IT @ HOSPITAL SURVEY 2008 Part 1-North India: August 2008 Issue

v o l u m e 3 | issue 8 | A U G UST 2008

A Monthly Magazine on Healthcare ICTs, Technologies & Applications

Cover Story: IT@Hospital Survey Part 1 - North India eHEALTH Page 8

In Conversation: Growing Through Innovation Anjan Bose, Senior Director and Business Head Philips Healthcare Page 21

Industry Speak: Bench-marking Clinical Diagnostics Suresh Vazirani, CMD TRANSASIA Bio-Medicals Ltd. Page 24

Spotlight: Making Healthcare Accessible Through Technology Ashok chandavarkar Marketing Programs Manager, APAC Healthcare Intel Technology India

Page 28

In Focus: Intelligence for Public Health Dr. Ashok Kumar, Deputy Director General & Director, Central Bureau of Health Intelligence, Government of India

Page 71

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ISSN 0973-8959

Rs. 75

Watch out for upcoming issues for exclusive regional surveys on IT usage and automation in Indian Hospitals.

September - West India || October - South & Central India || November - East & North East India

For advertising opportunity in these issues, get in touch with - Arpan (arpan@ehealthonline.org, 9911960753)

w w w . e h e a l t h o n l i n e . o r g | volume 3 | issue 8 | August 2008

Cover story

CONTENTS

IT@Hospital Survey

Part I-North India eHEALTH

iN CONVERSATION

Growing Through Innovation

Anjan Bose Senior Director and Business Head Philips Healthcare Philips Electronics India Ltd.

iNDUSTRY SPEAK

Bench-marking Clinical Diagnostics

Suresh Vazirani CMD TRANSASIA Bio-Medicals Ltd.

SPOTLIGHT

Making Healthcare Accessible Through Technology

Ashok Chandavarkar Marketing Programs Manager, Asia Pacific Healthcare Intel Technology India Pvt. Ltd.

DEVELOPMENT DIMENSION

MEDical NETwork

Wayne Menary Director GeoPac - UK

APPLICATIONS

Making Practise Management Easy Girish Mohata Chief Operating Officer Novel Medicare Solutions

August 2008

w w w . e h e a l t h o n l i n e . o r g | volume 3 | issue 8 | August 2008

PERSPECTIVE

The Elusive Culture of Compliance

Ajit Nigam Business Development Manager Relsys India Private Ltd.

ZOOM IN

Emerging Trends in Electronic Data Capture

Callum Bir Director, Life Sciences Global Industry Business Unit ORACLE Corporation Asia Pacific & Japan

TECHNOLOGY TRENDS

Innovating in Surgical Imaging

Dr. Shivaji Basu Chief Urologist, Wockhardt Hospital & Kidney Institute

IN FOCUS

Intelligence for Public Health

Dr. Ashok Kumar Deputy Director General & Director Central Bureau of Health Intelligence, Government of India

RE G U L AR SE C T IO NS india news 41 BUSINESS NEWS

wORLD NEWS

product profile

NUMBERS

EVENTS DIARY

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An excellent example of collaborative efforts that are leveraging ICTs for public health and welfare is eHEALTH and its monthly publication, which aim to link all the stakeholders.

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Dr Ashok Kumar, MD FISCD and FIPHA Dy. DG & Director Central Bureau of Health Intelligence Directorate General of Health Services Ministry of Health and Family Welfare Government of India

Editorial Guidelines eHealth is a print and online publication initiative of Elets Technomedia Pvt. Ltd. an information research and media services organisation based in India, working on a range of international ICT publications, portals, project consultancy and highend event services at national and international levels. eHealth aims to be a rich, relevant and wellresearched information and knowledge resource for healthcare service providers, medical professionals, researchers, policy makers and technology vendors involved in the business of healthcare IT and planning, service delivery, program management and application development. eHealth documents national and international case studies, research outcomes, policy developments, industry trends, expert interviews, news, views and market

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Volume 3 | Issue 8 | August 2008

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Healthcare the world over is facing enormous challenges with regard to the changing lifestyles and demographics. Higher wait-time and cost of care is driving the growth of what is now called Medical Value Travel. South East Asia and now India are major hubs of medical tourism. In India however, there are as many detractors as supporters of this new development. The cynics question the accessibility of basic care for the Indian populace - let alone quality care. Then how, if ever, are we going to match up to the standards of the South East Asian countries? Also in this respect, one often makes sweeping statements regarding the state India’s hospitals are in; especially as regards the use of technology, or rather the lack thereof. However, a keen observer can tell the ripple effect this new market force is having on the healthcare industry. Hospitals are scrambling to get their facilities accredited in order to grab as big a share of the medical tourism pie as possible. And this has been one of the key factors in the decision of many hospitals to invest on IT infrastructure – so reveals our ‘IT@Hospital Survey 2008’ Part I – for North India (covering Delhi NCR, Punjab & Haryana). The adoption of technology has of course, many more proven benefits, such as lower turnaround time - important for hospitals to be able to increase patient throughput, and lower operational cost per patient. eHEALTH has taken up the enormous challenge of surveying the adoption of IT in hospitals across India, a vast and as yet unconsolidated industry. And in this issue we present the first of a four series report, giving detailed analysis of technology adoption among hospitals in the northern region of India – covering Delhi NCR, Punjab and Haryana. The report has brought to light some interesting findings, which will definitely make stakeholders look at the issue with a fresh perspective. Many of you, our readers in the hospitals of India, must have received a survey questionnaire and responded to it in the last three months. We would like to express our sincere gratitude for the strong support and overwhelming response from the participants, and urge the ones who could not - to be sure that they do next time around! The survey is not only a method to quantify the transformation technology has (or has not) been able to bring to the hospitals; it is also a good method to connect with the immediate environment of the care providers and understand the requirements of the domain. Our survey notes that hospitals in India may not be very close to achieving complete automation (as we would like to believe!) but they are on the right track - no matter what is driving individual hospitals to it! Flip through this special issue to find out where we stand and how much farther we have to go.

Ravi Gupta Ravi.Gupta@ehealthonline.org

August 2008

COVER STORY

PART 1 - NORTH

National Capital Region, Punjab, Haryana

ewer advances in IT, technology and data management have had repercussions on the healthcare industry. Today’s discerning patient is increasingly demanding efficient service delivery – which is largely possible only through a reasonable degree of automation. The advantages of automation are numerous. First there is the advantage of speed and accuracy. Hospitals have other incentives such as lowering of turnaround time per bed, better quality control, and of late, business intelligence. The reasons why hospitals choose to automate certain processes and for which particular processes they chose to do so, we found, varies according to the size and type of facility. Any hospital with a 100+ bed capacity has the potential to improve services through the use of information technology. However, despite being a major IT hub, India’s hospital’s still follow manual processes to a large extent. Especially in a large facility, it is difficult to retrieve data of a single patient; and when it is done, it takes a long time - eating into precious man hours of hospital staff who can be gainfully employed in the care of patients. Southern and western India has traditionally been at the forefront of hi-tech medicine and hospitals. However, with a population of 17 million in Delhi alone, demand far exceeds supply and continues to increase in the north. Nearly 33% of the population in the National Capital Region is employed and the rapidly developing satellite towns of Gurgaon, Faridabad, NOIDA and Ghaziabad have witnessed variable but higher than average growths in per capita income over the past several years. Two of the worlds top 10 fastest growing cities, Ghaziabad and Faridabad, are situated here.

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The IT@Hospitals Survey is an attempt to capture the situation and trends with respect to automation in hospitals in India. The survey is being conducted in IV stages. This edition of eHEALTH brings you the first part, covering the National Capital Territory (NCR), Chandigarh and Punjab. This region has witnessed a considerable growth in the number of large medical facilities over the past decade. Besides being home to some of Indiaâ&#x20AC;&#x2122;s best hospitals, itâ&#x20AC;&#x2122;s proximity to New Delhi puts it in an advantageous position viz-a-viz supporting infrastructure.

via e-mail. The responses were stored in an online database and coded on a weekly basis, then tabulated and analysed before preparing the report. The survey threw up several challenges. We found that many hospitals, including some with over 300 beds, did not have a designated IT manager. Often a doctor in-charge of administration is assigned to oversee the IT implementation as well. At other times, a technician handles the system.

A good quality education system and significant Englishspeaking workforce has led to the growth of IT companies in the region. Telecommunications, real estate and health are integral contributors to the economy here. Chandigarh boasts of the highest per capita income in India, and the Tricity (Chandigarh, Panchkula and Mohali) is advancing rapidly in terms of income, industries and infrastructure, especially the service sector. Its high literacy rate of 77% makes for easier implementation of automation. According to reports, it is one of the top emerging outsourcing and IT services destinations worldwide. The Rajiv Gandhi Chandigarh Technology Park (RGCTP) and Centre for Development of Advanced Computing (C-DAC) in the vicinity can provide a strong technical and infrastructural support system. Methodology The IT heads/managers of 100+ bed hospitals in the region were contacted and familiarised with the survey, its purpose and scope. A questionnaire consisting of 12 relevant questions and other important information was then sent to them

Figure 2: Pie chart showing break-up of hospitals by size

Owing to the corporate healthcare boom in recent years, the northern region has a higher number of private medical institutions as compared to mission/trust/NGO-run hospitals. Out of the cross-section of hospitals surveyed, 52.2% belong to the private sector. 43.5% are non-government mission, NGO or Trust establishments whilst the rest are government hospitals. (Figure: 1) The other broad classification is by size as this has a direct impact on the kind of technology needed and used. The institutions are divided into those with less than 150 beds, 150-300 beds and over 300 beds. Nearly half the hospitals [47.8%] have over 300 beds. (Figure: 2) Whilst conducting the survey, we must admit to resistance to divulging details about operations and systems by several hospitals. This was more so with government hospitals, some of which demanded authorisation documents. This is why we have (for the most part) compared private facilities with mission/trust/NGO ones. Another thing we would like to mention is that most of

Figure 1: Break-up of hospitals by type

Less than 50% of large hospitals spend more than INR 50 lac on IT systems annually. August 2008

COVER STORY

Figure 3: Drivers of automation - by type of hospital.

the comparisons according to size compare the hospitals with <150 beds and those whose bed capacity exceeds 300, for better clarity. Driving forces of automation: Multiple factors are responsible for increasing automation in hospitals. It is true that most often, hospitals do not have a planned strategy for automation and implement a solution only when they find that the manual process has unacceptably high error rate or clinical and administrative processes need speeding up urgently. The single biggest factor is the need for higher service quality (in 86.96% of facilities) followed by the corporatisation of healthcare delivery [78.26%]. The significance of medical tourism appears to be increasing as a significant number of respondents [26%] cited it as a reason for automation. However, there is a marked difference in the perception of this as a driving force of automation when we look at private vs mission/trust/NGO hospitals. Approximately half the latter hospitals view medical tourism as promoting automation whilst just over 8% of private hospitals think the same.

In larger hospitals (>300 beds), corporatisation of healthcare delivery and medical tourism are more important causes of automation than in smaller facilities of less than 150 beds. Nearly 40% of IT managers surveyed think that demand from medical and nursing staff is leading to increasing automation of facilities - a positive sign for the sector. Interestingly, none of the hospitals surveyed admitted to health insurance being a factor responsible for increasing automation. (Figure: 3) The survey results indicate that the demand for automation is increasing from the end user â&#x20AC;&#x201C; medical staff. It is heartening to see that the enthusiasm for the same is high in the mission/trust/NGO facilities. Increasing competition between hospitals and a desire to differentiate themselves from other facilities is bound to impact the level of automation in the near future. With the development of IT solutions and both availability and choice of software on the rise, we can hope for lower costs and more accurate data management in the years to come.

Market reputation is more of a concern for 300+ bed hospitals. 10

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tion of clinical processes greater importance.

COVER STORY

Hospitals do not disagree too much about advantages of IT depending on their size. The larger facilities however, lay more stress on short term departmental processes. Those with <150 beds are more concerned with flexible clinical operations and strategic, long term planning. The need to increase speed is a factor irrespective of size. (Figure: 4) Kind of software in use

Figure 4: Diagram showing % of people who state the various advantages.

Advantages of IT From the front desk to archive management, the scope of IT in the healthcare sector is on the rise. New and innovative applications of ICT and technology are being tested. Its usage however, depends significantly on the size of the institution and the resources available at its disposal as our survey reveals. Automation has both long term and short term advantages, though the former exceeds the latter. Given this scenario, larger hospital chains may be in a more advantageous position with respect to implementation of IT systems, due to their deeper pockets and ability to put up with longer gestation periods. Out of the hospitals surveyed, an overwhelming majority [91.3%] said that long term strategic planning is an advantage of implementing IT systems. This is irrespective of the size of the institution. The private hospitals were unanimous in their agreement, indicating that IT implementation in these institutions is part of their long-term strategic plan and not just todayâ&#x20AC;&#x2122;s requirement. Nearly two-thirds of the hospitals use IT to make day-to-day administrative processes easier. These are perhaps the most time consuming, but assume great importance especially in emergency/medico-legal cases. Speeding up clinical processes is another important benefit of automation as nearly 61% of hospitals agreed. The data indicates that mission/trust/NGO hospitals give automa-

We at eHEALTH wanted to look into the kind of information systems that were most commonly used. A Hospital Management System (HMS) or Hospital Information System (HIS) is the most widely used software. Some kind of HIS is used by over 95% of hospitals. The Laboratory Information System (LIS) is also installed in 73.9% of facilities.

The data shows that overall, there is not much of a difference between private and mission/trust/NGO hospitals as far as the use of software goes. HIS/HMS is the most widely implemented software. All private hospitals and 90% of mission/trust/NGO ones have an HIS system in place. Laboratory Information Systems are the next most common software with an implementation rate of 70% and 75% respectively - not a significant difference. The biggest difference we see is in the implementation of Pictures Archiving and Communication System (PACS). Whilst over 58% of private hospitals use it, only 20% of mission/trust/NGO hospitals do so. It is to be noted here that picture archiving and transfer is a capital-intensive technology which also requires high bandwidth (Figure: 5). It is important to note here that most of the softwares were mostly adopted after 2002, hence the advantages may not yet be availed of completely. Moreover, it takes time for the end users â&#x20AC;&#x201C; doctors, nurses, other hospital staff and patients â&#x20AC;&#x201C; to use these systems most efficiently. IT managers can choose between commercially available off the shelf software, a customised solution package or even (in case of smaller establishments with limited budgets) hosted/managed solutions. A customised package, though ideal, is the most expensive type. More private hospitals [17%] prefer commercially available ready made software compared to 10% of mission/trust/ NGO facilities. The greatest difference in choice comes when the solution is hosted/managed. At 30%, the number of those

Flexibility / scalability of the software is more important to private hospitals than mission / trust / NGO ones. 12

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Figure 5: Percentage break-up of use of various solutions amongst different categories of hospitals

who would opt for it in the mission/trust/NGO institutions is almost double that of private institutions (approximately 16.5%) (Figure: 6). Changing for the better It is heartening to see that hospitals now have a choice of

vendors and packages to choose from. 56.5% of hospitals surveyed admit to having changed their software package. The most common reason for this was because of technical problems with the solution [34.78%]. Other reasons for switching from one software to another are lower than expected benefits [26.1%] and poor vendor support service [17.4%]. (Figure: 7)

Figure 6: Preferred software

An increase in market reputation through automation is sought by larger hospitals (>300 beds). August 2008

COVER STORY

Figure 7: Reasons for changing HIS

Presently Hospitals are driven by the need to keep track of revenues and Inventory and also by Customer relationship Management and these are the main driving forces for automation. Ideally this should change and Patient care should become the key focus area but there are large challenges before this becomes a reality.

Mission/trust/NGO hospitals appear to have much higher expectations as far as benefits go. 40% of these have changed due to this reason as opposed to just 16.7% of private hospitals. A larger number [50%] of non-government public hospitals also changed due to technical problems with the software, as compared to only half that number of private institutions.

Dr. Sumanth C Raman Advisor-Life Sciences and Healthcare Tata Consultancy Services Ltd.

Larger hospitals (>300 beds) appear to have more serious technical problems with the software [45.45%] than smaller facilities [37.5]. The latter (<150 beds) feel more plagued with poor vendor support [about a fourth of the hospitals] as compared to the large ones [18.18%]. Paperless - still a long way off

Undoubtedly it is patient satisfaction which is the backbone of all IT services. The other points are security of crucial medical data, availability on time & to right person specific medical data, exchange of medical data between different hospitals enabling right treatment to patients, different as well as fast modes connectivity available for specific data exchange between insurance companies etc. Mr. Ratnakar S. Marketing Manager IDMSYS

Though automation ensures speed, accuracy and easy retrieval of information, we are still a far cry from a functional paperless hospital. 86.4% of hospitals which have implemented automation, still maintain paper records. The percentage is high for both private and mission/trust/NGO facilities and also irrespective of the size of the facility. The primary reasons for this are the reluctance of staff members to use computer systems [over 26%] and legal reasons. The reluctance to use automated systems in private hospitals is more than three times that of mission/trust/NGO ones [10%]. In <150 bed hospitals, this is only marginally more than in 300+ bed ones. (Figure: 8) Electronic document management enables greater agility

The cost of the solution and support service are the most important criteria for selecting vendors. 14

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14% are paperless

86% still maintain paper records

Figure 8: How many hospitals having EDMS are paperless.

and is integral to end-to-end integration of hospital systems. It assists in better organising and managing patient data and information can be retrieved easily at any time. It saves the staff precious time which they would otherwise use to manually search for documents. Warehousing space and costs are also saved. Of the hospitals surveyed, only 4.4% have EDMS â&#x20AC;&#x201C; almost all from the mission/trust/NGO category. The silver lining is that close to 70% of hospitals currently without EDMS plan to install such a system in the future. This number varies according to size and type of hospital. Private hospitals [75%] and larger facilities [73%] have plans to implement an EDMS in the near future - more than 10% mission/trust/NGO and <150 bedded institutions. How is a vendor selected? The eHEALTH research team decided that the answer to this question is best sought by asking the IT managers to rank various criteria. These were 9 - Cost/Pricing, Maintenance and Support, Level of R&D Investment, Inbuilt Tools to Measure Outcomes, Implementation Assistance, User Training, Vendor/Support Organisation Reputation, Flexibility/Scalability and Provision of Managed/Hosted Services. The primary criteria for all hospitals, we found, is the cost of the automation solution. The next factor is maintenance and support systems. Mission/trust/NGO hospitals gave a marginally higher rank to the level of R&D investment of the company and also inbuilt tools to measure outcomes. Certain criteria like user training, (predictably) flex-

The national consumer disputes redressal commission has made it mandatory for all medical practitioners and hospitals across the country to provide the entire medical records of a patient to him\her or the authorised nominee or legal authorities concerned within 72 hours of the demand. ibility/scalability, implementation assistance and reputation of the vendor are given more weightage by private players. (Table: 1, see page 16) The size of a facility also has a bearing on the rank given to various criteria for selection of a vendor. Pricing and maintenance/support are ranked the highest irrespective of size. However, larger establishments (>300 beds) give greater weightage to the level of R&D investment of the vendor, inbuilt tools to measure outcomes, vendorâ&#x20AC;&#x2122;s reputation, flexibility/scalability of the solution and provision of managed/ hosted solutions. This is understandable as large hospitals have deeper pockets and are also more likely to be part of a chain/growing business. (Table: 2, see page 16) Measuring the success of implementation Once a hospital is partially or fully automated, administrators will look at the outcome of the new system. There is

Nearly 86% of hospitals who have Electronic Document Management Systems still maintain paper records. August 2008

COVER STORY

Various criteria to select a vendor for automation

Mission/trust/NGO

Private

Cost/pricing

1.00

Maintenance and Support

1.43

1.90

Level of R&D Investment

2.50

2.67

Inbuilt tools to measure outcomes

3.00

Implementation assistance

4.00

3.33

User Training

5.25

3.89

Vendor/Support Organisation Reputation

5.00

4.50

Flexibility/Scalability

6.00

4.67

Provision of Managed/Hosted Services

7.75

7.00

Table 1: How different TYPES of hospitals select a vendor

In the above table we see that the criterion to select a vendor differs significantly between mission/trust NGO and private hospitals only when it comes to the user training provided and the flexibility/scalability of the solution (both have rank differences >1).

Various criteria to select a vendor for automation

<150 beds

>300 beds

Cost/pricing

1.00

Maintenance and Support

1.75

1.43

Level of R&D Investment

3.00

2.00

Inbuilt tools to measure outcomes

4.00

2.67

Implementation assistance

4.00

3.50

User Training

4.33

4.25

Vendor/Support Organisation Reputation

5.50

4.00

Flexibility/Scalability

6.50

4.33

Provision of Managed/Hosted Services

9.00

7.00

Table 2: How different SIZED hospitals select a vendor

Factors like pricing, maintenance and user training receive similar rankings from facilities with <150 beds and large ones with >300 beds. However, value-addition such as inbuilt tools to measure outcomes, managed/hosted services and criteria like reputed vendors, high R&D investment which come at a higher price, are given greater weightage by large hospitals.

Over 26% hospitals changed HIS vendors because they did not deliver what they promised. 16

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To make the doctor community more open to using IT in hospitals, make Healthcare IT solutions in medical colleges a part of the curriculum. Radhika Sridharan Manager-Corporate Communications Srishti Software

What do hospitals

see as the major advantages of using IT systems?

There are two ways to look at major advantages of Healthcare IT from the perspective by Hospitals. Tangible benefits:  Improved productivity of high cost resources such as labs, imaging modalities such as CTs, MRIs, Cath Labs, operating theatres thus giving higher and faster return on investments.  Improved inventory management of pharmacy, surgical and non surgical items-thus reducing cost of holding inventories. Improvement is also on account of control over pilferages, wastage, expiry of good and working with ‘just in time’ inventories.  Lesser disputes and reasons/excuses for delays leading to faster and higher collections from credit clients and insurance companies. This leads to lower working capital and lower cost of funds along with higher profitability.  Non-medical manpower is also a big cost in hospitals. Proper computerisation can help to reduce substantial overheads on non medico-clerical manpower, especially in back office functions of accounts, billing, materials, house keeping etc . All the above benefits can be quantified to work out return of investment on IT Intangible Benefits : Higher satisfaction levels of hospital services

by patients and relatives due to correct information being available as and when it is required, more transparency, less waiting and anxiety and fewer errors in services - medicines, diets etc. provided to them.  Helps doctors, nursing and medical technologists to give faster and better services with fewer errors and less intuitive decisions due to online information required by them and better quality communication which is a legible documentation and not just verbal. This can help save lives and minimise complications. This also leads to high satisfaction of highly busy medical workers.  Helps management to ensure better availability of required resources (doctors, nursing, life saving equipment or medicines) by preventing stocks running out, faulty equipment etc. Also helps management keep good control over finances, quality parameters, medical audits. Finally a well streamlined hospital increases the image of the hospital in the eyes of patients and relatives.  Helps the staff at various points to provide service with a smile as they can rely on systems to remind and alert them for providing the right service to the right person without having to remember and search for information and things. Satish Kini

Chief Mentor 21st Century Health Management Solutions

Customised solutions are preferred by nearly 3/4th hospitals. August 2008

COVER STORY

no doubt that the success of a particular implementation will be measured according to the intention behind the project. 82.6% of respondents said that they measure the success of implementation by the corresponding increase in service levels and customer satisfaction. Hence, it is evident that public perception of service quality is a matter of concern to most hospitals. This figure varies according to the type of hospital. In private hospitals, it is given 11% more weightage

and customer satisfaction more than those with up to 150 beds (approximately 75%). Larger hospitals also take into account reputation (a difference of more than 10% between the two groups) and business intelligence ( 54.6% and 37.5% respectively). Smaller hospitals are more concerned about cost savings and turnaround time per bed. Business Intelligence (BI), i.e. the extraction, analysis, and reporting of information to improve business decision-mak-

Figure 9: How the success of implementation is measured

as compared to mission/trust/NGO hospitals, with 91.7% of hospitals considering this as a factor (Figure: 9). Better operational control was cited by both kinds of institutions with an average of 82.6% agreeing. The third measurement is by cost savings. Here we find a marked difference between private and mission/trust/NGO hospitals. Cost savings appear to be a bigger consideration amongst the latter with 70% measuring the success of a software against it. 58.3% of private institutions measure implementation success by cost savings. There are some differences in measuring implementation success depending on the size of the facility. Hospitals with over 300 beds [90.91%] look at increase in service levels

ing, is a fairly new role of hospital systems in a formal sense. 41.7% of IT managers in private hospitals surveyed said that they would factor in better business intelligence in assessing the success of a software, compared to half of the IT managers in mission/trust/NGO hospitals. The turnaround time per bed is more of a concern in private hospitals (half of them take it into account) than mission/trust/NGO institutions (about 40% agreed). Money matters Half of the private hospitals surveyed have an annual IT budget of more than 50 lacs. Within the mission/trust/NGO segment though, about half the hospitals spend between 5

HMS/HIS is the most widely used solution. PACS is the least widely used. 18

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COVER STORY

Figure 10: Average annual spending on IT by hospitals.

and 20 lacs. On the whole, the majority of hospitals spend less than 15 lacs a year on IT systems. A division by size would be more accurate and indicative. As expected, over 45% of 300+ bed hospitals spend over 50 lacs per annum on IT whereas 12.5% of hospitals with less than 150 beds do the same. Conclusion: While conducting the survey we realised that IT heads of hospitals are very often non-existent or technicians, and the hospital’s IT system is overseen by one of the doctors. Often, a decision has to be taken about whether a facility should go in for a complete solution from one vendor or whether different information systems should be sourced from different service providers. This is indeed a tough decision due to the limited budgets in India and scale of such projects. We observe that the majority of hospitals have limited automation with a solution that covers only a particular clinical or administrative process. Implementing an automation solution can take anywhere from a couple of months to a few years. The bigger the project, the more important is the choice of vendor. Hospitals need to pick a solution provider who has a local presence and will provide after-implementation assistance with minimum fuss. Keeping in mind future plans of expansion, the software should be scalable enough. They should also have complete knowledge of compliance regulations and standards as hospitals administrators have to keep in mind medico-legal issues. Medical and information technology is constantly chang-

ing, allowing for better diagnosis and greater accuracy. What is required to give the hospital IT business a boost is standardisation, keeping in mind that India and the region are key destinations for medical tourism – touted to be a US$ 40 million industry by 2010. Strengthening of infrastructure is another issue that needs to be addressed. Higher bandwidth is required for heavy PACS transfers. Telephone and Internet connectivity in smaller towns and cities is a major issue. Software vendors have raised the issue of inadequate manpower and training in the use of systems. In order to extract the maximum benefit from an information system, the staff using it and those who will be affected by its implementation, must be properly trained. As the market matures, we can expect more hospitals adopting integrated information systems and, in turn, more such solutions being developed. The ‘learning by doing’ concept is sure to lead to better innovations and improvements in information systems. But that is one side of the picture. The other side – and an equally important one – is the implementation and servicing that a vendor provides. One of the immediate major challenges today is to get doctors to overcome their reluctance and use IT regularly. The good news on this front is that things can only get better on this front as IT is fast becoming an integral part of the life of the common man.

Watch out for the September issue of eHEALTH carrying Part II of the Survey report (Maharastra, Gujarat, Rajasthan)

Nearly 40% of IT managers surveyed think that demand from medical and nursing staff is leading to increasing automation of facilities. 20

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in conversation

Growing Through Innovation A pioneer in consumer-centric technology, Philips has doubled its medical business in India in the past three years. Anjan Bose, Senior Director and Business Head of Philips Healthcare, speaks to eHEALTH about the growth story and the medical device market on the whole.

Q. Philips Healthcare enjoys a high brand value in the medical device industry. What has been the corporate vision in achieving such a success and what is your strategy to retain this market leadership in future? A. To expand its presence in India, Philips is constantly looking at growth opportunities and garnering customer confidence through new models of organisation, new products, innovative business models and channels of distribution in the healthcare segment. Philips is currently present at various levels of the patient care cycle and will continue to strengthen this.

With ‘Sense and Simplicity’ at the core of all products, the company believes in providing customer-centric solutions, using innovation to deliver products that are reliable and accurate for better diagnosis. Philips India’s medical business has doubled in the last 3 years. Philips has been the market leader in patient monitoring, angiography cath lab systems and MRI systems. Philips has been enjoying great success in corporate tertiary care hospitals. Q. What new innovations do you have to offer the Indian healthcare market today? A. Philips has delivered path-breaking technologies that are not only defined as highly innovative, but are also designed keeping the end-user in mind. Perhaps, a stark example in these regards would be the Philips Ambient Experience. The Ambient Experience MR brings a human design approach that patients prefer with increased contact between patient and staff, which in turn improves department workflow. The 256-slice Brilliance iCT scanner, allows radiologists to produce high-quality images with exceptional acquisition speed, including complete coverage of the heart and brain. It August 2008

“With ‘Sense and Simplicity’ at the core of all products, the company believes in providing customer-centric solutions, using innovation to deliver products that are reliable and accurate for better diagnosis.” is so powerful it can capture an image of the entire heart in just two beats, while incorporating Philips technology that has reduced radiation doses by up to 80 percent. Some of the other recent innovations include, Automatic External Defibrillator (AED). We introduced AEDs globally four years ago. Evaluating the cardiac disease situation in India we realised this was a much-needed healthcare device and made the AED available in the Indian markets in 2005. Philips has been a pioneer in various product segments and is also the first to design a defibrillator for home use. In 2004, Philips obtained the first - and so far the only - Food and Drug Administration approval to sell an AED over the counter for home use. In India we have already installed a number of units. We have entered relationships with companies such as Satyam for their emergency ambulatory services in Hyderabad and other places in Andhra Pradesh, also some of the airlines now keep Philips AED on their flights for emergency situations in air. An AED can be afforded by individual homes or even local communities/neighbourhoods and housing societies. Another new product is the SureSigns VM3, which leverages the high-quality platform of Philips’ industry leading patient monitoring portfolio. Combining advanced software and technology in a compact economical package, the VM3 is the perfect solution for caregivers across the wide variety of clinical environments we see here in India. This launch reaffirms Philips’ commitment to the Indian market, leveraging Philips’ global expertise to introduce technologically advanced offerings tailored to this market. Q. What is the long-term plan for developing R&D? What strategic growth plans do you have in terms of acquisitions? 22

A. Philips Innovation Campus (PIC), which is extensively into healthcare research and software development for healthcare products was established in August 1996, with the objective of meeting the growing need for high-quality, cost-effective software development capacity within the organisation. From a share of 8% of the total software resource of Philips in 1998, PIC’s share has gone up significantly and is now around 20%. Working at PIC are about 1000 of the industry’s finest professionals, using state-of-the-art software engineering paradigms and platforms including real-time systems, component-based software engineering and multi-threaded architecture to drive the creation of tomorrow’s products and services. Like any other organisation, Philips also has a strategic vision and growth plans to execute it. With the Indian economy growing at 9%, India is a key market for Philips. A few months ago, Philips announced a technology partnership with Gurgaon based Artemis Health Institute to collaborate in its worldwide research and development efforts. Philips is also engaged in discussions with other leading healthcare delivery institutions with different types of partnership. Such partnerships are synergistic and help both the players. Q. What do you think are the existing bottlenecks and proposed remedies at the policy and regulatory levels to boost domestic manufacturing? What is the existing and long-term plan for manufacturing for Philips in India? A. We have no plans to set up any manufacturing unit in India currently. Some of the challenges that the Indian healthcare industry may be facing are development of infrastructure and some tariffs and duty structures that need to be looked at to facilitate manufacturing.

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Q. Medical device market in India is currently witnessing 15% annual growth and expected to reach US$ 8-10 billion by 2012. What are your expectations from the domestic market in terms of growth in net revenue and market share for Philips? A. As a policy we cannot make any forward looking statements, however, according to an industry report, the size of the Indian medical equipment industry was US$ 2.16 billion in 2006, is growing at 15 per cent and is expected to reach US$ 3.2 billion by 2009 and US$ 4.5 billion by 2012. The two key drivers for healthcare are the increasing focus on ‘Wellness’ as a concept amongst people and growing patient awareness. The potential growth drivers in the years to come could be increasing availability of newer technologies to diagnose and treat various diseases; Molecular Imaging could turn out to be an interesting area if it fulfills the promise of being able to ultimately forecast diseases well before the onset of the first visible symptoms, including lifestyle diseases like cancer and cardio-vascular; Corporatisation of Private Healthcare in the backdrop of a growing and affluent middle class; Increase Governmental focus on providing quality healthcare to the people; Maturing of Health Insurance and Medical Tourism; Home healthcare solutions and remote patient monitoring. Considering these factors, we are very upbeat about India as a key market and a driver of growth for the healthcare business. Q. Industry associations like CII & FICCI are putting in a lot of effort to facilitate the growth of medical equipment industry in India. As an active member in both these organisations, what is your perception about the impact being delivered so far? A. There has been rationalisation of tariffs including import duties and VATs amongst others in the recent years, and I think Industry associations have played an important role in all these. There has been a symbiotic relationship between the industry and government in healthcare, over the last five years. An excellent example of this is the reduction in duty for equipment, which earlier attracted an import duty of 48–50 percent, which has been reduced to nine percent today. All these have been possible because both the industry and the government want to provide quality healthcare in an affordable manner. The environment has become more collaborative today.

“Philips Innovation Campus (PIC), which is extensively into healthcare research and software development for healthcare products was established in August 1996, with the objective of meeting the growing need for high-quality, cost-effective software development capacity within the organisation.”

Also, since about 35-40% of any new investment in healthcare delivery venture is on medical technology (CII-McKinsey Report), the recent tax holiday declared by the government for hospitals coming up in the tier - 2 cities should encourage hospitals to invest more in medical technology. August 2008

INDUSTRY SPEAK

Bench-marking Clinical Diagnostics TRANSASIA is recognised as a leading player in the Diagnostic world, providing world-class quality and technology with unmatched standards of customer satisfaction. Suresh Vazirani, CMD, TRANSASIA Bio-Medicals Ltd., set up the company almost single-handedly in 1985, and now speaks to eHEALTH about the growth opportunities for the Medical Diagnostics industry in India today.

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Q. TRANSASIA Bio-medicals has been the leading Indian manufacturer, exporter and marketer of Clinical Diagnostic equipment for more than a couple of decades. What has been the winning philosophy of the company in the face of stiff competition from foreign brands? A. TRANSASIA Bio-Medicals is the largest Indian manufacturer and exporter of diagnostic products and has an enviable 29-year track record in the industry. The company has successfully developed and manufactured hi-tech In-Vitro Diagnostic (IVD) instruments and reagents and has become a name to reckon with, in India and 55 other countries across the world. TRANSASIA is one of the few manufacturers to have a world-class quality system certified under ISO 13485. Our success is fully based on total commitment to the customers for providing them with quality products and services. Our strengths have been customer focus and service focus. We believe that customer is the king. Service support for TRANSASIA equipment and the infrastructure that we have built to support this has helped to set benchmarks for the industry in terms of service expectations. Our service network, which is spread across 54 centres with 102 service engineers, ensures that we offer impeccable service that meets international standards. We also continuously work towards improving our service and support resulting in a better response time.

“Our success is fully based on total commitment to the customers to provide them with quality products and services. Service support for TRANSASIA equipment and the infrastructure that we have built to support this has helped to set benchmarks for the industry in terms of service expectations.”

Biochemistry, Haematology and Coagulation segments. Q. What share of the Indian diagnostic equipment market are you currently holding? Keeping in mind your overseas success and export network in more than 55 countries, what is the share of your annual turnover from foreign business?

We have the largest sales and installation base with over 15000 installations all over the country supported by a network of 14 zonal offices in metros and major cities backed by a strong work force of 850 personnel across India.

A. Our total market share in India is around 20%. We are also proud of the fact that TRANSASIA has been rated as India’s largest In-vitro Diagnostics Company (2006) by McEvoy & Farmer, U.S.A. (International Experts on IVD Markets).

Thus, our 360 degrees approach to business from manufacturing and marketing to service and research and our commitment to excellence is our winning policy.

“Clearstate”, a niche healthcare consultancy, developed to provide accurate, reliable and comprehensive information on medical device usage and demand across Asia Pacific in their survey (2007) have revealed TRANSASIA’s market leadership over international players specifically in Clinical Chemistry and Hematology.

Q. What is your range of products at present across various diagnostic segments and which segment is showing the strongest growth? A. TRANSASIA Bio-Medicals offers ‘Total Solutions for Clinical Diagnosis’ whether it is Biochemistry, Haematology, Immunology, Critical Care, Coagulation, Urine Analysis, Liquid Handling systems or Blood Transfusion medicine. We have a complete suit of semi auto to fully automated instruments, which are indigenously manufactured at our state of the art manufacturing units. TRANSASIA also aims at serving hospitals, blood banks and laboratories around the globe by providing an exhaustive range of diagnostic reagents. We indigenously manufacture clinical diagnostic reagents that are cost competitive and of high quality. The strongest growth for TRANSASIA has been in August 2008

It also mentions TRANSASIA’s Erba Chem Series as the most placed Clinical Chemistry (CC) analysers in all types of facilities. Our exports contribute approx 20% to our overall sales. Q. What is your long-term strategy in terms of boosting research and development and manufacturing capacity in India? How do you plan to expand your product range and market base? A. TRANSASIA has always recognised research and development as the prime driver of innovation and leadership. To achieve this, the foray into indigenous research has resulted in development of state of the art products and technologies, enabling TRANSASIA to establish itself as a brand of Interna25

“The industry is expected to grow at 15% p.a. to US$ 60 billion by 2010 and the medical equipment market is the direct beneficiary of the boom in healthcare industry. The key driving forces are new investments in super-specialty hospitals and diagnostic centres, competition, existing setup upgrading their equipment, favourable government policies such as a reduction in import duties on medical equipment, expanding market boundaries etc.”

tional repute thereby making Indian products synonymous with “the best in the world. TRANSASIA’s young and enthusiastic team of experts in software, mechanical engineering, electronics and embedded software has built an impressive track record of successful projects. The research and development department, a team of 90+ engineers, are constantly working to bring out products with appropriate technology and features to meet the changing customer needs. In addition to our existing manufacturing facilities at Germany, Seepz and Daman, we now have a new manufacturing facility at Baddi, Himachal Pradesh, which has recently started operations. 2008-09 will see us expanding in the existing product range and venturing into Microbiology and Veterinary science. We also wish to embark on a progressive endeavour of contributing to the analytical research field in India. Q. What is your take on the booming healthcare industry in India, particularly the emergence of private and managed care services? What role and opportunities do you see for your company? A. India produces the largest number of doctors, nurses and technicians in the world. This puts us in an ideal position to be the ideal healthcare providers to the whole world. 26

Medical Tourism is the next big success story out of India. From less than 10,000 patients visiting India for Medical treatment five years ago, the medical tourism market in India is worth US$ 333 million, with about 100,000 foreign patients coming in every year. In the next 5 years, this should reach over US$ 3 billion. The other interesting development, which is taking place in our country, is the opening of health insurance to the private sector. On one hand, the Indian middle class, with its increasing purchasing power, is more willing than ever before to pay more for quality healthcare. On the other, the supply of healthcare services has grown steadily, as the private sector becomes more involved in owning and running hospitals. The future outlook says that the industry is expected to grow at 15% p.a. to US$ 60 billion by 2010 and the medical equipment market is the direct beneficiary of the boom in healthcare industry. The key driving forces are new investments in super-specialty hospitals and diagnostic centres, competition, existing setup upgrading their equipment, favourable government policies such as a reduction in import duties on medical equipment, expanding market boundaries etc. I feel this is certainly the industry of the future and India has tremendous potential in this field. Also with this kind of growth, I can very strongly say that the “Next BPO boom for India is Medical Diagnostics”. Q. What do you expect of the Government in terms of policy interventions and taxation incentives for encouraging sustained growth of equipment manufacturing industry in India? A. Per capita healthcare spending by Indian government needs to be increased substantially. Most governments spend over 1% of their GDP on healthcare. Indian government spends less than 1%. As a result, the governments health systems are not able to provide even basic healthcare to the poor people. Government should declare “Healthcare of India” by 2020 and make all healthcare products totally free of taxes. Apart from the fact that the government is not providing even the minimum required funds for healthcare, what is unacceptable is, the fact that the government is profiting from private health systems by charging all types of taxes and some taxes at very high rates. You would be amazed to know that the rates of taxes on basic medical products are much more than those on luxury items such as planes, mobile phones, electronic products and so on. How does a government committed to socialist values justify such unjust deprivation of healthcare to its people? Public-private partnership should also be encouraged in running Government Hospital/Healthcare centres. This will immensely help the common man in getting access to the latest technologies in healthcare system at an affordable cost. www.ehealthonline.org

SPOTLIGHT

Making Healthcare Accessible Through Technology

Q. What is the overall vision of Intel in forwarding the cause of technology in healthcare? A. We share the vision of healthcare leaders who recognise technology’s potential to evolve healthcare toward more proactive, consumer-centric models of care as well as the potential to improve the quality, cost, and accessibility of healthcare services. In homes and hospitals, clinics and pharmacies, we collaborate with healthcare leaders to better connect people and information, and enable new models of care. By helping individuals, families, and the extended healthcare community connect to the right information at the right time, we empower them to make better, more informed decisions - and accelerate the ability to radically improve health and healthcare.

Intel’s plans for revolve around easy, accessible, and integrated technology, that aims to improve patient care in the institutional setting, says Ashok Chandavarkar, Marketing Programs Manager, Asia Pacific Healthcare, Intel Technology India Pvt. Ltd.

As a world leader in technology, Intel is in a unique position to help advance healthcare, because only Intel provides a broad portfolio of key technology ingredients relevant to so many aspects of the system. It is this broad technology portfolio, and the fact that we work with many diverse partners throughout the system that allows us to take an unusually holistic approach to problem solving. Intel’s healthcare strategy focuses on improving patient care in the institutional setting; advancing personal health technologies with an emphasis on prevention, www.ehealthonline.org

early detection and personalised treatment of chronic disease; and advancing standards and policies that enable innovation and interoperability across the healthcare ecosystem. Intel is committed to applying its knowledge and assets to each of these areas, connecting people, and information in new ways that have the power to radically improve health. Q. What according to you is the primary cause of a relatively low adoption of IT in healthcare industry? What technological and/or human factor do you perceive as the bottleneck? A. We have observed that low adoption rates of technologies and digital solutions in healthcare tend to be chiefly because of three reasons, 1) Technology is perceived as too hard to use or less than reliable in terms of uptime and connectivity; 2) It doesn’t fit in well with workflow in healthcare environments; 3) It is too expensive to use and there is no clear return on investment (ROI) or way to measure ROI. The technologies and IT solutions that tend toward high adoption rates are those that are easy to use, intuitive and have a strong ROI. Picture Archival Communication System (PACS) is an example of one of these technologies. It fits in nicely with the workflow, it’s easy to use, is intuitive, and the technology is mature and reliable. Hence, PACS is one of the IT solutions that is most adopted worldwide and has even become a standard of care in many countries, such as the US, Korea, and Australia. The emerging industry of Teleradiology as seen in India is another example of the adoption of PACS. Intel’s Digital Health Group is focused on exploring new ways in which innovative technologies can help improve delivery of healthcare by observing and listening to patients, consumers and healthcare professionals. Since we began investigating health and healthcare more than 9 years ago, our ethnographic researchers have observed and interacted with more than 1000 households and 150 hospitals and clinics in 20 countries.

“The technologies and IT solutions that tend toward high adoption rates are those that are easy to use, intuitive and have a strong ROI. Picture Archival Communication System (PACS) is an example of one of these technologies”

In addition, Intel is working with agencies and governments in many locations around the world to support rural telemedicine pilots including Lebanon, India, China, and Brazil. In some of these situations we used a new technology for rural connectivity referred to as directional WiFi. In other pilots, Intel is exploring use of WiMAX. Intel is now looking at expanding those pilots. Telemedicine technologies have routinely been used to treat complex cases by general practitioners who seek consultations with remote specialists. We are now exploring how one might use telemedicine technologies to treat routine cases in higher volume in emerging economies. For example, in Shanghai, we are developing a pilot that allows routine cases in overcrowded community health clinics in the city to consult with doctors remote to the clinic. The Sichuan earthquake in May led to all of our pilot equipment being re-deployed into August 2008

the earthquake zone after all fixed telemedicine sites were destroyed in the earthquake. This allowed the more traditional uses of telemedicine to continue in a time of crisis. Eventually, we hope to see an evolution of complex cases in low volume to routine cases in high volume. This fits well with mass market emerging economies needs and their adoption of Information and Communication Technology. Q. Intel’s Integrated Digital Hospital architecture is known to have a futuristic approach of transforming healthcare delivery. What are its salient features and how does it promise to substantially value-add the healthcare experience? A. The Integrated Digital Hospital is intended to facilitate increased efficiencies for healthcare workers, improve the quality of decision-making that can help reduce medical errors, increase access to information available at the point of care or decision so that it can positively impact clinical outcomes, and enhance clinician and patient satisfaction while reducing costs. By delivering relevant information to healthcare workers wherever they are, these benefits can be realised. Currently, information in many hospitals is in silos. If a doctor can’t order timely and appropriate treatment, then the doctor can’t make the right decision and the clinical outcomes may be less than desired. Doctors and clinicians must be able to access patient record with up-to-date information, order medications, and lab tests, and communicate with other healthcare workers to carry out tasks and care instructions. Silo approaches have improvements at the margin, but it’s the integrated approach that produces the value-add that no one solution alone can achieve. Q. Kindly give a brief overview of the broad range of products, solutions and services that Intel is offering (or in the process of rollout) for healthcare industry. A. As a world leader in technology, Intel is in a unique position to help advance healthcare, because only Intel provides a broad portfolio of key technology ingredients relevant to so many aspects of the system. It is this broad technology portfolio and the fact that we work with many diverse partners throughout the system that allows us to take an unusually holistic approach to problem solving. Intel offers advanced multicore technologies and solutions for PCs, notebooks, and servers, as well as connectivity solutions that help healthcare enterprises optimise information flow and operations from the bedside, nurses’ workstation, business office, or back office. Intel also has a specific offering for healthcare providers in a purpose-built platform designed specifically for clini30

cians at the point-of-care to help optimise clinical workflows. This platform is called the mobile clinical assistant, or MCA. The MCA was developed after extensive research with participation from thousands of clinicians worldwide. It is a reference design, which we are rolling out through manufacturers worldwide. The mobile clinical assistant manufactured by Motion Computing has been rolled out in Singapore, Korea, and Australia. In India we are working with leading software vendors, both local and regional in making their solutions avail the full benefits of platform using a freely downloadable software development kit from Intel. We have a few pilots running and by end of this year hope to have some leading hospitals in India adopt these platforms. The IntelR SOA (Service Oriented Architecture) Expressway for healthcare provides a very efficient way to get computable healthcare information from one place to another - across departmental systems, among providers, and to a regional or national group supporting a healthcare community. The IntelR Healthcare IT Value Model provides a unique approach to analysing and measuring the business value of IT in healthcare environments. It focuses on meeting critical business objectives in delivering high-quality, efficient healthcare in areas such as workflow efficiencies, patient throughput, reduction in medication administration errors, etc. Intel has an interdisciplinary team of researchers and design engineers who have been investigating healthcare since 1999 to understand people’s needs, values and practices. One of these areas of research is focused on homecare platforms that allow people to age at home and to manage chronic disease in lower cost settings. www.ehealthonline.org

DEVELOPMENT DIMENSION

MEDical NETwork MedNET helps rural Peru access health care services with Telemedicine via satellite. Introduction Peru is officially classified as a middle-income country. Strong economic growth over 9 consecutive years (9% in 2007; 10% in Jan 2008 alone), low inflation and a budget surplus coupled with the growth in reserves have resulted in Fitch Ratings raising Peru’s foreign currency debt rating to the investment grade level of BBB in April 2008.1 However, despite surging economic growth, large sections of the population remain marginalised with distinct inequalities between those living in urban and rural areas. The aim of project MedNET is to develop a medical health network in Peru targeting locations that have been virtually abandoned by the state. The sites chosen for inclusion in MedNET are Chongos Alto, Comas, Pariahuanca, Puerto Ocopa, Mazamari, Rio Negro, S.M. de Pangoa (Figure 1).

Fig. 1. Map outline of the sites selected in Junín, Peru, for inclusion in MedNET

Medical situation Currently, patients travel long distances just to arrive at the rural health centres chosen for inclusion in MedNET. Unfortunately, there is a dearth of medical equipment at these health facilities. If the physician is uncertain and decides to refer the patient for further consultation and/or examination, only approximately 5% of patients can afford to attend. Large sections of the community in these regions are effectively disenfranchised from the health service as a result of long distances, high costs associated with travel and lodging, cultural obstacles and endemic poverty. Costs average around 46 for these transfers and considering daily wages are approximately 2.3 per day.2 Additionally, natives, particularly in the jungle region of Rio Negro, Pangoa, Mazamari and Rio Tambo do not like to travel to the urban regions for cultural reasons. The isolated nature of these sites also impact upon the medical staff with medics feeling isolated and vulnerable with no access to expert second opinion, severe lack of health resources and poor communication between health outposts August 2008

and the regional health authority - DIRESA Junín. After studying medicine in Peru, medical students have to spend a stipulated period of time practising medicine in a rural environment. Competition for these posts is very high since, without this experience, a medic will be unable to apply for employment at any public hospital in Peru. In addition, each rural health care centre has a named medic who is responsible for the site. However, the SERUM ([medical] Student Undertaking Rural Medical Service) working at any particular site often works alone, and is unable to seek a second opinion. The need therefore, is to facilitate continual professional development. Methodology The network participant will communicate with the help of the collaboration medical application based on TeleConsult and @HOME medical database for vital signs, which has been developed by Fraunhofer IGD and MedCom GmbH, with partial financing of the European Commission. 1. Architecture and major components 1.1 TeleConsult TeleConsult is a stand-alone application running on Windows 2000/XP. The application can acquire medical images from any ultrasound device through a video grabber attached to the computer. Furthermore, DICOM based agents would store medical images from any DICOM compliant device (DICOM is a worldwide standard for the representation of medical imaging data). TeleConsult application is a combination of a 2D/3D DICOM Viewer, an image grabbing software, medical annotation tool and a medical telecommunication tool. Figure 2 illustrates the user interface of TeleConsult.3,4,5

Fig. 2. TeleConsult user interface

The largest part of the user interface is used for the display of the images. On the left side of the software all images, currently loaded into TeleConsult are listed. In the centre of 31

the user interface, there is place for showing the details of one or more images. All operations, a user of the software can operate can be assigned to following eight modules:  The Database Interface menu  The Image View menu  The File I/O menu  The Geometry menu  The Greylevels/Colors menu  The Tools menu  The Cine menu  The Teleconsultation menu Teleconsult is currently used in several European locations, and provides an excellent, proven communication tool for telemedicine systems. The system also provides easy localisation options for Spanish and Portuguese. 1.2 Medical database/Health care records There are alternative ways to manage clinical information using paper cards and charts, but for clinical trials, monitoring and analysis of population data and telemedicine, computerisation of some sort is generally required. A key challenge is to create sustainable systems that are able to be used widely and can support several of the above tasks, rather than using multiple “stove pipe” applications. Our medical imaging application offers a patient management database with the following possible operations:  Creation, modification and deletion of patients.  Creation, modification and deletion of studies.  Storing of images, configurations, videos and other (additional) files assigned to a patient and study.  Swapping out data (images) to other storage medias, whereby the purpose is to prohibit the local hard disk of getting full.  Export and Import of patients/studies and images to external files, whereby the purpose is the exchange of data between several databases.  Loading of images, configurations and videos into TeleConsult.  Importing of DICOM images into the Database.  Sending and receiving of messages, together with patient, study and image information from and to other TeleConsult workstations (Offline Messaging)  Importing/exporting of vital signals (ECG, BP, SPO2, Glucose) into the database. The database is based on openEHR, the definition of the “electronic health record” corresponds to the “Integrated Care EHR” as defined in ISO/DTR 20514: The Integrated Care EHR is defined as a ‘repository of information regarding the health of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorised users. It has a commonly agreed logical information model which is independent of EHR systems. Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information, which is retrospective, concurrent and prospective’.6 The EHR has the following characteristics Patient-centred: one EHR relates to one subject of care, not 32

to an episode of care at an institution; Longitudinal: it is a long-term record of care, possibly birth to death; Comprehensive: it includes a record of care events from all types of carers and provider institutions tending to a patient, not just one speciality; in other words there are no important care events of any kind not in the EHR; Prospective: not only are previous events recorded, so is decisional and prospective information such as plans, goals, orders and evaluations. 1.3 Satellite Communication / AmerHis Most of the sites do not have any access to Internet. Where Internet access is available in the local community, it is extremely slow. Mazamari, Pangoa and Rio Negro are the only sites with a fixed telephone landline. Chongos Alto, Puerto Ocopa, Pariahuanca and Comas can be contacted through a satellite-community telephone. Mobile phone coverage is sporadic but CLARO (part of the telecom group América Móvil) provides better coverage, on average, to most of the MedNET sites in Peru compared to MOVISTAR (owned by Telefónica Móviles). The selected regions in Peru have no access to broadband communications. Therefore, AmerHis system is going to be utilized. AmerHis is making use of DVB-RCS bi-direction European standard. Thales Alenia Space España has leaded the AMERHIS project within the Hispasat Amazonas satellite. AmerHis is an advanced communication system, supported and co-funded by ESA and the Industry, to deploy an advanced communications system based on a regenerative payload on board the Amazonas satellite.7 The AMERHIS system integrates a Broadcasting MultiMedia network with an Interaction network by combining two standards, the DVB-S and DVB-RCS into one unique regenerative and multi-spot satellite system. In this manner, the users calling for broadband and interactive services will be able to utilize standard stations (RCSTs) at both transmitting and receiving sides. Next figure illustrates the concept. In this system, the DVB-RCS return channel standard is applied by all users to access through a standard uplink to the satellite. On board, the regenerative payload (OBP) is in charge of multiplexing that information from diverse sources into one or more DVB-S data streams capable of being received by any standard IRD equipment. The on board repeater is not only capable of multiplexing signals coming from the same uplink, but also cross-connecting and/or www.ehealthonline.org

“Resources for Success”

IDBUSINESS S O L U T I O N S

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Sage Development Partner of the Year 2007 - 2008

Winner

broadcasting channels coming from separate uplink coverage areas to different downlink coverage areas. 2 Community Engagement Through the medical staff and local community representatives, we managed to obtain a good impression of the needs of not only the health care establishment, but also the wider community. The recurring themes from the 7 sites chosen were the need for:  Basic medical diagnostic equipment (such as there were no [functioning] ultrasounds or working microscopes at any of the rural health centres)  The need for improved communications – for the wider local community and also for essential medical information  Expert second opinion  Improved institutional efficiency  Capacity building programmes  Stable electrical supply At each site in Peru chosen for inclusion in MedNET, the local municipality has offered their full support. The actual support provided depended on the clinical and technical requirements of each site, and also to a certain degree, the funds available with each municipality – though even municipalities with limited funds offered assistance “in-kind.” Stable electricity supply too will be taken care of by the municipalities. The additional services the projects consortium members plan to provide at each site in an attempt to exploit the MedNET infrastructure (e.g. internet, VoIP, etc.) are also of particular interest to each municipality and the services could easily be divided between municipality and health care centre, particularly in Chongos Alto, Mazamari, Rio Negro, Comas and S.M. de Pangoa due to the proximity of both. Sustainability is a primary objective of MedNET and involvement of the local community is crucial if sustainability is to be achieved. In total, round table meetings were held with over 56 top-level stakeholder representatives from the seven sites and the two referral hospitals in Huancayo. 3. Expected Impacts Regional workshops involving both public and private institutions delivering health services identified the most urgent health needs as viewed by the population. Based upon these locally perceived priority health concerns, together with statistics and epidemiological results from DIRESA Junín, the following were characterised as priority regional health problems. • Basic Hygiene • High prevalence of infant malnutrition • Female health problems: teenage pregnancy; maternal mortality. • High incidence of infectious / contagious diseases • Family violence Many of these priority health concerns can be addressed both clinically and through the design of public health programmes in MedNET. 34

Additionally, the Conditional Cash Transfer programme ‘Juntos’ is an anti-poverty initiative launched by the Peruvian Government in 2005. This pilot project proposal in Peru aims to identify opportunities and synergies for co-operation and integration with current health sector reforms and particularly the “Juntos” programme:  Helping the health services and education operators become involved in a more effective way.  Facilitating capacity building programmes aimed at improving service quality.  Providing a platform that can be exploited to deliver improved standards in education and promote social enterprise in order to alleviate poverty. General benefits accruing from the application of MedNET in Peru are:  Improved quality of health service to approximately 102,000, located in the pilot project locations.  Reduced the level of inequitable access to medical services.  Provided scientific and technological assistance to professional health workers - e.g. continuing professional development.  Facilitated an integrated level of patient attention.  Optimised administrative process embedding efficiency within the health system.  Augmented health awareness amongst the general population. Acknowledgments This project is partially funded under the 7th Framework Programme by the European Commission - ICT website on CORDIS http://cordis.europa.eu/fp7/ict/ References [1]Associated Press, 03 April 2008. [2]The average salary is considerably less in Satipo. M Gonzales, personal communication (April 2008). [3]Kontaxakis, G., Walter, S. and Sakas, G. (2000) “EU-TeleInViVo: an integrated portable telemedicine workstation featuring acquisition, processing and transmission over low-bandwidth lines of 3D ultrasound volume images”, Information Technology Applications in Biomedicine: Proceedings of IEEE EMBS International Conference, p. 158 – 163 [4]TeleInVivo, http://www.igd.fhg.de/teleInViVo [5]I. Sachpazidis, O. Hohlfeld, “Instant messaging communication gateway for medical applications”, IASTED International Conference on Telehealth 2005, 19-21July 2005, Banff, Canada [6]openEHR, http://www.openehr.org/home.html [7]AmerHis system, http://www.alcatel.es/espacio/pdf/amerhis.pdf

Authors W. Menary, GeoPac – UK I. Sachpazidis, Department Cognitive Computing and Medical Imaging, Fraunhofer IGD - Germany D. Rizou, Department Cognitive Computing and Medical Imaging, Fraunhofer IGD - Germany J. Cardenas, Department of Informatics, DIRESA Junin-Peru C. Cabrera, Department of Informatics, DIRESA Junin - Peru

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APPLICATIONS

Making

Practise Management Easy Q. Use of practice management software by physicians is still substantially low in India. How ready do you think the Indian market is for a product like Easy Clinic? A. The primary and secondary medical practices in India have been slow in adopting modern technologies compared to other service oriented industries. However, there already are doctors, who feel the need for higher standards of running their practice and better care delivery. We have come across doctors using word processors and spreadsheets to record notes, using generic overseas software, as well as trying their hands at some sub-standard local packages, due to lack of options. The first measure we undertake is to reach out to such doctors over the course of 2 years. They are the power users who will set the trend for others to follow.

Girish Mohata Chief Operating Officer Novel Medicare Solutions

Novel Medicare Solutions Pvt. Ltd., provider of clinical and practice management software for doctors in India has, backed by 3 years of R&D, developed Easy Clinic to seamlessly fit with an Indian doctor’s workflow. Its Chief Operating Officer, Girish Mohata, shares with eHEALTH the challenges and opportunities in the field of medical practice management.

In a longer-term view, there are a large number of doctors who already use computers for emails, letter writing, basic accounting and browsing the Internet, yet do not use software dedicated to their profession. We plan to demonstrate that Easy Clinic can easily bring together divergent clinical and practice management activities into a cohesive whole, record a doctor’s action, and intelligently generate medical records in the background, thereby creating a broader appeal in the medical community. Q. What are the special features offered by Easy Clinic? How does it value-add a doctor’s clinic? A. We have spent over 3 years in designing and developing Easy Clinic to seamlessly fit with a doctor’s workflow. Most clinical software focus on better patient care as the primary objective. We consider that to be a by-product. Easy Clinic focuses on the doctor and is designed to assist the doctor, thus, automatically leading to better care delivery. This makes a huge difference in the adoption and usability of Easy Clinic. It enables a doctor to maintain electronic health records and manage their practice better without being slowed down Each aspect of a doctor’s workflow has been thoroughly researched and catered to through customisation options in

August 2008

Easy Clinic. Special emphasis has been given on making all the processes easy to use and fast to accomplish. For example, prescribing of drugs or investigations can be done in less than 10 seconds; clinical notes can be written quickly using self defined shortcuts; bills to patients can be recorded with a single click and many more such features. The drugs database in Easy Clinic has been licensed through CIMS India and is updated quarterly. This empowers the doctor with the latest drug information at the click of a mouse. It also reduces medical errors by automatically prompting against drug, allergy, or pregnancy interactions. Practice management features such as accounting have been designed to suit a doctor rather than an accountant. They are extremely simple and intuitive. For example, a doctor can bill a patient with a single click and record expenses using simple voucher entries. Easy Clinic automatically generates their day book, form 3C and other financial reports. Easy Clinic records and presents data intelligently which enables informed decision making, automates routine tasks, prompts on clinical and drug related actions, provide quick, hassle-free accounting and makes the doctor’s day much more organised and error free. Internally the doctor will be able to see a substantial improvement in the management of patient health records and the practice as a business. Externally the patient will enjoy a sense of professionalism from the practice as a whole. Q. Since its launch earlier this year, you must have received user feedback about Easy Clinic. Has there been any further development of the product since it was launched, based on recommendations of users? A. Easy Clinic was launched in April 2008 and we have received a lot of positive testimonials and feedback from beta users and customers. At Easy Clinic, our aim is to become synonymous with medical software in India. We realise this goal can be reached only by having our ears very close to ground. This mantra has been driven across our team of software developers, database designers, team leaders, and medical informatics professionals. The result is that from its inception the design of a feature is always externally focused. We also look at what value-addition it brings forth to the doctor’s desk. After all, doctors are the best judges of it. Therefore, we are committed to listening very carefully to our end-users. Q. What is the approximate implementation time and cost for Easy Clinic? A. Easy Clinic is an out-of-box, ready-to-use product. It takes about 15 minutes to install on a computer. Once installed, a wizard walks the user through the important startup settings and Easy Clinic is ready to fire. Easy Clinic is very simple and intuitive to use right from the word go. To make it even easier, we provide a number of video tutorials for the 36

“Easy Clinic is an out-of-box, ready-touse product. It takes about 15 minutes to install on a computer. Once installed, a wizard walks the user through the important start-up settings and Easy Clinic is ready to fire. Easy Clinic is very simple and intuitive to use right from the word go.” user to watch and put Easy Clinic to use, right from day 1. A single doctor license for Easy Clinic is priced at INR 20,000, which includes a 1 year annual subscription. After the first 12 months, there is an annual maintenance and upgrades subscription priced at INR 8,000. The annual subscription includes quarterly updates to the drugs database, periodic application version upgrades, ongoing telephone and online remote support. Q. What is the support service system like for Easy Clinic? Are software updates available online? A. Easy Clinic comes with a comprehensive help manual and a number of video tutorials to assist the doctor as soon as it is installed. Easy Clinic users are also backed with a dedicated and intelligent support team. We offer a number of support solutions including online support, phone/email support, remote assistance and more. Easy Clinic has a Web update module, which notifies the user when an update is available. The user can download and install the update with a single click, at their convenience. Q. Does Novel Medicare plan to offer only clinical solutions, or diversify into other areas of medical data management? What other products/innovations does Novel Medicare have lined up in the near future? A. At the moment, we are focussed on developing clinical solutions and incorporating best practices from around the world into our solutions. We have two more versions of Easy Clinic in the pipeline, which we plan to release over the next 12 months, Easy Clinic Rx and Easy Clinic Professional (suited for multi-doctor and corporate clinics). Our business model lays out an organic growth for the company. As such, going into the future we will venture into other areas of medical informatics. Q. Is Easy Clinic available in languages other than English? A. Easy Clinic is available only in English at the moment. www.ehealthonline.org

PERSPECTIVE

The Elusive Culture of Compliance The demand for a medicinal product brings with it the issues of Safety and Efficacy. Regulators can play a pivotal role in monitoring the medicinal product and ensuring compliance with the law of the land. The following article suggests the role IT can play in stemming this issue that puts the life of millions at risk. Increased research and clinical trials in India too, have its own set of problems that may be checked by this method.

he Indian pilgrimage to prosperity comes along with structural reforms in various facets of public life. The great Indian population in its march forward requires apart from food, clothing and shelter, adequate Healthcare. The fast pace of change in healthcare has brought forth new opportunities and new players. India is not only the fourth largest market by volume but also a hot bed for research and a favorite destination for clinical trials. This metamorphosis in the healthcare Industry also exposes its underbelly. Lack of adequate oversight has resulted in counterfeit, ineffective and unsafe medicines in the market place. Looking at the brighter side, India has a number of homegrown ethical companies following the global best practices. But, they too are fighting a pitched battle for the consumerâ&#x20AC;&#x2122;s mindscape with a number of spurious medicine manufacturers. We desperately need to provide the right environment for ethical companies to function and grow so that they can play a much larger role in the world arena. The problems of counterfeit medicines, unsafe drugs, need to monitor a large number of clinical trials, all, can be solved by the country with its valuable resource pool in Information Technology. Our IT manpower has helped the global community in solving a number of outstanding problems and can definitely play a pivotal role here.

Ajit Nigam Business Development Manager Relsys India Private Ltd.

How IT can help Let us try to examine how IT can change the Life Sciences landscape in the country. The story of development of a medicinal product begins with IT getting involved in selection of a molecule for possible commercialisation. As we move from animal to human trials, we need to ensure that trials are ethical, privacy of the patients protected and adequate safeguards are maintained in the volunteer/patient consenting process. Clinical Trial Management systems developed by various software vendors play a pivotal role in laying down the best practices in order to increase efficiency and effectiveness. With the increase in number of clinical trials and the need www.ehealthonline.org

Figure 1: The pharmaceutical R&D Process

Figure 2: R&D Spending and NMEs and New Biologics

for cost/ value arbitrage, new business models are emerging. These help the emerging Clinical Research Organisations to concentrate on moving up the value chain and to do knowwhat they know best- Research. It is critical at this juncture to establish appropriate Regulatory Oversight. Using web based technology a Clinical Trial Registry can be established under Central Drug Authority and a system can be developed which marries the requirement of commercial privacy with that of societal need to know and monitor it. A quick reading of jurisprudence entails that society delegates its rights and authority through the instrumentality of governance. There is a need for this oversight to be continuous for the health and prosperity of the nation. During the clinical trial process only a tiny sample of population is monitored for safety and efficacy of the medicine. But when the medicine is out in the market there are multiple variables and having regulatory oversight without appropriate use of Information Technology is virtually impossible August 2008

Pharmacovigilance Post Authorisation Oversight or Pharmacovigilance as it is popularly called is a function, which is growing. Naturally the perspective of a regulator is different from that of a commercial enterprise. It is the duty of the organisation responsible for the oversight function to ensure the safety of its citizens. It also needs to ensure that the consumers of the medicinal products are not duped and the laws of the land respected. Let us now try to examine how an active Pharmacovigilance program can protect and safeguard the health of Indian citizen. In order to do so, the current regulations have to undergo a dramatic change. The discussion on active Pharmacovigilance has been going on for a few years but nothing has been implemented on the ground. There is a strong case for Pharmacovigilance to be institutionalised under the constitution like SEBI or TRAI. One could always dovetail it into the existing National Pharmacovigilance Infrastructure. The current infrastructure is composed of various nodes at Peripheral, Zonal, Regional and National Pharmacovigilance Centre. The current working of this set up leaves room for much to desire and it is here Information Technology can play a significant part. At the regulatory level, one must mandate the reporting of Adverse Events (Side Effects) to be compulsory by all medical and healthcare professionals. Reporting by the consumer will have to remain at a voluntary level. At yet another level one can draw a distinction between medicines undergoing trials and medicines in the market for public consumption, prescription or otherwise. But the fact remains, that the regulation remains a piece of paper unless and until effectively implemented. We need to create what I call a, â&#x20AC;&#x153;Culture of Complianceâ&#x20AC;?. In order to do so we have to ensure Adverse Event Reporting has to be as simple as possible for

The Marketing Authorisation Holder should ensure that he has an appropriate system of Pharmacovigilance in place in order to assume responsibility and liability for his products on the market and to ensure that appropriate action may be taken when necessary. The Marketing Authorisation Holder should therefore ensure that all information relevant to the risk-benefit balance of a medicinal product is reported to the Competent Authorities and the Agency fully and promptly in accordance with the legislation. Source: Volume 9A of European Medicines Agency 39

the healthcare community. It should not be an additional burden but has to be a part of the daily routine. Plan of action So how do we do this? There are two types of medical practitioners- Institutional and Independent. Institutional Medical practitioners are the ones who are attached to Hospitals, Medical Colleges, Research Institutes etc. On the other hand Independent medical practitioners are those who have a private practice and may or may not operate out of an established clinic. At the Institutional level, mechanisms can be set up to collect the Adverse Events at a central level in the Institute, validate the information collected and send to Regional / Zonal Pharmacovigilance Centre. During the course of time it can also be linked to Electronic Health Records of an individual. It is the duty of the Pharmacovigilance centre to send the information received to the manufacturer of medicinal product for assessment of causality resulting in meeting the natural laws of justice. At the level of Independent Medicinal Practitioner this could be collected and sent to the designated Peripheral

Researchers from the European Molecular Biology Laboratory (EMBL) discovered a new way to make use of drugs’ unwanted side effects. Similar drugs often share target proteins, modes of action and unpleasant side effects. In reverse this means that drugs that evoke similar side effects likely act on the same molecular targets. They developed a computational method that compares how similar the side effects of different drugs are and predicts how likely the drugs act on the same target molecule.

centre who would validate the information and send it to Regional / Zonal centre for consolidation and follow up with the Headquarters of the Manufacturer of the medicinal product. The third category of the players in our, “Culture of Compliance” paradigm are the consumers themselves. Direct consumer experiences of Adverse Effects should go to the Zonal/ Regional centre where the authority would ask for comments from the manufacturer. For a manufacturer of medicinal products there should be a legal obligation to report all Adverse Events related to the products they manufacture or market. This can be easily institutionalised at Company Headquarters and reported to Regional / Zonal authority. With the growth in the number of clinical trials, a Clinical Trial Registry could become a suitable mechanism to capture Adverse Events at an early stage.

Figure 3: Pharmaceutical R&D process

Information flow and data mining One would now wonder how this free flow of information and their consolidation happen. There are a number of software applications available in the market today and this can be used to aid this process. The applications have global best practices built-in and can be used on plug and play basis. The international council for harmonisation has developed the E2B Standard for transmission of data, which can be suitably used. With the advent of Web-based applications, one could use the power of Internet to safeguard the health of the Indian consumer. With this giant leap of faith, we could be at a cutting edge. Clearly Pharmacovigilance is an idea whose time has come. Conclusion I believe that any information to be useful has to be actionable. Once the information is in a consolidated form at the Zonal/Regional centre, one could mine the data for signals using various methodologies. These signals would tell us about the risk profile of a medicinal product within the Region/ Zone. Using the principles of benefit risk assessment, the Zonal/ Regional Authority could take informed decisions related to issuance of warnings, withdrawal of medicines, label changes etc. The true power of information technology comes forth here in its blazing glory. At the National level, it is again consolidated to get a macro picture across the Indian geography. The role of technology shifts here with a perspective towards Risk Management and planning. It provides credible and ongoing inputs to healthcare policy makers both in Policy planning as well as implementation strategy for National Missions for eradication of Tuberculosis, Polio etc. The story does not stop here, but goes on by taking care of Adverse Event Reporting obligation to Uppsala Monitoring Centre and India playing its true role in the global life sciences arena. The views expressed in this article are of the author’s himself, and do not represent the views of Relsys India Private Limited.

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news review

INDIA

ICRI forays into healthcare management Riding on the healthcare boom in India, Institute of Clinical Research India (ICRI), India’s first and the world’s largest institution in Clinical Research studies announced the launch of its healthcare division - ICRI HEALTH. The division will focus on imparting structured and relevant education and bringing in the science of management into healthcare services - both for medical tourism and hospital operations management. ICRI HEALTH has entered into an MoU with Academy of Hospital Administration (AHA) for jointly conducting Hospital Operations Management and healthcare industry related courses. AHA has done pioneering work and for the first time developed norms for accreditation of hospitals in India for National Accreditation Board for hospitals and healthcare institutions which has also been approved by ISQua and on the standards of Joint Commission International. ICRI Health is a division of Institute of Clinical Research (India) and pioneers of the Allied Healthcare education courses in India. The Institute aims to be a World Leader in “Scientific Health Care Management Education”. ICRI Health through its educational programs aims to develop the healthcare sector and support professionals in the Indian healthcare industry. The industry-centric job oriented courses are developed in association with the corporate world. The experienced faculty drawn from the industry and academia are from medical, management and tourism sectors. The Institute has large, well-equipped campuses in Delhi, Mumbai, Ahmedabad, Kochi, Hyderabad and Bangalore.

Omaxe Foundation teams up with Maitri in labour health initiative Omaxe Foundation, the philanthropic arm of Omaxe Ltd., fast growing and diversifying Indian realty major with a pan-Indian presence officially launched Project: ‘Sanjeevani’, a labour health initiative aimed at benefiting construction labour. The goal of this programme, which is to be implemented by Maitri - an established name in the social sector - is to enhance prevention and treatment of HIV and Tuberculosis besides care and support for migrant workers. With Omaxe’s v a r i o u s construction projects employing about 7% of all labour employed in infrastructure development, ‘Sanjeevani’ will provide an opportunity for an integrated HIV/TB response, by reaching out to a work force of about 12,000 men, 3,000 women and 2,600 dependent children. Speaking about ‘Sanjeevani’ Mrs. Sushma Goel, Co-Chairperson, Omaxe Foundation expressed a “Great sense of satisfaction in communicating from the portal of Omaxe Foundation. The AIDS pandemic today by its sheer magnitude was clearly an issue that no one can address alone.” A unique aspect of the project is the active partnership of the School of Public Health, Harvard University in the research methodology adopted for Sanjeevani. Others present on the occasion included senior functionaries of NACO, UNAIDS, UNDP, ILO, DDG Tuberculosis (Health Ministry), Ministry of Labour besides stakeholders in the programme.

August 2008

Centre carves out new pharma department Considering the growth of the Indian pharma industry, the government has finally issued a notification for setting up a separate department of pharmaceuticals. The notification was issued on July 1.

“The separate department would be carved out from the existing chemical and fertiliser department, which is now taking care of the sector. The process of setting up the separate department including finding a place, deciding on functions and number of joint secretaries may get completed in three months,” said an industry expert. Though the original idea was to bring the drug price regulator National Pharmaceutical Pricing Authority (NPPA) and Drug Controller General of India (DCGI) under one roof, the Cabinet has not approved it. “The NPPA and DCGI would not become part of the separate department. The pricing authority and the regulator would continue to work independently and this has been spelt out in the notification,” said the expert. With pricing and regulation, the two most important issues related to medicines, are kept out of the department, it would be interesting to see what all functions are defined for the department. It is learnt that NPPA chairman Ashok Kumar is among the front-runners for secretary of the new department. 41

Delhi’s govt hospitals told to ramp up

Earthquake-resistant hospital in New Delhi

Concerned over the deteriorating healthcare service in the government hospitals, the Chief Minister of Delhi Shiela Dikshit directed all the Medical Superintendents of the Government Hospitals to provide more attention on maintenance in hospitals to enable them to bring desired improvement in healthcare. The CM conveyed this direction in a meeting that was attended by Health Minister Yoganand Shastri, Chief Secretary Shri Rakesh Mehta, Principal Secretary to CM, Principal

In a first of its kind in Asia, a INR 100 crore earthquake-resistant hospital providing advanced treatment in the field of liver and biliary sciences will start functioning at Vasant Kunj in the national capital. In the first phase about 180 beds would become operational, 74 of which would cater as Intensive Care Unit (ICU) beds, the statement added. The second phase of the construction of the hospital would be done by Delhi Metro Rail Corporation (DMRC), according to a statement here. Project Director Institute of Liver and Biliary Sciences S K Sarin said, “the Institute will have a separate department to promote basic and translational research in the area of Hepatobiliary Sciences primarily.” The department of hepatobiliary medicine would be the first dedicated department in the country for patients of hepatobiliary diseases and will have transplant hepatology and paediatric hepatology as independent units, he added.

Secretary (Health), Secretary (PWD) and Medical Superintendents of all Delhi Government Hospitals. In order to provide more comforts to the patient, Shiela Dikshit instructed the hospitals to involve and constitute Arogya Samitis. To meet the requirement of more hospitals in the city, the government also decided to start a 750 bedded super-speciality hospital at Dwarka in the month of August, 2008. Moreover, the Government would open six allopathic, five homoeopathic, five ayurvedic and two unani dispensaries in the different parts of the city. The Chief Minister also directed the Department of Health & Family Welfare to expedite procurement of 150 quality ambulances to enable the government to deploy ambulances in year 2009 as the government is committed to ensure better health coverage before commencement of Commonwealth Games 2010.

Indian American medicos join hands with Apollo Apollo Hospitals Group has agreed to provide ground support and other assistance to 17 dispensaries set up in India’s rural areas by the Association of American Physicians of Indian Origin (AAPI). Apollo will also help in extension of the programme and provide telemedicine services at the dispensaries. An Memorandum of Understanding (MoU) signed during the just concluded four-day convention of AAPI, the largest ethnic medical organisation in the United States, also provides for training of medical students from the United States in the Indian hospitals. AAPI, which claims to represent over 40,000 physicians, on its part would help arrange a network of physicians in the United States who would offer post operation care to US patients who return home after surgery in the Indian hospitals. The MoU was signed by Hemant Patel on behalf of AAPI and Prathap C Reddy, founder- chairman of Apollo Hospitals and chairman of the National Committee on Healthcare of Confederation of Indian Industry. 42

Health in emergency to be on concurrent list The Health Ministry is working on a Bill which, if all goes to plan, will place public health in times of natural disasters, epidemic outbreaks and acts of terror in the Concurrent List before the end of this year, giving the Centre the power to independently promulgate laws and lay down rules (public health is so far a state subject, exclusively in the domain of state governments). The Public Health Bill 2007 aims “to provide, prevent, control and manage epidemics or dangerous epidemic diseases, acts of bioterrorism and threats thereof”. The proposed Bill is likely to be discussed in the forthcoming session of the House. Together with the National Disaster Management Authority (NDMA), states and Union Territories have evolved Standard Operating Procedures (SOPs) on disaster management. In case of Chemical, Biological, Radiological and Nuclear (CBRN) casualties, mass casualty management will begin with decontamination of wounds and burns injuries prior to admission. “The Railways have a network of 121 hospitals. In a situation that needs emergency medical response, the Railways have an infrastructure of 172 Accident Relief Medical Vans (ARMV) situated every 200 km. They also have trained manpower. Hence, there is a well-rehearsed action plan in case of a railway accident,” said Lt Gen Bhardwaj.

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Telemedicine soon across Maharashtra Project planned with Indian Space Research Organisation (ISRO) should have started in June last year; now, its initial phase will connect via satellite premier medical colleges and hospitals to patients at eight or nine district hospitals. Two years after it was first proposed to link the city’s premier KEM hospital with four district hospitals, the telemedicine project planned with ISRO is now being extended to centres across the state.

In the initial plan, super-speciality KEM Hospital in Parel was to be connected to the civic-run V N Desai Hospital in Santacruz and district hospitals at Latur, Beed, Nandurbar and Sindhudurg. Experts at KEM would, through satellite communication, offer consultation and advice to the team at these centres, serving a dual advantage of avoiding patients’ trips to Mumbai and adding to the skills and knowledge at the district hospitals. According to state health officials, the project has now been undertaken under the National Rural Health Mission and is being extended across the state. At the regional centres, doctors will receive results of medical tests, X-ray and other reports from the set-ups in the district hospitals. While the telemedicine systems - the dish antenna, the server, the computers, TV with video camera, X-ray scanner and digital ECR - are being provided by ISRO.

Rural healthcare improvement high on J&K govt agenda The Jammu and Kashmir government has taken a slew of initiatives and administrative reforms to improve healthcare facilities in rural areas of the state. The reforms undertaken by the Azad government include a proposal to make two years rural service mandatory for in-service doctors seeking admission to postgraduate courses. Under the proposed move, the state health department has decided to incentivise rural service for admission to the PG courses. PG admission seekers will be given 10 marks every year of rural service up to a maximum of 50 marks. Doctors can get the maximum marks by putting in five years of rural service and would automatically make a headway of other PG aspirants who do not wish to avail of this incentive, secretary health and medical education K. B. Jandial said. Healthcare facilities are severely affected in J&K, particularly in rural areas where doctors do not want to be posted. There is shortage of nearly 900 doctors in the rural areas. To make up for the shortage, the government has referred 469 posts of assistant surgeons (medical officers) to the public service commission. There are another 350 posts of B-grade specialists (junior consultants) which are to be filled, the secretary said.

Robotic surgery at AIIMS for rare neuro disorder Recently, for the first time ever, the All India Institute of Medical Sciences (AIIMS) performed robotic thoracoscopic thymectomy on patients with myasthenia gravis, a rare autoimmune disorder. AIIMS has been performing video assisted thoracoscopic (VAT)

Diagnostic clinics only a click away All authorised medical diagnostic centres across the country will soon be listed on a website. The government and the Indian Radiological and Imaging Association (IRIA) are working jointly to develop the website. This move comes in the wake of complaints that many diagnostic centres were conducting banned sex determination tests. Moreover, the move would help authorities easily trace unauthorised centres operating in various states. In Uttar Pradesh alone there were over 3,500 ultrasound centres against the approved strength of 600 sonologists, reports IANS. Preparation of such a database was long overdue. Once it is prepared, there would be an online monitoring of all authorised diagnostic centres operating in the country. For developing the software to ensure online monitoring, IRIA had approached the central government a few months back, said the officials. The website will be linked from the chief medical officers’ (CMOs) offices in every district from where it can also be uploaded.

August 2008

thymectomy, or removal of thymus gland, for the past eight years. This is the first time that doctors used a robot for the purpose, making the procedure more precise. “Robotic surgery is more precise and accurate. It is the future of all surgeries. The robots are so designed that they can reach inaccessible areas in the body and bend and curve as per the shape of the organ. If it works well, then AIIMS would be the only government hospital in India to offer robotic thymectomy. Thymectomy can be either performed through an open method or VAT. In VAT thymectomy, three tiny incisions are made in the left chest through which the surgical instruments along with a small scope is introduced into the body and the surgery is carried out with the help of a visual monitor. The robotic surgery is similar to VAT, but the only difference is that the surgeon uses a specialised console with monitor to perform the surgery. The plus point of VAT thymectomy is that it leaves minimal scars. 43

Indians can now dial 108 for emergency India is gradually moving to the use of one emergency telephone number across the country, 108, on the lines of America’s 911 and Britain’s 999. In June, the states of Madhya Pradesh and Uttarakhand adopted this number for providing emergency services. A 108 service for Delhi is in the pipeline. The three-year-old Emergency Management and Research Institute (EMRI) service also operates in Andhra Pradesh, Tamil Nadu, Kerala, Goa, Gujarat, Rajasthan, Assam and Jammu and Kashmir, hoping to provide services to 100 million people by 2010. “This is India’s first coordinated response service, at one number across the country, like the UK’s 999 and Europe’s 112, taking a call every two seconds,” Venkat Changavali, CEO of EMRI, told IANS. The 108 service in India is ambulance-based. It has more than 600 advanced life-saving ambulances operating in Andhra Pradesh and Gujarat. The Tamil Nadu government has made available 200 such emergency medical technician-manned ambulances for the EMRI service. When the blasts took place in Hyderabad’s Mecca Masjid on May 18, 2007, one EMRI ambulance managed to reach the blast site in one minute, and two more reached the site in another 15 minutes. If people get to know and use just one number, saving a life becomes that much easier, say those who support 108.

Indian Spinal Injuries Centre signs on Akhil Systems’ HIS Indian Spinal Injuries Centre, New Delhi is a National leader in providing multidisciplinary rehabilitation and spinal cord surgeries. The Indian Spinal Injuries Centre has been setup in collaboration with the Government of Italy along with the support from Government of India. Today it is a model institution comparable to the best in the world and most successful indo Italian collaboration. Recently, ISIC signed a contract with Akhil Systems Pvt. Ltd., New Delhi for replacement of their existing HIS System. As a new ISIC IT Partner, Akhil Systems will implement their complete HIS with Clinical, NonClinical, Administrative and Financial Modules for automation of all departments of the hospital in paperless and filmless environment interfaced with medical equipments, SMS & web technology.

Hospitals must give records within 72 hrs In a landmark order, the national consumer disputes redressal commission has made it mandatory for all medical practitioners and hospitals across the country to provide the entire medical records of a patient to him\her or the authorised nominee or legal authorities concerned within 72 hours of the demand. Simultaneously, the commission asked the Medical Council of India to promulgate a comprehensive notification. Accordingly, a week ago, the MCI directed medical practitioners and hospitals to provide the medical records of a patient within three days of the request. The commission’s directives, followed by the MCI circular, assume significance since the general tendency among medical practitioners and hospitals has been either to avoid a request for medical records or delay it for obvious reasons. However, Hinduja Hospital director G. B. Davar welcomed the move, saying it was in the interest of patients. A former dean of J J Hospital, Davar said parting with medical records would improve the relationship between the doctor and the hospital. “If all records are made available to a patient immediately, there will be no scope for doubt of any kind,” he said. 44

11th Workshop on “Medical Informatics & Biomedical Communication” 11th Workshop on “Medical Informatics & Biomedical Communication” supported by DBT, Ministry of Science and Technology and ICMR, New Delhi is being organised at Bioinformatics Centre, JB Tropical Disease Research Centre, mahatma Gandhi Institute of Medical Sciences, Sevagram, during November 20-22, 2008 to expose Medical Teachers, Scientists & PG/Ph.D. students to advances in Medical/Health Informatics, Hospital Information System, evidence based medicine &Telemedicine, Proteomics, Genomics etc. Interesting lectures, demonstrations and hands on sessions will be conducted by the eminent experts in these areas to promote use of Medical Informatics in health care management and retrieval of Biomeical Information, Databases/Software for promotion of medical research. Further, a one day special session on Biomedical Communication likely to be supported by ICMR will also be organised. Contact: Dr. Satish Kumar, Professor, Biochemistry & Dy. Coordinator, BIC, e-mail: mgims.btisnet@nic.in

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news review

BUSINESS

Remote patient monitoring market growing The European remote patient monitoring market is growing, but slowly, due to limited government reimbursement, reveals research from Frost & Sullivan. The market earned revenue stood at US$ 175 million in 2007 and is estimated to reach US$ 400 million by 2014. The heightened demands of an ageing population and a related increase in chronic diseases are encouraging market growth. Innovative and advanced technology continues to play a significant role in the remote patient monitoring market. Technology is constantly changing to support better healthcare services, while steadily improving patient monitoring capabilities. However, the lack of adequate reimbursement streams will pose a major challenge to companies wishing to boost their unit sales and market revenues. Privacy and confidentiality issues are further clouding the market. “With no financial incentive for healthcare providers to implement this technology, providers are likely to view remote patient monitoring as an increase in workload without a subsequent hike in pay. On the other hand, connecting personal health information to the Internet exposes this data to more hostile attacks than paper-based medical records,” says the report.

Panacea Biotec enters hospital business Vaccine maker Panacea Biotec is foraying into the hospital business by setting up a 220-bed multi-speciality hospital with Gurgaonbased Umkal Medicals. Panacea Biotec has picked up a 75% stake in Umkal’s project at Gurgaon and expects the hospital to be operational by January 2010. The Delhi-based pharma company has signed an agreement with shareholders of Umkal, who have three hospitals in Delhi and the national capital region (NCR). However, Panacea’s interest in Umkal will be limited to the Gurgaon project. According to initial estimates the project will cost around INR 80 crore. The company will target overseas patients and affluent Indians, which would be close to 25-30% of the market. Panacea Biotec joint MD Rajesh Jain said, “It is the company’s long term strategy to enter the private healthcare segment to make the company a leading health management company. Based on the experience from this project, we may look at starting a hospital chain.”

Piramal Healthcare to invest in China Piramal Healthcare will invest in manufacturing facilities in China and is looking for acquisitions. “We are looking at investing in manufacturing facilities in China that are good in large chemicals. We are continuously looking for acquisitions,” Piramal Healthcare Chairman, Ajay Piramal told shareholders at the company’s annual general meeting recently. The investment may be into a contract research manufacturing facility, he said. Piramal Healthcare, formerly Nicholas Piramal, has a sourcing office in Shanghai. The company’s facility in Baddi, Himachal Pradesh, has a capacity utilisation of 60%. Piramal Healthcare has a presence in 80% of the therapeutic areas, he added. 46

BioLink achieves Microsoft certified partner status BioLink was awarded Microsoft Competency in Independent Software Vendor (ISV)/Software Solutions. The Microsoft Certified Partner Status is achieved through BioLink’s extensive experience and expertise in building biometric ID systems for middle and large enterprises, its competency in developing ID solutions based on Microsoft technologies, and highly positive feedback from customers. Of importance is the maturity of BioLink’s biometric offerings, which is best witnessed by BioTime, an integrated biometric Time and Attendance/Access control solution which has received the Microsoft certification. All BioLink products run under Microsoft operating systems, including the latest Windows Vista version. In particular, BioLink IDenium is fully compatible with Microsoft Active Directory. Another example of Microsoft’s groundbreaking synergy with biometrics is the use of Windows Presentation Foundation (WPF) in BioLink’s universal ID platform BioLink BioID, providing for simplified check-in/check-out event registration for any applications requiring strong identification. As an ISV Software Solutions partner, BioLink is going to primarily focus on further development of the biometric ID market by satisfying the ever increasing demands of corporate customers and public bodies; promotion of BioLink’s products via resources and support offered by the Microsoft Partner program; and ongoing integration of Microsoft’s most recent technologies and architectures into biometric ID systems

CBaySystems to invest US$ 25 mn and up headcount in India With a view to rapidly ramp up operations and expand its footprint in the country, CBaySystems, has drawn up a US$ 25 m capex plan over the next two years. CBaySystems also plans to up its headcount to 10,000 from the present 5,500 and set up 10 new centres, primarily in Tier II and III locations, by 2010. The company is a global leader in the healthcare information management and patient financial services (PFS) space with over 400 large hospitals in the US, physician practices and clinics as its clients. “We have lined up an US$ 25 mn investment for India over the next two years to fuel our expansion. We also plan to raise our headcount to 10,000 by then,” CBaySystems India Director and Chief Operating Officer, Dinesh Kumar, said. The funds would be raised through internal accruals and “also through outside funding”, Kumar said. CBaySystems runs its global back-end operations from India through its wholly-owned subsidiary, CBaySystems India. Headquartered in Mumbai, the company presently has 37 centres in the country including Bangalore, Hyderabad, a small unit in Vijayawada which it plans to expand, and Nagpur. “We now plan to enter Tier II and III locations such as Hubli, Indore, Raipur, Belgaum and Coimbatore, apart from Chennai,” Kumar said.

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2 nd International Conference & Exhibition

“ Telemedicine: Myths and Reality” 23-24 October 2008, Lviv Topical issues of telemedicine and eHealth in Ukraine and worldwide

Dear collegues!

Conference discussion topics:

On behalf of Association for Ukrainian Telemedicine and eHealth Development (National Member of Іnternatіonal Socіety for Telemedіcіne and eHealth) let me invite you to participate in the 2nd International Conference "Telemedicine: Myths and Reality”, that will be held in Lviv on 23-24 October, 2008. 1st Conference "Telemedicine: Myths and Reality”, organized at the fall of 2007 by Western Ukrainian Telemedicine Center “Meditech” and Association for Ukrainian Telemedicine and eHealth Development (AfUTeHD), became really a success story of the project, that put together more than 200 participants from 10 countries worldwide. High growth of interest in telemedicine and ehealth from different environments: physicians, managers and decisionmakers, medical and technical university officials, private sector and students, - has been ascertained. It demonstrates the necessity of regular realization of scientific and practical forums on issues of telemedicine, informatization and computerization in Health Care as well as unified electronic medical space formation. Also, it is very necessary to create scientific approaches and evidence base for development of Ukrainian ehealth. Due to organisation of such conferences and seminars it become possible to exchange ideas and achievments, to discuss and to create working groups. Gained experience and knowledge will ensure the future work on standardization of medical information systems, for an effective decision making, for understanding the routine ehealth and telemedicine usefulness. I am glad to welcome you to attend 2nd International Conference "Telemedicine: Myths and Reality”. I believe this year we will also present you high-grade scientific program, helpful practical recommendations. New ideas and the way of their realization will be our gift for you. Best wishes, Anton Vladzymyrskyy, M.D., Ph.D., Head of Executive Board of Association for Ukrainian Telemedicine and eHealth Development Organizers

Supported by

• Clinical telemedicine (teleradiology, teletraumatology, telepediatrics, teledermatology, telepsychiatry, emergency telemedicine etc.) • eHealth • Home and mobile telemedicine, telemonitoring • Hospital information systems and telemedicine networks • Medical electronic records, medical information safety • Technical and program solutions for telemedicine and eHealth • Informatization of Public Health • IT-managemant in Public Health and pharmacy • Telemedicine as certified education • Distance education • Transboundary telemedical projects • Deontology in telemedicine • Legal regulations of telemedicine functioning in Ukraine and abroad • Telemedical services payment About the Conference: Conference materials will be published in «Ukrainian Journal of Telemedicine and Medical Telematics» An exhibition of technical equipment and software for telemedicine and eHealth will be held during the conference. Please visit conference website: www.telemed.net.ua to find information on terms of registration and participation in conference. Deadline for abstracs submission - 1 September 2008 Conference venue: Large conference hall, Hotel “Dnister” Address: 6, Mateyka str, Lviv Ukraine

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Apollo Hospitals to hive off pharma retailing into separate company

Healthcare driving speech recognition technology growth The automation of healthcare processes is the main driving force behind the growth of speech recognition technology, according to a report released by Datamonitor recently.

Apollo Hospitals Enterprise Ltd intends to spin off its pharma retailing business into a separate company, though not immediately. At present, the company has 642 pharmacies across the country and the plan is to raise this number to 1,000 by February next year, according to Ms Shobhana Kamineni, Director, Apollo Hospitals, who looks after pharma retailing. Apollo has been selling medicines through its pharmacies within the hospitals for a long time, but it was only in 2006 that the company began setting up standalone pharmacies. Like for any retail business, the major challenge is finding manpower. Apollo has sought to tackle this problem by working with NGOs and picking up youngsters from semi-urban centres and training them in pharma retailing. In this context, she criticised poaching by “new entrants”, who offer double the salaries and pick up Apollo-trained staff, even though such salaries could not be sustainable. Apollo is also set to increase volume of medicines manufactured for it. Ms Kamineni observed that there is no need for Apollo to buy basic, over-the-counter medicines of other brands, paying more. “The generic strategy is to get the best material and get it manufactured,” she said. Shortly, Apollo would launch a “big vitamin range” under a separate brand, details of which would be disclosed in due course, she said.

HCL Info bags US$ 23 m deal for Pan-African project Domestic IT major HCL Infosystems has bagged a US$ 23 million deal to implement IT infrastructure for the PanAfrican e-Network Project, which provides tele-education and telemedicine. “HCL Infosystems will receive US$ 23 million from this project, which will span over 18-24 months, HCL Infosystems Executive VP George Paul told reporters. The project would connect 53 African countries into one network. This is an initiative by Indian government to share its expertise in the fields of education and medicine. The network would benefit all the 53 African nations by providing teleeducation, telemedicine, video-conferencing and VOIP services. Facilitating education and knowledge sharing, the network would connect seven universities from India with five universities from Africa; the African centres will further be linked to one centre in each of 53 countries within the continent. The network would also connect 12 Super Speciality Hospitals from India with five from Africa. These Hospitals in Africa would also be linked to one remote hospital (Patient-End Locations) in each of the 53 countries as apart of the project to extend healthcare services to rural Africa. 48

Healthcare currently represents 85% of the market for PC- and server-based speech recognition technologies. Patient information is gradually becoming digitised in order to address issues with delivering records and test results faster. By reducing the number of illegible handwritten documents and simplifying processes, providers can eradicate errors in diagnosis. Speech recognition is also being used for medical transcription, easing pressure on transcriptionists and allowing healthcare providers to save on staffing costs. The two leading suppliers, providing specialist solutions for the healthcare market globally are Philips and Nuance, the report says - with Philips taking a stronger position than its rivals in the UK. The UK market has also seen the take-up of Nuance’s Dragon NaturallySpeaking, a consumer-based speech recognition system, designed mainly for customers with disabilities. There are also a few specialist resellers for speech and digital dictation in the UK, with companies including SRC and BigHand. The adoption of speech recognition still remains behind the US. In the UK, where the healthcare market is in the public sector, there are limited budgets, as well as long sales cycles and it’s difficult to change technology patterns - unlike in the US where healthcare is revenue-driven.

ViScope enables doctors to visualise the heart sounds HD Medical Services (India) Pvt. Ltd., a wholly owned subsidiary of HD Medical Group Ltd. of Australia, has entered into an agreement with BPL for the distribution of ViScope 100. ViScope is an audio-visual cardiac screening device that enables doctors to visualise the heart sounds along with hearing them better. ViScope also enables the better detection of murmurs and other heart sound components so as to achieve an effective screening of cardiac anomalies. The distribution agreement is valued at US$ 10 million. The company had filed 14 patents applications and obtained one patent in the field of cardiac auscultation. The chief inventor of the company, Arvind Thiagarajan, said the company had strategic collaboration with many leading global institutions for clinical trials and technology validation. Chief Operating Officer and Vice-President of BPL, A. Vijay Sinha, said the agreement is valid for two years and had decided to set up a team to train the doctors and explain the importance of the product.

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Oracle announces creation of health sciences global business unit Responding to continued growth in clinical trials as well as the increasing linkages across life sciences, diagnostics and healthcare, Oracle recently announced the formation of a new Global Business Unit focused on software applications for the health sciences industry. Neil de Crescenzo has been named Senior Vice President and General Manager for the business unit. The Oracle Health Sciences Global Business Unit will build on Oracle’s proven track record in the sector. Today, all of the 20 top pharmas and 14 of the 15 top U.S. hospitals run Oracle. Oracle today offers the sector’s most comprehensive suite of software applications for clinical development. These products can be deployed individually or together and include Oracle Clinical, Oracle Remote Data Capture, Oracle Thesaurus Management System, Oracle Adverse Event Reporting System, Oracle Life Sciences Data Hub and Oracle’s Siebel Clinical Trial Management System. Oracle’s application platform for health sciences helps companies bring together all the critical aspects of the clinical development, safety and pharmacovigilance processes into a single, open platform built on state-of-the-art technology. The company also offers Oracle Healthcare Transaction Base, which helps healthcare companies simultaneously improve patient care and control costs by providing a foundation for interoperability and integration of existing and new systems.

Eastern Europe explores PFI for medical imaging Public hospitals in Eastern Europe are exploring private finance service (PFI) approaches to enable them to invest in medical imaging equipment. According to a new report from Frost & Sullivan the market for Eastern European medical imaging modalities will double from 195m in 2007 to reach 411.8m by 2014. The report says insurance companies and individual operators are also supporting growth in the medical imaging modalities market in Eastern Europe. The Frost & Sullivan analyst said: “The private sector owns and runs several diagnostic centres for MR and CT in Eastern Europe. Being self-financed, such centres are open to vendors’ recommendations

of purchasing more sophisticated, high-end equipment that will enhance patient throughput and eventual return on investment.” The report says, however, that governments in Eastern Europe are relaxing policies and encouraging private sector investment in diagnostic services and the purchase of new medical equipment. Currently, the market is dominated by old equipment, particularly in modalities that are the most popular and commonly used, such as X-rays. To date strict healthcare budgets and low reimbursement have resulted in little incentive to replace existing X-ray systems and purchase new ones. “Although countries like Poland, the Czech Republic and Hungary are becoming more stable, they still experience many challenges that will need to be overcome if market success is to be sustained,” said Munshi. 50

Neon Healthcare ties with US based Hayes Lab Neon Healthcare and Research Institute Ltd. has signed an agreement with US-based pathological lab Hayes Lab for outsourcing in the healthcare space. “The joint venture with Hayes would work on different projects like teleradiology between US and India,” NHIL chairman and managing director Sajal Dutta said. “Hospitals in the US would send images through satellite to our facility in Kolkata and reporting would be done by specialists here,” Dutta said. The global outsourcing of lab activity was estimated to be INR 60,000 crore while India’s share was only INR 200 crore.

Neon Healthcare and Hayes Lab would also scout for buyout of pathological labs in Europe and US for faster growth, the company said. Dutta said the JV company has also put a proposal to the West Bengal government to set up 54 labs in districts, divisional and sub-divisional hospitals across the state. “We have made a presentation with the state health minister for setting up labs in government hospitals in PPP model. We will require about US$ 100 for setting up 54 advanced labs,” Dutta said. Asked about funding, Dutta said beside investment from the JV company, funds would be tapped from foreign institutional investors who were keen to invest. Meanwhile, Dutta said he was also setting up a speciality hospital here that would have 750 beds by December 2009.

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news review

WORLD

CIGNA creating virtual health community CIGNA, a leading health service company, has announced the development of a virtual health care community. This computersimulated world is situated on a Second Life island, where seminars, interactive displays, educational games and virtual health consultations help foster real and sustainable behaviour change that improves health. Developed by Method, a brand experience agency, CIGNA’s virtual community provides 3D video game-like interactivity that enables people to learn and interact anonymously with like-minded peers in order to positively change the way they live their lives. For example, the newly-developed nutrition zone helps participants develop their nutrition knowledge, learn how to make healthier food choices, manage their weight and understand portion sizes and food labels - skills that will enable them to lead healthier, more energetic and productive lives. To make the presentation come alive and increase audience involvement, the presenter uses a number of 3D props and graphics. For example, real-time voting about the fat content of particular food items encourages audience participation. Up until now, virtual worlds have been pegged as a niche phenomenon, but the work Method is doing with CIGNA illustrates how virtual worlds can be properly integrated with multiple channels and communication media to educate users and increase results on existing programs.

Technology can help older people who forget New research has looked at how technology can be used to provide reminders to assist older people in decision making. These assistance technologies have significant potential to help older people and their carers in everyday life. The research investigated the reminder systems currently used by a small group of older people, their attitudes to technology, and, through some simple experiments, their reaction to certain reminders presented using a variety of simple technologies and formats. The project developed a prototype ‘living room’ system featuring a wireless network connecting typical home devices, including a telephone (conventional and cordless), a remote control device, analog radio, TV and computer. The participants disliked impersonal services, such as those provided by call-centres, and preferred the interaction that accompanies a telephone conversation. The format and delivery of automated reminders needs to be straightforward and able to capture the attention of the individual without becoming bewildering to manage or irritating. Spoken reminders worked well when someone was undertaking a quiet task such as reading, but less so when watching TV, for which, repeated on-screen messages worked best. Overall, it appears that to be effective, messages and messaging systems have to be tailored to the particular behaviours and routines of the individual.” 52

New telemedicine service to help care for sick babies Tiny Tom is the latest development of the tele-paediatric service, a major research project run by The University of Queensland’s Centre for Online Health (COH), a research centre based in the Royal Children’s Hospital in Brisbane. COH Deputy Director, Dr Anthony Smith said the new service linked clinicians at Mackay Base Hospital, by video, with the neonatal intensive care unit (NICU) at The Townsville Hospital. “Tiny Tom also enables parents and family members, who are unable to travel to Townsville, to see their baby and talk to NICU specialists and nursing staff,” Dr Smith said. The research will investigate the potential economic and clinical benefits of using telemedicine in neonatal intensive care. This generous funding has allowed the Centre for Online Health to extend its tele-paediatric service into a number of regional areas, including Townsville and Mackay for neonatal continuity of care; Gympie and Nambour Hospital for general paediatric support; and Mount Isa and Emerald Hospitals for specialist paediatric support.

German insurer AOK requires doctors to digitise The AOK Baden-Württemberg, a regional German health insurance company with three million members, has signed a direct primary care contract with up to 5,000 doctors in the state of Baden-Württemberg that requires them to digitise. Media and health policy experts have hailed the new contract as a minor revolution, cutting through the layers of bureaucracy that currently exist. The German healthcare system is organised in a collective fashion. Health insurance companies pay fixed budgets to regional doctor’s associations, the “Kassenärztliche Vereinigungen”. These regional associations then give the money to usually several thousand doctors in the region. How much money a doctor actually receives out of this budget depends on how many patients he sees, on the kind of diagnostics he performs and on the therapy he prescribes. The new contract is also about paying them more. On average, what the doctor gets for an AOK patient is expected to increase 30%. AOK will have to refinance the increase in expenses, and this is where IT comes into play. When making a prescription, the software will recommend a cheap vendor. The doctor does not necessarily have to follow the recommendation. But a refusal will reduce his payments, at least when it happens with regularity. What is criticized, though, is that the software will be offered exclusively by the HÄVG Software GmbH, a joint venture of doctors and the IT company ICW.

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Agfa HealthCare launches nursing solution ORBIS Care Agfa HealthCare, a leading provider of IT-enabled clinical workflow and diagnostic imaging solutions, and the Imelda Hospital in Bonheiden (Belgium) announced recently that more than 15,000 nursing documentation forms have been registered electronically in ORBIS(TM), after the initial go-live in November, 2007. ORBIS’ capability to easily customise electronic forms based on bestpractice standards now allows the nurses at Imelda Hospital document their main nursing activities within ORBIS Care. Successfully reaching this important milestone for an electronic nursing record with a stable interface to Imelda’s existing ADT System (“Admission, Discharge, Transfer”) underlines the close cooperation of Agfa HealthCare and the Hospital. ORBIS now transparently represents Imelda’s efficient nursing workflows electronically acknowledging individual needs and how the nurses prefer to work. Since January 1, 1988, all Belgian general hospitals are required by law to collect data for a Nursing Minimum Data Set (NMDS) four times a year. One of the next project steps at Imelda will be the implementation of Care Planning within ORBIS, where the captured data from the Nursing Documentation is immediately available for planning processes.

Face to face with the future Just like the iconic picture from the 1968 film 2001: A Space Odyssey, future ultrasounds will spring to life bringing the mother and her child closer than ever before. One of the world’s leading medical technology companies, Philips Healthcare, is developing the ultrasound imagery. It is yet to set a release date but it could be within the next five years. The amazing vision is created by using current 3D technology. Philips Healthcare business manager, ultrasound, Ian Schroen said it was an exciting time for parents. But a leading obstetrician denied the company’s claims, saying the future images would be of no benefit for diagnostic purposes. Relying on a belt that lies across the woman’s belly, ultrasonic waves are transmitted to create the image, which is bounced on to a wall giving the appearance of being inside the womb. It will allow parents to watch the foetus develop in detail including the ability to view the chambers of the heart, spinal cord, fingers and toes. While it won’t be every parents’ choice, Philips and doctors expect it will be in high demand, following the success of 3D/4D ultrasounds.

Teleradiology plus electronic health record RFID may cause hospitals’ lifesaving equipment to malfunction: Study Radio frequency identification devices (RFIDs), commonly used in hospitals for tracking supplies may prove potentially dangerous for the patients, a team of Dutch scientists claim. The radio waves generated by the wireless systems actually interfere in the working of certain lifesaving equipment like respirators, external pacemakers and kidney dialysis machines and simply switch them off, according to the news research. The current study conducted by Vrije University in Amsterdam, the researchers evaluated the functioning of 41 lifesaving medical equipment including pacemakers, ventilators, IV pumps and anaesthesia define machines. Out of a total of 123 tests conducted, 34 electromagnetic interference (EMI) incidents were recorded - of which 24 were deemed as either “significant” or “hazardous” by an independent panel of intensive care doctors, the report published in the Journal of the American Medical Association reports. In certain incidents reported, a distance of over 10 inches (between the RFID and the medical equipment) was sufficient to either switch off the devices or to change their settings. Additionally, at times, the radio waves generated by the RFIDs were powerful enough to completely stop the working of syringe pumps, cause external pacemakers to malfunction and to halt dialysis machines besides often switching them off, researchers found.

August 2008

Klinikum Chemnitz GmbH has become one of the first hospitals in Germany to link its teleradiology service with the electronic health record (EHR). This means that, effective immediately, data obtained from a remote diagnosis, e.g. computed tomography images and the corresponding findings, can be stored in a shared health record and then used for information exchange between different facilities participating in the patient’s treatment.

Siemens supplied and implemented the overall technical solution. This included the software for the radiological image communication as well as the Soarian Integrated Care (Soarian IC) eHealth solution for the electronic health record. In cooperation with the regional county hospitals as well as numerous practising physicians and medical centres in its service area, Klinikum Chemnitz has thus assumed a leading role in integrated healthcare in Germany. The advantages include, a high quality of healthcare and treatment that can be offered even outside of major centres, the cost effectiveness of clinics will be increased due to common utilisation of the available resources, and patient satisfaction will be enhanced, since waiting periods will decrease and unnecessary patient transports can thus be avoided. 53

Award for open source application for analysing health data Health Atlas Ireland, an Open Source application to analyse health related datasets using geographical information systems (GIS) and statistical software, was one of twenty projects that were given the ‘Prime Minister Public Service Excellence Award’. Health Atlas Ireland is based on the Open Source content management system Plone and the Open Source application server Zope. It was selected for the Award because of its capacity to innovate and its technical perfection, writes Zeapartners, a network of companies involved in Plone and Zope. The Health Atlas Ireland application is easily transferable to other organisations. This project opens the way to international software collaboration. The development of such software sharing initiatives helps underpin the sustainability of public services and makes a real difference now and into the future. The e-Government project Health Atlas Ireland is a joint Health Service Executive and academic initiative. It integrates geographical information technologies, database software and statistical techniques. A user friendly interface supports web-enabled access across the Irish health sector and collaborating agencies. Health Atlas Ireland enables controlled access to maps, data and analyses for service planning and delivery, major incident response, epidemiology and research to improve the health of patients, their families and the population.

CIGNA Reaches across borders to improve healthcare CIGNA is supporting a program that is searching the world for solutions to improving healthcare. The Global Knowledge Exchange Network (GKEN) was created through an unrestricted grant from the CIGNA Foundation to the Wye River Group on Healthcare (WRGH), a non-partisan group known as a catalyst for constructive health care change. Through this work, the GKEN will explore health care systems around the world to discover what works well and why, and will examine how to replicate successful models that address healthcare challenges and improve healthcare quality. Issues to be considered include cost, delivery, administration, public health and the workforce. Over the three-year period, the GKEN will identify better practices in healthcare, such as process changes, use of technology, and new roles for doctors and other members of the provider community. This information will be delivered through a robust internet site. The GKEN also will promote these better practices through speaking engagements, printed materials, events and other channels, including the development of an electronic newsletter. “This initiative will build on the strength of existing international exchanges by partnering to promote cross-cultural knowledge exchange among the leadership of nations. 54

Pan-European health network planned Smart Open Services (SOS) is a panEuropean ehealth project facilitating cross-border healthcare. The project aims to develop services providing patients travelling across Europe with access to high-quality care. The project involves 12 member states: Sweden, France, Germany, the Netherlands, Italy, Spain, the Czech Republic, Greece, Austria, Belgium, Denmark and Slovakia. It is supported by the European Competitiveness and Innovation Framework Programme (CIP). There are two services that will be developed in a first step: a patient summary, which contains basic medical information such as diagnoses or laboratory results, and an electronic prescription service with an electronic medication list. These will get basic, but important patient data to foreign doctors urgently when needed. The European Commission announced at the eHealth conference in Portoroz, Slovenia last week that the contract for the SOS project will be signed before the summer break. To achieve the new services, the participating countries will for the first time establish IT links between their healthcare systems. The package’s key components include information on local rules, co-payments and other aspects of healthcare for citizens in their respective language at the point and time of treatment abroad, as well as instantaneous online verification of their insurance status for healthcare providers.

Cell phones to transmit medical images People living in remote places away from the modern medical centres across the world can soon avail sophisticated radiological diagnoses and treatment. A Hebrew University researcher has developed a new process to transmit medical images via cellular phones. Jointly patented and owned by the Hebrew University’s technology transfer company Yissum and by the University of California at Berkeley, the system provides an independent Data Acquisition Device (DAD) at a remote patient site, where users have no image display capabilities. The device is then connected via cellular phone technology to a hardware control multiserver unit at a central site with an advanced image reconstruction capability, with the processed data then returned to the DAD site. The DAD can be made with off-the-shelf parts that somebody with basic technical training can operate. Around three-quarters of the world’s population has no access to ultrasounds, Xrays, magnetic resonance images and other medical imaging technology used for a wide range of applications. The researchers further said that by simplifying the apparatus at the patient site, they have been able to reduces the cost of medical imaging devices in general. Besides, it also removes the need for advanced imaging training of the personnel at the patient site.

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Health record microchip injected under skin Healthcare RFID systems provider VeriChip Corporation has launched its first-ever direct-to-consumer marketing campaign for its personal health record microchip which is injected under the skin of patients. As part of this campaign, VeriChip has renamed its patient identification system Health Link and created a new website. The site provides complete information about the product and how to enroll as a Health Link member. The Health Link microchip stores only a unique 16-digit identification number and is injected just under the skin in the rear upper portion of the right arm. When a Health Link member is unconscious, unresponsive or confused, emergency medical personnel use the Health Link scanner to retrieve the member’s identification number to access his or her personal health record. Scott R Silverman, Chairman and CEO of VeriChip, said: “Given our successful infrastructure build-out in South Florida, we are now ready to escalate our marketing efforts to increase consumer awareness and adoption through the first DTC launch of our product.”

Europe aims for interoperable EHRs by 2015 The European Commission has published new draft of interoperability guidelines setting out a roadmap to achieve interoperable electronic health records across the continent by the middle of the next decade. “It would also make it possible for pharmacies to electronically process prescriptions from other member states, so that patients travelling within the EU or living in another member state can obtain a refill of essential medicine,” it adds. In order to achieve this, the EC is calling on member states to work on three main action points. The recommendation calls on them to establish aspects of electronic health records that should be exchangeable between systems, such as patient summaries, emergency data sets, and medication records facilitating ePrescription. It also says they should enable health data to be shared among different healthcare systems, based on a limited range of applications currently in use in different member states, and build appropriate networked systems and services covering all areas of healthcare, while fulfilling appropriate legal, operational and educational requirements. Having records available would also help patients who need to refill prescriptions or replace lost medicines, and would ensure the continuity of care, facilitating unscheduled medical encounters and continued treatment afterwards. 56

Supercomputer helps predict risk of bone fracture A research team from the Swiss Federal Institute of Technology (ETH Zurich) and IBM’s Zurich Research Laboratory have used the Blue Gene /L supercomputer to simulate the strain on a piece of bone to help determine the likely place of fracture. The breakthrough method developed by the team combines density measurements with a large-scale mechanical analysis of the innerbone microstructure. Using large-scale, massively parallel simulations, the researchers were able to obtain a dynamic ‘heat map’ of strain, which changes with the load applied to the bone. This map shows the clinician exactly where and under what load a bone is likely to fracture. The joint team utilised the massively large-scale capabilities of the 8rack Blue Gene /L supercomputer to conduct the first simulations on a 5 by 5 mm specimen of real bone. Within 20 minutes, the supercomputer simulation generated 90 Gigabytes of output data. ETH Zurich Professor Peter Arbenz, who initiated the collaboration of the involved groups, explains that what was first needed for large scale bone simulations were state-of-the-art numerical algorithms to solve extremely large problems in a short time. Scientists in future aim to advance simulation techniques to go beyond the calculation of static bone strength to the simulation of the actual formation of the fractures for individual patients, in yet another step towards the fast, reliable and early detection of people at highfracture risk.

iSoft introduces LabCentre in Netherlands iSoft has announced that its LabCentre laboratory information system is to be introduced in the Netherlands. An iSoft spokesperson said the system will be available immediately in the Netherlands and is to offer benefits including “extremely rapid implementation, ease of use, improved remote requesting, improved test turn around, embedded word processing and cancer dataset support”. LabCentre is a modern, scalable and full graphic laboratory information system for clinical chemical, bacteriological disciplines and blood bank and is used at laboratories in Germany, Switzerland, Austria and Russia. The system is also available in the UK, launched in April as i.Laboratory Enterprise. The system meets traditional laboratory needs, as well as providing a more advanced database design for easier adoption of emerging and evolving standards and technologies. It has been designed to support flexible workflows and improve efficiency and meets clinical safety and laboratory accreditation requirements. iSoft’s new parent company, IBA Health, has been keen to promote LabCentre across Europe and help create integrated laboratory services across multiple sites. iSoft said in a statement: “LabCentre currently runs some of the largest distributed, integrated laboratory services in Europe. It improves efficiency while ensuring that organisations adhere to the strictest safety and quality standards.” The system enables a wide range of processes to be automated including results validation, queue allocation, cascade requesting, report formatting, and electronic results notification.

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product profile

LightSpeed Volume Computed Tomography XT from GE Healthcare  The first-ever computed tomography (CT) scanner volume CT system capable of capturing Images of the heart and coronary arteries in just five heartbeats.  Earlier and more definitive diagnosis at very less radiation.  Innovative Volume CT XT system maintains outstanding image quality while reducing a patient’s radiation exposure by up to 83% percent for diagnostic cardiac scans.  An entire body scan can be completed in less than 6 seconds - something patients prefer who otherwise have claustrophobia. LightSpeed VCT XT has two new technology: The Snap Shot PulseTM technique which:  Allows for quick switching of the X-ray Exposure  Synchronized Table movement  Determination of scan location  Accurate and high precision synchronization of X-ray with respect to ECG

 It uses prospectively triggered axial step and shoot scans in which x-rays are turned on only during the required heart phase and turned off completely at all other time.  Radiation exposure typically can be reduced to the range of 2.8 mSv – i.e. 83% less dose than that of retrospective gated acquisitions with ECG controlled mA modulation.  Snapshot Pulse is an adaptable technology where the timing of the scanning is determined by calculating the length and the variability of previous cardiac cycle by monitoring the ECG from the patient. GE’s VolumeShuttle™ a technology that  Addresses the need for wide anatomical coverage (80mm) with up to 24% less radiation exposure compared to a conventional 40 mm cine perfusion protocol.  This single injection acquisition generates clinically comparable perfusion maps and angiographic studies and allows clinicians to see more anatomy and enables whole organ anatomical and physiological assessment.

Defigard 400 Multi-pulse Biphasic Defibrillator from Schiller India

 India’s first indigenously manufactured Multi-pulse Biphasic Defibrillator  Lower tissue damage to the patient’s heart and facilitates faster recovery  Large 6.4” colour TFT screen  Suitable for Adult and paediatric application  Multi-pulse Biowave Technology for external defibrillation. Selectable from 1 to 180J.  Visual instructions and simple 3 steps operation  3 channel memory

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Trends :  24 hours ECG  Last 11 shocks data saved  Trim Knob and direct function keys for Print, Mute and freeze  Digital out for ECG data to Central Monitoring Station  Intergrated thermal printer with auto and manual modes (optional)

Hansa Soneji Product Specialist Schiller Healthcare India Pvt. Ltd. D.C. Silk Mills Compound, Kondivitta Lane Andheri East Mumbai - 400 059 Phone: 022 6692 0520

Glucocard 01 the latest Blood Glucose Meter from Arkray Piramal Medical Pvt Ltd.

 Superior Accuracy and Precision to patients with diabetes  A unique and Patented combination of a Ruthenium based mediator and thin film carbon coated electrodes which makes the strips free from temperature and humidity interference thus ensuring accurate and precise results  Automatic calibration – There is no need to manually calibrate the instrument before using (as in other BG meters available in India). The calibration code is embedded in each individual strip and the meter get automatically calibrated once the strip is inserted. This ensures that there is no chance of manual error and the reading is accurate.  Temperature Compensation Mechanism – Each Glucocard 01 has an in-built thermostat, which recognises the atmospheric temperature and makes a correction in the meter software so as to give a “temperature corrected measurement result”  Dual Packaging – each Glucocard 01 bottle comes in a dual package of a laminated aluminium foil enclosed within a cardboard carton. This ensures minimum interference from humidity and temperature

August 2008

 Enhanced shelf-life – Once the bottle of strips is opened, the strips can be safely used for up to 6 months (unlike other strips which have to be used within 3 months of opening)  Under dosing detection – Glucocard 01 has in-built mechanisms to detect for under dosing (less sample application). Hence in the event of less sample application, the instrument will not perform the test and not give erroneous readings.  Tiniest sample size – The sample required for testing with Glucocard 01 is just 0.3 micro litres. This ensures a virtually error-free and pain-free testing experience for the patient.

Arkray Piramal Medical Pvt. Ltd. Nicholas Piramal Tower, G.K. Marg, Lower Parel, Mumbai 400013 India Tel: 022 – 3204 3204

eClinician: Clinical Decision Support System (CDSS) from CoreSys Infotech Clinical Decision Support Systems (CDSS) are relatively new to India though they have been in use by Doctors in the West for more than a decade. CDSS systems are difficult to create considering their complex database requirements. While clinic or hospital management applications can be created with the right efforts in a few months, a functional CDSS require years to create with a quality database and supporting information. CoreSys Infotech has put in continuous efforts for over 8 years to create eClinician, their latest CDSS. Their first edition has over 2000 users spread over 6 countries and has clear leadership in the Indian market. The company has fulltime doctors continuously working with their team of 26 specialists in developing and upgrading the database. eClinician has modules which provide Doctors with disease information as well as decision making support. The database is created at the General Practitioner (GP) level, which comes in handy for any specialist for cross-reference as well. The new eClinician comes with an Electronic Medical Record, which replaces paper records in Clinics. CDSS module An easy to use, symptom-to-diagnosis model, which is pending a patent approval, is the key highlight of eClinician. You can choose the patientâ&#x20AC;&#x2122;s symptoms from the comprehensive list of clinical presentations and the system will give you a probable diagnosis with amazing accuracy. Even the uncommon conditions are not missed by the system. The system highlights a range of probabilities in clinical diagnosis and hence the number of patient visits to reach a diagnosis can be reduced considerably. 4568 disease information is provided in summarised, bullet points for quick reference in nine standard headings, namely, basics, clinical presentations, clinical examinations, etiology, difficult diagnosis, lab, treatment, medications and prognosis. If you have to refer the causes of a disease, you need to choose that disease from the list and view Etiology. The data is very easy to access and in most user-friendly format. While the busy schedule of doctors does not permit them with the time to refer to hundreds of pages in textbooks, this system is a ready-made solution to keep updated. The company offers online updates, which will keep the database in line with new developments. ICD 10 for 2000 diseases has been included in the system. In the lab investigations module, 1300 lab tests explained and their normal values are given in SI units and Conventional units. In the drug interactions section all the generic drugs are listed with their interactions, contraindications and precautions. HIV and AIDS module is a comprehensive manual with treatment guidelines and drug interactions. The guidelines are based on WHO and NACO recommendations. 60

EMR module This module enables outpatient management in clinics. Has patient registration module, history taking, general and system examinations, lab, prescription, billing and administrative sections. CDSS potential in Rural India In challenging rural environments Doctors work with minimum lab and diagnostic facilities. It is also not practical for them to get specialistâ&#x20AC;&#x2122;s advice at the right time. The CDSS system can be used for a second opinion as well as for reaching diagnosis in difficult cases. Both patients and doctors will benefit in the process.

CDSS to Tele Triage CoreSys is in the process of developing a Tele Triage system as a logical extension to their CDSS. The triage systems can be used in rural India for telephonic medical recommendations to patients. The goal of the system is to filter and give directions to patients on whether they need home care, need to visit a doctor with an appointment or need to rush to an emergency room. Our system will address specific Indian scenarios and conditions from both the patient end and the advisor end.

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www.healthcareexpansion.com 13th - 14th OCTOBER 2008, DUBAI

3rd Annual

Improving Healthcare Access, Cost and Delivery naseba is proud to present MENA Healtcare Excellence Awards 2008

Under the High Patronage of the Ministry of Health of UAE

Case Studies Presented by the Key Industry Experts Dr. Fahad Bin Saleh Al OriďŹ , Al OriďŹ , MD, FAAP, FACEP, ABP, Director, Health Outreach Services Director, eHealth Center, King Faisal Specialist Hospital & Research Center - Riyadh Chris Lewis, Senior Director, International Hospital of Bahrain Dr. Khurshid Khowaja, Director Nursing Services, Aga Khan University Hospital Pakistan Dr. Ahmed Mohd Alsaidi, Head of the medical Division & deputy director General, The Royal Hospital Oman

Gold Sponsor

Bronze Sponsors

Paul Kingsmore, Director Health Facilities Scotland, National Healthcare Services Scotland N. Nallasivam, Medical Director, Medcare Hospital UAE

3rd annual Global Healthc are E xpansion Congress is the leading upper level executive congress in the Middle East Healthcare industry

Naseem Javed, President, ABC Namebank

Over 200 Decision Makers from healthcare industry from all around Middle East will Explore and discuss new trends and techniques of their industry.

Ahmad Nasrallah, COO, Dar Al Shifa Hospital Kuwait

Interactive panel discussions and Conference agenda

Judith D. Mitchell, AIA/Director of Planning, Harvard Medical International, USA

Silver Sponsors

Keynote Sponsor

Solution Provider

Pre scheduled C-level Business Meetings Exclusive Networking Functions

Media Partners

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For further information, please contact: elena bykova, event producer. tel: +971 4 367 1376 - fax: +971 4 367 2764 - elenab@naseba.com Disclaimer: This document is a promotional event release and is not contractual.

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Open and Inclusive Marketing Plan After analysing the market trend for the first two years, CoreSys has decided to involve Doctors and Professionals in marketing the eClinician system. So they have come up with an Independent Business Associate (IBA) concept. Anyone with a laptop computer can sign up as an IBA and start selling

the products and earn handsome returns. The IBA concept has attracted a large number of Doctors who are looking to earn extra income by spending a few hours a week to promote CDSS. The company provides training and support product promotion. CoreSys plans to have an IBA in every town in India by end of the year.

Cortex (Online Hospital Management System) from CoreSys Infotech The Web is taking over traditional applications in most industries. This trend is going to reflect in Hospital Management as well. The connectivity speeds are increasing and more and more users are going online in India. An effective Web-based system shall be ideal for small and medium size hospitals. CoreSys Infotech has launched Cortex - a web based Hospital Management System, which can function online as well as within an intranet environment. Cortex has all the modules required for a multi specialty hospital like Patient appoint-

ments, Registration, Billing, Insurance, Pharmacy, IP, Operation Theater, Lab, Imaging, Canteen, Inventory, Purchase, HR, Payroll, Accounts and Finance. The system maybe integrated with a website and the patients can take appointment, view results etc. online. Cortex is functional on any Internet browser and is free of platforms. So investment in hardware and software for hospitals can be minimised while opting for Cortex. CoreSys also offers an integrated solution of Hospital Management with a comprehensive College Management System for automation of medical colleges.

SAPPHIRE™ Release 5 Laboratory Information Management Suite (LIMS) from LabVantage  Zero footprint and configurable off-the-shelf (COTS) LIMS  New reagents and standards management module that consolidates functionality typically found in multiple full-featured management, maintenance, and tracking laboratory systems. of laboratory consumables.  It can tailor point specific or enterprise wide solutions to  Comprehensive Reporting and Analytics-Driven Decision Support: address each organisation’s unique needs.  SAPPHIRE Dashboards - powerful business manage Ubiquitous Global Deployment-Multi-nationalisation ment tool provides an “at a glance” view of definable (M18N) compliance for data translation, time zones, regional settings, and date formatting coupled with Unicode key performance indicators (KPIs). support enables seamless multi-site and multi-language  SAPPHIRE Ad-hoc Query Tool - real-time “in-applicadeployment and collaboration. tion” data mining and analysis without the need for  Enhanced User Experience - Leveraging a true zero footSQL programming. print thin-client architecture, SAPPHIRE R5 lowers cost  SAPPHIRE Reporting - seamlessly embedded, on-deof ownership by providing secure enterprise-wide access mand reporting and data visualization tools.  SAPPHIRE Advanced Reporting – robust information with no plug-ins, downloads, or applets on the client. and performance management tools powered by BusiSAPPHIRE R5 includes greater out-of-the-box configuness Objects™. ration options with over 600 pre-configured SAPPHIRE  SAPPHIRE Analytics - built-in visual charting for contemplates ready to deploy and/or modify. Additional setrol charts and trend charts. curity options, calculations, and business rules provide  SAPPHIRE Advanced Analytics - full-featured SPC improved security and knowledge management based on charting and statistics powered by Northwest Analytia user’s role and/or department. cal®.  Expanded Functionality - Across the board enhancements  SAPPHIRE Operational Intelligence – real-time, workof the SAPPHIRE R5 suite of modules including, stability and shelf life analyses, advanced storage and logistics flow-driven, multi-source data integration, visualiza(ASL), BioBanking, and the SAPPHIRE SAP EnterpriseCtion, and analytics powered by InforSense™. onnector. Also available are the:  Multi-optional application server and standards-based ser Recently released Corrective Action & Preventive Acvices - expansive support for industry-leading application tion (CAPA) module - monitors quality control and servers including: IBM WebSphere®, BEA WebLogic® assurance for maintaining compliance with standards and Sybase® EA Server. Expanded support for standardsand regulatory guidelines based Web services methods for ease of integration with external applications.

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ZOOM IN

Emerging trends in Electronic Data Capture Integration of EDC with eSource from EHR systems at sites Increasingly clinical trials are coming under the regulatory lense because of lack of necessary accounting of the patient and drug effects information. The following article takes a look at the new trends in electronic data capture that help track the data better.

he adoption of electronic medical records (EMRs) in both hospitals and private practice is on a steady incline. Alongside the growth in EMR, Electronic Data Capture (EDC) systems are today used in an estimated 3035% of clinical trials, again in both hospitals and private practices. The use of electronic data capture technologies provides the opportunity to significantly enhance clinical trial conduct through improved efficiency and accuracy, as well as the potential for real-time response to possible adverse situations. The data captured in clinical trial systems may be based upon a prior electronic source (eSource), such as EMR. Unfortunately, many of the EMR systems that manage the electronic source today cannot be used reliably for clinical research purposes because of the variability among these systems and the fact that they are not required to meet regulatory requirements for clinical trials. Therefore the data that are in the EMR system have to be printed or hand-transcribed and re-entered into the EDC system. The duplication of tasks, generation of paper and associated costs and inefficiencies, will only grow with the increasing use of electronic data sources. With the transformation in healthcare data collection migrating from a paper world to an EDC one, the scenario begs the question, â&#x20AC;&#x153;How can EDC integrate with these systems at sites and avoid redundant data collection?â&#x20AC;? The eClinical Forum (www.eclinicalforum.com) and PhRMA EDC/eSource taskforce is very active in formulating standards around integrating aspects of clinical trial data with healthcare data. This article has reference to many of the survey work and visionary publications of these groups.

Callum Bir Director, Life Sciences Global Industry Business Unit ORACLE Corporation Asia Pacific & Japan August 2008

 Information that is first recorded on paper by the investigator’s staff or the patient, is subsequently entered into a computer at the investigator’s site, and is delivered electronically to the sponsor or sponsor’s representative such as a Clinical Research Organisation (CRO), without a hand-written case report form. The computerised system into which the site enters the clinical trial data is generally provided and maintained by the sponsor or a third-party vendor.  Clinical laboratory data that are transmitted to the sponsor electronically and batch-loaded into the sponsor’s database (includes other electronic data such as device data).  Patient data that are directly captured by instrumentation.  Electronic patient reported outcome (ePRO) i.e., information that is entered by the patient directly into an electronic device, such as personal digital assistant (PDA), or directly into a web-based system.  Information that is entered by the investigator’s staff directly into a computer, without first writing the data on paper (i.e., electronic source (eSource) data) and which must then be backfilled to the patient’s permanent record (paper or EMR) in order to satisfy regulatory obligations. The use of electronic data capture (EDC) by the bio-pharmaceutical industry to conduct prospective clinical trials on new drug candidates is growing as bio-pharmaceutical companies face increasing pressure to bring new, innovative products to market faster and in a more cost-conscious manner than ever before. At the same time, increasing concern over product safety has resulted in the need for more and longer trials, causing costs and time-to-market to increase. The use of EDC is seen as a way to improve data quality and drive efficiency in the clinical research process. eSource background The capture of patient data into electronic systems, initially used for patient care purposes, is an emerging concept and has great potential to be a source of data for clinical trials, enabling automated transfer. Today, the terms Electronic Health Record (EHR), Electronic Medical Record (EMR), Electronic Patient Record (EPR), Clinical Patient Record (CPR) and Lifetime Clinical Record (LCR) are all used by various individuals and organisations, at times to mean the same thing and at other times to mean different things. In the remainder of this article, the term Electronic Health Record (EHR) will mean eSource data captured in a format that enables structured electronic transfer to clinical research systems. Using this definition, other eSource data, such as the electronic patient reported outcomes (ePRO) and central laboratory data are not considered parts of EHR data, as these data are not captured within the EHR initially, although they could be integrated with it subsequently. 64

The vision: EHR/EDC integrated system The existing “transitional” or “emerging” environment of EHR and EDC systems both being used in an investigator’s office may at times seem like a step backward. For various reasons, the records are entered and maintained in up to three or four different places. Healthcare practices often involve a process in which the provider hand-writes information on a patient chart, which is then later entered into the EHR system. This same information may be printed off the EHR system and transcribed for entry into the EDC system. At the end of the study, regulations require that the data in the EDC system remain with the investigator, necessitating printing or copying it to a CD for inclusion with the patient’s medical information. Collaboration between these two worlds may work as follows:  Pharmaceutical company designs and deploys study at the site using a clinical data management/electronic data capture solution (possibly provided by the vendor). This solution would have an in-built module that employs standard interface definitions developed by a standards committee within bio-pharmaceutical community and healthcare industries. Using which, the clinical module can be recognised by any certified electronic health record (EHR) system being used by the investigator sites.  The investigator staff will have access to each patient’s entire history, regardless of where the care was given. This would include any third party diagnostic parameters (such as lab tests, x-ray results etc.). The staff will record all information pertinent to the patient visits. Additional information and screens (related to clinical trials) will be displayed to prompt the staff to collect the same and to assist with scheduling and patient visit reminders.  The clinical trial patient data will physically reside in both the EHR system and the sponsor’s analysis database. But only the EHR system’s clinical data module will be considered the source, and it must stay in a validated state Source: eClinical Forum’s report on EHR as eSource for clinical research.

EDC background EDC is a technique for collecting clinical trial data in such a way that they are delivered to the sponsor in electronic form instead of paper. This includes the following scenarios:

Figure 1: Illustrates the flow of data between EHR, EDC and other systems.

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under the control of the investigator. Security features surround this module so that it is in compliance with all regulations pertaining to clinical data.  At the end of the study, data from this module will be archived in a standard format (perhaps XML or PDF) such that it can be easily read by the investigator and/or an auditor in the future, using standard tools, if need be. Why it’s necessary to merge these worlds EDC provides acknowledged benefits over paper Case Report Form (CRF) data capture. Since a significant portion of the clinical data (e.g., medical history, medical procedures, prescribed medications, vital signs) needed for the trial will already be available in an electronic form through the EHR, the introduction of the clinical research processes in EHR systems and processes will extend and accelerate the existing benefits of EDC into an increasing number of clinical trials and an increasing number of hospitals and healthcare clinics. Clinical trials available to more physicians Additionally, more physicians could become involved in clinical research barring one major hurdle to participation, which would be eliminated if, clinical data capture were to be straightforward and readily available for those facilities that have adopted EHR systems that include EHR/EDC technology. Avoid duplicate tasks Duplicate tasks increase cost of clinical research and thus increase costs for marketed medications. Significant benefits can be accrued through collaboration of both the healthcare and research worlds by effectively and efficiently sharing data. Without such collaboration, and as the use of EHRs grows, both the healthcare sector and bio-pharmaceutical companies will be obliged to spend valuable resources on duplicate tasks, increasing the overall cost of clinical research and its product. Benefits to patients All patients whose healthcare provider participates in a nationwide EHR system will reap benefits of that system facilitating clinical research. These benefits are:  Potential to address underserved populations through clinical trial recruitment and participation.  Greater possibility of being identified for a clinical trial because their physician will have better ability to search his/her patient population for inclusion criteria.  New therapies get to market and reach patients faster due to more efficient clinical research process.  Higher data quality leads to better safety. Benefits to investigator staff  Patient recruitment – EHR records can be searched for patients satisfying inclusion/exclusion criteria. The assumption is that EHR systems will have the capability to define criteria for selection of patients (e.g., disease, severity, medications taken, medical history, and specific vital signs such as blood pressure). August 2008

 The time required to check-in a patient and complete the medical record will be significantly reduced.  Data entry will be simplified and more efficient due to a one-time data entry into the EHR system (instead of multiple entries, as it happens today) and improved record retrieval  Direct transfer of validated data to research systems will be simplified and more efficient due to a common validated interface.  Information storage will be more efficient as data will be stored electronically saving on space requirements currently needed for paper trials and/or multiple trial/sponsor hardware.  Serious adverse event (SAE) reporting and management may be simplified and improved, as SAEs and associated relevant information, maintained within the EHR would be sent to the sponsor. The sponsor would have the capability to obtain information pertinent to the outcome and causality of the SAE by having real time ongoing access specific to the SAE enabling them to prepare a comprehensive narrative.  Regulations and controls surrounding clinical data capture can improve overall quality of all data managed by the EHR system.  Potential to perform more trials with the same level of inhouse resource due to efficiency in trial management.  Investigators will access their data through the use of a single and familiar EHR rather than through different sponsor/vendor developed front-ends, reducing training and ongoing support issues.  Incresed efficiency in presentation of patients’ entire medical history, including data from clinical trial participation.  Standards will enable data collection and integration to be more consistent and investigators will have a common understanding with regard to data definitions and format when dealing with multiple sponsors. Benefits to Regulatory authorities  With a nationwide network, regulatory authorities could have the capability to review and audit sites’ electronic source data against the data provided by the sponsor, thus reducing need for actual site visits by auditors while giving more transparency to the authorities.  Refocus workload – the reduction of paperwork will allow for auditors to focus more on areas.  Facilitated audit trail – standard audit trail information for review with a submission. Benefits to Sponsor / Bio-pharmaceutical Industry  With the ability to compare safety data from a clinical trial to a much larger baseline (i.e. all EHR patients), there is a potential for improved analysis and projection of long-term safety. This can be accomplished through the sponsor’s ability to do large retrospective trials to identify potential safety issues or review post-market product use, via access to information on patients who are using these products. Such retrospective trials would need to be in compliance with patient privacy regulations. New regula65

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tions may be required to address how aggregate data can be accessed and by whom. Better access to target patient populations. Ease of study execution: - Utilisation of standardised EHR/EDC components. - As data transferred to research is a transaction copy of the source data; no source data verification (SDV) will be required and queries will be reduced. Eliminates redundant computer systems and overhead: Application and hardware support, helpdesk, and training will be reduced. Archiving requirements will be significantly reduced: - More of the Trial Master File will be electronic. - Sites will already hold research data (as source); therefore, preparation of an archive copy for retention at the site may not be required. Pharmacy and patient records will be integrated within the EHR environment allowing drug accountability to be performed electronically via electronic access to dispensing and usage, monitoring of supplies, automated ordering, etc.; Randomisation to treatment will be handled external to the EHR. Transcription errors are reduced or eliminated. EHR/EDC will lead to improved efficiencies with regard to saving time and can contribute to reduced costs in clinical trial execution. This will be achieved through elimination of redundant processes. Collect data in a format that lends itself to integration for submission Potential to reference data, required supporting the clinical research, maintained and stored on the EHR rather than duplicating it in the sponsor’s database (e.g., medical history, prior medication and procedures). Data necessary to prove efficacy and safety would still exist within the sponsor’s submission datasets as well as the EHR. Potential investigator list is expanded to include any physician with a certified EHR/EDC system.

Conclusion: Impact on Data Management What do you need to do as a Data Manager/CRA/Programmer/QA personal to prepare for the future of data management? Educate and involve! You need to educate yourself on what is going on in the industry by attending conferences, webinars and other training sessions to learn about what is changing and developing. Look outside of the usual data management box to see the other potential influences on the profession. Following is an analysis about potential change / impact on the current clinical research roles and responsibilities that may evolve because of EHR/EDC integration: 1. Roles and responsibilities in all areas will evolve:  Clinical Research Associate (CRA): The traditional work of the CRA will change into more of a site relationship management role. The EHR/EDC system removes the need for much of the CRA’s time to be spent checking and managing paper CRFs, allowing time on-site to be spent more effectively providing protocol and safety 66

training, ensuring GCP compliance, etc. More complex interrogation of the EHR may allow the detection of omitted information such as non-compliance with exclusion criteria, non-reporting of prohibited concomitant medications, etc.  Data Manager: This role changes to be far more site oriented, as data managers become the link between the data and the site staff communicating primarily via the EHR/EDC system. Preparation of ongoing reports for safety and review purposes and programming of extraction algorithms may move this toward a more technical role. New tasks might involve transferring research data back to EHR (e.g., laboratory data). In addition, Data Managers will have more involvement in protocol development as data definitions will need to be built into the protocol to assist ethics committees/Institutional Review Board (IRB) in reviewing data collection requirements and to enable the development trial-specific EHR modules.  Information Technology (IT) Support Personnel: IT staff will need to be more aware of the total process of clinical trials from eSource through submissions. They will need to be more involved in defining the study protocol, as it will additionally need to specify electronic methods of data collection and identify electronic source.  Quality Assurance: QA must audit EHR/EDC systems to ensure appropriate controls exist, such that investigators can be accountable for the integrity of the data (eSource) they provide. 2. The informed consent process will change. This will include all that are involved in the process (e.g., sponsor, site, patients and IRB/ethics committees):  Data is moving to patient ownership. The informed consent documentation will need to be adapted to collect patient approval for clinical trial participation.  Informed consent can be given electronically. 3. Some cost may be shifted due to a shift in some responsibilities for activities such as data hosting, on-site validation (data/system), trial module development/ configuration. 4. Review of data for fraud will change: • Fraudulent data will likely be reduced (never eliminated), as sponsors will be able to monitor the timeliness of the data entry and any changes. • Since the EHR is usually accessible to many medical and nursing staff, it is less vulnerable to fraudulent changes by an individual. • The sponsor will look for data trends, in order to detect fraud. One must now realise that it is time to re-establish the value proposition for data management / EDC within one’s organization; Data Managers today can choose to take an active role, or to let the change happen to them in time. Making the right data management decisions today will help clarify goals, reduce stress, focus energies, simplify decisions and prepare for success. Forward-thinking Data Managers will continue to be invaluable contributors in the growth and success of clinical research by being ready for the next generation of Electronic Data Capture! www.ehealthonline.org

EV NN T ORLEOP G OYR TT R E N D S T E CE H

Innovating in Surgical Imaging Dr. Shivaji Basu, Chief Urologist, Wockhardt Hospital & Kidney Institute in an interview with eHEALTH speaks about innovative solutions for Surgical Imaging.

Q. How do you see technology advancing in Operation Theatres (OT), the core competency area of a speciality hospital? A. Advancement in the OT infrastructure in terms of structure, such as edgeless OT rooms, pendant systems, OT tables / OT light and surgical equipment have definitely improved the efficacy of the procedures and provided the best opportunity to apply surgical skills. Minimal access surgeries (MAS) and endoscopy diagnostic procedures have revolutionised the operating procedure that uses various endoscopes for different body parts. MAS involves lower risk in terms of blood loss and infection and drastically reduces complications in post-surgical recovery/ medication. As the procedures are getting more sophisticated, need to document the procedural details is naturally perceived strongly. Imaging has emerged as a core part of procedure documentation in the recent past. The subsequent sections explain its benefit to service seekers as well as providers and other stakeholders. Q. How do you see Information Technology in particular, utilised in the Operation Theatres? A. In a Super speciality Healthcare facility like Wockhardt Kidney Hospital and Urology Centre, we stress upon the best surgical practices and institutionalisation of optimal treatment protocols. Many of the Pre-OP details such as preparations, kits and material, and intra-OP events, are documented in the HIS system; the documentation of actual surgery has always been a challenge. Our experience over

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the past few years is worth sharing in terms of how imaging has revolutionised the procedural documentation. We have digitally recorded 7000 Urological procedures over the last 3 years for 3 Urology OTs and the data is archived centrally in the imaging server. When we were looking out for an appropriate solution for OT imaging a few years ago, we realised that the conventional approach, better known as PACS, was not suitable for our need. We therefore decided to implement 21st Century Advanced Imaging System in 2005. Endoscopy, C-arm, Lithotripter and other modalities are not covered in the scope of DICOM services. DICOM services predominantly focus on radiology imaging needs and workflows. They also cover Cardiology, Nuclear Medicine and Radiation therapy equipment in detail, however, imaging and movies of the surgery is an entirely different type of data.

TUR prostate - documentation of end point

Q. But most of the PACS systems do capture non-DICOM data using video grabbers and subsequently make it DICOM-ready to be a part of PACS. A. You have raised a valid point. Almost all PACS vendors claim this. But it is done in such a way that it ‘fits in’ the conventional PACS for storage. It only adds DICOM overheads without providing any specific advantage to the users, such as a surgeon like me.

C arm imaging - documentation of pathology

For example, the most important thing for surgical recording is a movie clip. Most of the PACS workstations do not have the capability to handle movie compression, editing and other basic processing. So we work around this to store this data, which is known as ‘secondary captured’ images. Q. Wockhardt Kolkata is one of the first institutions in the country to implement such a solution. Can you please tell us how it has benefited the institution? A. The first thing that comes to my mind is that the entire surgical recording is available to us today and we do not miss out on any case. It has generated a huge data bank for us for research. We regularly index the data and prepare presentations for conferences and CME initiatives.

Endoscopic view of prostate - a document

We have participated in many conferences so far, and over last two years, the time taken to prepare a presentation from scratch is reduced from 5 days to 3 hours, purely because of efficient archival and retrieval. We often have to speak for a short time and it is necessary that we have a movie clip precisely demonstrating the clinical aspects! Earlier we needed help from a graphics expert and it would be a nightmarish experience to adjust time for the activity. Now we are self-sufficient and our users can do everything that was outsourced earlier and in a fraction of the time it took before. Laparoscopic removal of donor kidney August 2008

We have a discharge summary module integrated with imaging and it has been a standard norm to educate the patient through intra-OP images. We decided to allocate a separate terminal for preparing daily discharge summaries connecting to Advanced Imaging server. Patients are becoming more and more aware and appreciate this additional information about themselves. We also use images for actively counseling the patients during pre-procedure and postoperative sessions. Diseases like Bladder Tumour, which needs repeated endoscopic monitoring is a good example. Patients keep a copy of the details of the tumour on a CD with the final analysis of the treatment. This CD is updated every time the patient has a checkup. We can get hold of some very similar cases and discuss risk factors and success stories openly with the patients. Medical jargon is always a hurdle in communicating to the patient, in which case images speak for themselves and are a very effective counseling tool. But in my opinion the biggest advantage is that we have introduced best clinical practices with self-evaluation and reviews. Whenever necessary, we review the data on-line or retrospectively. We realised that the turn-around time of the OT can be improved by identifying bottlenecks during the review. We could also review the procedures within the team and always learn a few new things.

“OTs are the hub of excellence and knowledge centres for the hospital. ICT benefits must reach surgeons. Imaging will play a key role in the efficiency and outcomes of surgical processes and the documentation of critical data from the OT’s will also leverage accreditations. Adapting to digital culture in OT’s has always been a challenge, but our team in Kolkata has demonstrated that IT cannot remain isolated from OT’s any more. OT imaging is a part of Patient Health Records in a broader sense and our goal is to implement full-fledged PHR next.” Vishal Bali CEO, Wockhardt Hospitals

Another very interesting byproduct is the computer motivation amongst the OT staff and the technician. Almost everybody now is computer savvy or at least taking enough interest in computer education. To conclude I would say that OT imaging is the last bastion and all we need to conquer this to change mindsets and adopt digitisation completely. The benefits are too many to be ignored. Picture archival and communication traditionally was considered only for Radiology. Cardiology and Nuclear medicine extended the horizon. Clinical or summary image distribution systems took the benefit to clinicians. Surgical imaging is a late entrant to ICT integration. Partly because of the sterile environment which gives very little flexibility for access and usage. Partly because of the mindsets of the OT users, and partly the need for innovations from imaging solution providers. This unique solution by 21st Century Health at Wockhardt Hospital & Kidney Institute, Kolkata would not have been possible but for Dr. Shivaji Basu and his team of surgeons’ enthusiasm and conviction about ICT and their invaluable contribution in terms of user feedback for enhancing our first-of-its-kind OT imaging system. The wholehearted support to the initiative by the top management was also key to its success.

“I am confident that with positive attitude of clinical users and foresight of management, innovative solutions can get implemented successfully in India. We hope more and more hospitals take a message home. We at 21st Century are confident that our innovative solutions in advanced imaging will completely change the perspective about traditional PACS and we will see more and more innovative products emerging from India.” Aniruddha Nene Principal Consultant Imaging and Director, 21st Century Health Management Solutions

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IN FOCUS

Intelligence for Public Health Established in 1961, Central Bureau of Health Intelligence (CBHI) is the National Nodal Institute of the Directorate General of Health Services (Dte.GHS), Ministry of Health and Family Welfare (MoHFW), Government of India. Its objectives include providing ready information on the National Health Profile of India, as well as undertaking need-based operational research besides various capacity building & trained manpower development programs in the country. Dr. Ashok Kumar MD, Deputy Director General & Director, CBHI, shares with eHEALTH the role of this body and its current activities.

Prof. Diana Schmidt School of Medical Informatics IT Faculty of Heilbronn University and Medical Faculty of Heidelberg University

Q. What are the roles and responsibilities of the Central Bureau of Health Intelligence (CBHI) in supporting national health programs of the Ministry of Health and Family Welfare (MoHFW)? A. Based on the recommendations of various high level Committees, the MoHFW / GoI established the Central Bureau August 2008

of Health Intelligence (CBHI) in 1961 under the Dte.GHS, to serve as the National Nodal Institution for Health Intelligence in the country. This premier organisation efficiently functions with the broad objectives of maintaining and disseminating the National Health Profile of India (NHP), the Health Sector Policy Reform Options Database (HS-PROD), 71

and the Inventory (and GIS mapping) of government health infrastructure in India. It facilitates capacity building and human resource development and undertakes need-based operational research for efficient Health Information System (HIS) and Family of International Classification (ICD-10, ICF & ICHI). Besides discharging its national responsibilities, CBHI accomplishes its international role as the designate WHO Collaborating Centre on Family of International Classifications (FIC) for the South East Asia Region. The CBHI is well organised and equipped with modern infrastructure and is headed by a Deputy Director General as its Director and has four divisions at its headquarters viz. Policy and Infrastructure (P&I), Training, Research and Collaboration (TR&C), Information and Evaluation (I&E) and Administration. Each headed by a Joint Director and also supported by Deputy / Assistant Directors as well as statistical and ministerial staff. The six health information Field Survey Units (FSUs) of CBHI are located in regional offices of the Ministry of Health and Family Welfare / GOI at Bangalore, Bhopal, Bhubaneswar, Jaipur, Lucknow and Patna. All these six FSUs along with Regional Health Statistics Training Centre (RHSTC) of CBHI at Mohali (Punjab) and two Medical Record Department and Training Centers (MRDT&C) at Safdarjung Hospital, New Delhi and JIPMER Puducherry, conduct well designed CBHI in-service national training programs for eligible candidates sponsored by various states and Union Territories. These trained manpower development programs of CBHI include certificate courses for Medical Record Officers (MRO) and Technicians (MRT), Orientation Training Courses on Health Statistics for Non-medical Personnel and Medical Officers, as well as Orientation Training Courses on ICD10 for Non-medical Personnel and National Workshops of State Coordinators for Training on Morbidity and Mortality Coding using ICD-10. The CBHI functions in close linkages with many national and international organisations, such as National Health Programs, all 19 Regional Offices of Health and FW of GoI, all 35 States / UTs, the Planning Commission, the Census Commission and Registrar General of India, the Ministry of Statistics and Program Implementation, Medical / Nursing / Para-Medical Councils and Institutions, the Union Ministries of Railways, Defence, Labour, HRD, Rural Development etc., Public Health / Medical Care and Research Institutions (including ICMR) under government / non-government / private sectors, WHO and other UN agencies concerned with health and socio-economic development, etc. Q. How significant a role do you think information and communication technologies (ICTs) can play in improving access, delivery and management of public healthcare in India? What are the measures being considered by the government towards improving healthcare through ICTs? A. ICTs surely play a very significant role in (a) widely reaching the people even in the most peripheral and difficult terrain to effectively communicate and create health related awareness, attitude and behavior change, and (b) efficient 72

health information management for better health planning, programs implementation with improved access, efficient delivery, management and timely corrective measures to achieve their objectives. The National Rural Health Mission (NRHM) of the MoHFW / GoI aims to accomplish the national challenge of strengthening the health infrastructure, services outreach and utilising them to the fullest by the beneficiaries up to the most peripheral levels, while optimally utilising the available ICTs. The government of India through its dedicated Ministry of Information Technology has accorded a very high national priority for promoting and ensuring the best use of ICTs with mandatory allocation / utilisation of 3% of the allocated budgets on ICTs in each of the Ministries, including HFW. Quite a few good ICT based efforts have already been made by the MoHFW / GoI in this direction and include computerised and satellite based health information and surveillance systems (viz. IDSP) in the country, web based online health data inputs and reports generation, video-conference, reviews, training, education and telemedicine linking tertiary with secondary and peripheral hospitals. Considering the very large population base of our vast country with socio-cultural and geographic diversities and complexities, India is surely and successfully moving ahead with ICTs in spite of constraints and challenges. Nevertheless, the further strengthened, inter-sectoral co-ordination with determined public private partnership, as prioritised by GoI, warrants sustained commitments on part of all concerned with our countryâ&#x20AC;&#x2122;s development. Q. Kindly tell us more about the role of CBHI in the help-line project undertaken by National Population Stabilisation Fund/Jansankhya Sthirata Kosh (JSK). Are there other such collaborative efforts that are leveraging ICTs for public health and welfare? A. CBHI recently extended its technical expertise and support to JSK in designing and launching its helpline project, which I think is of great national importance. Through it, people can seek help and guidance about appropriate medical / health institution(s) and the facilities related to reproductive health. JSK will surely succeed in extending this project in the larger areas of our country, in the near future, wherein the CBHIâ&#x20AC;&#x2122;s inventory and GIS mapping of government health facilities with the help of NIC can further assist this community based project of JSK, utilising ICTs, etc. Some of our many other such collaborative efforts using ICT for public health and welfare include (a) electronic health information flow from the periphery upwards under primary healthcare delivery system in India, (b) road safety profile of India as prepared by CBHI / Dte.GHS in collaboration with various stakeholders in the country, (c) road traffic injury surveillance while linking more than 140 Trauma Centers being developed in the Dte.GHS / MoHFW, (d) the disaster management and related surveillance mechanism requiring multi-departmental collaboration and (e) recent launch of national program for prevention and management of diabetes and cardio-vascular diseases by the MoHFW. Another excellent example of collaborative efforts that are www.ehealthonline.org

Q. Currently, India lacks a robust national health information strategy. What measures can be adopted to overcome the lack of standardisation in the capture and usage of health-related data and improving accessibility of information across public and private stakeholders of the healthcare ecosystem? A. It may not be correct to say that India lacks a robust national health information strategy. Rather, our country is one of the few countries in the world which have a well-established primary healthcare delivery and health information system from most peripheral (sub centre/village) / primary health centre (PHC), community health center (CHC), district / state and national levels. However, the health information system by and large is paper based and the MoHFW had already launched the Integrated Disease Surveillance Project (IDSP) in the country, with weekly health information flow through computerised and satellite-based system from each district up to the national level. Efforts are in progress under NRHM to also computerise the HIS at PHC levels in due course. Considering the vastness of our country, large quantum of requisite health and related information and ICT advancements, MoHFW has further moved to standardise the health information system i.e. health indicators, information needs, recording and quick reporting mechanism for timely corrective measures under NRHM. The Public Health Standards of services at PHC, Community Health Centers (CHC) and District levels have been prepared and are in force to ensure the quality of health infrastructure and services in the country. Efforts are vigorously in progress for effective public-private partnership focusing on health information sharing as well as the delivery of healthcare services in the country.

all the 35 states and union territories in India to ensure steps towards the use of ICD 10 by all government and private medical institutions. The feedback indicates that most of the secondary and tertiary medical care institutions are using it with respect to the mortality as well as morbidity amongst inpatients and wherever hospital management system is being computerised, the ICD-10 codes are inbuilt. In order to address one of the major constraints for use of this standard, CBHI from the year 2005 has taken initiatives of conducting the short-term national orientation training course on ICD-10 wherein, the non-medical personnel handling the medical/health records, especially from district and lower hospitals, are oriented. CBHI has also developed the module and work book for such orientation training on it, which serves as self learning material for concerned medical, nursing, para-medical personnel and the same is shared free of cost with all the trainees as well. It is also available on the CBHI website (www.cbhidghs.nic.in) for wide viewing / downloading. In order to help the states/UTs to undertake such continued orientation training programs, CBHI has already conducted four national workshops for state coordinators for training on morbidity and mortality coding using ICD 10 and a team of three such officers per state from 30 states and UTs of India have already been oriented. Likewise, all the Government medical colleges and their governing councils, including nursing and para-medicals, have also been requested to ensure due emphasis on teaching the under- graduates / post graduate students on the use of ICD-10. Such measures, along with cooperation and support from all concerned will further facilitate better use of ICD 10 in our country. CBHI as designate WHO Collaborating Centre on Family of International Classification (ICD 10, ICF and ICHI) will continue further steps in this direction, while soliciting the support from all concerned.

Q. In 2006, CBHI recommended that all government and private medical institutions in India should use ICD-10 in their records and reports. How far has this been implemented as of today? What are the constraints faced in the implementation of ICD 10? A.The International Statistical Classification of Diseases and related Health problems, 10th version (ICD-10) is the international standard prescribed by World Health Organisation. All member countries need to adopt and implement this classification so that the morbidity and mortality databases are comparable within the various region / states of the country and between countries of region / world. Such reliable information is essential for meaningful conclusion on the health status of the population and for planning the development of facilities for medical and healthcare and their efficient functioning. ICD-10 coding was introduced by WHO in the year 1993 and India adopted the same in the year 2000. India is to move along with other countries of the world. CBHIâ&#x20AC;&#x2122;s continuing efforts have definitely promoted the use of this standard in the country. CBHI / Dte. General of Health Services had recommended to the medical and health authorities of

Q. Please tell us about HS-PROD, developed in collaboration with the European Commission. Is HS-PROD limited to archiving Indian best practices and innovations? How does it aid healthcare policy reforms? A. Though states and UTs of India have undertaken reforms in the health sector, a lot of this goes unnoticed and is hence not documented. Thus, MoHFW under its Sector Investment Program (SIP) funded by the European Commission, entrusted CBHI to develop and maintain HS-PROD. It is a web-enabled database that documents and further creates a platform for sharing the information on good practices and innovations in health services management in India while also highlighting their failures, which are very important for the success of NRHM. These initiatives have been taken from a varied range of fields and stakeholders like the state and UT governments, development partners and non-government organisations, and categorised under 16 major management subject areas. CBHI solicits information on such reforms from State/UT governments, health program managers, researchers, teachers, and institutions in order to regularly update this national database (www.hsprodindia.nic.in).

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Only of child deliveries in rural India are institutional.

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