VALUE-BASED HEALTHCARE GLOBAL EVOLUTION PERSPECTIVES
An article from the Insights Series
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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.
For a Remote Viewer to view information displayed on a Programmer, the Remote Viewer needs to install or access the Bomgar Representative Console software (“Licensed Software”). By installing or using the Licensed Software to view the Programmer screen information, registering a username and password in connection with the Medtronic RemoteView feature, or clicking on any acceptance button in connection herewith, you, a Remote Viewer, agree to be bound by all of the terms and conditions set forth in these Terms of Use (this “Agreement”).
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.
IN NO EVENT SHALL MEDTRONIC BE LIABLE TO YOU OR YOUR ASSOCIATED HOSPITAL, CLINIC, OR PRACTICE FOR ANY INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES ARISING IN CONNECTION WITH YOUR USE OF THE LICENSED SOFTWARE, SESSIONS KEYS, OR THESE TERMS OF USE (WHETHER IN WARRANTY, CONTRACT, TORT, OR OTHERWISE, INCLUDING NEGLIGENCE, AND EVEN IF MEDTRONIC HAS BEEN ADVISED OF THE POSSIBILITY THEREOF), INCLUDING WITHOUT LIMITATION MEDICAL EXPENSES, LOSS OF REVENUE OR PROFITS, OR DAMAGES RESULTING FROM LOSS, MISAPPROPRIATION, OR UNAUTHORIZED OR MALICIOUS ACCESS TO OR MODIFICATION OF DEVICE DATA, OR FROM MISTAKES, OMISSIONS, OR DELAYS IN TRANSMISSION OF INFORMATION, OR FROM INTERRUPTIONS IN TELECOMMUNICATIONS CONNECTIONS, VIRUSES OR FAILURES OF PERFORMANCE, OR FROM THE IMPACT OF THE USE ON YOUR SYSTEM. IN NO EVENT SHALL MEDTRONIC BE LIABLE TO YOU FOR INTERCEPTION OR COMPROMISE OF ANY INFORMATION OR FOR ANY RECORD OR OTHER COMMUNICATION PROVIDED IN CONNECTION WITH YOUR USE OF THE LICENSED SOFTWARE.
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.
Miscellaneous. This Agreement constitutes the entire agreement between Medtronic and you regarding your use of the Licensed Software and supersedes any prior and contemporaneous written or oral agreements or understandings related to the Licensed Software. You may not assign any of your rights or responsibilities under this Agreement without the prior written consent of Medtronic. Except as expressly provided herein, no person or entity other than Medtronic and you, including without limitation any patient, is or shall be a third party beneficiary of this Agreement or otherwise entitled to bring any action to enforce any provision of this Agreement against Medtronic or you. With regard to any purported agreement or terms of use between you and Bomgar Corporation in connection with the Licensed Software (“Bomgar EULA”): (a) any Bomgar EULA shall be solely between you and Bomgar Corporation; (b) Medtronic shall not be a party to any Bomgar EULA; (c) any Bomgar EULA shall not necessarily reflect the contents of any agreement between Bomgar Corporation and Medtronic; (d) any Bomgar EULA shall not modify or take precedence over this Agreement; and (e) nothing in this Agreement shall be construed to suggest the enforceability or unenforceability of any Bomgar EULA. This Agreement shall be governed by and interpreted, construed, and enforced in accordance with the laws of the State of Minnesota (exclusive of the choice of law rules thereof). The parties hereby expressly waive any right to a trial by jury or class treatment of any claim, demand, action, or cause of action arising out of or relating to the Licensed Software or this Agreement. In the event that any provision of this Agreement violates any applicable statute, ordinance, or rule of law, such provision shall be ineffective to the extent of such violation without invalidating any other provision of this Agreement. No provision of this Agreement may be waived except by an agreement in writing signed by the waiving party. A waiver of any terms or provisions shall not be construed as a waiver of any other term or provision.
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.
An article from the Insights Series
Dr. Jason Arora, BMBCh, MPH, MA,
director of Value-Based Healthcare, Latin America, Medtronic
The healthcare industry is buzzing with the term ‘value.' In part, due to changes in government policy (e.g., the Medicare Access and CHIP Reauthorisation Act/MACRA or the Most Economically Advantageous Tender/MEAT procurement policy in Europe), a growing number of international stakeholders are starting to get behind the need for a value-based approach to healthcare. While many still debate the exact definition of value, most agree that it requires us to look at outcomes relative to costs.
If you take Harvard Business School professor Michael Porter’s view, you define value as the outcomes achieved relative to the cost of achieving those outcomes. In mathematical terms:
Value = Outcomes / Cost
Outcomes are defined as the results that matter most to the patient — the one true 'consumer' in healthcare. Cost is defined as the total costs of developing and delivering healthcare, rather than charges or prices.
While VBHC is conceptually simple, its implementation is not. Accelerating real-world execution of VBHC over the past few years has primarily involved providers utilising patient-centred outcomes for quality improvement activities, or — less frequently — payers developing outcomes-based payment models. Most successful examples of these initiatives have come out of Europe and the United States. Supporting these inspiring but somewhat disparate initiatives have been a few large-scale international efforts, aiming to provide common frameworks and define standards for widespread change across the global health care ecosystem. Three well-known examples are:
1. The International Consortium for Health Outcomes Measurement (ICHOM)
A global VBHC non-profit co-founded by Professor Porter at Harvard Business School, the Boston Consulting Group, and the Karolinska Institute. ICHOM believes that the routine measurement of outcomes is the first step towards VBHC. They are developing globally standardized, patient-centred outcomes datasets for different medical conditions and patient cohorts. The goal is to generate outcomes data (the numerator of the value equation) that can be used for value-enhancing cost reduction, and for international benchmarking, learning, and improvement.
2. The World Economic Forum’s Value in Healthcare project
A five-year, global, multi-sector effort to identify successful case studies and develop VBHC frameworks for healthcare stakeholders around the world. For example, one pilot project is tackling the topic of multi-stakeholder cooperation by bringing together 40 healthcare stakeholders (including payers, providers, patient groups, government, and medtech) to help manage heart failure.
3. The Economist Intelligence Unit’s global VBHC assessment
A 2016 VBHC readiness assessment conducted across 25 countries, against four domains:
Overall, the study concluded we are still in the early stages of VBHC transformation globally. By providing a common lens for VBHC readiness, however, it helped generate goal-oriented conversations in early markets for VBHC with ‘low readiness’, such as Latin America.
These system-wide initiatives intend to connect the dots and help healthcare systems and institutions globally navigate the journey towards value together. Since much of this is uncharted territory, information-sharing and collective learning can and will continue to be tremendously beneficial for all.
However, even with the support of these global endeavours, VBHC implementation remains a complex science that requires a significant degree of tailoring — from national systems down to the individual patient. While we are all still figuring out how to do it, it is very easy to get lost in the nuances. From cultural change in clinical practice to the reconfiguration of data systems, healthcare institutions — hospitals, payers, suppliers, and others — are required to develop value strategies that challenge deep-rooted behaviours and outdated operational norms in medicine. It requires both a revolution and a redefinition of healthcare. Many have been surprised by how long it can take to undergo such a transformation, with the journey throwing up new and unexpected learning points on a regular basis. Naturally, these tend to vary between institutions, which introduces a level of heterogeneity and uncertainty that can put some people off. Further, successful case studies tend to focus primarily on hospitals, rather than other stakeholders.
Since my shift from focus from more advanced VBHC markets in Europe and the United States at ICHOM, to early-stage VBHC markets in Latin America at Medtronic, I’ve come to realise that systemic initiatives won’t be enough on their own. While they will continue to play a vital role in driving common frameworks, there is a need for individual healthcare institutions to independently steer themselves in the right direction — to meet systemic initiatives at the same key touchpoints. The independent nature of this is critical because every healthcare institution — like every patient — is different, culturally, strategically, and operationally. The question then, is how does one effectively wield VBHC theory (such as the 6 points offered by Porter) in the real world, without help? Many (mostly providers) have been trying to do this for years — in particular, by beginning with the generation of patient-centred outcomes data.
By examining an early-stage VBHC market like Latin America, we’ve started to learn that the answer lies in simplifying the framework and empowering individual institutions — regardless of their role in healthcare — to develop their own tailored VBHC strategies based on the same fundamental principles, keeping those principles nimble enough such that they remain relevant for everyone — to providers, payers, and suppliers.
As we begin to form VBHC partnerships in Latin America, two interrelated themes continue to pop up and ultimately infuse every aspect of value-based programs with payers and providers: data and partnerships. Neither is a novel concept, but how we think about the two and apply them to VBHC transformation needs to be different.
Dr. Jason Arora, BMBCh, MPH, MA
Director of Value-Based Healthcare, Latin America, Medtronic
Jason Arora
Jason leads Medtronic’s VBHC work across Latin America. He also serves as a Global Health Expert at the World Economic Forum and a Global Leader at the Center for Health Care Innovation. Prior to this, Jason was a director at the International Consortium for Health Outcomes Measurement (ICHOM) and a practicing physician in the UK. He is the recipient of Harvard’s 2018 Public Health Innovator Award, and was named on Forbes’ "30 under 30 Health Care and Science" list in 2017 and on KPMG’s "Top 100 Asians in Tech" list in 2018. Jason holds degrees in medicine and medical sciences from Oxford, and public health from Harvard, and is a former Fulbright Scholar.
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