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Medtronic, Inc. (“Medtronic”) offers RemoteView, which permits a user (“Programmer User”) of the Medtronic CareLink® 2090 Programmer (“Programmer”) to allow the viewing of information presently displayed on the Programmer screen with one or more individuals in remote locations anywhere in the world (“Remote Viewer”), including remote health care professionals or Medtronic representatives.
Limited License Grant. You are hereby granted a nonexclusive, nontransferable, terminable, nonassignable, nonsublicensable, limited license to install and use a copy of the Licensed Software solely for authorized and legitimate purposes. You may not otherwise copy, use, modify, reverse engineer, decompile, disassemble, create derivative works based on, or integrate with other systems or programs the Licensed Software without the prior written consent of Medtronic. You shall have sole responsibility for any fees or charges, including service or data charges, incurred by you in connection with your use of the Licensed Software. You shall not remove any proprietary or other legend or restrictive notice contained or included in the Licensed Software or other documentation associated with such Licensed Software. You agree to maintain any and all copyright, trademark, and other notices on the Licensed Software and any associated documentation.
Licensed Software Functionality and Data Use, Collection, Viewing, and Transfer.
“Active Remote Viewer” as referred to herein shall mean a Remote Viewer that has installed the Licensed Software and has at the relevant point in time an active network connection to a Medtronic server via the Licensed Software.
By installing or using the Licensed Software or clicking any acceptance button in connection with this Agreement, you acknowledge, understand, agree to, and consent to all of the following, including when you are an Active Remoter User:
) Registration. To obtain access to the Licensed Software, you must register at the Medtronic RemoteView website and establish a user name and password. All information that you provide in connection with such registration must be complete, accurate, and truthful. The user name and password are personal to you and must not be shared with anyone else. You will also not attempt, directly or indirectly, to disable, bypass, or defeat any password protection associated with the Licensed Software. Medtronic reserves the right to deny or disable any user name or password or request for any user name or password.
) Your Personal Information. Medtronic will collect information in connection with your registration and installation and use of the Licensed Software, including your first and last name, your email address, a selected security question(s) and your corresponding answer(s), your address, and your telephone number. You agree that Medtronic may store this personal information about you on a Medtronic server, including a server located in the United States of America.
) Session Key. To view the information on the Programmer, the Remote Viewer must generate a Session Key that must be shared with and entered by the Programmer User. “Session Key” as used herein means a unique token active for a limited period of time generated by the Remote Viewer. You agree not to share this Session Key with anyone other than the Programmer User who has initiated the specific session.
) Logging of Session Activity. Each time you log in to the Licensed Software, Medtronic will collect information about your activity, including in an aggregated log or database, regarding you and your session, including your name, username, computer name, IP address, operating system details, and session details (including transferring and sharing activity, start and end times, view only or control activity, and any chat messages between or among any Active Remote Viewers. You agree that Medtronic may store any personal information about you on a Medtronic server, including a server located in the United States of America.
) Active Remote Users. When you are an Active Remote Viewer: (1) you will be able to view the name and/or user name of any other Active Remote Viewer who is logged into the same Medtronic server; and (2) any other Active Remote Viewer who is actively logged into the same Medtronic server will be able to view your name and/or user name. The Licensed Software also permits one Active Remote Viewer to share the information being viewed to any other Active Remote Viewer. You must not share any information from the Medtronic programmer, including with any other Active Remote Viewer, absent the express permission from the Programmer User that is allowing you to view the information.
) Availability. Medtronic has limitations on the number of users that can concurrently log in to the Licensed Software at any given time. Thus, installation of or accessing the Licensed Software does not guarantee that it will be available to you for use at any time.
Permissions. By installing and using the Licensed Software, you represent that you have permission to do so from any associated clinic, hospital, or medical practice and that your use of the Licensed Software complies with any policies or requirements of such associated clinic, hospital, or medical practice. You are also responsible for confirming that the Programmer User has obtained any necessary patient consent before allowing you to view any patient information via the Licensed Software.
Your Acknowledgements. You acknowledge that the Licensed Software is not the exclusive method of viewing information from the Programmer and that the Licensed Software is not the exclusive method by which to obtain a patient’s implanted cardiac device data, including any data on the Programmer. You also acknowledge that the Licensed Software is not intended to be used as a life-sustaining or interventional tool during medical emergencies. You further acknowledge that Medtronic is not, and shall not be deemed to be, a provider of patient health care services by virtue of its provision of access to the Programmer screen information via the Licensed Software. You also acknowledge that information from the Licensed Software is not an electronic medical record and use of the Licensed Software does not in any way relieve you from using your best medical judgment to determine a proper course of treatment for patients.
Security/Privacy of Patient Data. Your use of the Licensed Software and any Session Keys shall be solely for legitimate and lawful purposes and not for any malicious purpose. You are solely responsible for and will use your best efforts in maintaining the confidentiality and security of any copies of the Licensed Software as well as any user name, password credentials, and any Session Keys that can be used in accessing the Licensed Software, a Medtronic server, or any information from a Programmer. You are solely responsible for and will use your best efforts in keeping any patient information you may receive or view in connection with the Licensed Software confidential and secure, and you will not attempt to capture or copy any patient information you view in any electronic or hard copy format without the express permission of the Programmer User. You will be responsible for any obligations or liabilities associated with any lost, stolen, or otherwise compromised patient information.
Reporting Issues and Feedback. You agree that you will report any issues or questions, technical or otherwise, regarding the Licensed Software promptly and directly to Medtronic. If you submit any comments or ideas to Medtronic, in the absence of a separate agreement regarding such submissions, you grant to Medtronic an unrestricted, royalty-free, irrevocable license to use, reproduce, display, perform, modify, transmit, and distribute such ideas in any medium and agree that Medtronic is free to use them for any purpose. In addition, Medtronic has no obligation to provide continued maintenance and support to you in connection with the Licensed Software. Any maintenance and support services provided by Medtronic shall be at Medtronic’s sole discretion.
Limitations of Liability.
THE LICENSED SOFTWARE IS PROVIDED TO YOU “AS IS,” AND MEDTRONIC EXPRESSLY DISCLAIMS ANY AND ALL WARRANTIES WITH RESPECT TO THE LICENSED SOFTWARE AND YOUR USE THEREOF, INCLUDING WITHOUT LIMITATION ANY IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NONINFRINGEMENT. MEDTRONIC DOES NOT WARRANT THAT THE USE OF THE LICENSED SOFTWARE WILL BE UNINTERRUPTED OR ERROR-FREE.
Legal Compliance. You shall at all times use the Licensed Software in compliance with all applicable laws. You shall ensure that your installation and use of the Licensed Software complies with all applicable export and import laws, regulations, orders, and policies of the United States of America and any other applicable jurisdiction. You represent and warrant that (i) you are not located in a country that is subject to a U.S. Government embargo, or that has been designated by the U.S. Government as a “terrorist supporting” country, and (ii) you are not listed on any U.S. Government list of prohibited or restricted parties.
Term, Termination, Modifications, and Support. This Agreement shall be in effect from the date when you first install or use the Licensed Software. Medtronic may modify, amend, or terminate this Agreement at any time, including by providing notices or an updated version of this Agreement on a Medtronic website. Medtronic may modify, disable, or terminate your use or Medtronic’s support of the Licensed Software at any time, including by providing notices on a Medtronic website. All obligations which are ongoing in nature shall survive termination or expiration of this Agreement. At any time upon Medtronic’s request (including via a notice on a Medtronic website), you agree to promptly delete and terminate use of any and all copies of the Licensed Software. In addition, upon Medtronic’s request, you agree to provide written verification that you have destroyed all copies of the Licensed Software together with the manner, date, and time of such destruction.
NayaMed International Sárl Customers: Whether the RemoteView feature shall be used in connection with NayaMed customers or devices shall be solely within the discretion of NayaMed International Sárl. If the Licensed Software is used connection with NayaMed customers or devices, this Agreement shall be directly between you and NayaMed with respect to those uses.
Case study describing how Canada's Shouldice Hospital uses a care delivery model predicated on specialisation, standardisation, and high volume to reduce hernia surgery turnaround time and achieve world-class clinical outcomes and high patient satisfaction.
Hyper-specialisation has been one approach to delivering value-based healthcare, because it aims to achieve the best possible clinical outcomes at the lowest cost. Since 1945 Shouldice Hospital in Canada has maintained a singular surgical focus on primary inguinal hernias. Over those 70 years the hospital has achieved a 99.5% lifetime success rate while consistently delivering services at a lower cost than other health providers.
A delivery model predicated on specialisation, standardisation and high volume is more reminiscent of manufacturing rather than medicine. But the core aim of high-performance manufacturing — consistent delivery of high-quality products at the lowest per unit cost — is wholly applicable to Shouldice Hospital, an Ontario-based hospital specialising in hernia surgery. To deliver value-based healthcare systemically in a specialised hospital, also referred to as the focused-factory model of hospital surgery,1 process efficiency must be accompanied by clinical expertise throughout the standardisation of care.
With this competitive advantage, Shouldice has reduced surgical time and achieved world-class clinical outcome levels and high patient satisfaction. Research done in 2014 by the University College of Dublin reported that Shouldice is able to offer hernia treatments at approximately half the market rate by controlling costs and realising efficiencies in its activities.2 While the procedure is free for Ontario residents, Shouldice bills the province C$618 for the surgery plus the hospital stay, which is 50% less than other general hospitals bill the province for the surgery alone.
When we operate, we keep the same rule that Dr Shouldice insisted upon — that we do everything possible to make sure there is not a recurrence.Dr Michael Alexander, chief medical officer, Shouldice Hospital
Inguinal hernias are the most common type of hernia, representing two-thirds of all adult hernias3 and accounting for the most frequent operation in general surgery.4 The “Shouldice Technique” for repairing inguinal hernias was developed by the hospital’s founder, Dr Edward Earle Shouldice, in 1945; it has been practised and refined for 70 years at the centre to become what is considered to be one of the best available today for pure-tissue hernia repair. Even with a high success rate of 99.5%, the hospital’s system is designed to learn and to improve outcomes whenever possible. As explained by Shouldice’s chief medical officer, Dr Michael Alexander, “When we operate, we keep the same rule that Dr Shouldice insisted upon — that we do everything possible to make sure there is not a recurrence. If the patient comes back to us because the procedure failed, we fix the hernia free of charge. We write off the cost of surgery to learn.”
Dr Alexander, who has been at Shouldice for 30 years, makes clear that mastering the Shouldice Technique is of the utmost importance. At Shouldice, mastery comes from practice, peer consultation and experience. Its surgeons have been with the hospital an average of 10 years, but what stands apart is the volume of hernia surgeries. While general surgeons typically don’t do more than 20 hernia surgeries in a year on average, at Shouldice surgeons perform five to six a day, and as a staff nearly 7,000 operations annually or approximately one-quarter of all abdominal hernia surgeries done in Ontario. The clinical experience and effectiveness are also evident in operational efficiency and staffing levels. At Shouldice turnaround time for surgeries is 10 minutes versus up to an hour at other hospitals and the ratio of staff-to-bed is approximately 1.8:1, while other hospitals in Canada, albeit likely treating more conditions, have a staff-to-bed ratio from 9 to 12.6 per bed. This combination of lean staffing and quick surgical turnaround is a considerable cost advantage for Shouldice, which, combined with being able to consistently deliver strong outcomes, makes it a unique example of value-based healthcare in Canada.
For Shouldice, pre- and post-surgery care plays a major role in preventing patient readmissions. Cindy Giroux, business development manager at Shouldice, explains, “We are patient-care centred. We look at the patient as a commitment of the staff to deliver the highest surgical outcome and best patient experience.” The four-day stay begins with patient orientation a full day prior to scheduled surgery and a two-day stay post-surgery for monitoring and rehabilitation versus a same day outpatient procedure at a public hospital. Normally more time and services increase costs, but Shouldice has tailored all aspects of the patient experience, surgical and non-surgical, to achieve the best possible outcomes, cost-effectiveness and patient satisfaction.
At Shouldice they believe that during their stay patients develop an informal support network that builds trust in the Shouldice model and increases patient satisfaction. When post-operative patients interact with newly admitted patients, they are able to answer questions about what to expect before and after the operation. During the two-day post-surgery recovery period, patients can be monitored by the staff for complications, while the camaraderie of the patients makes recovery and rehabilitation more effective than if an individual is discharged and sent home. After patients are discharged from Shouldice, they are eligible for free annual check-ups, which provide an opportunity for Shouldice to collect qualitative data through patient feedback and track longitudinal outcomes.
Despite the success of Shouldice, hyper-specialised hospitals in Canada are not common. Under Ontario’s Private Hospitals Act of 1990, private hospitals are not allowed in the province. However, Shouldice is one of seven Ontario hospitals grandfathered in as private but are still part of the public health system and are reimbursed by the government. Elsewhere in Canada, the Cambie Surgery Centre of British Columbia specialises in orthopaedics within sports medicine and has treated more than 55,000 patients since 1996.5 Surgeons at the Gimbel Eye Centre in Calgary have performed more than 200,000 vision-correction procedures and corrective eye surgeries since 1964.6 In November 2015, the province of Saskatchewan passed legislation that allows people to pay for their MRIs at private, specialised facilities.
What Shouldice contributes to these deliberations is an example of the potential for specialised private providers and facilities to deliver value-based healthcare within public provincial health systems.
What Shouldice contributes to these deliberations is an example of the potential for specialised private providers and facilities to deliver value-based healthcare within public provincial health systems. “Although there are challenges on the regulatory and funding levels on how best to do it, the Ontario Ministry of Health and Long-Term Care do understand the benefits of specialisation,” says John Hughes, managing director of Shouldice.
Indeed the ministry is working to introduce and integrate more specialisation into the health system. As such the Kensington Eye Institute is a non-profit, independent health facility that has performed more than 9,500 cataract surgeries in 2015 alone; like Shouldice, Kensington is accessible through the public health system. These community-based specialty clinics were first proposed as a key part of the 2012 Action Plan for Health Care and fall into two categories, a public hospital operating in a new site (such as an ambulatory care centre) or a non-profit, independent health facility. The Kensington Eye Institute, following the success of the Shouldice hospital, suggests that the government is open to more specialised health services. This approach is intended to improve access to low-risk procedures providing the right care, at the right time and in the right place.
As a specialised private hospital, Shouldice is permitted some discretion when considering what hernia patients fall under a set of criteria that deem them fit for the Shouldice Technique. Patients better-suited for a procedure reduce the risk of complications from surgery, improve the likelihood of successful outcomes and lower the probability of readmission — which reduces the long-term cost associated with the procedure. What Shouldice has proven, however, is that highly specialised and standardised care can achieve consistently excellent outcomes that are cost-effective — and even as a private hospital, have generated more value for the public health systems.
A case study from The Economist Intelligence Unit commissioned by Medtronic.
D Cook, et al., “From ‘Solution Shop’ Model To ‘Focused Factory’ In Hospital Surgery: Increasing Care Value And Predictability”, Health Affairs, 2014.
D Taylor, et al., Supply Chain Operations–Shouldice Case Report, University College Dublin, March 2014
B Amato, et al., Shouldice technique versus other open techniques for inguinal hernia repair, Cochran Database System Review, 2012, Abstract [PubMed]
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