HEALTH IT SPECIAL ISSUE: April 2011

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HEALTH it SPECIAL ISSUE

INTERVIEW

Dr Nagendra Swamy SC, President, Manipal Hospitals

interview

Prof K Ganapathy, President, Apollo Telemedicine Networking Foundation

INTERVIEW

Anil Swarup, DG for Labour Welfare, Ministry of Labour & Employment

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Contents Volume 6 > Issue 04 > april 2011 > ISSN 0973-8959

expert corner

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“Local innovations and partnerships are the two pillars that we stand on” Rajeev Agarwal, General Manager – Healthcare Informatics, Philips

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“In the coming decade, ICT will play an important role in hospital management” Dr Nagendra Swamy SC, President, Manipal Hospitals

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EMRs - An Odyssey to Holy Nirvana Gp Capt (Dr) Sanjeev Sood, Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh

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“mHealth is empowering the healthcare delivery system in India” Dr BS Bedi, Advisor-Health Informatics, C-DAC, Government of India

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“Tele-health is being viewed as a distinct service, as a subspecialty”

COVER STORY

Prof K Ganapathy, President, Apollo Telemedicine Networking Foundation & Telemedicine Society of India

Riding high on hope The highs and lows of healthcare information technology

By Divya Chawla

special focus

12 Managing New-Age Hospitals

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HIS are an absolute necessity for managing information and data within hospitals

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Accessibility - any time, anywhere Easy accessibility, improved clinical decision, reduced costs, increased hospital process efficiency—electronic medical records offers it all

34 Healthcare at your Doorstep mHealth focuses on wellness and not illness as it stands on the brink of creating a revolution in the recession proof industry

43 Securely Yours special focus

expert corner

RIS and PACS: Defining Trends in Radiology

“We plan to develop a national database system called cies”

With the advent of RIS and PACS, the era of digital radiology has arrived

By Divya Chawla

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Anil Swarup, Director General for Labour Welfare, Ministry of Labour & Employment

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The health insurance industry, worldwide has benefitted immensely with the implementation of information technology, which offers a win-win situation for all

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Telemedicine: Bridging Gap between Technology and Treatment The integration of ICT into the health sector has globally empowered the status of health in recent years

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Editorial Correspondence eHEALTH, G-4 Sector 39, NOIDA 201301, India, Tel: +91-120-2502180-85, fax: +91-120-2500060, email: info@ehealthonline.org ehealth does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors.

The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. ehealth is published by Elets Technomedia Pvt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS) Owner, Publisher, Printer - Ravi Gupta, Printed at R P Printers, G-68, Sector-6, Noida, UP, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP, Editor: Dr. Ravi Gupta Š All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic and mechanical, including photocopy, or any information storage or retrieval system, without publisher’s permission.

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Editorial

Volume 5 > Issue 10 > october 2010 ISSN 0973-8959

Bells of change

T

he global healthcare IT market is estimated to touch US $53.8 billion by 2014, growing at a CAGR of 16.1 percent. It is expected that the market for general applications in health IT will grow at an overall CAGR of 13 percent from 2009 to 2014. Although, the figures suggest tremendous growth for health IT in the coming years, yet growth in the Indian market is uncertain. Statistics suggest, that large corporate hospitals in India spend less than 1 percent of their operational budgets on IT, while hospitals in the west spend somewhere close to 3 percent on IT applications. EMR services, within the health IT market in India, have a high growth potential with an estimated CAGR of 13.5 percent from 2009 to 2016. Further as per reports, healthcare IT spending in most emerging Asian economies has increased appreciably, yet certain developed and emerging nations are still lagging behind.

The figures, although contrasting, point towards the growing awareness and interest towards healthcare IT across the globe. India is springing forward to match the footsteps of the western world. The government has also shown tremendous interest in this sector. The Eleventh Five Year Plan stresses on the appropriate use of IT for an enhanced role in health. India has witnessed the set-up of a number of pilot projects on ehealth over the past years by private concerns, corporate, NGOs, medical colleges, and research institutions. Indian Space Research Organisation, Ministry of Health & Family Welfare, Ministry of Communications and Technology and Ministry of External Affairs have all contributed towards development of health IT in India, through innovative projects and programmes.

To meet eHEALTH’s objective of promoting the use of ICTs in healthcare, we are proud to present the first edition of Health IT Special. The edition provides a complete review of the healthcare IT industry in India with a special focus on market dynamics, emerging trends and technologies, perspectives of industry and government experts, and product profiles of leading health IT solutions in the Indian healthcare market. It covers key health IT segments such as hospital information systems, electronic medical records, radiology information systems and picture archiving and communication systems, mHealth, telemedicine, cardiology information systems and technology in health insurance.

Hope you find this issue informative!

Dr. Ravi Gupta Ravi.Gupta@ehealthonline.org April 2011 < www.ehealthonline.org <

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cover story

Riding high on hope The highs and lows of healthcare information technology

By Divya Chawla

T

here has been a recent surge of IT applications in healthcare and health entities across the globe are increasing their IT spend.

India being a low-income country, and while pockets of extraordinary innovation exist, its national health IT infrastructure continues to lag. While on the one hand, India is considered to be an IT hub, on the other, it lags behind in the adoption of health IT as compared to the western

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world. Statistics suggest, that large corporate hospitals in India spend less than 1 percent of their operational budgets on IT, while hospitals in the west spend somewhere close to 3 percent on IT applications. Dr Rajendra Pratap Gupta, Chairman – Board of Directors, HIMSS Asia Pacific India Chapter says, “India is often quoted as the IT capital of the world, but it faces challenges multi-fold. It has both opportunities as well as threats to handle simultaneously. India still needs to leverage its technical competencies and market it more

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aggressively the world over. We are not just an IT body shop, we have the best transformative brains working in the IT sector, and the world has to fall back on Indian IT to draw system efficiencies and also save cost.”

Ray of hope India has witnessed the set-up of a number of pilot projects on ehealth over the past years by private concerns, corporate, NGOs, medical colleges, and research institutions.

In 2003, the Department of Science and

cover story Technology, Ministry of Communications and Technology, in consultation with Apollo Health Street Limited created an Information Technology Infrastructure for Health (ITIH) Framework. The framework is a guideline document and comprehensive roadmap that prescribes IT standards and guidelines for each stakeholder across diverse healthcare settings in India with the goal of building an Integrated Healthcare Information Network.

The Indian Space Research Organisation (ISRO), through its telemedicine projects has successfully connected 42 super-specialty hospitals with 8 mobile telemedicine vans and 200 rural and remote hospitals through INSAT satellites, throughout the country. So far about 3 lakh people have benefited from this programme. Facility of telemedicine will be provided in district hospitals and government medical colleges.

The Ministry of Health & Family Welfare has also launched various projects in this direction including the Integrated Disease Surveillance Project, Tele-ophthalmology project, National Telemedicine Grid, National Onconet Project, National Medical

eHealth Initiatives to be undertaken during the Eleventh Five Year Plan • Training, education and capacity building for eHealth • Monitoring by e-enabled HMIS to ensure timely flow of data and collation to be used at various levels • Geographical Information System (GIS) resource mapping of various health facilities (allopathic and AYUSH), laboratories, training centres, health manpower, and other inputs to optimise utilisation • Providing service delivery and other e-enabled activities like, disease surveillance, teleconsultations, health helpline, district hospital referral net, and e-enabled mobile medical units

“Indian healthcare IT has a long way to go. Besides a few states like AP, Karnataka, Gujarat and Tamil Nadu, other states are still to leverage the deployment of IT and develop competencies” Dr Rajendra Pratap Gupta Chairman – Board of Directors HIMSS Asia Pacific India Chapter

Impediments to Health IT • Absence of government policy to promote use of health IT • Lack of government funding • Low computer literacy • Lack of proper infrastructure • Legacy systems • Lack of proper standards • Privacy of data

College Network and National Digital Medical Library Consortium.

The Ministry of External Affairs initiated the SAARC telemedicine network and Pan-African eNetwork project that promote the use of ICTs in healthcare. The National Informatics Centre developed various telemedicine and hospital management software and got involved in ehealth projects in Orissa and NE states.

Realising the benefits of healthcare IT, the Eleventh Five Year Plan stresses on the appropriate use of IT for an enhanced role in health. The plan explores the feasibility of setting up a National Grid to be shared by healthcare providers, trainers, beneficiaries, and civil society. India already has the advantage of a strong fibre backbone and indigenous satellite communication technology with trained human resources, which will facilitate the implementation of this. Health Management Information System (HMIS) would be an important new initiative during this period. The government plans to establish a computerised web

enabled data capturing and analytical system to provide valid and reliable data and reports for use at all levels. The HMIS will also integrate the various vertical systems having their own reporting machinery into an integrated umbrella of holistic ME to cater to the needs of Sarva Swasthya Abhiyan.

Eventually, the Integrated Disease Surveillance Project (IDSP) will be a by-product of the HMIS.

Market forecast The global healthcare IT market is estimated to be US $53.8 billion by 2014, growing at a CAGR of 16.1 percent. It is expected that the market for general applications in health IT will grow at an overall CAGR of 13 percent from 2009 to 2014. EMR services, within the health IT market in India, have a high growth potential with an estimated CAGR of 13.5 percent from 2009 to 2016.

While healthcare IT spending in most emerging Asian economies has increased appreciably, yet certain developed and emerging nations are still lagging behind.

Considering the global aspect, judging by percentage of healthcare IT spending as part of overall national IT spending, Australia tops the chart, followed by China, Malaysia, New Zealand, Philippines and Vitenam. The trends and spending patterns of Australia have been found to be most typical in the region, resulting in sustained growth of the market, at a pace that is even higher than many of the currently emerging economies.

The changing paradigms suggest that the global healthcare IT market will touch the pinnacle of growth in coming years; and India will be an integral part of this growth.

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expert corner

“Local innovations and partnerships are the two pillars that we stand on”

W Rajeev Agarwal, General Manager – Healthcare Informatics, Philips is a business leader, having extensive experience in healthcare IT solutions for emerging markets.

In conversation with Shally Makin, he speaks about the range of products provided by Philips in the healthcare IT market

hat is your perspective on the growing healthcare IT market in India vis-ávis the global market?

What is your share of this market?

Primary healthcare market in India is growing very rapidly because a lot of users are harnessing the power of IT along with the power of telecommunication. These help in increasing the efficiency of people. People, who do not adopt them, get convinced at a later stage. They swing like a pendulum in the other direction to do much better in the sector because of its potentiality. The Indian market and the global market are both different as their needs are different. We still are not able to provide healthcare to a lot of people; there is a need to reach to a large number of people in a systematic way. We hope to make health the centre of government with more public private partnerships.

Enlist some key opportunities and challenges that health IT

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solution providers face in the Indian market.

The challenge is adoption. The providers have to show the value of the product. The other opportunity is telecommunication from the perspective of healthcare industry needs. We talk about reliability in healthcare, which is not offered by the telecom industry despite the high speed. Healthcare is a patient oriented industry and due to slow speed, the networks are not reliable and one cannot take risk of patient life with such service. The second area is demonstrating the return on investment (ROI). This is not needed in other countries as either the government or insurers provide funds, and neither of the option is available here in India. But I do not take this as one of the major barriers Provide an overview of the products, solutions and services offered by Philips in this space.

We have been in the market for quite a few years. Earlier, health informatics was only an add on for the company, but now it is one of our core areas of focus.

We are currently working on four areas—radiology informat-

expert corner ics, cardiology informatics, critical care informatics and teleenabling. There are few changes being made in Delhi, and other major projects which will be introduced next year. With respect to radiology informatics, there has been a huge change in terms of adoption by users as compared to five years back. To the extent that government and state government are putting up a lot of tenders and typically they are the last ones to adopt except for teaching institutes.

Definitely there has been a great change there. We have launched product range for’ IntelliSpace’ in healthcare. The ‘IntelliSpace’ has two things to focus on—radiology and the whole community behind them, like clinicians, surgeons, and whoever needs that information critically with all categories of users. Image reporting, management, distribution, analysis, and all other areas of activity, which occur between practitioners and clinicians, can now be done anytime anywhere not only on the workstations but also on a laptop or an iPad. The idea is to put the power in their hands and ensure that they are not tied down to their desk.

With this power, it helps them to collaborate. With collaboration they can make much better decision.

Radiology informatics is being increasingly adopted by radiology departments for improving their workflow.

What is the USP of the solutions offered by you in this segment?

IntelliSpace’s USP is, that it can be used anywhere anytime. For instance, when a patient gets a CT scan or MRI done, the reports might be confined to the radiologists’ desk only. With this solution provided by Philips,

We want to bring value. With this reason, we are spending a lot in innovation for the local market. Our approach to achieve this will focus on more partnerships in our ecosystem. Local innovation and partnership are the two pillars that we stand on they are not restricted, and from anywhere the analysis can be done at any point of time. With such solutions, the total cost of ownership (TCO) also comes down as it is on the server.

The product becomes a costeffective entity in the following years. Even from perspective of IT department, it’s beneficial as they don’t have to maintain or upgrade the whole database for the end points. They just have to focus on the server. The product has a complete TCO oriented approach, which adds value to encourage more and more clinical collaborations.

The integration of IT in the cardiology department has emerged as one of the key focus areas within the health IT space. How do you plan to target this segment in India with the range of products offered by you in the clinical informatics department?

We have the longest pedigree in this area and we are taking this pedigree forward. The cardiology department is a closed loop as the same department works on treatment and analysis unlike the radiology department.

The technology ensures the whole care cycle of the patient

starting from the point when an ambulance is called for. The ambulance may have an MRx monitor, a product offered by Philips. From there they transmit information to the hospital.

Alternatively it can advise the nurse in the ambulance, what action has to be taken. In the hospital, the cardiology department already receives the information, thereafter ECG, path lab and ultrasound reports are collated together in a unified manner to be made available to the clinician.

India being a costsensitive market, IT accounts for a meagre investment in a hospital’s budget. How cost-effective are your products/solutions as compared to other solutions in the sector?

I do not think that India is a cost-sensitive market; rather it’s a value-sensitive market.

The difference is that if you try to bring in the solution which worked somewhere else, it will not work here because the value equation is completely different. Our approach is to bring the right technology mix in the product, which is required to provide additional value to the market and the customer is

ready to pay any amount for it.

The customer sees the benefit in the product, which makes them understand the value of it. As we have seen over the years, the radiology and the cardiology solutions are not the blind adaption. On the other hand, with respect to the budget of the county, we see the industry as the commercial product. Out of the three verticals, capital expenditure (CAPEX), operating expenditure (OPEX) and Financing Expenditure (FEX) models, if there is no upfront for CAPEX, it becomes the commercial product with the other two.

Going further, what are your future plans and strategies for growth in the Indian healthcare IT market?

We invest in a lot of local R&D at the Philips Innovation Campus with a more focussed eye on the Indian solutions. We prefer more of R&D, as we do not want to blindly bring technology. We want to bring value. With this reason, we are spending a lot in innovation for the local market.

Our approach to achieve this will focus on more partnerships in our ecosystem. Local innovation and partnership are the two pillars that we stand on.

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special focus

Managing

New-Age Hospitals Hospital information systems are an absolute necessity for managing information and data within hospitals

By Divya Chawla

H

ealthcare, over the past decade, has witnessed the foray of information technology in different sectors. Albeit, with slow progress, numerous information systems have been developed and implemented in hospitals across the globe. This is evident in the increasing investments being made by hospitals towards information technology.

And the scenario is no different in India.

However, a strata of the healthcare society still believes that IT implementations in India still stands weak as compared to health-

care in the west. Sharing his views on this trend, Atul Bal, Director, Protech Systems said, “Information and management systems, when treated away from IT backbone, appear to be at primary stage (after crossing a stage of infancy), in India as compared to the similar medical setups in the west.”

There is, however, a change in scenario. As put in by Sajal Kumar Agarwal, Managing Director, bbnisys Technologies, “With the rise in the per capita income of the Indian population, the demand for quality healthcare services including latest healthcare IT in the country has risen. This has compelled Indian hospitals and services providers to invest in the sector.

“India is a very big and untapped market for HIS and HMIS software” Sajal Kumar Agarwal Managing Director bbnisys Technologies

Consequently, adoption of IT has become one of the top priorities for the Indian healthcare companies.” While, government hospitals are also now showing interest in IT solutions, the private sector remains the major driving force behind the growth of this market. Sajal Kumar Agarwal says, “India’s private healthcare sector, which currently contributes around 75 percent of the total healthcare expenditure, is expected to increase its spending on IT products specially hospital information systems (HIS) and

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special focus hospital management information systems (HMIS) substantially in near future. However, initially the scope of the services will be limited to the Metro and Tier I cities only.”

Need and objectives The ultimate objective of an HIS solution is to build a network of interdependent centres and departments. Departments such as the clinical laboratory, radiology, pharmacy, and so on can be interconnected, through an HIS, in order to effectively meet the needs arising within the hospital. This is extremely beneficial, as although these departments are individual centres, yet they are interdependent in terms of delivering services and to ensure effectiveness of providing care. An ideal HIS is expected to meet all information needs within a hospital. This includes data generated by various departments including patient information, billing, finance and accounting, staffing and scheduling, pharmacy ordering, prescription handling, supplies, inventory, maintenance and orders management, diagnostic reports related to laboratory, radiology and patient monitoring as well as providing decision support.

The need for information availability and management, within a hospital set-up, arises because of various reasons. Up-to-date factual information is an absolute necessity when planning day-to-day tasks. The basic operational requirements can only be defined if there is availability of adequate information. Further, information is required for accurate planning, be it short-term or long-term. Patient-care and hospital management decisions are more or less based on the day-to-day trends, which can be analysed only if information is present in an organised format. Another important fac-

tor is that documentation requirements such as maintenance of records, accreditation and legal records. Dr Ashish Dhawad, Founder and CEO, Medsynaptic, says “Any modern hospital in India today has to implement an HIS/HMIS to integrate and manage various departments like administration, finance and clinical.”

Giving an outline of the need of an HIS, Jospeh Puthooram, Managing Director, Edgeware Technologies, says, “When one looks at the health of the nation preventive care needs to be a priority. While, a second perspective of healthcare relates to the micro local view of a patient, clinic or a hospital, as compared to macro national issues where the health of whole populations or nations are to be managed. In addressing both these perspectives through information technology, it is important to have clarity on the following concepts.”

He adds, “When we look at the HIS or the HMIS, one is essentially looking at the local level of the hospital.” It is this perspective that needs to be changed to increase the adoption of HIS and HMIS at the level of government projects and health of the nation.

Market opportunities Healthcare is expected to be one of the key

“A boom is seen coming in next 3 to 4 years in the entire concept of HIS, whereas it will not limit itself to information paradigm” Atul Bal Director Protech Systems

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“In addition to providing administrative and clinical decision making support, HIS permits the creation of electronic medical records” Joseph Puthooram Managing Director Edgeware Technologies

industries fuelling the software industry growth over the next five years. The healthcare industry has witnessed an increased spending on IT with most of the hospitals and healthcare organisations shifting to electronically-based information systems.

As per reports, although, the Asia-Pacific region witnessed numerous HIS implementations across various hospitals in Australia, Japan, South Korea, Singapore and Malaysia, yet, India and China have been lagging behind in terms of technology adoption. India undoubtedly is the hub of HIS software and development activity but Indian hospitals have been very late in realising the advantages of information technology. The future is however, expected to be bright with the industry gearing towards adopting IT in a big way.

expert corner

Dr Nagendra Swamy SC President Manipal Hospitals

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expert corner

“In the coming decade, ICT will play an important role in hospital management”

W

hat is your perspective on the growing implementation of IT in Indian hospitals?

Indian healthcare is a US $60 billion industry, which is expected to reach US $150 billion by 2017.

Beds in excess of 1 million need to be added to reach a ratio of 1.98 per thousand population (world average is 3.3) at an investment of US $88 billion; 74 percent of which will come from the private sector.

WHO recommends India to add 80,000 hospital beds a year for the next 5 years to meet the demands of healthcare sector.

With this boom in healthcare industry, in the coming decade, IT will play an important role in the management of Indian hospitals. Process management, patient care and management information systems are key areas where IT will add immense value for cost optimisation and effective management. Unlike other industries like manufacturing, banking, insurance, pharma, aviation and insurance, where IT has became a business enabler and is helping these sectors to improve overall efficiency, enhance customer satisfaction, process standardisations, cutting

costs, increase revenue, and bring in more transparency, the healthcare sector, which has so far been bit conservative from the perspective of IT usage, has started realising that IT can really add value to the business.

As a part of this understanding, the major hospitals in India have started investing in IT and are engaging with reputed service providers in the healthcare IT domain. The key components of hospital digitisation include a clear strategy and roadmap, mandate from management, strong IT and functional leadership team identified to drive the implementation and adoption, reliable and cost effective partner for applications and infrastructure.

Electronic Medical Records (EMRs) are making their way into hospitals. Do you believe that Indian hospitals are ready to adopt EMRs in a big way and go paperless?

Indian corporate hospitals have already made substantial progress in implementation of EMR in their hospitals. Though complete paperless environment is challenging but 80 percent of this aim is achievable in immediate future. With user friendly initiatives and cost reduction it is possible to achieve this in private sector. Training and change management is the key challenge.

EMR has some 18-20 data components, which need to be captured in the system. These include details like patient history, chief complaints, diagnosis, clinical notes, lab diagnostics/results, medication, medication charts, pharmacy, operations, discharge summary, and so on. From the technical standpoint, this is not a big challenge and the system can be fine tuned to capture all these details.

However, from the adoption perspective, Indian hospitals will need to manage the ‘culture change’ more effectively especially from the ‘clinical adoption’ perspective. For EMR to become successful, doctors will need to make use of the system and capture essential clinical information. I feel that hospitals integrating 100 percent EMR, considering they start this journey in a planned way, will take around 3-4 years for becoming paperless.

Please tell us about the health IT solutions installed at Manipal. How can an IT solution transform the functioning of a healthcare provider like you?

We have recently implemented HIS solution at our flagship hospital in Bangalore and the same HIS is implemented at our hospital at Jayanagar, Bangalore. This implementation covers core HIS

With a hospital information system already in place, Manipal Hospitals is planning an expansion spree by connecting all its hospitals through an HIS. Dr Nagendra Swamy oversees, among other responsibilities, the functioning and operations of the Bangalore Cluster of Manipal Hospitals.

In conversation with Divya Chawla, Dr Swamy throws light on the IT initiatives of Manipal Hospitals and its future plans in this space

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expert corner

Managing medical records electronically can help the healthcare industry boost its operational efficiency, make life easier for doctors and help eliminate hassles for patients. EMR adoption would help doctors to access patient reports faster, enabling them to begin treating the patients promptly system, LAB, OP and IP, pharmacy, MRD digitisation and materials management. This also covers integrations with finance system and lab equipment, etc. With this implementation, our flagship hospital has achieved around 80 percent of the planned digitisation initiatives and we are in the process of covering other network hospitals, also.

The HIS has transformed the functioning of key areas of our operations. Some of the benefits are enhanced patient safety through better decision making; reduced operational costs through reduction in staff required for back office tasks; better inventory management through accurate estimation of demand, timely procurement and distribution of medical and non-medical items; increased productivity and elimination of human error through seamless integration with medical equipment; improved patient satisfaction through reduced turnaround time at points of care; and appropriate revenue capturing through online charge capturing and tracking of all billable services thus resulting in revenue enhancement.

What has been your approximate spend on IT solutions? Also, share details about your IT vendor.

Our approximate IT spend is around 1 percent of the revenue.

We have entered into a strategic

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partnership with Intersystems Corporation for HIS application at Manipal Hospital Bangalore and Manipal Malathi Hospital, Bangalore; 3i Infotech for IT Infrastructure management, data centre management, server and end user hardware and software support over a period of 5 years; and E4E for application support.

Please share your experience of the IT implementation process at Manipal. What are the major benefits that IT has offered to you?

Our Chief Information Officer (CIO) prepares a detailed IT strategic plan in consultation with various stakeholders across our network hospitals and the senior management of Manipal.

The IT strategic plan is prepared keeping our long terms business requirement in view and it covers all aspects of IT implementation like business applications, IT infrastructure, manpower, investment details and implementation timelines. The benefits achieved by us include simple decision making process that enhances patient safety; increase in revenues through online charge capturing and tracking of all billable services; reduced operational costs through reduction in staff required for back office tasks; better inventory management through accurate estimation of demand, timely procurement and distribution of medical and non-medical items;

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increased productivity and elimination of human error through seamless integration with medical equipment; improved patient satisfaction through reduced turnaround time at points of care; and improved decision making through online availability of information across departments.

How do you see the future growth of EMRs, considering that the technology is still not being fully utilised in the Indian subcontinent?

An added but important benefit of managing records electronically is minimising the use of paper.

Going paper free not only helps save the environment, but also helps organisations cut costs in terms of time, effort and money.

As per the recent study conducted by Accenture, emerging EMR markets like Malaysia, Thailand, Brazil, Russia, India and China may experience rapid growth in the coming years.

In fact, they may leapfrog developed nationsâ&#x20AC;&#x2122; levels of EMR adoption and usage. Managing medical records electronically can help the healthcare industry boost its operational efficiency, make life easier for doctors and help eliminate hassles for patients. EMR adoption would help doctors to access patient reports faster, enabling them to begin treating the patients promptly. For the patients, this would mean their treatment starts early and they recover sooner.

The present EMR modules provided by the HIS vendors are not very easy to use and are too rudimentary and user unfriendly.

For smooth adoption and successful EMP implementation, the healthcare IT service providers will need to make sure that it is made simple to use and also it should be easy to extract the analytical data from the EMR module. There is also a need to standardise the EMR framework across India in line with the international best practices so that the service providers can provide a common EMR framework to all the hospitals in India.

Enlist the challenges faced by you while implementing the IT solution?

We have implemented TrakCare HIS in Manipal Hospital Bangalore and key challenge was to customise this solution to meet the requirement of Indian hospital environment. Training of more than 1,000 nurses and more than 200 doctors was another big issue. Further, streamlining infrastructure for better security and high uptime of servers, storage systems storing patient information also creates problems. Lastly, I think change management and clinical adoption of IT solutions is a big challenge.

What are your future plans for the expansion of IT solutions at various Manipal Hospitals?

We have plans to extend the centralised HIS to all our hospitals over a period of next 2-3 years.

We want to streamline our IT infrastructure so that it supports high uptime to all our business applications, build dashboard reports for real time information.

We also wish to implement strong back office solutions using SAP platform at all our hospitals.

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Featured Product

Empowering Healthcare Applications Next-generation healthcare application development framework: tailored to meet industry expectations

I

nformatics is rapidly becoming an integrated part of healthcare industry. Today, IT solutions have begun to play an important role in the quality of patient care and profitability of the healthcare institutes. Naturally, the healthcare institutes have started demanding a lot from the IT solutions they use. As far as one can see, the demands of sophistication on the Health IT solutions will only increase with time.

While designing the products at 21st Century Health, we had to think long and hard on this important question: we have to base our products on sound design principles so that they will not fall behind the expectations of our industry. What are these principles? The search for an answer led to an architecture that today serves as the basis of out health IT products. Over the years, it was fine tuned more and more as a result of real world experience of implementing our solutions in hospitals, laboratories and diagnostics centers.

Today, it has become so integral to our working that we almost take it for granted.

The architecture, called health Application Development Framework or HADF, is based on few but strong principles: • Domain oriented programming • Customerization • Interoperability • Modularity

Domain Oriented Programming Creating business software means a lot of programming. Every small possibility in the business process will turn into lines of code.

This vast store of code keeps on growing, as we make our software more and more versatile to take care of a multitude of business requirement.

What HADF does is to let programmers

20

concentrate on the business logic, and takes care of the rest. This way, the programmers can spend their time incorporating more business logic than worrying about technical stuff. This translates into a much quicker delivery of end product than the traditional method. It also means that the application is less prone to errors, since most programming errors come from the technical part of code.

Customerization Whenever a software product is implemented as solution in a healthcare institute, it needs modification to suit the specific practices and policies. In the classical model, this is termed as customization and is usually achieved by coding. Now, whenever you add code to your product you better give it a thorough testing, otherwise you are getting yourself in trouble. This takes long time and increases the lead time for the implementation. Needless to mention, it also involves considerable cost.

The designers of HADF kept this as one of their most important objective: it should be possible to customize the product without coding. We coined a new word, Customerization, to represent this approach. HADF enables the implementers of the product to fine tune the product to an amazing extent, to fit the business requirements. Screens, menus,

> www.ehealthonline.org > April 2011

fields, outputs, reports, almost every aspect of the product can be adjusted. More importantly, this fine tuning can be done by experts in healthcare, rather than experts in technology.

Interoperability The designers considered the fact that our solution will have to work in conjunction with many other systems in a health institute. In fact, the success of IT in a health institute depends upon how well the different systems talk to each other. To give a few examples, pathology equipments need to talk to lab information system, imaging equipments talk to PACS and RIS, billing systems interact with financial management systems and so on.

Transforming Healthcare through People, Processes & Technology Article contributed by 21CHMS. For more information please email: contact@21chms.com or call +91. 98205 24680 www.21chms.com

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Aarogya Infotech and Management Systems

AIMS Hospital Information System

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arogya Infotech and Management Systems Pvt Ltd (formerly AarogyaSoft) is a leading provider of solutions, systems and services to healthcare providers since 2004. The company has a successful track record of implementing its Aayush range of software products to the entire spectrum of healthcare providers.

“Our company does not offer just software but a complete hospital management system. What initially started as a healthcare software product has been transformed into an integrated IT and management system for healthcare providers”

Features

Rakesh Singh, Director Healthcare-IT,

The software was first implemented at Choithram Hospital and Research Centre, Indore (a 350 bed tertiary care hospital) in 2004. Today, this proven solution has a large customer base with nation-wide presence.

Intuitive user interface, consistency in GUI design, user defined reporting system and online help has made it easily acceptable among end-users. Reliability, lower TCO, compliance with standards, proactive training and consultation by implementation team, configurable design and relevancy due to continuous upgrades for contemporary business practices and latest technologies have made it a hospital management system of choice.

Functionality It is a comprehensive solution for administrative, clinical and financial aspects of hospital management. A set of fully integrated 40 modules, covers all departments and functional requirements of mid-size or large hospitals. Excellent domain knowledge with deep understanding of practical problems faced by hospitals has resulted in a system which leads to a less-paper, automated work environment.

Changing with times, the latest release of AIMS range of software have been designed specifically for accreditation and certification requirements like NABH and NABL.

Aarogya Infotech and Management Systems

cation developed on .NET platform. It has been designed for distributed computing environment with SOA. The application can connect to multiple databases simultaneously and can be integrated with other software easily. Tertiary care hospitals generate huge amount of data, which needs to be managed routinely for performance and security. Hence the software is implemented with Oracle 11g as database. Although the client terminals and application server require Windows OS, it can be implemented with Linux as Network OS and Oracle on Linux.

Highly scalable, easy to implement and easiest to maintain, the software is a real friend of system administrators.

Business Model The software is available as on-premise SaaS. Instead of buying the software license the hospital pays a monthly subscription charge for concurrent user licenses. Hospital gets the entire set of modules for the same charge.

De-linking of software cost from number of modules makes it highly cost-effective. The hospital not only gets the regular updates and upgrades for free, but also eliminates customisation charges.

Ideal software for any hospital which wants to • Upgrade existing system without investing in license cost again • Going for standardisation and accreditation • Bring automation and efficiency in its processes • Cut costs and control expenditure • Implement rule based administration • Remain flexible and adaptable to change • Move from capital expenditure for software license to operational expenditure in new project If resources and processes are not exactly mapped with IT Systems, it will only create bottlenecks. True to its motto ‘Better Systems for Better Healthcare’, the objective of AIMS-HIS is to provide a well planned, fully integrated and automated workflow approach for implementing management policies and procedures.

For enquiries contact: Aarogya Infotech & Management Systems Pvt. Ltd. 302/27, Aditya Nagar, A.B. Road, Indore 452001

Technology AIMS-HIS is a web enabled, N-Tier appli-

22

It is amply clear that to get the most out of IT systems, a holistic approach in needed.

> www.ehealthonline.org > April 2011

+731-4066043/9826017970 sales@aarogyahms.com | www.aarogyahms.com

special focus

Accessibility - any time, anywhere Easy accessibility, improved clinical decision, reduced costs, increased hospital process efficiency— electronic medical records offers it all

By Dhirendra Pratap Singh

T

he Indian healthcare market is currently estimated at US $35 billion and is expected to reach over US $75 billion by 2012 and US $150 billion by 2017.

According to the Investment Commission of India, the healthcare sector has experienced phenomenal growth of 12 percent per annum in the last 4 years. Rising income levels and a growing elderly population are key factors driving this growth.

The increasing demand for quality care with rising competition has made hospitals maximise utilisation of technology in driving processes and streamlining operations. Not only corporate, but also stand-alone small and mid-size hospitals have woken up to the adoption of hospital information systems (HIS) making it an integral part of hospital management.

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Similarly, electronic medical records (EMR) and electronic health records (EHR) are making their way into the hospitals, albeit at a slow pace.

While both EHR and EMR refer electronic version of records, EMR is limited to a specific institution or a group of institutions, while EHR relates to a common platform that would allow disparate institutions in the private and government sector to share medical charts electronically (within strict guidelines for maintaining privacy of patient records).

The whole idea behind the EHR philosophy is to allow the chart to be portable between hospitals allowing greater flexibility for patients and doctors.

Joseph Puthooram, Managing Director, Edgeware Technologies says, “A quantum leap from the EMR is the EHR. When a patient’s electronic clini-

> www.ehealthonline.org > April 2011

cal record exists across disparate institutions, either vertically from primary care through secondary and tertiary care or horizontally across geographic boundaries, we achieve the EHR. In fact the paper record’s biggest weakness is its inability to be available at multiple locations at the same time.”

He adds, “Without the EHR, even telemedicine is crippled, having hardware without the supporting software, and its absence is a major cause of telemedicine’s ineffectiveness! When one is looking at the health of the nation, the transparency, access, quality, control of costs and a host of previously unimaginable benefits, including preventive care, can accrue with the implementation of the EHR.” Sajal Kumar Agarwal, Managing Director, bbnisys Technologies says, “Indian healthcare is experiencing a transformation, with the commencement of newer, better IT applications with secured technology. With increasing IT applications and insurance penetration, the demand for EMR is anticipated to increase robustly in next few years.”

Pre-requisites When introducing EMR to the hospital environment, it is critical to establish an HIS, prepare and involve various stakeholders (internal and external), and define a clear implementation path for EMR. All components of EMR must be compliant to integrate with other existing information systems in the hospital. Dr Ashish Dhawad, Founder and CEO, Medsynaptic says, “Today systems like HIS/EMR have become a necessary tool to provide quality healthcare to patients.”

special focus

“With increasing IT applications and insurance penetration, the demand for EMR is anticipated to increase robustly in next few years” Sajal Kumar Agarwal Managing Director, bbnisys Technologies

Benefits An EMR system must capture the entire patient data on a fixed format at the pointof-care. It should ideally be using a database, rules engine and knowledge base as the primary source of information; it should allow software integration of the EMR data with other data such as billing, practice management, laboratory, imaging and pharmacy systems. This saves time for the clinician by reducing double data entry in the other systems, while also ensuring the quality of data throughout the entire system.

A good EMR system has the capability of providing clinical decision support (CDS), helping in developing and implementing a provider’s decision making.

Since, the capture of clinical and demographic data is in a pre-determined format, it allows several clinical attributes to the data processing like, clinical decisionmaking by accessing a rules engine to provide alerts, reminders, clinical protocols, coding assistance.

Further, since the system integrates with other components of hospital in-

26

formation and management systems like lab, pharmacy and imaging, it can provide real-time data to the provider in its entirety, right from symptomatology, signs and investigations, thereby facilitating better clinical decision-making.

It also allows access to large amounts of data quickly, permitting to analyse and report data quickly and easily, including clinical statistics analysis, population health, and other reports.

The EHR maintained by an individual to have better control of his own care is known as a personal health record (PHR).

It is an electronic, cumulative record of health-related information on an individual, drawn from multiple sources that is created, gathered, and managed by the individual. A PHR should include cumulative health information ranging from past and current illnesses, demographics, allergies, prescriptions and more.

Challenges

“Today systems like HIS/ EMR have become a necessary tool to provide quality healthcare to patients” Dr Ashish Dhawad Founder and CEO, Medsynaptic

> www.ehealthonline.org > April 2011

At present, only a miniscule portion of doctors are enthusiastic about embracing this technology. Given the volume of patients they see in a day, it is hard to imagine physicians taking time to make notes directly into the system.

There are several software packages currently available in the Indian market that offer EMR along with HIS, but unfortunately, there are only few takers for the EMR. Unless there is a serious effort at educating the medical community in India about benefits of an electronic system, we will miss out on this marvelous revolution. Selling HIS or EMR packages to hospitals should not be the goal but a by-product. Software companies should first invest time and effort to educate the customer. Then they need to sell the appropriate package if it is the right fit.

Joseph Puthooram says, “The EHR seems a distant reality in India today.

But there is the silver lining of VistA, the multi-billion dollar EHR system that is available free under the US Government Freedom of Information Act. With its implementation at the AIIMS Trauma Center, Rajiv Gandhi Cancer Institute and the Max group of Hospitals, it is a technology that can potentially enable India leapfrog in promoting the Healthcare of this great nation.”

     

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 •  •  •      •    •     

                 

                   • 

  

•   •     •   •    

•    • 

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    •      •      •     •  •               •           •    • 

  • • • • •

          

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

 

 

  

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•      •     •    •    

 

  

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  

 

•  • 

      

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expert corner

EMRs - An Odyssey to Holy Nirvana Gp Capt (Dr) Sanjeev Sood, Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh, has successfully managed several Air Force Hospitals (Station Medicare Centres) providing quality and comprehensive medical cover to a large dependent population.

With a special interest in ICT applications in healthcare, Gp Capt (Dr) Sanjeev Sood shares insights into the electronic medical records implementation status in India, in conversation with Divya Chawla

P

lease give an estimate of compliance on EHR/EMR in Indian hospitals. How has it been complying with the global scenario?

The adoption of meaningful IT and EMRs has been slow all over world including US hospitals.

Though no survey has been carried out on adoption of EHR/ EMRs in India, but of the 15,000 odd hospitals, there are only a few (less than 300) that may have migrated to some form of EMRs. The hospitals that have moved on to digital records are mainly private corporate hospitals; some trust run hospitals like SGRH, Delhi and AIMS, Kochi; and few progressive state government hospitals on funding from State Health Projects.

Only a fraction of hospitals among these, have just begun to deep archive their EMR data into warehouses, so as to subsequently use it for research, data mining and analytics to facilitate smarter decisions and improve

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quality of care. Thus, though some Indian hospitals have commenced their odyssey to EMRs; not many have been successfully able to implement ICT solutions in their facilities, and those who have implemented, only a few have been able to fully incorporate and integrate in their work culture and achieve seamless, paperless, wireless and filmless environment so far. Since there are no standards prescribed by any Indian regulatory authority, issue of compliance does not arise.

In US, after the enactment of American Recovery and Reinvestment Act (ARRA) in 2009, an estimated US $19 billion are being infused into health IT. The level of US hospitals, having meaningful use of IT is less than 17 percent (less than 5 percent at comprehensive level—generation V, as per Gartener classification i.e., present in all clinical units with all functionalities; and 17 percent at basic level). The adoption is higher in large, urban and teaching hospitals. It is estimated that 90 percent of all physicians and 70 percent of all hospitals in the US will adopt EHRs

> www.ehealthonline.org > April 2010 2011

under the Health Information Technology for Economic and Clinical Health (HITECH) Act by 2019.

What are the barriers that limit the adoption of EMRs and EHRs? According to UN MDGs, goals, especially target 18, the benefits of ICT should be made available to the healthcare sector. Most sectors in general and healthcare in particular lag behind in keeping pace with revolutionary changes occurring in ICT in the past one decade, due to various barriers, such as, lack of resources and initial capital costs involved in implementation of technology projects.

Further, healthcare providers are generally perceived to be less techno savvy, resistant to EMR adoption due to cultural barriers. Once installed, HCWs have limited option for trial and to experiment with EMRs. Further, EMR innovation is inconsistent with adopters’ values and beliefs; physicians view guidelines and protocols as ‘cookbook’ medicine. The approach to project

implementation is fragmented and piecemeal. There are issues like interoperability and seamless connectivity, big-bang or incremental approach of implementation; and lack of overall policy and vision in EMR adoption in healthcare. There are also some unfounded concerns like dehumanization of patient care, loss of customer base by sharing patient EMRs, erosion of clinical acumen and unclear return on investment. Many problems associated with EHRs—tedious data entry, increasing of staff workloads ,poor user interface, disrupted workflow, faulty connectivity, and inadequate software updates—have been gradually solved over the past decade by early adopters.

Other challenges are that healthcare delivery is incredibly complex and uniquely personal, making IT system designing a daunting task; and not like repetitive, factory chores in manufacturing where one size may fit all. The success of IT projects depends on successful marriage between people, processes and technologies from the stage of

expert corner inception to competition. The US $31 million EMR at the Cedars-Sinai’s hospital had to be rolled back just after implementation because it was not user friendly. Sometimes, the process of EMR implementation may become so arduous and bogged down in the minutia of databases, software features, interoperability, ontologies, and codes that the intrepid HCOs may run out of wherewithal and capital, before getting anywhere near the Holy Nirvana that EHRs promise to deliver unto them. But the gains at the end of odyssey are worth the efforts.

Please give us the status EHR/EMR in your hospital. What are the criteria that you look upon while choosing particular software for EHR/EMR? My HCO has initiated few IT projects and has taken major steps towards issue of smart health information cards for each individual with biometric authentication based access control. EMRs have to deliver on certain key parameters and criteria that include performance; security, privacy and confidentiality; high storage capacity of servers; ability to integrate and operate with legacy systems across various departments, hospitals and other systems and sources like biomedical equipment and devices; and finally integration with other EHR system functionalities, such as computerised provider order entry for prescription drugs and electronic reporting of performance measures.

How do you see the future of the implementation of EHR/EMR in Indian healthcare scenario extensively at per of the global standards?

According to NASSCOM report, the future IT growth will be

In future, longitudinal medical records will allow tracking of patients’ conditions and medications so that providers in HCOs will have detailed information at their fingertips

driven by healthcare sectors in short and long term. Growth of IT in healthcare will be driven by increased usage of web for data warehousing, customer portals by health service providers, cloud computing, remote medical diagnostics, digitisation of medical records, drug research and clinical trials, billing systems and other front/back office services. As the volumes increase, and models like SaaS and cloud computing becomes available, the cost will come down further making IT applications affordable to all.

In future, longitudinal medi-

cal records will allow tracking of patients’ conditions and medications so that providers in HCOs will have detailed information at their fingertips. Clinicians will document using structured tools that allow capture of patient symptoms, clinical findings, and the physician’s assessment. The interdisciplinary teams that manage patients with chronic conditions will be able to track their panels, and seamlessly exchange information.

When patients are admitted to a hospital, they will be tracked from the instant they enter the hospital until they leave, and whether guidelines are being followed. Both patients and providers will have a better sense of what will occur and when, and this will result in higher satisfaction in all stakeholders. When patients leave the hospital, their discharge summary will go with them to the team responsible for follow up care. This system will include safety nets that are not present today. The providers and patients are willing to provide conducive environment for this tremendous, complex, and sophisticated transformation.

Many believe that it represents the dawn of a whole new era of medicine. The examples of the VA and Kaiser Permanente suggest that these hopes may come to fruition. Thus, I foresee a great holy nirvana waiting for health care sector at the end of this odyssey.

Do you think that there is a need for implementing standards, regulation to

run an effective system of EHR/EMR in India?

How can the government intervene in the scenario?

The government and regulatory agencies have a major role in how EMRs are developed and implemented by HCOs. They need to reward and incentivise HCOs that adopt IT and EMRs with ‘meaningful use’, as done in US under HITECH Act. Professional autonomous bodies can also institute competitive awards for excellence for hospitals on line of National Balridge Quality Criteria that are much coveted in USA. Further, government needs to enact suitable legislation and policies to encourage adoption of EMR, legally accept digital signatures, and provide guidelines to standardise records formats, nomenclature, and communication protocols to enhance interoperability of IT applications across healthcare spectrum. While in the U.S, Health Insurance Portability and Accessibility Act (HIPAA) addresses some of the relevant issues, much remains to be done in India. The Government may also educate care providers and public at large about benefits of EHR and may also mandate compliance. Thus, while additional legislation is needed, it must be crafted in ways that make a revolution in healthcare information possible, and do not paralyse this revolution with possible unintended consequences-such as implementation failures due to organizations’ inability to make the necessary cultural changes.

April 2011 < www.ehealthonline.org <

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special focus

RIS and PACS

Defining Trends in

Radiology With the advent of RIS and PACS, the era of digital radiology has arrived

By Divya Chawla

T

he advent of picture archiving and communication systems (PACS) has allowed for digitally capturing, storing and retrieving medical images and other related information at anytime, from anywhere. Replacing the traditional hard copy films used for radiology reports, PACS offers immense benefits in terms of saving costs and enhancing quality. Sharing his perspective on the benefits of PACS, Dr Ashish Dhawad, Founder & CEO, Medsynaptic, said, “PACS not just helps the hospital to go filmless by reducing cost of consumables like films but also helps improve staff performance by increasing their productivity and managing workflows efficiently.”

Together with radiology information systems (RIS), the productivity of a healthcare provider can be tremendously enhanced by

bringing in efficiently managed solutions for multiple departments.

The Need The complexity of the current healthcare delivery system is the biggest bottleneck for communication among caregivers resulting in fragmentation of patient care. To address these issues, hospitals across the world, are now implementing processes to facilitate clinical integration in an effort to improve patient care and safety. Clinical informatics, including image storage in a PACS, represents a tool whereby clinical integration can be accomplished, offering a seamless working environment.

Initially developed to archive, retrieve and view images, the functions of PACS have now evolved from storing images to include data and workflow management.

The accessibility and portability of patient

“Implementation of a good RIS/PACS system adds substantial value to any hospital and leads to better patient care” Dr Ashish Dhawad Founder & CEO Medsynaptic Pvt Ltd

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> www.ehealthonline.org > April 2011

radiographic imaging offered by PACS has revolutionalised the practice of radiology, thereby providing immense benefit to the medical fraternity.

Defining the need of a seamlessly integrated RIS/PACS solution in today’s healthcare organisations, Suresh Ranganathan, Chief Executive Officer, Agfa Healthcare India, said, “I believe there are two dimensions to the growing significance of RIS/PACS in India’s healthcare domain. On the one hand, there is a pressing need to improve the workflow in large institutions (mainly government owned) with robust, proven, high-end systems in the context of high workload environments. On the other axis, we have an urgent need for simple, cost-effective solutions to address the image management requirements for the huge market of private radiology practices and small hospitals.”

Beyond Radiology The many possible specialities where PACS can offer benefits include cardiology, ophthalmology, pathology, medical imaging, dermatology, trauma and endoscopy. As cardiological imaging uses the same modalities as radiology, PACS can be easily integrated with cardiology. RIS remains an option for laboratories and hospitals, where cardiology is performed by both radiologists and cardiologists.

Future developments will include output from

special focus

“In the coming years, both RIS and PACS will go through a steep demand curve in India” Suresh Ranganathan Chief Executive Officer Agfa Healthcare India

“Cloud computing is the holy grail of PACS/RIS” Gaurav Mundra Director & Chief Operating Officer Truworth

various specialties to be stored in PACS without integration of separate software.

Gaurav Mundra, Director and Chief Operating Officer, Truworth India said, “RIS/ PACS is going to be the next big wave in healthcare IT for larger hospitals. They will need special support in integration with existing systems and legacy equipment. They must look at the cloud as an option to expensive hardware and maintenance. Pricing should move to an ASP model too.” He adds, “Once we have enough bandwidth to put all the images and data on the cloud, the cost would go down dramatically as hospitals would no longer need the expensive storage and servers for processing. Compatibility

with legacy systems is the biggest driver as costs for new systems is very high. If there are solutions that allow using older equipment or existing pieces of software with the new RIS/PACS, we have a winner.”

Indian Scenario The market penetration of PACS in India is gaining momentum owing to the growing popularity of digitisation at the level of hospitals and healthcare delivery centres. Sharing his perspective on the demand for PACS in India, Dr Ashish Dhawad said, “India is witnessing a revolution in PACS with several hospitals including smaller diagnostic centers implementing solutions to manage their

digital images. Fortunately, India has availability of high-tech RIS/PACS solutions like Medsynapse at affordable costs and this has helped in rapid acceptability and increased market for such solutions.”

The major drivers for the growth of PACS in India include increasing adoption across imaging centers and hospitals, advancing communication and enterprise technologies, and ability of PACS systems to be integrated with other imaging modalities. As the PACS technology has now evolved beyond being just a radiology-centric technology to a data management technology for various departments under a healthcare facility, the benefits it offers to the healthcare facility have multiplied. Further, increasing demand for advanced reporting and management capabilities owing to rise in imaging data volumes, coupled with technological advancements, and extending benefits beyond the radiology department to other modalities, are the major drivers for growth.

The challenge is to extend the reach of these technologies. Most importantly, India being a cost-sensitive market, the extent to which PACS-like technologies can evolve is limited.

Hopefully, in future healthcare providers will realise the need to balance costs with the benefits of IT implementation and opt for solutions like PACS for better delivery of care.

April 2011 < www.ehealthonline.org <

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> www.ehealthonline.org > April 2011

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special focus

Healthcare at your Doorstep mHealth focuses on wellness and not illness as it stands on the brink of creating a revolution in the recession proof industry

By Shally Makin

O

ver the years, the healthcare industry has seen an increased focus on preventive healthcare by the private sector. The technology has greatly transformed the healthcare scenario with a prospective future of mHealth. Mobile health information technology (mHealth) is basically defined as the portable devices with the capability to create, store, retrieve, and transmit data in between the patient and the doctor for the purpose of improving patient safety and quality of care. It is referred to as the ‘virtual visit to the doctor’.

Smart phones have brought a new era in the health sector by introducing health application such as blood pressure monitoring, smart-health sensors, fitness training and so on. The development of mHealth has been rapid enough to reach globally with a fusion of wireless smart phone technology with healthcare. Most of the people of different age, whether old or young, have cell phones.

This has made the world smaller, connected and easier to communicate with. According to TRAI, by December last year, there were 750 million mobile users with 18 million of them increasing every month. This shows the long expected mobile revolution in health

34

“Although we have over 600 telemedicine nodes in India and the country has opened up to mHealth too but utilisation in more than half of these nodes is limited to video conferencing systems” Dr Sanjay P Sood Former Telemedicine Consultant, WHO Healthcare Informatics CDAC, Mohali

care sector with the introduction of smart phones and awareness in the rural areas about preventive health. Such business models have encouraged traditional healthcare providers in the mobile application market to broaden the utility and aspects of healthcare services. Continued Medical Education (CME), remote monitoring and healthcare management applications are some of the many mHealth applications existing in the market. According to a report, the mHealth market is expected to reach US $4.6 billion by 2014 and 30 percent of the total smart phone users will be benefitting with the

> www.ehealthonline.org > April 2011

mHealth application. The figure below gives the statistics of the mHealth and its market.

As Dr Sanjay Sood, former Telemedicine Consultant, WHO puts in, “mHealth has evolved to a level where these technological marvels can be classified as practical, feasible, beneficial and affordable.” mHealth provides great benefits to patient by using medicine reminders and appointment reminders, conducting research on confusing symptoms or connecting to a system such as iPath to ask for assistance in diagnosis, enables last/first mile communication with the patients enabling users to access health in-

special focus

formation when and as they need. To ensure that patients can find stock of prescribed medicines in a dispensary close-by, this application can also be connected to HMISenabled dispensaries in SMS-based query applications. These services will save time and resources travelling to dispensaries that don’t have the required medicine.

With such technology, doctors can receive a share of revenues from downloads or subscription fees from specialized mHealth app stores; pharma companies will be encouraged to advertise and increase sales through improved patient outcomes by focusing straight to the patient’s health; rural areas with shortage of physicians will be benefitted greatly with the mHealth application reaching to specialists’ advice directly; and data

collection and information distribution will be made much simpler.

Anurag Dubey, Industry Manager, Frost & Sullivan, says, “These types of innovative mobile solutions will revolutionise and enhance the accessibility of health services empowering the population with anytime anywhere healthcare service offerings.”

Trends and Future Applications With increasing technology, Indian railways is introducing internet facility in the next two years for the passengers to help them use mHealth application in emergency. NHS in UK has validated over 40 languages for communicating every patient surpassing all language barriers. In India, a two year MD

“We are delivering thousands of views every week on health topics” Nandu Madhava CEO, mDhil

Source of graph: research2guidance

“mHealth models have been used for disease surveillance and tracking, health education and awareness, remote data collection and patient monitoring and healthcare worker training” Anurag Dubey Industry Manager, Health IT & Healthcare Delivery Practice, South Asia & Middle East, Frost & Sullivan

course in wireless medicine for doctors is being offered for encouraging doctors to involve in mHealth services. Textbooks are also available on mobile such as reference lab on cyber space for matching and diagnosis.

Anurag Dubey appreciates the Apollo-Aircel service ‘Tele Triage’, which empowers patient to connect to Apollo hospitals’ consultants round-the-clock to discuss health concerns or symptoms and get advice over precautions and drugs to be taken. Nandu Madhva adds, “3G and low cost smart-phones are helping mHealth information services reach significantly larger audiences in India.” mHealth includes the merger of research and mobile technology with the extensive use of mobile phones, telehealth and GPS. With the advancement in cloud computing and improved connectivity along with mobile health innovations, mHealth has come a long way from idea to innovation. The connectivity base is now expanding to digitise the patient electronic medical records, as well. The 3G technology makes mHealth application to be used efficiently by sharing audio files, video files, visual images between patient and the doctor.

Today, mHealth is reaching in rural villages of India, which still do not have a landline and a wired phone but a wireless technology.

April 2011 < www.ehealthonline.org <

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expert corner

â&#x20AC;&#x153;mHealth is empowering the healthcare delivery system in Indiaâ&#x20AC;?

W Dr BS Bedi, Advisor-Health Informatics, C-DAC, Government of India, has streamlined telemedicine centers and standardised mHealth services with effective framework of IT into the industry.

In conversation with Divya Chawla and Shally Makin, he speaks about mHealth and its role in reaching to the rural population despite lack of awareness

36

> www.ehealthonline.org > April 2011

hat is the current status of use of mHealth in the country?

Mobile health has permeated to most of our population. Today, ICT is being used in every field and with mobile technology becoming cheaper day by day, there is a huge increase in number of mobile users. According to TRAI, by December last year, there were 750 million mobile users with 18 million of them increasing every month.

Once this tool is available to most of the people, this tool can be used with ICT, making it more efficient. The network providers have been successful in reaching even to the rural areas and creating a mesh by joining the poor to all the facilities.

What are the various government-funded healthcare projects in India?

Government majorly focusses on connecting the poor with high-end services like mHealth to save people in case of epidemics and making people aware of

how to keep good health. Access to health information is the precursor to planning and managing diseases. Out of the primary, secondary and tertiary health, rural health workers operate in 310 primary health centres. These health workers created database manually but with introduction of computers and technology, the databases are now organised and created on computers at block level in specialised primary healthcare centres. The connectivity is reaching to the interiors, empowering healthcare delivery system in India. With technology, we have the potential to reach people at their households through mobile handsets.

During an epidemic, there is pressure on DMO to provide figures. The lack of information is now being planned and collected by the health information system. For this, technology has empowered health workers in Mallapuram district in Kerala through C-DAC in collaboration with DIT and Media Lab Asia. There are 200 blocks for experiment, using mHealth application for keeping good health and mobile phone for consultation. IT shows successful results which will engage in taking the information to

expert corner the next generation. Within a month the current status of the ground level reality can be available to the planners.

How can government leverage technology to the illiterate and BPL to avail such service?

Technological problems are much easier to solve in India.

Many technologies have been introduced by C-DAC and other agencies. To access the information, national health information is shared in local languages already. It may not be that difficult or rather a major challenge in implementing the application to the existing mobile users. In todayâ&#x20AC;&#x2122;s world, technology and network providers in the league, has tapped this issue. With introduction of handsets in local languages, there is a clear cut solution to this. Also, the application is now integrating into the next generation with providing information through voice communication and consultation in local language, depending on the state which provides various schemes according to the population prevalent. The language problem can be managed in the overall logistic management.

Do you think mHealth can stand for sharing info on chronic diseases?

The potentialities have been realised and special care is taken in case of chronic diseases.

Corporate hospitals such as Apollo have made it possible by merging with Aircel to provide health through mobile.

Such super speciality IT savvy hospitals give expert advices to the patient on diseases such as cancer. The facility provided to the masses is 24X7 and one can consult for any symptoms and receive advice by using

There is a great potential for mHealth in the coming years to save lives in our country.

There are projects being planned with IIT Kharagpur and Government Medical College, Calcutta with the empowerment of doctor and his accessibility to the patients What are the challenges suffered by mHealth providers which refrain them from extending their reach?

There are majorly 2 challenges faced by this application so farâ&#x20AC;&#x201D; privacy and authorisation. Privacy is a need of the patient, who is sharing information about his health and the medical records stored in the software. The other is authorization of the service providers. But he believes that with the advent of technology and experts, these two can also be surpassed.

IVRS or experts in case of an emergency. This corporate hospital has recently tied up with NHS which provides algorithms for authenticated information.

Do you think telecom provider will share reliable info with users? Do we have any standards for monitoring?

So far I am not aware of any particular rules, policies or regulation enforced for this application. Although, medical ethics

by ICMR, telecommunication act and IT act of India do enforce their terms and conditions to be followed by the doctors as well as the moderators and service providers.

How much do you think mHealth will contribute to healthcare in the coming years?

There is a great potential for mHealth in the coming years to save lives in our country. There are projects being planned with IIT Kharagpur and Government Medical College, Calcutta with the empowerment of doctor and his accessibility to the patients which gives a greater possibility of mHealth into the market. It will provide all the facilities including accessibility of records, emergency alerts, and full technology for particular handset compatible with x-rays etc. We cannot compromise on healthcare delivery and need treatment information to be authenticated. The doctor cannot miss a treatment because he is not accessible to the patient

and his records. Also, we need to keep a check on the technology as we cannot cause error in medical records or x-ray picture leading to false diagnosis. Presently, there are 2 samples, 300 â&#x20AC;&#x201C; 400 T.B and HIV patients in each, for paediatrics using this service with all the safety measures being taken care of.

There is a clear lack of evidence that demonstrates the practical and monetary benefits of mobile healthcare, a reason for less participation of industries and people in to the sector?

The kind of penetration this application is doing, irrespective of rural or urban divide is opening up tremendous possibilities of taking care of some of the weaknesses of healthcare delivery.

It is very important to explore this area and integrate into the national health program in some way or the other so that the whole program of healthcare delivery is strengthened.

I am very hopeful that time is not far when this going to happen. I do not agree of any monetary or practical reasons or less participation. The only reason is less attention being given by the private sector due to lesser opportunities although public private partnership would be great aspect in strengthening the application with spreading the base to whole country.

April 2011 < www.ehealthonline.org <

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The Prognosys mHealth solution provides assessing of various communicable diseases (Malaria, Kala-Azar, Dengue, etc.) and monitoring of mother and child health, especially in the rural community and communicating through short messaging services (SMS) through mobile telephony technology. SMS is the easiest and the best method to send health information in an appropriate format required for doctors and researcher. It elimi-

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This is a simple and efficient health monitoring system using mobile telephony for various communicable diseases and mother and child health. Transmission and reception of patient

38

and other health related information through SMS. The Server–Browser based SMS software is used to send/receive vital information through SMS to and from remote users to labs/ doctors/ specialists and provides complete data and statistical analysis.

> www.ehealthonline.org > April 2011

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expert corner

Anil Swarup Director General for Labour Welfare, Ministry of Labour and Employment, Government of India

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> www.ehealthonline.org > April 2011

expert corner

â&#x20AC;&#x153;We plan to develop a national database system called ciesâ&#x20AC;?

W

hat was your objective behind implementing IT in the RSBY scheme?

RSBY started its operation on April 1, 2008 and has now been operational for almost three years. While we were conceptualising the scheme, we were cautious of the basic characteristics of the target beneficiaries, which are the below poverty line workers. We were aware that these persons were primarily by definition poor. We wanted a scheme, which is cashless because a poor man can not raise resources to meet his requirements and claim in the insurance company. Another challenge was that majority of the beneficiary population was illiterate. Therefore, we wanted to evolve a paperless health insurance scheme and thatâ&#x20AC;&#x2122;s where technology became handy to us.

How have biometrics and smart cards helped the scheme?

Since most of the workers migrate from one place to another. It was a challenge for us to enable them avail these facility anywhere in the country and again in this context technology became handy for us.

I am not very sure ten years ago

this could happen; technology was not mature enough to take care of these problems. We are fortunate that use of smart cards became the basis of the scheme. It helps the identification of beneficiaries through biometric system. Large number of schemes in India have not been successful as beneficiaries were not clearly identified as there was no foolproof method of identification. Here biometrics has been immensely beneficial in the identification process.

Do you think that biometric identification is more workable than real time connectivity system?

There has been a debate that whether smart card should actually be used or there should be real time connectivity. Unfortunately, in India all places are not real time connected and it will take some time for the entire country to be real time connected. When you visit hospitals, how does the hospital verify whether you are what you are?

In biometric identification, the data is stored on a chip. When the person goes to hospital the data is verified with the data on chip and it enables the offline system. Smart card also helps to ascertain whether there is sufficient amount available in the card.

Now the smart card platform is

stabilised for the purpose of health insurance. In future, amart card can also be used as a health card. Right now, it is just an insurance card as no health related information is stored on the chip. However, there is space available for the health related information to be stored. We are currently examining the aspect of putting this information on the cards.

Almost every state of the country is now offering RSBY scheme to its BPL population. As on date 23 million smart cards are active in the country and more than 1.5 million people have already availed treatment at various hospitals. The scheme has been chosen by the World Bank as one of the top 18 social security schemes. Countries like Bangladesh and Maldives have also taken decision on replicating a similar scheme in their countries.

The current union budget proposes to expand the reach of this scheme to include various unorganised sectors. Please throw light on this decision.

Now, the scheme is by and large stabilised. It started with BPL and is now going beyond BPL. It is going to extend to the street vendors. In the current Union budget finance minister has announced the extension to MGNREGA beneficiaries and beedi workers, also. Railway Ministry is going to extend this scheme to railway portals and postal departments

The brainchild of Anil Swarup, Director General for Labour Welfare, Ministry of Labour and Employment, Government of India has transformed the life of millions of people in the unorganised sector, through the Rashtriya Swasthya Bima Yojana (RSBY).

In an interaction with Divya Chawla and Dhirendra Pratap Singh, he shared his perspective on this health insurance scheme and threw light upon the role of IT in streamlining its processes.

Excerpts:

April 2011 < www.ehealthonline.org <

41

expert corner

The scheme has created a demand for healthcare in rural areas and hence, the supply comes. So it’s a demand based service that we are providing to extend it to their postmen.

The latest incident of application of this scheme is in the German embassy. They are going to implement RSBY for all their casual workers working for them.

In India corruption and fraud has always been a challenge in the implementation of various government schemes.

How you have dealt with such challenges?

Technology plays very important role in the overall implementation of RSBY. To control fraudulent activities the data generated everyday is analysed.

We study the trends on daily basis to check what is happening where and in this way we can verify if something goes wrong somewhere. We can access data,

42

analyse data and then take appropriate action.

What are the major benefits of this scheme?

Technology has helped us to look into various disease trends and profiles. We can have a disease profiling done and find out the occurrence and prevalence of various diseases. The scheme has very positive fall out also.

The first advantage is the increase in number of women availing healthcare facilities through this scheme. There are 11 districts where number of women beneficiaries has outnumbered men.

Poor women didn’t have money to go the hospital, earlier, but through RSBY they have the facility for free hospitalisation. Another major development is setting up of private sector hospitals

> www.ehealthonline.org > April 2011

in remote areas. Having an insurance scheme without any healthcare providers doesn’t make sense as people can not avail the facilities, anywhere. The scheme has created a demand for healthcare in rural areas and hence, the supply comes. So it’s a demand based service that we are providing.

Besides, the government hospitals are improving their services because, under the scheme, the government doctors get 25 percent of the total cost of the procedure. Now these doctors are competing with private sector doctors to provide benefits to the poor. This trend has been clearly demonstrated in states like Kerala. Facilities of hospitals are improving. So there are number of positive changes that are emerging in this scheme.

Do you think RSBY will be able to achieve the goal of inclusive growth in India?

It has achieved the goal of inclusive growth. It is addressing poorest of the poor and the out of pocket expenses of the poor have come down to a large extent. In case of RSBY every penny is electronically accounted for. Perhaps, this is first ever business model for a social sector scheme in India. Fortunes are lying at the bottom of the pyramid. The scheme has a business sense for everyone involved and by doing this business, they are serving the poors.

Such business models are very sustainable. It is a very unique that it is happening in India and I think this is quite a revolution.

Could you please tell us about your technology providers?

We don’t have a single technology provider. One is the security software, which is entirely prepared by the NIC as the security software could not be given to anybody else. Another is data

software, which is developed by World Bank. Then there are host of process software, out of which the enrollment software has been prepared in-house and the other software have been developed by different agencies.

When you initially started scheme, what was your motive behind using technology in such a huge way?

Everything was not preplanned.

In term of poverty and illiteracy, we learnt that technology was the only solution as we wanted to make the scheme cashless and paperless. We have committed mistakes and corrected ourselves and have evolved after a period of time. It has been quite a journey. We are still evolving on the technology front. We are planning for a national database system called CIES (Comprehensive Information Exchange System). We plan to link all hospitals through the CIES What were the challenges in technology implementation in RSBY? Smart card technology was not stabilised anywhere in country.

Secondly, health insurance was itself a challenge because health insurance was collapsing worldwide. I think the biggest challenge was our internal attitudes to believe that it can happen. Fortunately, we have an outstanding team, which is full of energy and is always looking towards solutions.

Also, we have not been able to reach out the beneficiaries as much as we wanted. We are glad that a lot of agencies like UNDP are helping us. However, a lot of things still need to happen. For instance, we are not so happy with the quality of service. In future, we are going to evolve a methodology to prevent collusive frauds and misuse of cards.

special focus

Securely Yours The health insurance industry, worldwide has benefitted immensely with the implementation of information technology, which offers a win-win situation for all

by Dhirendra Pratap Singh

H

ealth insurance has been the fastest growing segment in the non-life insurance industry in India over the last few years. According to IRDA, in 2009-10, industry premium revenue has grown about 12-fold from a level of `675 crore in 2001-02 to `8300 crore, in just 8 years.

IRDA report says that insurance currently pays less than one-tenth of all hospitalisation expenditure in the country but the share is much larger for hospitals in metro cities and large towns, where it could be 30-40 percent.

Also, still there are schemes that do not cover all procedures, because of which, there are substantial out of pocket payments even for those covered by insurance.

IT in Health Insurance Information technology (IT) plays the most critical role in automating the fulfillment processes in customer facing businesses such as insurance.

Anjana Agrawal, Head of Customer Services and Operations, Max Bupa says, â&#x20AC;&#x153;Ability to compare different insurance options, seek an immediate clarification on all queries, which could arise while surfing the net

April 2011 < www.ehealthonline.org <

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special focus

“We still depend on snail mails to share information resulting in high turnaround times and customer dissatisfaction. This is due to the fact that the processes related to claims require integration of stakeholders” Antony Jacob CEO, Apollo Munich Health Insurance

(similar to phone a friend), ability to select and buy a product on-line (similar to online banking), being underwritten over the phone including a remote medical examination along with a generation of medical report/prescription (similar experience as you are sitting in a Doctor’s clinic and is being examined by them) and completing a transaction of delivery of health insurance certificate in few minutes is no more a dream.

Organisations have been able to utilise technology and other electronic gadgets efficiently for a world-class customer service.”

She adds, “From a customer perspective, real customer service experience starts with an after-sale-service, wherein the customer would like to have a personalised 24x7 service, along with availability of emergency services, something similar to having a personal medical assistant, who can prepare a daily wellness schedule and track the implementation of the same, fulfill day-to-day medical needs, guide and nurture the concept of proactive caring and ensure availability of medical facilities at just a click. Technology in today’s environment has capability to provide all this at an affordable cost right at your doorstep.”

Health insurance is one of the fastest growing business lines in general insurance.

McKinsey forecasts a `25000-30000 crore health insurance market by 2015, at a CAGR of 25-30 percent (for perspective, CAGR for 2001-02 to 2007-08 is 39 percent). This business involves various stakeholders and voluminous data capture and transfer takes place between the stakeholders. This includes the client, intermediary, the insurance company, the TPA (if involved), the hospital, doctors and diagnostic centers. All the stakeholders

44

require excellent IT infrastructure in terms of hardware as well as software.

Shreeraj Deshpande, Head – Health Insurance, Future Generali India Insurance Co. Ltd says, “The capabilities of each of the stakeholder in capturing data effectively and transferring the data across are very important. Health insurance involves personalised services and the efficiencies required are of a much higher level. Extensive quality data, analysis and inference are very vital for a viable health insurance portfolio. Health

insurance underwriting as well as claims processing system capabilities play a pivotal role. The extent and quality of data captured by an insurance company helps in more efficient product designing and pricing.” He adds, “Fraud detection is another important area in health insurance where IT has a major role to play. New regulatory initiatives such as portability require quick retrieval and exchange of data within insurers and would require the insurance companies to have excellent IT systems.”

Sharing the benefits of information technology in health insurance, K.Murali, Head – Health Underwriting, L&T General Insurance Co. Ltd says, “India being an IT powerhouse, no wonder we have progressed far in using technology. RSBY is a good example to show where we use biometric cards, paperless claims processing and electronic transfer of funds. The best part is that the lower strata of the society benefits immensely with use of technology in this scheme. For others, there is e-filing of claims, online cashless authorisation and web based tracking of claims. In future, customers would be able to enter their claim details to get online approval and claim amount transferred to their account instantly, with the use of rule engines.”

Challenges

“Fraud detection is important area in health insurance where IT has a major role to play. New regulatory initiatives require quick retrieval and exchange of data within insurers” Shreeraj Deshpande Head – Health Insurance, Future Generali India Insurance Co. Ltd

> www.ehealthonline.org > April 2011

Of course there will be barriers to the adoption or increased use of IT in healthcare, which include infrastructural ones like power supply, telecommunications and connectivity issues, as well as poor IT awareness.

But an information based approach will form the cornerstone for a modern healthcare system that will be more efficient and transparent and in the long term will result in better quality and coverage. A national health data network, electronic records, and standards will form the foundations of an information based healthcare system.

India is a developing country with over 26 percent of the population still living below the poverty line. Almost 35 percent of the population is illiterate. The living conditions in semi urban and rural India, makes the population living there vulnerable to various diseases. Nearly one million Indians die every year due to inadequate healthcare facilities and 700 million people have no access to specialist care and almost 75-80 percent of medical specialists live in metros

special focus

Government Funding for Health Insurance schemes

Through Pvt Insurers, risk transferred

• RSBY • Rajiv Arogyashri • Kalaignar

and urban cities. Most of the people in India refrain themselves from better medical facilities offered by private players due to the exorbitant expenses. Some avoid medication in totality due to expenses. There is very little awareness about medical insurance in India.

Healthcare financing in India is unique with considerably low share of public financing in total healthcare financing. It amounts to only about one percent of the GDP, whereas the average share of public financing in other low and middle-income countries is about 2.8 percent. Moreover, a significant portion of the public spending goes into tertiary care, whose beneficiaries are mostly non-poor.

Further, in the past decade our industry has seen considerable development and innovation pertaining to the sales process, which involves the sharing of information at the application stage. But sadly the pace of development has been far too slow when it comes to the claims processes. Antony Jacob, CEO, Apollo Munich Health Insurance says, “We still heavily depend on snail mails or facsimiles to share information resulting in high turn-around times and customer dissatisfaction. This may be due to the fact that

Using Insurance Intermediaries (no risk transfer)

• Yeshaswini • Bajpeyee Aarogyashri

Directly managed

• ESIS • CGHS • ECHS

An information based approach will form the cornerstone for a modern healthcare system that will be more efficient and transparent and in the long term will result in better quality and coverage. A national health data network, electronic records, and standards will form the foundations of an information based healthcare system the processes related to claims require integration of multiple stakeholders including thousands of healthcare providers.” He adds, “IT should play a significant role in enabling real time data sharing requirements between the claims facilitators and providers. This may be possible by creating a data highway where each customer, provider and claims facilitator can work in tandem for faster decision making through real time sharing of information.”

Public spending on healthcare is stagnant and most of this is by the states. There is an enormous variance across states, and the

“India being an IT powerhouse, no wonder we have progressed far in using technology. RSBY is a good example to show where we use biometric cards and paperless claims processing” K Murali Head – Health Underwriting, L&T General Insurance Co. Ltd

overall result is that healthcare infrastructure, utilisation, and disease burden compare unfavorably with the average of even low income countries. Availability of physicians and hospital beds are low, despite the fact that India accounts for 20 percent of the global disease burden.

Also, since the poor still depend on the public health system for major health services, non-existent, poor, or underutilised medical facilities and a shortage of medical staff often force patients to travel large distances to get specialist care. Lack of standardised data transmission protocols can make the process very inefficient. The hospitals and insurance companies will benefit immensely from co-operating in the development of protocols for efficient workflow.

Health insurance can improve access to good quality healthcare only if it is able to provide for healthcare institutions with adequate facilities and skilled personnel at affordable cost. Given this scenario, the challenge, then, for the industry and policymakers is to find ways to improve upon the existing situation in the health sector and to make equitable, affordable and quality healthcare accessible to the population.

April 2011 < www.ehealthonline.org <

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special focus

Telemedicine

Bridging Gap between Technology and Treatment The integration of ICT into the health sector has globally empowered the status of health in recent years

By Shally Makin

T

elemedicine dates back to the 1990s when the technology was first used to communicate through telephone, facsimile machine, and slow-scan images. The advent of communication technology, especially Satellite Communications (SatCom) combined with information technology, has infused life into the industry of telemedicine.

The word telemedicine basically defines â&#x20AC;&#x2DC;the use of telecommunication technology for medical diagnosis, treatment and patient

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â&#x20AC;&#x153;Telemedicine will become the game for the entire medical sector and it will transform healthcare drasticallyâ&#x20AC;?

Dr Devendra Patel Founder and Director, Medisoft technologies

special focus care’. It is the exchange of medical information via electronic communication such as interactive audio-visual intending towards improving patient’s health. The solution consists of a well equipped system of medical software integrated with medical diagnostic instruments connected to the commercial VSAT (Very Small Aperture Terminal) at each location or fibre optics. Dr Devendra Patel, Founder and Director, Medisoft Technologies, defines telemedicine as, “a patient centric healthcare delivery model. In other words, it means, putting the power directly in the hands of the patients by harnessing the power of the World Wide Web.” The global market of telemedicine is forecasted to reach US $13.9 billion by 2012. The market of telemedicine in India is expected to grow by 21 percent till 2014. With a 700 million rural population, India is in a need of a highly networked digital data transmission process for a better health infrastructure.

Telemedicine proves to be a boon for an ailing patient, who needs super-specialty opinion.

Dr AC Mullick, MS, Chief Evangelist, EMR Mavens says, “Telemedicine moves the information and not the patient. Teleconnected healthcare systems now offer primary healthcare clinic chains with video consultation for travelling patients via hosted applications, right here in India.” He adds, “Patients discharged after major procedures are being remotely monitored at home with next generation tele-health platforms in the US, and this will soon happen in India too.

The technology has matured enough to be disruptive and has the potential to change the basic paradigms of healthcare delivery.

The future is here.”

The tech savvy world has transformed the way healthcare is delivered to the masses.

In India, there are presently 700 million mobile users, out of which 35 percent of them use smart phones. Today, if people are ready to shell out `200 a month to receive cricket info, then most of the health conscious people would be happy to know the health tips being received on their phones as a new service being introduced. The 3G phones being popular nowadays serve as an important device to share health reports, xrays and photos with doctors and specialists for advice and treatment options, through the new telecommunication technology.

The use of telemedicine in treating soldiers

“The future of healthcare delivery lies in telemedicine reaching out to the soldiers in the battlefield through an audio-visual consultation” Dr Aloke Mullick, MS Chief Evangelist EMR Mavens

posted at borders will also become a reality in the near future. Dr AC Mullick adds, “Severe battlefield injury patients on the frontline are remotely monitored by specialists in base hospitals via secure mobile tele-health systems in the Iraqi battlefield.” This is a fair example of how healthcare delivery systems have transformed into.

Dr Devendra Patel adds, “Telemedicine has a broader spectrum than what appears first hand. In its simplest form it can be represented by a telephonic conversation be-

“Broadband technology has now bridged the gap between the patient and the doctor for treatment, transforming healthcare delivery in a virtual format” Dr Arjun Kalyanpur CEO & Chief Radiologist, Tele Radiology Solutions

tween a patient and a medical practitioner.

At the other extreme end, telemedicine can mean a robotic surgery being performed remotely.” So far, telemedicine is implemented in orthopaedics, dermatology, psychiatry, oncology, neurology, paediatrics, internal medicine, ophthalmology and surgery. Dr Arjun Kalyanpur, CEO and Chief Radiologist, Teleradiology solutions says, “Teleradiology has proved to be the feather in the cap of telemedicine, as it provides a real-life success story of what telemedicine can achieve, with the right focus on appropriate technology and process.”

Since telecommunication has now become the primary source of communication, in the coming years, telemedicine has a great scope of development. Use of phones and internet is now an affordable source of communication. Thus, it prospects to improve the quality, increases the efficiency and expands the access of the healthcare delivery system to the rural population and developing countries.

A ubiquitous wireless technology helps the transfer of the patient’s condition virtually to a doctor far away from the site. This not only saves time but promises to greatly improve the cost and convenience associated with long-term outpatient monitoring.

Dr Arjun Kalyanpur believes that the role of telemedicine should therefore no longer be a subject of discussion or debate, but rather it needs to be rapidly implemented on a large scale within the healthcare enterprise, and rightfully recognized as one of the key enablers of healthcare delivery. Telemedicine is a way to reach out to peoples’ home rather than encouraging them to go to doctors for health related advices.

April 2011 < www.ehealthonline.org <

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expert corner

“Tele-health is being viewed as a distinct service, as a subspecialty”

T

Prof K Ganapathy, President, Apollo Telemedicine Networking Foundation and Telemedicine Society of India, and President Elect, Indian Society for Stereotactic & Functional Neurosurgery, is a pioneer in introducing telemedicine in India. A renowned neurosurgeon, Dr Ganapathy has initiated pilot projects in using wireless telemedicine in several rural areas in India.

In conversation with Shally Makin, he speaks about telemedicine and its role in enhancing accessibility of health services, along with the challenges that affect its implementation, so far

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he advantages of telemedicine applications, for overcoming distance barriers and compensating for the lack of healthcare professionals, are many. How do you see the future growth of this technology, considering that it is still not being fully utilised in the Indian subcontinent?

It is only 11 years since pilot projects and proof of concept validation studies were initiated in telehealth in India. The growth of telehealth in India has been slow but steady. Hopefully we will soon achieve that critical mass essential for a successful take off. While it is true that the advantages of telemedicine are many, we must remember that for the last 6000 years when ‘formal healthcare’ commenced, the doctor patient relationship has traditionally, been a one-to-one, face-to-face encounter. To replace this with a ‘virtual’ image on a giant plasma screen or being examined by your doctor on your 3G enabled smart phone and a DIY (Do It Yourself) pocket ultrasound, obviously is a break from convention and

will take time. Several scientific studies have unambiguously demonstrated (and some of us hardcore telehealth enthusiasts in India strongly endorse this) that the success or failure of deployment and utilisation of telemedicine is not technology dependent. It is not an administrative or a financial issue. It is just the lack of enough evangelists to initiate and operationalise this relatively new innovation. We have all heard of Wi-max, Wi-Fi, FM, etc.

What is impeding the growth of telemedicine is the difficulty in making available Wiii FM (What Is in It for Me). Once all the stakeholders realise and are convinced of Wiii FM, telehealth will take off!

Do you think there is a need for a National Telemedicine Policy in different nations, especially the developing countries, for increasing and streamlining the use of telemedicine?

Yes absolutely! It has now been accepted, almost universally, that telehealth must be integrated into the healthcare delivery system. Just as all healthcare personnel (doctors, nurses, pharmacists etc), bio-medical

expert corner equipments, drugs, laboratories, etc. must be registered so do most telemedicine units. Having a National Telemedicine Policy is the first step. It must be followed by enforcement of the standards and regulations, which will form part of this policy. Though a National Task Force on Telemedicine was constituted by the Ministry of Health (Govt of India), technical standards for telemedicine equipments were laid down by the Ministry of Information Technology. But, these policies have unfortunately yet to be formalised and enforced.

Do you think telemedicine is patient friendly and can reap benefits?

We are in the transition stage where telehealth is being viewed as a distinct service, as a subspecialty. Telehealth is only the use of information and communication technology in various aspects of healthcare to bridge a gap, to connect the unconnected, to make distance meaningless and essentially to make Geography History! Unless such a service is patient and doctor friendly it will not reap benefits. Today we do not talk of customer satisfaction, we talk of customer delight!

Is the technology available in the country affordable?

The terms ‘technology’ and ‘affordable’ are both dynamic and not static. India is too big a country with too many groups of individuals, with various socio-economic and techno-savvy levels to answer a simple ‘yes’ or ‘ no’. Mobile phones have become affordable purely because of appropriate technology which is user friendly and culturally relevant. It is only because 50 mobile phones are sold every second that ‘technology becomes available and affordable’. So far as tel-

ehealth is concerned technology is in ‘bits and pieces’ available ‘here and there’. It is still not affordable for people who require it the most namely those at the bottom of the pyramid. One reason for this is that in telehealth, a doctor is still an important part of the chain and he has to be compensated adequately if he/she is to be excited enough to evangelise this concept.

Is there any training or workshop being conducted with regard to telemedicine?

As early as 2004, Apollo Telemedicine Networking Foundation started a formal certificate course on Telehealth Technology in conjunction with Anna University. Six courses were conducted and about 175 candidates completed the course. However, placement could be given for only about 10 percent there were not enough takers subsequently.

We feel that the time is right now for starting degree/ post graduate courses and we are now in advanced stages of discussion with the Tamil Nadu Dr MGR Medical University and IIT Madras.

The National Institute of Medical Informatics located at the Sanjay Gandhi Institute of Medical sciences Lucknow has commenced formal training in various aspects of telehealth.

There are various legal and ethical issues being faced by telemedicine today?

How do you perceive to tackle such issue?

It is unfortunate that this myth ‘there are various legal and ethical issues being faced by telemedicine today’ continues to be propagated. In the last 11 years more than 750,000 teleconsultations in India, we are not aware of cases which have come to court. This is not to undermine

the importance of taking appropriate preventive measures.

The legal and ethical issues are the same as that faced in a faceto-face encounter during a consultation. It is presumed that all stakeholders (teleconsultants, patients, administrators etc.) are mature enough to recognise the limitations of technology and will refrain from giving an opinion remotely when the information is provided is sub optimal.

While disclaimers are important let us not be on the back seat and

External Affairs initiated the Pan African eNetwork (Apollo Hospitals Chennai has accounted for 52.5 percent of all the teleconsults with the other 11 super speciality hospitals contributing to the rest) and the SAARC telemedicine network.

The Planning Commission has identified telemedicine as a thrust area and a sub committee was formed. Many state governments have their own telemedicine programmes. With the penetration of the mobile

There is no doubt that telehealth can reach the unreached start applying brakes before the journey has even commenced.

Personally I look forward to the day when there is a ’test’ case before a court. Till such time these issues will be conjectural and a will provide fodder for ‘intellectual’ debates. The Telemedicine Society of India is in the process of preparing a white paper to address some of these issues. Hopefully this will throw some light.

Please elaborate on the government and ISRO’s initiatives towards telemedicine in India.

ISRO has certainly played a very important role in the growth and development of telemedicine in India. Starting from a pilot project in Aragonda Apollo Hospital (the world’s first VSAT enabled village hospital commissioned by Bill Clinton the then President of the USA) ISRO has set up almost 400 VSAT units about 350 of which are in peripheral suburban and rural areas. There are almost 30 VSAT enabled mobile telemedicine units in different parts of the country. The Ministry of

phone into suburban and rural India it is hoped that mHealth will be a reality and probably overtake wired telemedicine.

How far has telemedicine been effective in providing good healthcare facilities to the soldiers in defence services posted on borders?

As a civilian I am not privy to detailed information to answer this question. However I was personally responsible for providing assistance to the Southern Command and the Central Command for setting up telehealth units in various military hospitals, and for conducting courses as early as 2003. The fact that information and communication technology (I had been invited to give a guest lecture on eMedicine at the last annual conference of the Armed Forces Medical Services) is being recognised as an important component of providing healthcare is obviously a step in the right direction. There is no doubt that telehealth can reach the unreached.

April 2011 < www.ehealthonline.org <

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