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The healthcare industry is stirring. In the words of Bob Dylan: “the times they are a changin’”.

It seems that with the advent of new technologies, coupled with a greater need to improve the current healthcare system, the digital health revolution arrived. This great experiment is about to start, but there seems to be a few problems in the way. There are some massive hurdles preventing the widespread adoption of digital health technologies in healthcare. Some examples include slow improvements in health IT, complicated healthcare and provider systems, segregated devices, and limited value proven by digital health companies. This has prevented novel technologies to enter and be tested in the greater healthcare system. This is very true when one looks at the electronic stethoscope, an example of a (possibly) revolutionary healthcare device.

The electronic stethoscope is not a new invention. It has been around for more than 20 years. And it changed nothing.

In that time computer and mobile processing power has skyrocketed, we have migrated to the cloud for storage and computing power and internet connectivity has become ubiquitous in developed nations. So why has the stethoscope been left behind? We were all expecting primary care doctors and nurses to be using electronic stethoscopes by now. Stethoscopes that are linked to the cloud, providing analysis and helpful insights into what the doctor or nurse were hearing. The interesting thing is that this problem is perpetuated by the stethoscope industry itselfironically.

Electronic vs Acoustic

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In the past few years the telemedicine market has grown substantially. A report estimated that the global telemedicine market would grow from $14B in 2014  to $35B in 2020. This growth has attracted many new players aiming to ‘disrupt the healthcare market’ including digital health companies, EHRs, technology integrators and providers, amongst others. These companies come in all shapes and sizes, and promise to deliver or enable high quality healthcare from a remote location. Telemedicine threatens to challenge current fee-for-service models by offering value-based care that can surpass many of the current challenges faced by those who work and offer health care.

Telemedicine, for me, solves two major problems. More than 46 million Americans live in rural areas. Telemedicine can help provide specialized services to these underserved communities, and could do this at a much more affordable rate. Another problem that can be solved is the large cost associated with having and retaining specialized services. Healthcare providers can centralize many services, and deliver care from a central point. This can increase the volume of patients served, and overcome many of the logistical challenges being faced by major healthcare organizations. This also means that professional healthcare services could be incorporated in businesses such as retail clinics, where basic primary care is served but not all healthcare services can be delivered. Telemedicine will expand the services they offer, and promise to do so at a reduced cost.

The question still remains – will Telemedicine disrupt healthcare in the way it imagines? Will it cause a new system to be adopted where all retail clinics, hospitals and caregivers access care via smartphones, tablets, or specifically tailored carts with a myriad of peripheral devices? I think this will depend on a few very important and key factors. Firstly, how well will this new technology be adopted? Healthcare technology adoption is famously slow. How will these companies expedite technological adoption in a market that clearly shows resistance to new tech? The second question to be asked is what kind of technology should be added, and what should this offering look like? Developers and integrators have to constantly iterate their technological offering to match customer preferences, and to ensure they add value. That leads to the third question – is there actual validated value that is being added to care being provided. Not perceived value that might encourage some sales, but actual validated value that will lead to the wide spread adoption of telemedicine?

So will telemedicine disrupt the healthcare market? Only time will tell, but the initial signs are promising. Telemedicine does look like the best solution to provide care to a large underserved part of the market.

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A long time ago in a galaxy far far away…oh wait, not so long ago, in our galaxy, technical support was a different ball game. If something that your company produced broke and the factory was in another country, you either made a plan to fix it locally, or order the part and wait out the months as it was being shipped to you. This is still the case in many industries, but in healthcare technology this has changed dramatically.

With the advent of information technology and smart support systems, the tech support landscape has changed. Now, with the click of a button, a support technician can help you establish what the problem is, talk you through a problem, and have you up and running within a few minutes. This is wonderful, but can sometimes also be a challenge. Support technicians might be in other countries, causing a delay in when you can appropriately schedule calls. This can be frustrating for multinational companies. But I believe some of these problems can be mitigated by providing excellent customer support.

The first thing a client support consultant must do is try keep your client happy. This is the most important thing to remember. If you behave like a idiot in front of your client and try to blame them for the mistake you most likely will lose your client and this will have a ripple effect across the whole company. To counter this you need to approach the problem from a different angle. You need to fit in with your client’s schedule, this can be difficult but an arrangement can always be made so that both parties are happy about the arranged time.

You must always keep an open line of communication. Talk to your client and try to understand the frustration that they are experiencing. Most of the time the problem is easily solved and can be fixed within 10 minutes. If it takes longer remember the second rule: keep your client informed. An informed client will be a happy client. If a user knows that you are working on the problem, they will mostly show patience as they know they are your current priority.

Great technical support does not end there. Once the problem is resolved, contact your client after a few days and ask if everything is working. This is the last step to a happy client. This helps in keeping the communication channel open.   

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Posted by on in Business Model

It is inevitable that the healthcare system is changing. A major shift is from the current fee-for-service (FFS) model to a value-based model. This aims to improve patient outcomes while reducing costs. This is a major change in the system, and is challenging the way many primary care providers are thinking about healthcare. How can we rethink healthcare, how do we position ourselves, and how should we operate in this new environment? 

Many leaders in primary healthcare (thankfully) are realizing that this shift is taking place. The advent of the retail clinic is an example of a major change in the primary healthcare spectrum. A recent Accenture study found that the amount of retail clinics in the USA would have risen by 47% from 2014 till 2017, exceeding 2800 clinics. This shows a shift in many patients’ mindset about retail clinics. They seem to prefer the convenience, and with many uninsured Americans, this could be a solution to the heavily burdened primary care system.

Data is very important in the new healthcare business model. The amount of patients, re-admittance rates, tracking of conditions, treatments and diagnostics are all-important in optimizing the healthcare system and in tracking costs and patient outcomes. A paper-based system is not going to make the cut. Technology, especially cloud-based services, is going to become even more prevalent in the new way of delivering primary healthcare. Trying to deliver better care at a lower cost will require a few new business strategies. Providers will have to improve operating costs, increase patient volumes and effectively track and monitor patients to ensure that their health is improving. These could all be addressed with the use of new health technologies.

To improve operating costs, low-cost screening tests and preventative healthcare technologies will reduce referral rates and limit patient discomfort. This means a better service is delivered to the patient. To increase patient volumes these clinics must be able to differentiate themselves with their services, level of quality, or by ensuring they have the most satisfied patients. Cloud-managed software services could improve the way patients are tracked, and mobile applications could increase monitoring of conditions, as well as create a valuable patient feedback loop. 

There is definitely a shift in the way that healthcare is being provided. The transition to a value-based care model will place strain on healthcare providers. I believe various technologies will be able to mitigate these changes, and ensure satisfied and healthy patients.

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Tagged in: auscultation heart

Posted by on in Clinical Decision Support

A while ago I was at a panel discussion on the advantages and concerns of electronic health records at a conference in Boston, MA. A few weeks before, our family physician passed away at the age of 89. He practiced in the day’s before the internet and his mind was our search engine for any health related issues. With his death, three generations' health information also passed away. I can’t remember a computer on his desk, but he still remembered to phone me on my birthday, 21 years after he assisted my transition into this life.

He auscultated each member of my extended family’s hearts. He knew exactly how our hearts were beating. He was also available 24/7. Always ready to assist.

While listening to the discussion on electronic health records, I thought to myself how uncomplicated were the days before information systems. When you had access to a single person with a wealth of information, not only on you, but your whole extended family. The days where there was a direct link between the cost, value and outcome of the service you received.

There is a school of thought that we should move back to a system where we have a single point of entry into the healthcare system. A point with access to my extended medical history. A point that could effectively manage my health. But how realistic is that? We are a generation that’s on the move.

So, the idea of building a relationship with a virtual doctor came to my mind. Imagine my family could also visit the same “virtual” doctor for the next few generations. Imagine if this doctor could learn the in’s and out’s of each of my family members' health. Imagine if this virtual doctor would know exactly how each family member's heart sounds. If it can provide you with individual care and specialist advice from the comfort of your couch.

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Posted by on in Business Model

Every day I work with doctors, nurses, physician’s assistants and chiropractors. Many of these healthcare practitioners have their own practice, which in essence is still a business. And how do you effectively run a business on your own (with an assistant if you are lucky)? You wear many hats. You have to be the head of customer service, marketing, technology, information systems, financial administration, and not to forget the primary care practitioner who is supposed to see patients. This might sound familiar to many people who have started their own business, but in healthcare it is having a detrimental impact.

When your attention is divided among many different types of roles, you could get lost in a sea of administration. This could negatively impact your patients, or even your business. In a short survey done by SensiCardiac we found that half of Department of Transport (DOT) physical examiners don’t market themselves to carriers in their community. Half don’t use social media, and less than 30% actually post newsletters or blogs. And to be honest, who can blame them? When you have to perform assessments, do administrative tasks, and be the marketing manager, you will try and prioritize the service you are providing to your patients. But this might leave a few blind spots in your business strategy. You might be missing out on some fantastic ways to improve the way your patients feel about your service, reach a wider group of patients, and ensure that the care you are providing is the best that you can.

Healthcare practitioners are providing valuable primary care services to patients every day. Primary care is the first defence in ensuring that communities are healthy. I believe that this is the way towards a healthier general population. I also believe that this is linked to technology. Technology is supposed to simplify diagnostics, improve your care, and ensure that patients leave your practice healthier or with correct treatments. But most technology is just adding to the burden of administrative tasks that you need to perform in order to provide a great service. I think it is our challenge as technology leaders to ensure that primary care practitioners are receiving the best ways to diagnose patients, ensure that the diagnosis is provided in an easy-to-understand format, and stop us from overworking an already overworked part of our population. Let’s simplify their lives, and ensure that the many hats become less of a burden.



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Posted by on in Clinical Techniques

There seems to be a slight problem in the digital healthcare industry. Ok well not a slight problem, a few massive gaps. In a recent Forbes article Todd Hixon discusses why healthcare practitioners are frustrated with digital health companies. And I am inclined to agree.

Healthcare practitioners have been encouraged, either by companies, their peers or the healthcare community to accept new technologies into their practices. Instead of assisting them in making valuable diagnostic decisions, simplifying their lives and making it, well, easier to deliver healthcare, it has been plagued with issues. Most of these technologies have usability issues, and do not deliver useable results to the practitioners. These systems are hard-to-use, are sometimes divided into multiple systems (i.e. no integration on multiple platforms), and they are not allowing practitioners to enable their patients to engage in their care. So digital healthcare is not being seen in a very pretty light.

I think this has its origin in a few places. Firstly the adoption of technology is at a very slow pace. In most other industries, like consumer electronics, aviation, automotive and automation, retail etc. there seems to be a much higher uptake on new technologies. These technologies have been positioned to reduce production times, increase sales, simplify their work etc. In healthcare, however, it is moving at a snail’s pace.

A review article published by England, Stewart and Walker discussed the problem of information technology adoption in healthcare. They found that organizational factors within healthcare as well as the delivery of products and services by vendors are to blame. Healthcare organizations seem to be very complex and tend to have fragmented internal structures. This can delay the adoption of new technologies, as well as hinder the implementation of a one-time digital solution. Health information technology is also relatively immature, can be complicated to implement, and are usually unable to show measurable benefits to healthcare practitioners or larger organizations.

The organizational aspects cannot be directly solved by the digital health industry (or can it?), but we do have the chance to provide simple-to-use technologies that are great for the user. It must show a direct benefit (saving time, reducing costs, improving patient participation in their care etc.) to the healthcare industry. Otherwise the adoption will continue to be painfully slow.

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Posted by on in Clinical Techniques

One football program. Five years. Six deaths. Two life-altering injuries. Earlier this year I visited Tarleton University in Stephenville, Texas, "The Cowboy Capital of the world". I was devastated to hear about the tragedies that hammered this small community over the last few years. The immediate question that jumps to one's mind is, Why does this happen? Is this totally random, or could it be prevented? 

Why are tragedies happening on the sports field?

In the US, 10 to 15 million athletes participate in organized sport. Fewer than 300 die annually due to a cardiovascular cause, but with head injuries are the main cause for sports deaths. In the bigger picture, this is not a lot of fatal incidents, but are highly visible events with significant liability considerations.

Pre-participation examinations (PPE) are a rite of passage for young athletes. Will it minimize the number of tragedies? The fact is, PPEs are a challenge for most healthcare providers. And it is usually a last minute job.

A study published in the Clinical Journal of Sports Medicine examined PPE in clinical practice among AAP members and family practitioners in the State of Washington. Many participants reported barriers to the effective performance of PPE:

  • 37% were unsure on how to perform PPE.
  • 50% were unsure about the relative importance of a PPE.
  • 58% reported a lack of standardized approach.
  • 63% felt they did not have enough time with patients.

Guidance for performing effective PPEs is readily available and provided by the AAP and ACSM. The ACC also provides a specific statement on Cardiovascular Screening for competitive athletes

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Posted by on in Business Model

How do you decide on introducing a new technology to your practice? The cost is a concern and will it add value to your practice?

The healthcare industry is notorious for its slow adoption to new technologies. A recent Forbes report is listing the following 5 issues that are preventing technology adoption in healthcare:

  1. Many new technologies don’t address the real problem
  2. No one wants to pay for new technologies
  3. Physicians are reluctant to show patients their medical information
  4. Technology slows down many physicians
  5. Many physicians see technology as impersonal

The big question is, will new technology enhance your business model?

For me the real issue is: when does a new technology add value to my business or work. To make a decision on this, you need to understand how your practice or business creates, delivers and captures value. And what role will this technology play in this process.

To guide me through a decision I’m using the 9 basic building blocks of the business model canvas (feel free to consult the following book: Business Model Generation written by Alexander Osterwalder and Yves Pigneur):

1 - Any organization serves customers:

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Posted by on in Clinical Decision Support

Please raise your hand if you ever felt that you would never use a computer program or app to diagnose a patient during a physical exam.

The healthcare sector is notorious for being slow when it comes to adopting new technologies. Even for some patients it could be scary if they know that their trusted physician is relying on a computer program to make a diagnosis.

The main arguments are that computers are lacking consciousness, human intuition and most of all, instinct. While physicians are naturally good at matching patterns, logic and knowledge with their instinct.

Where are we in the human vs. machine race today?

Where do you get a second opinion?

A recent article in the NY Times introduced Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor of clinical medicine at the University of California, San Francisco. He is considered one of the most skillful clinical diagnosticians in practice today.

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Tagged in: auscultation heart

Posted by on in Clinical Techniques

Users often ask us what they could do to get the best results from SensiCardiac. Here are a few tips from our experience:

  • If you can’t hear the heart sound, SensiCardiac can’t either.

Most users violate this rule! Make sure the S1/S2 heart sounds are clearly audible before you start recording.  This is sometimes challenging at the aortic position. Ask the patient to do three to five squats to make the heart work a little bit harder. This may help to hear the heart more clearly.

  • Get the heart as close as possible to the chest wall.

If the patient is in the supine position there’s always the possibility of creating a cavity between the heart and the chest wall. Sounds from within the body, especially the lungs, can resonate within these cavities, creating unwanted noise.

  • Avoid breathing sounds, at all cost.

Ask the patient to hold his/her breath for the duration of the recording.

  • Body tissue is a heart sound killer.

If the patient does have excessive body tissue around the chest/breast and the heart sounds are not audible, don’t use SensiCardiac, or limit the recordings to the positions where the heart sounds are audible.

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This weekend, experts in internal medicine from around the world will convene at the American College of Physicians’s (ACP) Annual Meeting held Apr 28 – May 2, 2015, at the Boston Convention and Exhibition Center. The event garners 6,500+ practicing physicians and delivers scientific research and opinions designed to advance the practice of internal medicine and various subspecialities across global health care systems. What's making this event even more special is the fact that it marks the ACP's 100th anniversary.

We welcome attendees to join us at booth #1249. See how SensiCardiac is dedicated to enhance the way physicians performs cardiac assessments to improve clinical decision making and patient safety. SensiCardiac is an innovative, cloud based solution to record, interpret and share heart sounds. Optimised for effective early diagnosis and record keeping of auscultation findings.

Visit the SensiCardiac booth: #1249

Follow the conversation on Twitter: @Sensicardiac and @ACPinternests with hashtag #im2015

Read more about SensiCardiac here.

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We frequently do get the question: What heart defects can SensiCardiac detect? The short answer is any structural defect of the heart that will create a murmur. The most common structural defect among children is a congenital heart defect (CHD) and is a structural defect presented at birth. In most cases this defect will be undiagnosed at discharge after birth. Common examples of CHDs include holes in the inside walls of the heart and narrowed or leaky valves. In more severe forms of CHDs, blood vessels or heart chambers may be missing, poorly formed, and/or in the wrong place.

Globally, every 100th baby is born with a CHD and is therefore the most common birth defect. Nearly 40,000 infants in the USA are born annually with CHDs. CHDs are therefore as common as autism. Between two and three million individuals are thought to be living in the United States with CHDs, with many of these individuals not being aware of it. Except for patient records, there's no other system in place to track CHDs beyond childhood. Due to improved care, the number of adults living with CHDs is increasing. The result is that CHDs are now the most common heart problem among pregnant women.

CHDs are still the most common cause of infant death due to birth defects. Nearly one in every four babies born with a CHD will need surgery or other interventions to survive. Most babies with a CHD will reach adulthood, but will face a life-long risk of health problems such as issues with growth and eating, developmental delays, difficulty with exercise, heart rhythm problems, heart failure, sudden cardiac arrest or stroke.

Although 15-20% of all CHDs are related to known genetic conditions, most causes are unknown. A combination of factors can lead to a CHD, but in most cases the damage is already done before most women know they are pregnant.

A structural defect of the heart can also be acquired later in life.Some infections and disorders that may lead to heart disease include:

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According to the American Academy of Family Physicians (AAFP) distinguishing between pathological and benign (innocent) cardiac murmurs is perhaps the most challenging aspect of a physical examination. It is recommended that patients with signs or symptoms of a pathological murmur should be referred to a cardiologist.

This is even more true when making decisions during a pre-participation, school, college or DOT physical. When making eligible and disqualifying decisions, it is important to follow current clinical guidelines. Practitioners are often under pressure to clear a person for a certain activity, or may rush the exam, because no symptoms are presented.

Benign (functional, innocent or physiological) murmurs occurs in the absence of a cardiac structural abnormality with no symptoms or family history. The S2 sound pulse has a normal, physiological split, best heard at the pulmonary and there're no clicks or gallops. The murmur is usually early to mid-systolic with a musical, vibratory, or buzzing quality. And it is soft, grade two or lower.

The next image shows the relative mid-range energy distribution of the average heart beat for a patient with a benign murmur. The relative energy levels for the S1/S2 sound pulses, early-, mid- and late systole and diastole are also indicated. Note the relative low energy levels within the early and mid-systolic region. Typical for a benign murmur.

 Innocent Cardiac Murmurs

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According to an article in the NY Times “a young athlete dies from a cardiac incident once every three days in the United States” (Hidden Threats to Young Athletes – May 11, 2013). Sudden cardiac arrest is the number one killer of young athletes and is typically brought on by a pre-existing, detectable condition that could have been treated. According to nearly 360,000 sudden cardiac arrests occur outside of hospitals each year in the United States alone.

How could Sensi be used in pre-participation screening?

One of the key clinical findings to evaluate when screening athletes for cardiac defects are murmurs, to detect structural defects within the heart.

The American College of Preventive Medicine (ACPM) supports an evaluation prior to participating in high school and college sports using a history and physical assessment as developed by the American Heart Association[1]. This assessment includes 12 criteria for pre-participation cardiovascular screening of competitive athletes:

Personal History

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A recent study at Johns Hopkins Hospital in Baltimore, Maryland, showed that cardiology residents were not able to identify 25% of the pathological murmurs presented to them.

How confident is a primary care clinician in identifying and classifying cardiac murmurs? To answer this question, two professions within the primary care sector were surveyed with the help of Altogether 45 physicians (MDs) and 160 chiropractors (DCs) were surveyed. Both groups perform physical assessments as part of their daily routine and see the same population groups (See Figure 1).


Figure 1: Physical assessment services offered by MDs and DCs.

  How often are primary care clinicians confronted with cardiac murmurs?

Identifying S1/S2 and hearing a cardiac murmur are the first steps in classifying a murmur. Although they frequently perform cardiac auscultation, chiropractors indicated that they very seldom hear a cardiac murmur (more than 50%). Only 1,3% indicated that they do hear a cardiac murmur frequently.

Is this due to an absence of cardiac murmurs in their patient population?

Physicians hear cardiac murmurs more frequently, 24,4% indicated frequent to very frequent, but still a bigger percentage indicated that they hear a murmur seldom to very seldom (35,6%).

How confident are they in classifying the murmur?

Classifying cardiac murmurs accurately is a skill that takes years to master. Confidence in cardiac auscultation is built by frequently using a stethoscope and being exposed to heart murmurs. More than 30% of the physicians interviewed indicated that they are confident with their ability to distinguish between innocent and pathological cardiac murmurs, while 46,7% rated their confidence as average.

67,5% of chiropractors rated their confidence as limited.

Can this have a direct impact on the quality of their service?


Figure 2: The relative frequency with which MDs and DCs are confronted with a cardiac murmur. 


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Identifying extra heart sounds while auscultating is very challenging. Especially in relation to the third (S3) and fourth (S4) heart sounds.

The third heart sound is very common in children and even in people under 40, but later in life it is an indication of serious problems, like heart failure, and only appears when the problem is relatively far advanced. In some cases the third heart sound may never be heard, due to chest size, obesity or lung sounds, or due to hearing constraints of the listener. Therefore, the absence of a third heart sound does not exclude ventricular dysfunction or volume overload.

The low intensity, very low frequency and small audible area challenge clinicians auscultation skills and in most cases the third heart sound falls outside the human ear’s audio range.

The ability to detect and monitor third heart sounds in older patients is very important as this is associated with heart failure.

Hearing skills of trained cardiologists were recently compared with Sensi. Results confirmed that Sensi detected and indicated the third heart sound in cases where the human ear could not detect it, as well as in cases where the human ear detected the sound. This confirmed the importance of having a tool to assist in identifying extra, impossible-to-hear, heart sounds.

The next two figures show heart sounds recorded at the APEX. Figure 1 shows the presence of a very subtle S3 sound while Figure 2 indicates a prominent S3 sound. In both cases Sensi was used to visually confirm the presence of an S3 sound. S1, S2 and S3 annotation were added by hand.



Figure 1: Subtle S3 sound.

Although very small, a S3 sound pulse is present in the consecutive heart beats shown in Figure 1.


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Less than 50% of the people that suffered from rheumatic fever are aware of it. This could have  devastating effects  later on in life.

Diacoustic Medical Devices is proud to be part of the SUNHeart Project at Stellenbosch University and Tygerberg Hospital’s Cardiology Department where about 2 000 learners from Khayelitsha and Ravensmead are currently being screened for possible heart defects.

Africa has one of the highest prevalences of heart disease in children and young adults, including congenital and rheumatic heart disease, and there is an urgent need to improve access to early diagnosis and treatment for patients.

Children in the age group 6 to 21 have the highest risk of throat infection, a cause of rheumatic fever. According to Prof Anton Doubell, Head of Cardiology at Stellenbosch University, many sufferers of the disease are only diagnosed with heart defects later in life, especially during pregnancy.  

During the eight-week SUNHeart Project each child will undergo a physical examination, heart sound will be recorded and analysed with SensiCardiac to detect abnormal cardiac sound, and each child’s heart will be screened with a hand-held echo, as well as a traditional sonar.

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Posted by on in Strategy

How amazing it was to watch the soccer world cup and to see a team reap the benefits of a long-term strategy.

In the start-up world innovative business models are the talk of the day. Entrepreneurs are not only developing new products and services, but are challenging the status quo on how value is delivered to customers. In many cases entirely new industries are being formed.
Value creation is one of the challenges the healthcare industry has been struggling with for years. Many have written about this topic before, but we are still struggling to capture and deliver value to patients.

To really deliver value an organization needs a clear long-term vision and strategy based on innovation and value. This belief must be so well embedded within the organization, that no short term gain will distract the organization from the long term plan.

The soccer world cup in Brazil showed us what could be achieved if you have a well-articulated long term strategic plan and not playing for the romantic notions of passion and desire (as Ken Early described Brazil’s effort). Germany’s success was not (only) a result of a passionate team talk or playing to the expectations of the crowd. No, it started about 10 years ago after some major losses. They formulated a vision, set goals and created objectives. The got the buy-in of all the stakeholders, created structures, made investments in talent and executed the plan meticulously.

“Without a clear strategy, an organization lacks the clarity of direction to attain true excellence”. - Michael Porter

This is one of the major shortcomings of healthcare providers. You need a clear strategy. You need to map your own path to excellence. Define the value proposition you will deliver to patients, which problems you will solve, and which needs you will satisfy.
Michael Porter described three types of strategic problems common to the healthcare sector. Firstly, the range of services offered is too broad. This is where a hospital or physician group’s strategy is to become a one-stop shop. The services offered could also be too narrow and unintegrated. This is, in most cases, the result of the shotgun approach where the various service lines offered are narrow and discrete. The last mistake is where the focus is too localized, with no vision to compete geographically even in areas of medical excellence.

Which soccer team's strategy does your clinic, practice or hospital value?

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