Making a Difference – Global Health Technology Success Stories: Overview of over 400 submissions from 125 Countries

Health Technology (HT) is vital to global health care. The dependence of health, rehabilitation, and wellness programs on technology for the delivery of services has never been greater. It is essential therefore, that HT be optimally managed. Clinical and biomedical engineers have been recognized by World Health Organization (WHO) as essential to providing this critical management. At the 1st International Clinical Engineering and HT Management Congress and Summit held in China in 2015, a resolution was adopted by the global Clinical Engineering (CE) country participants to identify and promote CE unique qualifications, and to record the CE contributions to the improvement of world health status. Review of published literature and submissions of case studies resulted in the first group of CE success stories. The review captured 150 stories from 90 countries – spanning over a period from the prior 10 years and the results were presented to health leaders at the WHO World Health Assembly in 2016. Last year, in 2017, additional 250 case studies from a total of 125 countries were added from the 2016-2017 period. This paper describes the evidence identified during the review, their sources and the 6 major categories they represent.


INTRODUCTION
Health Technology (HT) is vital to health and the dependence of health, rehabilitation and wellness programs on HT for the delivery of their services has never been greater. Therefore, it essential that competent and trained professionals manage in an optimal and safe way for better response to the burden of diseases and resources. Trained clinical engineers are academically prepared and appropriately responsible for HT life-cycle management, fulfilling a critical role as members of the healthcare team focusing on availability and reliability of safe and effective technologies and outcomes.
Over the past 50 years growing concerns among Clinical Engineering (CE) professionals about lack of knowledge of government agencies and key stakeholders, coupled with the mute recognition for their vast contributions to the safe and effective creation and deployment of HT, led to programs that address these concerns. Knowledge about and recognition for the professionals of CE community who provide critical services will help recruit students and future practitioners into this needed field. Is CE practice important for health, rehabilitation, and wellness programs and are their contributions recognized? This paper shares the methodology and the findings identified following a three-year examination of published evidence.
Following the international congress on CE and HT management in Hangzhou, China in 2015, a Global CE Summit took place to determine whether regional issues are shared across the world and present common international challenges requiring global strategy for optimal addressing of the critical issues. After order ranking of the issues that identified at the end of the Global CE Summit, the attending members voted that there were 2 major concerns: (1) a lack of understanding of and recognition for the CE contribution to improvements in healthcare delivery.
(2) a lack of sufficient education and training for both those who would like to enter the field and for ongoing professional development. An action plan was devised to address these and other issues raised at the summit. At the second global CE summit in Sao Paulo, Brazil, in 2017, these challenges were reviewed and confirmed with attendees adopting resolutions seeking to continue to address these concerns. The action plans from the summit focused first on data collection identifying if CE contributions qualify as improvement to world health and wellness and can they be substantiated through evidence-based records. Addressing the second issue, an international survey of Body of Practice and Body of Knowledge was initiated and has been now completed.

Rationale
A task force consisting of senior certified clinical engineers from IFMBE/CED issued a global call for submissions of evidence-supported case studies of CE contributions to the improvement of delivery of healthcare services or of patient outcomes. In addition, literature survey was performed in 2016, and of both sources, the literature and the submitted studies, an aggregate volume of 150 responses from 90 countries was examined and qualified as evidence-based contributions, (see http://global. icehtmc.com/publication/healthteachnology).
Results were rated and tabulated into categories (Innovation, Improved Access, Health Systems, HT Management, Safety & Quality, and e-Technology) and incorporated into document http://global.icehtmc.com/publication/ globalsuccess that was submitted to WHO's World Health Assembly in May 2016.
We expanded our review in 2017, as submissions and publications continued to be collected, to include conference-accepted data that was presented and published at IFMBE sponsored events. Our examination methodology identified 250 additional stories from 35 more countries -now raising the total volume over 2 years to 400 publications from 125 countries. These CE success stories point to improved outcomes with benefit from HT, and present overall demonstration of complex integrated systems that must be effectively managed for their optimal and safe clinical and business impact to be realized. Clinical outcomes included change in human life quality, care management decisions support, improving 365×24×7 readiness, and improving operational efficiency.

Definitions
For the present study, we classified the collected database into 6 categories with definitions:

• Innovation
Through provision of new HT solutions, adaptation of existing, or a combination to address several issues.

• Improved Access
Ease in reaching HT-related health services or facilities in terms of location, time, and ease of approach.

• Health Systems
Positive impact from more efficient and effective deployment of HT at national or policy level.

• Safety & Quality
HT's positive impact on health services safety or quality outcomes, or through HT human resource development.

• Healthcare Technology Management (HTM)
Establishing or improving HTM methodology resulting in improved population health or wellness.
• e-Technology Improvements achieved due to deployment of Internetbased HT tools.

Measures
During the first Global Clinical Engineering Summit in 2015 the question was raised whether evidence of successful HT innovation, management, accessibility, e-technology applications, safety, and quality outcomes can be identified. To accomplish this, a successful project (or submission) was defined as satisfying 2 objective measures developed by the sponsors. These measures included timeliness, cost saving, deployment or adoption by care providers, impact on services, and overall projection for success. Each success metric was evaluated using 3-point scale against a statement representing the success construct (1= strongly disagree; 3=strongly agree).
• Timeliness refers to whether the project/submission was implemented in timely manner. This was measure by the statement "The submission will impact outcomes on present time." • The cost measure was evaluated by whether the submission's overall costs were within budget constraints and reasonable for the conditions in the region. This was assessed by the statement, "The submission cost objectives can be met in the region." • The next 2 metrics were combined into the statements "The submission will be deployed by its intended users" and "The submission will have a positive impact on those who will adopt it." • Finally, overall submission success expectations were assessed with the statement "All things considered, the submission will be a success." Innovation is the beginning of the technology life cycle where new ideas offer solutions to current problems faced by healthcare providers or their patients. Clinical engineers are well positioned to understand the current problems and guide different or new approaches to resolve them. Innovation, in our category, means to demonstrate the team approach to solving problems all the way from the concept and building of a prototype, to continuing with clinical trials, and a demonstration of compliance with standards, regulations, and intended outcomes. Improved Access to services follows the innovation stage the same as the Safety and Quality category, e-Technology category, and HTM. Products and applications that are considered in successful deployment were rated high and included in the total count for the evidence-based category. A new resource summary document of the findings -with links below -demonstrates that a benefit was registered in the 6 categories from every region around the world. The case studies -grouped in 6 categories -aim to formulate national strategies and plans to improve use of health technologies and better manage costs. In several countries, this has best been achieved by developing a HT unit at the Ministry of Health level with CE leadership. The studies provide clear evidence that HT is beneficial; at times, presenting complex systems that must be effectively guided and managed for optimal impact to be realized.

• Innovation • Access • Management • Health Systems • e-Technology • Quality & Safety
The case studies are actually Health Technology Success Stories demonstrating, in a limited resource environment, that it is desirable to include professional HT expertise, such as clinical engineers, in national decision-making in order to maximize health systems' services. Case studies from the links on the following pages demonstrate these benefits: • Access: The Ministry of Health HT Unit-led project in Albania that doubled access to critical diagnostic services, such as computed tomography scanners, magnetic resonance and angiography imaging, while reducing equipment downtime to zero, and significantly reducing cost.
• Health Systems: Improved coordination between multiple stakeholders in the National Laboratory and its satellites in Colombia, led by the Ministry of Health and clinical engineers who partner with experts from academia and industry.

• Quality & Safety:
A clinical engineer-led 122-hospital program in the Shanghai region that cooperates with officials, industry, and academic entities, resulting in improved device user satisfaction, tracking of emerging technologies, and closer partnerships with industry.

CONCLUSIONS
HT is vital to health and the dependence of health, rehabilitation, and wellness programs that rely on HT for the delivery of their services has never been greater. Beyond the ongoing healthcare burdens of population growth, political and economic instability, disease management, disasters, the refugee crisis, accidents, and terror attacks, world healthcare technological systems are facing enormous challenges to be innovative and optimally managed. The transition into health programs for the 21st century requires the employment of trained competent CE professionals. Disease prevention, treatment, and rehabilitation is more efficient and effective when health services are provided with appropriate tools. Along with World Health Organization (WHO), the International Federation for Medical and Biological Engineering (IFMBE) Clinical Engineering Division (CED) recognizes and emphasizes how important the use of appropriate, integrated, and safe health technologies (HT) is to successful outcomes for every healthcare delivery systems. In the May 2016 HT resource document that was prepared for the World Health Assembly (WHA), a recommendation was made: Health technologies must be managed to ensure full clinical benefit and expected financial return on investment.
It is critical, therefore, that with limited resources, HT must be professionally managed and its deployment over its life cycle be appropriately guided. This paper describes the extensive study of published data on the vast contributions by CE that positively impact patient outcomes. This study shows that every region of the world including low-resource regions face a challenge of improving health services while facing varied levels of infrastructure and human resources capacity challenges. CEs play vital roles in all stages of healthcare technology life-cycle management. From creation to planning, and from commissioning to utilization and integration; technology-based systems must and can be managed for optimal performance. In each of the technology life-cycle stages the requirement for trained and competent CE input makes critical difference as shown in the analyzed evidence reviewed here. It is our hope that government agencies and other interested parties will have better understanding of CEs role and thus will support their inclusion in the healthcare team of professionals.

RECOMMENDATION
To encourage the availability, recognition, and increased participation of clinical engineers as part of the health workforce in your national healthcare delivery programs.