claim that
globalisation has simply allowed Western corporations to overwhelm world
markets at the expense of small businesses, local cultures, traditions and
values. Globalisation should not be seen as a process that is inherently �bad�
or �good� but rather, a process capable of both positive and negative outcomes.
The outcomes of globalisation are entirely dependent on how policies are guided
and implemented. The promotion and resistance of globalisation has taken shape
at both a popular and governmental level. It is believed that such efforts can
only hope to steer globalisation, not alter it.
Contemporary globalisation has been promoted, facilitated
and not uncommonly enforced by political choices about such matters as trade
liberalisation, financial (de)regulation, provision of support for domestically
headquartered corporations  and the conditions under which development
assistance is provided. Sadly, globalisation, to a large extent, appears to have
economically benefited the heavily industrialised countries with serious adverse
consequences for developing nations, with some notable exceptions. Several
national economies collapsed under the forced introduction of global market
economics through conditional loans granted by the International Monetary Fund
[the IMF is incidentally the primary lender of money to developing countries]. This
was evident during the Asian Financial Crisis of 1997. However, China chose to
implement its own non-IMF dictated path towards a market economy which highlighted
that implementation and guidance of a winning policy makes or breaks the
results of globalisation. What is even more important to recognise is that they
are alternative pathways for developing countries, using non-IMF dictated
policies, to allow a more gradual approach to introducing market economics. Such
notable successes would go a long way in allowing developing nations to claim a
stake on the potential profits of globalisation.
In the medical domain, irrespective of the state of
development, globalisation has resulted in the increased speed with which
information about new treatments, technologies and strategies for health
promotion can be diffused. There are also more opportunities for enhanced
political participation and social inclusion that are offered by new, potentially
widely accessible forms of electronic communication. However, it must be
recognised that it has been the �economic aspects of globalisation� of
healthcare that has been the driving force behind the overall process of
globalisation over the last two decades" 
Indeed the accrued benefits of globalisation vary between
the developed and less-developed nations and, as a result, globalisation of
healthcare raises some more serious issues, which are:
- How can countries deal with globalisation in the context of their
existing cultures, beliefs, resources and systems?
- How do we deal with the impact of globalisation on the healthcare
delivery systems of the various jurisdictions ?
- How does one cope with the massive impact on a country�s economy of
claiming a share of the economic activity that the health industries and
service sectors represent, which incidentally is the largest industry on a
global scale ?
- How can developing nations protect their indigenous treatments from being
patented in industrialised nations?
- How can the serious brain drain of the limited healthcare personnel from
developing nations toward the industrialised West be moderated to ensure the
needy have access to the services of this invaluable resource?
- What mechanisms should be in place to ensure universal access to
essential medication and basic imaging facilities?
Medical imaging may not be the only productivity driver as
digital imaging and information technology (IT) allow providers to better
manage vast volumes of data at a lower cost. When one looks at the benefits of health
IT, the logic behind such IT-intensive investments include efficiency gains,
such as enhanced transaction speed, reduced labour costs associated with the
administrative tasks � which can make up 25 percent of the overall cost �
improved patient safety, privacy and access to information. The increased
competitive environment, with the commodification of healthcare has also resulted
in the thinning profit margins putting the very survival of healthcare
facilities to the test. Many are betting that IT can produce the efficiency
gains and compensate for dwindling reimbursements. ROI [return-on-investment]
of 10 percent with increasing overall efficiency of 13 to 15 percent have been
shown when the PACs have been employed.
The prevailing perception among hospital administrators
and physicians is that implementation of IT will also provide a competitive
advantage. The better use of technology and interoperable electronic networks
should accelerate integration, standardisation and knowledge transfer of the
administrative and clinical information, especially in the context of the
globalisation of healthcare and efforts in many countries to create a
sustainable health system .
With the increased competitiveness in the healthcare
industry, both nationally and regionally, the issue of data management is a vital
consideration for success in this globalised digital world. Only two elements
exist in a connected world: the customer and the information . The key to
the former lies in managing the latter. The use of data mining of electronic
patient data generated by IT systems such as PACS and RIS, along with
analysis/trending by charge codes, has also been promoted to help justify
healthcare�s increasing reliance on medical imaging. There is a trend toward
using IT solutions and sophisticated practice management tools, be they Web
solution, real-time data mining or dashboards, to help them manage their
practice as a business. This would make key business data seamlessly available
for decision support that could cut costs by identifying and managing process
inefficiencies and track revenues to improve business. This would allow
organisations to track revenues by exams vs. charges; planned vs. actual
scheduling; referring physician trends � where are referrals coming from?;
referral market trends � measure referrals by zip codes and demographics;
staff efficiency � average and individual, track productivity �
volume trends; incomplete exam work � unfinished exams affect your bottom line
and efficiency; accounts receivables � average payment periods; and total
patient time � how long does it take to get the report to the referring
physician? . Ultimately, it is hoped that such use of data-mining would
result in better outcomes, more cost-effective processes and overall improved
healthcare. The current scenario where the information is stored in different
�silo� or databases with different software and operating systems makes this
all the more impossible.
It has been promoted that information technology will
allow a significant proportion of healthcare services to be offshored. Many of
the leading healthcare technology vendors have significant or growing overseas
operations, while others are contracting for these services. The future of
healthcare outsourcing and offshore services will vary across the provider,
payer, and supplier sectors. The jury is still out, since major challenges
occur when one looks at issues of cross-border transfer of digital image
information, whether for purposes of reading or management. This is, in part, due
to the highly regulatory environment and national compliance requirements. The
promotion of cost reduction and savings for using offshore services in
healthcare should not by themselves be solid business grounds for offshoring. It
is essential that organisations consider the use of offshore services as a
strategic tool which must be integrated with their business model e.g. would
these offshore services support and improve the organisation's overall ability
to deliver quality services? Would patient safety or improved care delivery
efficiencies and service levels get better?
On the downside, the implementation of such sophisticated
healthcare information technology systems are a heavy initial investment that come
at a hefty price. Several solutions have been proposed to overcome this. The
use of a Web-based platform or application service provider solutions may be a
way for organisations to cost-effectively utilise these solutions to provide
high-quality patient care. Application service provider solutions shift the
burden of technical support away from the organisation, allowing them to focus
on their core competency of healthcare so as to spread out the costs over an extended
period of time. Upgrades or changes to the systems to stay current come with
risks and inconvenience to the users who have to learn to use a variety of
different log-ins, platforms and formats to access the data. In addition, the
increased frenzy of mergers and acquisitions between organisations, big and
small, raise additional issues of integration of the digital management systems.
This further adds to the cost and complexity of managing the outcomes with a possible
decrease in the quality of services of the smaller entities as those systems
are slowly phased out with no possibility of any upgrades.
Even though branding is very often used to sell products
with no real value beyond that perceived by the buyer, the promotion of vital
and good technology i.e. digital image management, in the bigger picture may be
pointless unless its �brand� is perceived to be of value and requires the
necessary buy-in from governments, professionals, managers and the public.
Therefore the use of price as the sole criterion for success in the
information-based industry may not be enough  as the tools for conducting
business electronically are low. Even though the image reads being performed by
expert radiologists in India of images from either the US or UK may be as good,
if not better, than those of their countries of origin, the lack of �branding�
by the offshore readers is a major hindrance resulting in numerous
unsubstantiated claims. This is in contrast to the image reads being done in
Australia, for instance, where these same issues are not raised.
With the growing trend in healthcare toward higher
operational costs, reduced reimbursement and heightened competition among
imaging service providers, healthcare facilities must carefully plan capital
equipment acquisitions and budgets. Many of today�s high-end modalities such as
CT, MRI and PET/CT are multi-million dollar purchases that require strategic
planning for implementation as well as detailed marketing initiatives that can
help maximise utilisation. Increasing the efficiency of radiology � from the
technical to the professional component � is a key factor in maximising utilisation
of nearly all diagnostic imaging modalities. Accomplishing more with less,
particularly with a shortage of radiologists, and in some areas, technologists
is an operational reality. Data mining RIS/PACS and CPT code analysis may help
justify healthcare�s increasing reliance on medical imaging, despite reduced
A survey of hospital management by the PricewaterhouseCoopers
Health Research Institute in conjunction with the Healthcare Financial
Management Association (HFMA) found that the three most frequently cited
capital projects slated for the next five years are all IT acquisitions: 71.7 %
for digital radiology systems, 64.1 % for computerised physician order entry
systems and 61.3 % for major IT systems .
As the sum of the parts is larger than of the sum of each
individual piece combined, the benefits of digital image management will only
accrue if it can be made available across various platforms (HIS. LIS, PIS,
ect) within the same institution, across institutions and ultimately across
borders. It is interesting to note that all the disparate digital information
systems that make up the Total Hospital Information system (THIS) have been
developed independently by the various suppliers for hardware e.g. the
Laboratory Information System (LIS) was developed by the people who
manufactured and supplied the laboratory instrumentation and it was developed
based on the operating software running on all these very different pieces of
equipment. As the size, number and complexity of the equipment grew larger, the
�fixes� needed became even more mind boggling. Essentially the difficulty of
developing common operating standards suggests that the proposed benefits for
most institutions is yet to come.
The benefits of information technology in healthcare are
widely recognised and have been promoted in industrialised nations against the
background of escalating costs of healthcare, increased competitiveness,
changing demographics and different disease patterns. However, the relevance of
IT in healthcare in developing nations, where the basic healthcare needs have
not been met, has not been clearly defined. Very often technology is promoted
as the saviour to overcome a myriad of challenges faced by developing nations
and technology is seen as an end in itself and not an enabler for a larger
purpose. Nations are often seduced into acquiring expensive technology because
it is seen as sexy! Or technology is acquired as a marketing tool to convince
the public that this is the �happening� community or hospital at the forefront
Would the accrual benefits highlighted for the developed
nations be applicable? At what level, and at what cost? What models will be
most appropriate for this wide range of development states? What level of
technology would be most appropriate? What would be the prerequisites that
nations should possess, if information technology in healthcare is to deliver
on its potential and promise? Is the promotion of healthcare information
technology relevant? Are doctors to be equally blamed for these excesses as a
result of creative marketing? We may not have the answers today, but certainly,
these are issues that we must come to sooner or later.
The convergence of economics, culture and politics is
happening around the globe. Globalisation is causing profound and complex
changes in the very nature of our society, bringing new opportunities as well
as risks. Therefore, to truly comprehend the interconnected nature of a
globalised world, to truly understand the consequences of our policy choices,
and to truly grasp the new face of the world, all of us need to understand how
globalisation works, what are the policy choices we are facing, and what are
the consequences of such choices. While thoughtful, deliberate, and innovative
leadership is necessary to help shape globalisation, the process itself is
inevitable, even if the final form may be very different.
Globalisation is causing a growing concern for our health,
and the intergenerational equity implied by 'sustainable development' forces us
to think about the right of future generations to a healthy environment and a
healthy life. Even though we are unable to predict the future, we have an
opportunity to shape our operating systems and determine the future scope and
design of our healthcare systems. The need to balance healthcare costs while
providing high-quality care and universal access is nothing less than an
exercise in leadership for this 21st century .
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|Received 24 March 2008; accepted 18 April 2008
Correspondence: Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: firstname.lastname@example.org (Basri J.J. Abdullah).
Please cite as: Abdullah BJJ,
Digital image management in a globalised world: opportunities and challenges, Biomed Imaging Interv J 2008; 4(4):e26