MCIF: Siemens has been a renowned industrial partner for medical corps worldwide for decades. What is your experience in this special environment?
Siemens: We have been working closely together with the respective users and with the technical staff for a long time. Military medical customers have a very high focus on quality. Next to diagnostic or therapeutical quality, mechanical robustness is extremely important. This is, of course, especially true for mobile applications which require much more rugged equipment than state-of-the-art hospital technology. We have extensive experience in this field, Siemens medical devices have been in deployment for decades. In the Siemens Museum you will see devices that were actually used in World War II, such as “Feldröntgengeräte” (Field x-ray systems). Also, there were the coach-integrated systems for mass screenings.
We are drawing from this experience in developing new devices.
Another extremely important point is logistics and transportation standardization. We are doing our utmost to bring this in line with ISO standards. This means, for example, that our CTs are mounted in standard-size ISO containers, so that all containers of a field hospital meet identical transportation specifications. In our view, it is not feasible having, for example, a container which is just a few centimetres larger than all other containers, which would cause great headaches to the logistics officer.
MCIF: What is your experience with devices that are deployed on ships?
Siemens: We have numerous X-ray units in use on ships. Experiences in the American and German navies (among others) are unanimously positive. Of course, there are always limitations in terms of space and weight. You have to look very carefully to which extent you can deploy these in a limited space.
There is a clear trend to equip smaller vessels with medical technology, thus providing enhanced capability for improved immediate care before evacuation to a hospital ship or a land-based hospital. We are talking about a utilization profile which is also highly interesting for civilian ships in a similar form. The trend towards miniaturization electronics is working for us. This applies for a large part of our portfolio: For laboratory diagnostics as well as for imaging systems, as portable ultrasound units and digital X-ray units with wireless detectors. This gives us the opportunity to provide a full diagnostic spectrum while requiring minimum valuable space.
MCIF: Siemens medical technology is used in military hospitals as well as in deployment. Are there any special training offerings for military personnel?
Siemens: There is two-fold answer to your question. One for medical staff, and one for technical staff. As far as the medical personnel is concerned, I think that top priority should be that hospital equipment and field equipment should be identical or very similar, i.e. sharing the same user interface. This policy assures that all medical staff is keeping a continuous high level of practice which, in turn, eliminates the need for a separate training for deployment. In keeping with the motto: Train as you fight. For the technical staff, we offer qualified service engineer trainings so that technical maintenance of the devices can be guaranteed in the field. This is where the Siemens Training Centre comes in. We have a training centre that offers certified courses for medical and for technical specialists. This extends to our preparing education plans together with clients from the medical corps as well as civilian clients to the specific needs of the respective customer to ensure that the customer’s staff can be just as qualified as our own people. With these certified trainings in addition to the on-site application training we can make sure that the users can exploit the potential of their systems to their full capability.
If we look at this on a higher level now, it is important for all manufacturers of hardware and electronics to also be active in the field of services. Hardware suppliers are increasingly being looked down on as commodity movers, while services are more and more appreciated by the markets and clients and finally also paid for. We are entering an additional business field by offering customised education plans and thus addressing the client’s legal obligation for continuous education of their medical staff. These solutions are currently appreciated by advanced private institutions, for whom we train technical and medical personnel on site and here in our training centre according to an individual curriculum, and for whom we may even administer their education records as an additional service in the future. This is a trend which the German military in a way has pioneered with us, by our having trained the German armed forces’ service engineers as Siemens-qualified engineers, and who are now able to do practically anything required in terms of service and repairs for the device that is present in the field.
MCIF: Does that include certification?
Siemens: It sure does. They are fully certified CT or X-ray service engineers. Of course, they already have a high standard of education when they start the system-specific training at our training centre. Their receiving the training in our Siemens facilities gives them two equally important advantages. On one hand, they get to know the systems inside out, with confidence that this level matches the Siemens engineers’ expertise. On the other hand, they also know the Siemens escalation process and spare part process. They know our processes. They know where our hotline is, how to talk to them and, when there really is a difficult case for once, also quickly tell them which spare parts are needed.
In actual deployment this provides a huge advantage over other concepts. Some nations have completely outsourced the service of their medical devices to private companies just like that of many other materials. If there is a need for a service engineer in a combat zone, you will have to address security. If the military can send one of their own people first, who come “from the system”, you don’t have to wait for days until it’s been sorted out who is responsible for which security and how this can be guaranteed. We have made outstanding experiences in this regard. We only recall one single case in Afghanistan where a Siemens service technician was flown in from a neighbouring country to assist. He then worked with the personnel from the medical corps to complete the repair.
So, we have our own technicians worldwide, as well as our partner’ technicians, too, on the same level of qualification and they have to pass the same certification procedures and tests globally. This is required by Siemens as well as the supervisory authorities, be it the FDA or the Chinese SFDA or the European authorities. In this regard, just like basically all renowned producers, we maintain an extremely high standard of quality.
In a nutshell: Our concept, especially service, international service, includes various components:
We are available; we provide our service in more than 120 countries globally. Either through Siemens subsidiaries or distributors, who were all trained to the same standard in Erlangen or one of our other global training centres. That’s one point. The other point is obviously the supply of spare parts. We have central hubs for spare parts supply. More than 97 % of our spare parts will be where they are needed the very next day, anywhere in the world. This means that devices can be repaired very quickly once the needed parts are identified. That’s extremely important. And then, of course, as we already discussed in the previous question, the training of the user’s own personnel, the medical corps’ engineers. This tightly-interlocked service concept assures continuous and sustainable operation of our systems even under very adverse conditions.
May I add something here? From our side, there are no problems technically to also connect systems already in use to remote diagnostics. Meaning, a device allows prospective diagnostics. Let’s take the most important consumable in computed tomography. That would be the X-ray tube. This can be identified early on as being at risk of failure, and so at least from our side there would be no problem in connecting such a device that is being deployed on a ship to the diagnostics and then be able to tell at an early stage that, watch out, it is at risk of failure.
MCIF: But this requires some kind of connection from the field directly to your company?
Siemens: Right. Military security concerns are major obstacles at the moment, but we are increasingly seeing in various countries around the world that the military is making sure that not only devices located in hospitals, but also those used in the field, are systematically connected remotely and serviced. This is not just about technical breakdowns. It’s also about safety-related software updates, today typically performed via remote connection. We are very confident that in a few years time many armed forces will have all their systems linked to this remote point.
MCIF: This means, in layman’s terms, so-called remote diagnostics!
Siemens: Remote diagnostics and also remote maintenance, remote software updates.
MCIF: Is there an option for a replacement in case a device is damaged beyond repair?
Siemens: Damaged beyond repair is almost always due to massive mechanical damage from a fire or a crash.
For mobile systems, it is quite straightforward: We have a maintenance float in all major countries. If there is an emergency in a hospital, we are then able to supply a loan unit or an interim machine at short notice. This is a realistic scenario. For systems permanently integrated into containers this is not a feasible solution, since you may safely assume that the container will also be a total loss. We have to rely on the respective medical corps to have reserve units available.
MCIF: What do you expect further development in the area of mobile field hospitals to look like?
Siemens: Well, in recent years we have seen a continuous increase in medical capabilities in mobile field hospitals. There are a few medical services here, such as the German Armed Forces, who aspire to ensure the same standard of care in deployment as for medical care domestically. This, of course, also has ramifications on the requirements in field hospitals. This means that the modalities commonly used domestically must be available in deployment, too. The other thing we’re seeing here is a requirement towards reducing the footprint in-country, especially in mobile field hospitals. The smaller the space needed for the field hospital, the easier it can be securely integrated in a forward base without requiring additional forces for security. This requirement for reduced footprint is a great promoter for high-tech, since it forces the physicians to focus on equipment that is most likely to give them the best diagnosis or therapy in the shortest time with lowest space requirements.
I do think that the issue of footprint is indeed a very important one. Analysis of recent deployments shows that units were dispersed over a large geographical area, so that when attempting to stay compliant to the doctrine of “Platinum 10 Minutes and the Golden Hour”, flying times alone took up a large part of the time available. We have been witnessing a clear trend towards having multiple mobile surgery facilities distributed in forward bases in order to get soldiers to medical care within the time specified. The medical device industry must be an active partner in these considerations. Where are the priorities? What should be available in these relatively small units? In conversations with users we are observing a trend towards rather having one large modality available, which is capable of addressing all medical questions, than many different ones which then again would make the installation so big that it doesn’t fit into the country and security considerations anymore.
MCIF: In the field, there is not always a radiologist available. Is there a chance in this regard to link the devices to remote diagnostics in terms of telemedicine?
Siemens: Absolutely. That’s the standard today. The limiting factor is available data bandwidth. Using the DICOM Standard makes it possible to reduce data significantly, as not every image has to be sent as a single image, but information for the previous image is attached. This is called DICOM Multiframe. If we want to go one step further, today’s devices also allow remote control. Of course, for safety and medical reasons, there still needs to be qualified staff on site in order to position patients correctly, but everything else can be done remotely.
We need to distinguish between these two points. One being the pure diagnosis of the images sent over and the other the operation of the device, a feature we call Expert-I: The device is usually operated by radiographers. Now, of course, not every radiographer can handle the entire spectrum of available applications, and in these cases it is possible for someone who is more skilled to, so to speak, guide the hand. This is already happening today, like in remote areas of Canada where a community hospital may service an area the size of half of Western Europe and they have one radiologist and one or two radiographers. They are already linked with a mother hospital located in Toronto or Vancouver. They work together remotely when examining patients. They just have to secure a data connection.
MCIF: What influence do the medical services have on operationally-related device adaptation?
Siemens: Well, generally, the field devices are based on our civilian devices. This way we ensure that the devices share innovation cycles and they share the economy of scale. International medical device legislation compels us to certify all our products as medical devices. This way we also ensure that the devices meet current international standards. For established standard products there is also an established logistics chain for spare parts. This point is also crucial for armed forces. This could clearly not always be guaranteed for custom-made products.
The above mentioned notwithstanding, we make sure in development that our devices, or parts thereof, can be used in a mobile environment. In the design process we consider allowing for higher mechanical requirements, or offer additional mobile kits to meet these requirements. The combination of these measures will permit mobile usage of these standard devices to a large extent while retaining their status of full compliance with medical device legislation.
MCIF: Apart from purchasing devices, are there any other means of acquisition?
Siemens: This varies by country. We provide a wide range of purchasing and financing options tailored to the specific situation of the respective country. Here we stick to local legislation. Basically, these financing options can also be used for the military medical services.
We’re open in this regard, we have the flexibility. Every offer or every procurement project requires thorough analysis of the customer’s needs, including usage-based payment, and life-cycle and so on, and then it’s surely possible to develop such a concept. Developing such a scenario for a mobile hospital in a combat environment with possible mass casualties could become somewhat challenging. In the civilian and stationary sector where there is a continuous workload, or a usage history, this is quite possible, yes.
After all, we go all the way to provider models, where we simply provide certain capabilities. Innovation cycles for the equipment involved may be part of this service agreement in order to ascertain long-term sustainability.
All of these cases are individually tailored solutions. Let us assume a model scenario: There is an investor, or a government organisation. They want to build a new hospital and tell us they need a radiologist and want to perform this or that examination there, or they may say they’ll have the following specialist departments: cardiology, gastroenterology, neurology. Based on our experience we prepare an equipment recommendation and take this as a basis for making an offer which may include a list of devices and the respective innovation cycles. So we may say that ultrasound units be replaced every 5 years. Or replacement of CTs is provided for every 5-7 years. For the MRs, we assume a useful life of 8 years plus upgrade, so that’s an extension of 50 percent, or 12 years. From this package, we then prepare a, let’s say monthly, cost schedule. We then expect monthly payments of an amount X. This monthly instalment may include service, consumables and everything else. This is the chance to provide you with all essential capabilities at a predicable cost schedule and this is precisely what you need if you want to build a very big hospital without tying up too much capital.
We are currently discussing the possibility of including operating staff in these solutions. In these discussions we have to take various legal and customer-specific limitations into account.
Something we have been doing for a long time is called Integrated Service Management. This means there are hospitals, often very big hospitals, which leave the complete technical management of their medical devices to us.
In these agreements, we take over management of the entire technical department of a hospital. This is most attractive in scenarios with a large Siemens-share in the installed base. We will also include other manufacturers’ equipment and ensure that service for this equipment is performed by qualified staff (usually the manufacturer’s staff). These management models are attractive to users or end clients because they take the complexity out of their own operations. So they can transfer the entire area of service of medical technology as a black box to us and focus their efforts on patients and medicine.
MCIF: Telemedicine is being increasingly used by medical corps world-wide. What about Siemens’ technological development in this area?
Siemens: We have not only seen the introduction of telemedicine into practical routine in Afghanistan but also an extreme scenario in the Chinese earthquake of 2008 with image transfer in a disaster environment.
Sending images for remote diagnosis or a second opinion has been standard in telemedicine for some time. Our military users, in particular, have grown accustomed to sending images from the country of deployment to the specialist at home. They just need sufficient bandwidth for image transfer. We have mentioned Expert-i before that gives you the capability to remotely perform procedures. The combination of these features has a high potential for making state-of-the-art medicine available to even the most remote locations in the field.
Another aspect is the fact that telemedicine moves field hospitals and domestic hospitals much closer together. Thanks to modern intensive care, even very critical patients can be evacuated home at an early point. Telemedicine contributes greatly to the patient getting transferred to the most suitable medical institution at home without delay. It also ascertains that this institution is optimally prepared once the patient arrives.
While the concepts and some of the implementation have been around for some years, Siemens is actively pursuing further steps to make these benefits even easier to use in daily routine or in extreme situations. Standardized electronic patient records or high-performance server structures for a web-space concept for distributed reading and reporting are just some examples.