Redefining Public Health: December 2009 Issue

Narayana Nethralaya Pilots Telemedicine on iPhone

Carestream Launches New Tabletop Laser Imager

A Monthly Magazine on Healthcare ICTs, Technologies & Applications Vo l u m e 4 | Issue 12 | DECEMBER 2009 | INR 75 / USD 10 | ISSN 0973-8959

Rapid Deployment of TrakCare Yields Immediate Beneﬁts for United Family Hospitals and Clinics in China InterSystems Corporation PAGE 32

Connectivity Keeping a service focus through Mobile Point of Care Technologies Ashok Chandavarkar, Healthcare Industry Manager – Digital Health Group, Intel PAGE 34

Technology Policy

Accessibility Affordability

Capacity

The New Face of Radiology Divya Chawla, Principal Correspondent, eHealth PAGE 40

Device Innovations for Ophthalmic Surgery Dr. Amarpreet Sawhney, President and CEO, I-Therapeutix PAGE 46

Challenges in Current Medico-Legal Environment in India D. Samuel Abraham, Legal Ofﬁcer, Directorate, CMC Hospital, Vellore PAGE 48

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Redefining Public Health

Select case studies of technology application in public health, drawn from eHealth Asia 2009, 2-4 December, 2009, Colombo, Sri Lanka

CONTENTS w w w . e h e a l t h o n l i n e . o r g | volume 4 | issue 12 | December 2009

Dr. SMS – a novel mobile-Health Application

ISSN 0973-8959

Rathan U Kelkar, Director, Kerala State IT Mission &

Sabarish. K, Kerala State IT Mission

Effective e-Transformation Strategy for Implementation of e-Clinics in Sri Lanka

Tamilnadu Health Systems Project - successful implementation of HMIS across government hospitals Dr. S. Vijayakumar, Project Director, Tamil Nadu Health Systems Project & Special Secretary, Department of

Dr. Keith R.P. Chapman Consultant General Surgeon, District General Hospital Chilaw, Sri Lanka & Dr. Shiromi M.K.D. Arunatileka Senior Lecturer, University of Colombo School of Computing, Sri Lanka

Health and Family Welfare, Government of Tamil Nadu & Dr.P.K.Amarnath Babu, Project Coordinator, Health Management Information Systems,Tamil Nadu Health Systems Project

Saving children through teleconsultation in remote Egypt

GIS-enabled Disease Surveillance Architecture for National Disease Notification System

CASE STUDY: Rapid Deployment of TrakCare Yields Immediate Benefits for United Family Hospitals and Clinics in China

Sherif El Tokali, Poverty Reduction, MDGs & Private Sector Team Leader, UNDP- Egypt; Ada Fishta, ICT Specialist, UNDP- Egypt; Alexandra Gil, UN University Volunteer Khaled Shams, World Health Organization, Eastern Mediterranean Regional Office

Roshan Hewapathirana, Post Graduate Institute of Medicine, University of Colombo, Sri Lanka & Gamini Wijayarathna, Department of Industrial Management, Faculty of Science, University of Kelaniya, Sri Lanka

InterSystems Corporation

APPLICATION: Importance of Clinical Decision Support Software in Clinical Practice

TECH TRENDS: The New Face of Radiology

EXPERT CORNER: Device Innovations for Ophthalmic Surgery

ZOOM IN: Challenges in Current Medico-Legal Environment in India

EVENT REPORT: CII Medical Technology Conference 09, IIHMR Health Conclave 09

NEWS

Dr. Vijayabhaskar Reddy Kandula Physician, St Mark’s Hospital Salt Lake City, Utah. USA & Dr. Sanjay Deodhar Consultant, National Rural Health Mission, Ministry of Health, Govt. of India

Divya Chawla. Principal Correspondent, eHEALTH

Dr. Amarpreet Sawhney, President and CEO, I-Therapeutix, Inc.

D. Samuel Abraham, Legal Officer, Directorate, CMC Hospital, Vellore

December 2009

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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 well-researched 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 intelligence on all aspects of IT applications in the healthcare sector. Contributions to eHealth magazine could be in the form of articles, case studies, book reviews, event report and news related to e-Health projects and initiatives, which are of immense value for practitioners, professionals, corporate and academicians. We would like the contributors to follow the guidelines outlined below, while submitting their material for publication: ARTICLES/ CASE STUDIES should not exceed 2500 words. For book reviews and event reports, the word limit is 800. AN ABSTRACT of the article/case study not exceeding 200 words should be submitted along with the article/case study. ALL ARTICLES/ CASE STUDIES should provide proper references. Authors should give in writing stating that the work is new and has not been published in any

form so far. BOOK REVIEWS should include details of the book like the title, name of the author(s), publisher, year of publication, price and number of pages and also have the cover photograph of the book in JPEG/TIFF (resolution 300 dpi). Book reviews of books on e-Health related themes, published from year 2002 onwards, are preferable. In the case of website, provide the URL. THE MANUSCRIPTS should be typed in a standard printable font (Times New Roman 12 font size, titles in bold) and submitted either through mail or post. RELEVANT FIGURES of adequate quality (300 dpi) should be submitted in JPEG/ TIFF format. A BRIEF BIO-DATA and passport size photograph(s) of the author(s) must be enclosed. All contributions are subject to approval by the publisher.

Please send in your papers/articles/comments to: The Editor, eHealth, G-4, Sector 39, NOIDA (UP) 201 301, India. tel: +91 120 2502180-85, fax: +91 120 2500060, email: info@ehealthonline.org, www.ehealthonline.org

December 2009

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EDITORIAL Volume 4 | Issue 12 | December 2009

PRES IDENT

Dr. M P Narayanan EDITOR-IN-CHI EF

‘Technnovation’ in Healthcare

Dr. Ravi Gupta PRODUC T MANAGER

Dipanjan Banerjee mobile: +91-9968251626 email: dipanjan@ehealthonline.org PRINC IPAL C ORRESPONDENT

Divya Chawla email: divya@ehealthonline.org S ALES & MARKETI NG

Arpan Dasgupta Executive Officer - Business Development mobile: +91-9911960753, +91-9818644022 email: arpan@ehealthonline.org Bharat Kumar Jaiswal Sr. Executive - Business Development mobile: +91-9971047550 email: bharat@ehealthonline.org S R GRAPHIC DESI GNER

Bishwajeet Kumar Singh GRAPH IC DESI GNER

Om Prakash Thakur

eASIA 2009, the fourth annual event on information and communication technologies for development is being held this year during 2-4 December 2009 in Sri Lanka. Jointly organised by Centre for Science Media and Development (CSDMS) and Elets Technomedia from India, and ICT Agency (ICTA) of Sri Lanka, the event is a collaborative effort to fuel knowledge-centric growth by re-enforcing technology, capitalising market economy and boosting human development. As Sri Lanka celebrates ‘the year of ICT and English’ under the patronage of H.E. Mahinda Rajapaksa, President of Democratic Socialist Republic of Sri Lanka, the event will help in ICT proliferation across multiple sectors and growth of the industry in Sri Lanka vis-a-vis Asia. Through the ‘Special Focus’ section of this issue, we bring you abridged version of some select papers received in the eHealth track of this event. The papers illustrate some notable initiatives and ideas in innovative technology application for public health transformation in India, Sri Lanka and Egypt. The emergence of mobile point-of-care solutions have marked the beginning of a new era in patient care, offering improved workflow with help of mobile computing devices, mobilized applications and wireless networks. This issue includes an interesting article on the latest point-of-care technologies and its varied benefits in terms of clinical workflow, quality, cost, as well as staff and patient satisfaction.

WEB

Zia Salahuddin S UBS C RIPTIONS & CI RCU LATI ON

Lipika Dutta (+91- 9871481708) subscription@elets.in

EDITORIAL C ORRESPONDENCE

eHEALTH G-4 Sector 39, NOIDA 201301, India tel: +91-120-2502180-85 fax: +91-120-2500060

While m-Health is the latest buzz in healthcare arena, health informatics has been and is going to be a key enabler of top-of-the-class healthcare services. A very interesting case study in this issue touches upon the extremely advantageous deployment of IT applications in a complex healthcare setting in China. It is hard to ignore the rapid technological advancement in the health ICT arena and through this issue of eHEALTH we bring to you the latest in this industry. Hope you find it informative!

email: info@ehealthonline.org does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. is published by Elets Technomedia PVt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS). Owner, Publisher, Printer - Ravi Gupta. Printed at Vinayak Print Media, D - 320, Sector - 10, Noida, UPs, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP Editor: Dr. Ravi Gupta

Dr. Ravi Gupta Ravi.Gupta@ehealthonline.org

December 2009

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- SELECT PAPERS

Redefining Public Health Select case studies of technology application in public health drawn from eHealth Asia 2009, 2-4 December, 2009, Colombo, Sri Lanka

eHEALTH Asia 2009, part of the fourth annual Asian ICT conference and exhibition – ‘eASIA 2009’, is being held this year between 2-4 December, 2009 in the Sri Lankan capital city of Colombo. At present, most countries across the world are grappling with surmounting healthcare challenges born out of unprecedented population pressure, strained economic resources and increasing disease burden. IT and telecommunications are offering new vistas of opportunity to overcome, and even surpass many of these hurdles. To most of our oblivion, many individuals and organisations have indeed taken up the task of exploiting the latent potential of technology to redefine the process, practice and efficiency with which healthcare is traditionally addressed and delivered. Interestingly, the span of such initiatives pervade across private, government, academic and developmental sectors. While, alike previous years, a substantial number of people expressed their intent to share such initiatives in this year’s eHEALTH Asia conference, limiting conditions of physical, financial and time factors involved in organising an event does prevail – thus restricting us from being able to accommodate everyone. Herein, we bring you an abridged compilation of some select

papers from this conference .

All articles in this section are edited and abridged version of their full papers submitted for eHealth Asia 2009 conference. Papers published herein do not indicate in any sense superiority over others. Order of articles in the magazine is purely random and do not indicate any ranking or preferential sequence.

December 2009

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Dr. SMS – a Novel MobileHealth Application Dr. SMS is a novel project of the Kerala State IT Mission - the technology implementation wing of the Government of Kerala in India, launched on 29th May 2008 with the aim to increase access of health care services by common people through simple and innovative use of mobile telephony.

Rathan U Kelkar Director Kerala State IT Mission

Co-Author Sabarish K Kerala State IT Mission

Project Rationale: The State of Kerala is recognised the world over for its notable achievements in the field of health. With low per capita incomes, Kerala has managed to achieve health indicators that are at par with advanced countries. Kerala’s mortality indicators including death rate, infant mortality rate (IMR) and expectation of life at birth has got it a positive berth in the health status ranking across states of India as well as advanced countries.

This rosy picture can be quite misleading for outsiders who are not quite aware of the extent of health problems faced by Kerala. The glowing achievements in Kerala’s mortality indicators notwithstanding, all does not seem too well with the health sector here. There have been growing concerns about the rising morbidity levels in the State, led chiefly by the increasing incidence of lifestyle related diseases like diabetes, hypertension, heart diseases and cancer. Kerala also has seen a re-emergence of infectious diseases like leptospirosis, malaria coupled with increasing reports on diseases like Chikungunya and Dengue. The State also has the highest road accident rate in India. For lifestyle-induced conditions like heart attacks, timely care is very essential to prevent further complications and even mortality. Known widely as the “golden hour”, it refers to the first hour of a heart attack. Getting medical help during this period greatly improves chances of recovery. The “golden hour” is equally pertinent in trauma care, which also mandates rapid medical intervention to improve chances of survival. It is in this backdrop that the project Dr. SMS was conceived to facilitate quick information delivery on the nearest medical service centre. Kerala was also prompted to launch this m-Health project as

it ranks as one of the leading States in India on mobile penetration. According to Telecom Regulatory Authority of India, in March 2008, Kerala has a tele-density of over 72 per cent as against the national teledensity of 32 per cent.

Project Objectives: The project aims at improving health of the citizens of Kerala by: • Improving access to health care resources by making available authentic information on the same. • Providing timely information on medical and diagnostic facilities • Providing informational alerts about emerging diseases.

Project Details: The main idea behind this project has been to enable people to use their mobile phones to receive information on health resources. The project aims at providing users with a comprehensive list of medical facilities available in a particular locality including hospitals with infrastructure and expertise in various medical specialties (cardiology, gynaecology etc), specialised doctors in the locality, all through the simple facility of the short service message (SMS). Since a SMS is used to gain information on medical services, the project has been named ‘Dr. SMS’.

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The project was piloted in Kozhikode (Calicut) in the district of Kozhikode in Kerala. The choice of Kozhikode was based on the fact that it is the third largest city in Kerala with a population of approximately 20 lakhs. Kozhikode was also chosen for the project piloting because it has the highest rates of mobile penetration in the State. Kozhikode also attracts a huge migrant population/tourists, who are also one of the main targets of this project. The pilot project met with overwhelming success. The service was especially lapped by the large numbers of tourist population who did not know whom to contact in case of a medical emergency. During the pilot phase, an average of 200 daily transactions took place through the Dr. SMS facility. To avail the facility all that the user has to do is send an SMS to a pre-designated number. Given below are some of the formats of inputs (SMS by the citizen) and outputs (SMS from Dr. SMS) in this platform: • Input - Health<space><Pincod e><space><facility> - Example - Health 673004 heart Output - <Hospital Name> <Address> <Phone> - Example - Baby Memorial Hospital, Indira Gandhi Road, Calicut,Tel:04952723270, Fax:495723484 Input • Health<space><Hospital Name> - Example - Health BABY Output - Hospital phone No> <Major Facilities> - Example Tel: 04952723270, Heart, eye, Child, skin Facilities available Input - Health<space><Hosp • italName><space><facility> – Example - Health BABY eye Output - <Hospital phone No> <Facility Status> - Example Tel: 04952723270, Eye Facility Available The Dr SMS project operates at different levels and can be availed across various media. A message is sent with one’s pin-code and email ID generates an automatic system e-mail reply to specified ID. The project also incorporates a

December 2009

health portal and can be accessed at www.drsms.kerala.gov.in. This portal provides a Web-based information mechanism enabled via the Geographical Information System (GIS)-based details on various health-related attributes. The health centres can be easily located through the portal. The latitudes and longitudes of the health facility centres are also stored in the database. This GIS is regularly supplied with data and helps in providing an interactive map of the health facilities available across the city, how to reach those hospitals listed there. There are facilities available in the portal which can be accessed through the mobile and to fix the location the user is located in the map, or the same can be automatically fixed, if the user is having a GPS enabled mobile phone, this feature allows the user to search medical facility available within a selcted radius (5 Kms, 10 Kms, X Kms etc.). And will display in the map the routes. The project has a credible and sound database on hospitals and emergency health centres drawn from a large data from the Health Infrastructure Survey, conducted by the National Commission on Macro economics and Health (NCMH), Ministry of Health and Family Welfare, Government of India. The system is supported by the National Informatics Centre and the State Information Technology Department. Encouraged by the success of the pilot project, the Government announced the launch of the project in all districts of Kerala. The project was launched State-wide launch by the Hon’ble Minister for Health and Family Welfare on 20th July 2009. The facility is now fully operational with the database of details of about 8 out of 14 the districts of the state and the rest of the district data will be appended to the database soon As part of the State-wide implementation, centralized facility for Dr. SMS has been established at Government owned secure state of the art tier 3 State Data Center, Trivandrum and a ‘Long Code’ for

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the State (9495949000) has been established, and this facility is accessible to subscriber base of all the mobile service providers in the State and even from any operator in India, ‘pan India reach.

Project Achievements: •

The major achievement of the project is its enshrined ability to deliver health related information to the citizens, including location hospitals, medical centres, facilities and doctors in a time-sensitive manner. • The project is noted for its cost affordability and effectiveness. To send the message, the customer has to pay a nominal amount of 40 paise or less. The cost of the return SMS is borne by the Government of Kerala. • The service has come to be seen as a first aid kit for any health emergency for the large number of tourists who are on the move in the town and are not aware of the whereabouts of the place. • The project has helped hospital authorities prepare the emergency room as per the requirements as well as to mobilise the resources like specialist doctors and specialised equipment to take care of the emergency. The State-wide launch of • the project in a little more than a year of the launch of the pilot project speaks of its achievements. To conclude, by leveraging the other segments of mHealth, like improving ability to diagnose and track diseases, providing timelier, more actionable public health information and expanding access to ongoing medical education and training for health workers , the project can influence people to manage their health better and provide complete continuity of care. Concentration on such aspects will lead to improved focus on the new roles of providers and patients and pave the way for participatory health management in Kerala.

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e-Transformation Strategy for Implementation of e-Clinics In Sri Lanka, to overcome this problem of accessibility to specialized healthcare, a patient centric eHealth initiative – ‘Vidusuwa’ was carried out by conducting eConsultations and eClinics to help the patients in remote locations to meet consultants based in cities making available specialized healthcare to many. Significance of Transformation

Dr. Keith R.P. Chapman , Consultant General and Laparoscopic Surgeon at the District General Hospital, Chilaw, North Western Province, Sri Lanka

Dr. Shiromi M.K.D. Arunatileka Senior Lecturer, University of Colombo School of Computing, Sri Lanka

December 2009

Strategic

eHealth

One of the main objectives of the Sri Lankan healthcare system is to improve health services delivery & health actions. In compliance with the health policy of Sri Lanka, the main emphasis of Vidusuwa is on setting up of eConsultation centers and eClinics to link the specialist in a general hospital in a city with a patient in a peripheral setting. The Vidusuwa process starts in a non-complicated environment which is easy to use by the patients, doctors and other healthcare workers. Therefore, the concept as well as the product is fundamentally based on the following principals • Keep the technology simple/local • Build on existing technology used by all • Involve users to feel ownership • Use a participatory approach to introduce ICT • Use a strategy that is relatively resilient in the face of developingworld conditions. • Strengthen ICT infrastructure and create a conducive environment to develop healthcare • Interoperability, flexibility and adaptability should be key enabling features. The main eHealth deployment areas identified were electronic health records, patient identifiers, health portals for informing patients and professionals on health issues and disease prevention, citizen card activities and telemedicine. With regard

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to electronic health records, there is substantial variability in development priorities between countries. The main emphasis of Vidusuwa is on setting up of an eConsultation Clinic to link the specialist in a general hospital in a city with a patient in a peripheral setting. This will consist of a peripheral eClinic, a web-based EMR, m-Communication system (Vatsalan et al, 2009) and an e-Consultation centre with a medical specialist. Sri Lanka has a total teledensity (fixed and cellular phones) of 78.6% by the end of the 2nd quarter of 2009 which is high as compared with other developing countries (TRC, 2009). In order to extend the usage of eClinics across the country using existing infrastructure, a proper strategy of deployment need to be adopted. The eTransformation process needs careful attention as it is essential to get the support of patients, healthcare professionals, healthcare institutions, health-related businesses, governments, international donor agencies, private and public sector ICT and telecom service providers who are the main stakeholders (ICT and Health Vision 2025).

Seven E’s in eTransformation The 7Es in eTransformation is a methodology that has been developed to strategically and successfully transform Small and Medium Enterprises (SMEs) in the business sector. It has been tried and tested in the manufacturing sector with success (Arunatileka & Ginige, 2003b). However, in this paper, the 7E

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Model has been adopted for public sector transformation. This will be the first time the model is applied for eHealth transformation. The paper explains the suitability of the 7E Model and how it will be modified to eTransform the health sector. The following description briefly explains the 7E Model (Figure 1) and how it is modified to effectively eTransform the health sector.

Stage 1: Environmental Analysis The environmental analysis takes in to consideration, the global as well as the local environment with regard to the healthcare institution. The strategy would be to ‘Think Globally and Act Locally’. The characteristics studied under four main areas are - Global trends in eHealth, National State of Affairs, Institutional situation and Patient related aspects. Under Global eHealth trends, the main activities are identifying specific successes, failures, and lessons learned from existing applications and technologies and studying eHealth policies, frameworks, new technologies, practices related to developed and developing countries.

tribution (areas as well as numbers), demographics, disease spectrum, Cost and difficulties, pre-assessment surveys, privacy and legal issues, cultural and ethnic peculiarities as well as language issues.

Stage 2: eHealth Goals and Strategies Using the information gathered in the first stage, eHealth goals and strategies are developed for the healthcare institution. This will decide which eClinics are needed by the health care provider in the periphery and which peripheral units need to be linked. At this stage it is very important to follow an evolutionary and participatory approach of healthcare providers to transform and decide on strategies. There are four main strategies to decide, such as - Single Specialty Point to point locations; Single specialty to multiple peripheral locations; Multiple specialties to Single peripheral location; Highly Specialized clinic (centre of excellence) – peripheral institution or eClinic location (Eg. Neuro surgical clinic, endocrinology clinic); International consultancy link- Global eClinics; Expandability and innovation – linking ITU net, Hospital net, epidemiology unit or poison information centre etc.

Stage 3: eReadiness

Figure 1: Adapted from The 7E Model for eTransformation (Arunatileka & Ginige, 2003a).

National eHealth policies and initiatives are analyzed as it is important to understand the government instigated health initiatives and policies as well as eHealth initiatives to have an idea about how to develop strategies to facilitate deployment of eClinics across the country. Studying the institutional environment is of utmost importance for the development of specific strategies for each healthcare provider. The information related to the patients who attending the healthcare institution are studied in terms of Patient population & dis-

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Infrastructure development for an eHealth process will require key enablers like interoperability, secure ID controls and common platforms for data exchange such as open source. Professor Herbert Kubicek and Ralph Cimander (2009) present a useful model that suggests that each of these dimensions of interoperability must be addressed from three perspectives simultaneously – (i) politically, to negotiate among institutional actors (ii) functionally, to align data, information and workflows effectively (iii) and as a service to govern and regulate directories, formats, and message routing. Government should put effort into inclusion, building trust in the new technologies and the promotion of, at least, basic IT skills. eReadiness of hospitals as well as patients should

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be ensured to identify major barriers and issues related to change management. eReadiness of Institutions is measured through following parameters - Infrastructure (Hardware & Software); Connectivity (ADSL, DSL, Broadband, VPN); Funding (Government, Private sector, NGO etc); Support of Senior management (Regional heads, Ministry level, Influential personalities, Hospital administrators, Consultants, Doctors, etc.); Identifying champions for the cause within institutions; IT literacy and IT Training needs of the healthcare provider. eReadiness of patients is measured through parameters such as - economic status and concerns; psychological preparedness to participate in an eClinic; disease peculiarities that may have an impact on the clinic; psychological and physical disabilities that may have an influence on the clinic.

Stage 4: The eTeleconsultation Roadmap The current position identified by the eReadiness stage is mapped in the eTransformation roadmap to develop a specific step-by-step path to proceed with the transformation process. It is important to note that there is an internal process as well as an external process of transformation to achieve the ideal state of convergence (Figure 2). Points to point clinics are easier to establish as a starting point to sense the local IT environment and introduce users to the eClinic system. A micro analysis and feedback can be arranged to overcome connectivity problems and technicalities. During this time efforts should be made to improve the confidence of staff in using the system, workout maneuvers to shorten the actual consultancy times, improve familiarity of staff with the EMR. This is the stage where champions in the cause can influence their peers to conduct clinics in other specialties. This will lead to multiple specialties being linked to a single peripheral hospital. Administrators can encourage other hospitals in their region to embark on eClinics if a specific need exists by

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sharing the successes of the system with counterparts. Finally single specialties can be joined to multiple peripheral eClinics and also multiple specialties to multiple eClinics. This would happen when the regional awareness and the need for eClinics reaches its optimum. Key players such as service providers, health officials, specialists, health media personnel and key enablers are deployed to the maximum. When multiple hospitals are communicating with each other using the eClinic systems a platform is created for effective integration of data networks between these institutions and their support services like labs and radiology departments. Thus a peripheral eClinic can be linked to a Peripheral eConsultation clinic, to a Central eClinic or to a Highly Specialized eConsultation Centre. It would also be possible in the future to establish links with global eConsultation Centres across borders. Patient smart cards using digital signatures and access ID can enable health information and patient data to be securely transferred to relevant institutions around the world to deliver quality healthcare to a given patient.

Stage 5: The Methodology

eTransformation

In order to eTransform an organisation in an iterative manner, a step-bystep approach is used in modeling, re-engineering, implementing and

training on business processes. The Evolutionary eTransformation methodology is used for this stage as the iterative technique. It has been proven beyond doubt that the most successful projects always had the secret of integrating people, process and technology successfully. The following illustration (Figure 4) shows the importance of the integration between the 3 aspects as well as when it is linked with other processes. Performance attributes such as technical feasibility, diagnostic accuracy, sensitivity, specificity, clinical outcome, and cost effectiveness have to be taken into consideration when setting up a telemedicine project. In setting up of eClinics in Sri Lanka during the pilot project, concerns were expressed regarding technical aspects of the consultation itself. Past experience in limited telemedicine projects had problems with connectivity line efficiency, lighting illusions making difficult accurate diagnoses, delay in uploading data and some hassle in transferring of data to health officials via e-mails. But promising data emerged from these studies showing a seventy five percent accuracy rate in diagnoses (when a TMVC camera was used) and a twelve percent inaccuracy of diagnoses (Oakley et al 1997). However, the study (Oakley et al., 1997) concluded that TMVC could be used with a reasonable degree of accuracy. An asynchronous

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software application can provide levels of diagnostic accuracy and concordance equivalent to those reported using live teleconsultation. The concordance between the inperson and teleconsultant diagnoses was in agreement 77% of the time (90% if differential diagnoses were included). The ViduSuwa project was able to overcome most of these barriers by paying attention to the room environment that eClinics are conducted in, using pretested webcams which could give clear images of the patient, using dedicated broadband connection, uploading digital images of lesions captured with a 10 megapixel camera and incorporating these into to the ViduSuwa EMR prior to starting the actual eConsultation. This allows more time for the specialist to communicate with the patient.

Stage 6: eSystems This stage deals with three main components in the post implementation stage which are management controls, Security measures and IT Management & support. The main activities in this stage involves development of IT policies, standards, guidelines to users, user manuals, support and maintenance procedures for the new systems, ensuring security measures to deal with sabotage, hacking and privacy, assuring support and maintenance for ICT infrastructure, upgrading, backing up etc. A contingency plan and a disaster recovery plan also need to be in place for sustainability of the project. Health standards apply as in industry models but with some peculiarities specific to healthcare. The Vidusuwa EMR meets the standard requirement of patient notes or medical record with all aspects represented in a concise way but maintaining simplicity of use and a user friendly interface. As time is of utmost importance in running an eClinic the number of clicks necessary and the number of windows or folders to be opened are kept at a minimum. Doctors and other staff adhere to procedures

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and practices carried out at normal clinics. Availability of a disclaimer and a ViduSuwa user manual guide users on the proper usage of the system effectively. At every step of developing the ViduSuwa EMR, security and non loyal user abuse and access have been looked into and possible safeguards added to ensure patient data protection. Data backup is done at the moment by service providers. The authors propose to use local backup facilities to be totally independent in management. The EMR is constantly being upgraded to improve features as well as expand the system making it a dynamic and flexible entity according to the evolutionary approach. Many issues have been looked into with regard to access rights, the role of each user category (consultants, hospital administrators, junior doctors, nurses etc.), hierarchy in the healthcare setup and administrative procedures related to the system itself.

Stage 7: Evolution – Change Management This is the most important stage that runs across all other stages managing the changes in an evolutionary manner. The methodology is needed in change management of health sector initiatives still in its infancy in the developing world as well as some developed countries. The seven main aspects to be addressed at this stage are the changes in Structure, Systems, Style, Strategies, Shared values, Staff & Skills as described by McKensey’s 7S (Waterman, 1980). Understanding the healthcare system as a whole and its rural infrastructure was crucial to identifying and deploying eClinics in Sri lanka. Healthcare institutions in Sri Lanka have their own peculiarities with regard to patient management chain and arranging follow up care. These issues need to be addressed when locating eClinics. Strategic marketing of the concept has to be done carefully as many key players have their own sensitivities and concerns. A participatory approach helped to overcome skepticism

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unfounded fears among healthcare staff. Setting up the ViduSuwa eClinic system was challenging as participants from many sectors were contributing their expertise and interacting to meet requirements across different specialties. Therefore, a common ground had to be found to integrate technical capabilities, IT infrastructure development and healthcare needs of the patient. The real problem, as experienced in the above study and applicable to Vidusuwa is to integrate electronic flows between pre-existing obsolete proprietary systems and to entice clinicians to use technology for their daily activities (e.g. medical reports issuing, referral notes etc;). What are the effects of this mode of healthcare delivery on the doctor-patient relationship? Examining patient perceptions would help to address the reasons why patients liked or disliked a service and help healthcare providers to better understand patients’ subjective definitions of acceptability and utility. Cadre training in basic IT related applications, attitude changing brainstorming sessions and dedicated healthcare workers and administrators can contribute to overcome obstacles in eTransformation. In the process of change management, Governments should put efforts into inclusion, building trust in the new technologies and the promotion of, at least, basic

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eSkills. “Key enablers are the glue that binds eGovernment together” (European Commission, 2007). Therefore, the experiences between different stakeholders, whether from the public or the private sector, and members of research centres and academia should be encouraged in order to enhance collaboration and better cooperation for interoperability (Archmann & Iglesias, 2009)

Conclusion Telehealth’s successful implementation in communities and in links to remote providers, as well as its acceptance by patients and families, depends to a very large extent on the commitment and capacity of individual people in the community to make it happen, in service to the community. The Vidusuwa approach has a firm foundation as all its key players have one common shared value – well being of the patient. This evolutionary approach using the 7E model for eHealth transformation takes into consideration cultural and other factors specific to a country to systematically and successfully eTransform the Health sector. This ensures sustainable and quality healthcare to all citizens making a patient-centric approach more acceptable to quality healthcare in Sri Lanka as well as in other developing countries.

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Tamil Nadu Health Systems Project Successful Implementation of HMIS across Government Hospitals The article illustrates implementation of a centralised web-based health management information system for all government-run secondary care hospitals and medical colleges under Tamil Nadu Health Systems Project. The broad objective of the project is to use ICT in improving the ability to collect, store and analyze accurate health data across the state. The project was conceptualized to provide critical health data across the health chain for quick and timely intervention by health directorates. Scope of the Project:

Dr. S. Vijayakumar Project Director, Tamil Nadu Health Systems Project Special Secretary, Department of Health and Family Welfare, Government of Tamil Nadu

Dr.P.K.Amarnath Babu Project Coordinator Health Management Information Systems Tamil Nadu Health Systems Project

The HMIS project comprehensively covers the key functionalities and processes within the hospitals as well as provides for an online reporting system for all health information. 1. The services covered for hospitals as part of the HMS comprise 10 modules including a. Registration, Lab services, Pharmacy, Stores, Wards, Blood Bank, Linen management, Diet, Biomedical waste management, Equipment Inventory and Clinical module covering patient Outpatient (OP) record, In patient (IP) record, Nurses notes, Operation notes, discharge summary, Ante Natal Records (ANC) record, Natal & Post Natal record , Family welfare services and Referral services. b. Online access is provided to all end users/primary data entry owners to input data directly into the online system with no data entry support. Patients receive printouts of the OP slip, lab results, and prescriptions. c. The services computerised include • Online registration of outpatients and inpatients • Doctors services for OP patients including diagnosis, prescriptions, and lab requests entered online (real time) • Reporting of the lab test results online

•

Online indents and issues (for drugs) • Online ward transfers, linen, diet and biomedical waste management related transactions • Online day end/ periodic reports generation saving significant time for end users in collation and consolidation of data. • Discharge Summary and the final disease diagnosis is mapped to International Classification of Diseases- 10 2. The HMIS comprises four modules, namely, Clinical, Ancillary, Programme Information and Administrative Information system. • The clinical module comprises OP, IP census and details of maternal, child health, immunization details, family welfare services and disease wise data of treatment and cases, etc. • The Programme information module covers the national and state level programmes like Blindness control, Malaria, TB, Infectious diseases, School Health, etc. • The Ancillary module includes reporting forms for blood bank services, laboratory services, Stores/Inventory details for drugs and other consumables, diet details and biomedical waste management. The Administrative information •

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system module contains Finance related forms for budget, etc.; and infrastructure related forms including buildings, equipment, vehicles, etc. This module also comprises establishment related forms for capture and reporting details of all the health department personnel including transfers, training, leave, etc. 3. The security module handles all the access and privileges to be given to end users for each application and reporting. 4. The Pilot was implemented in 5 secondary care hospitals during January 2009. After the successful implementation of the pilot the next Phase of implementation was carried out in 5 districts, which begun during May 2009. 5. The Project will be extended to cover the remaining 222 secondary care hospitals across 25 districts in the state, during Phase II implementation.

All the hospital records were being maintained manually, which meant more time consuming and even more time utilised for retrieving records Government was spending more funds towards procurement of manual registers which were difficult to maintain. Duplication of records in the sense, same patient was registered each time he/she visits the hospital and difficulty in maintenance of the old vital records of the patients. For analysis of health care data, reliability of the collected data was questionable. There were no snap shot/ dashboard view available to monitor the performance of the hospitals, prior to introduction of this system. Real time data transactions happening at the hospitals, were previously unavailable at the Institutional level, District level or the state level. Proper maintenance of Equipment Inventory, monitoring of

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Strategy Adopted to overcome the challenges: 1.

Scenario before implementing the project: 1.

Equipment downtime, Drug stocks auto indent, drug stock accountability and monitoring for the drug expiry dates were some of the challenges, that we have now overcome to a large extent. At the Institutional level, it was very difficult to map the In Patient Disease classification to the International Classification of Diseases (ICD)-10 that is recommended and followed worldwide.

The project has been conceptualized as a centralised web based software solution to minimize technology support and maintenance dependencies. The end users across various Institutions and Offices were called upon for finalizing the Software requirement specifications, so that the entire application was customized to suit the needs of each and every department. TNHSP wisely chose an Open Source software stack in order to prevent a vendor lock in state, in case the project needs to be up scaled. Extremely simple, user friendly screens designed by application provider to ensure end user ease of use and optimized for performance. Adequate training for the end users on HMS, at the Institutional level, to ensure the full participation and to increase the comfort level of the end users. The HMIS training were carried out at the ELCOT district training centers. Hassle free connectivity through Tamil Nadu State Wide Area Network (TNSWAN) , which is a 2 Mbps dedicated leased line terminating at each hospital level. Broadband Connectivity of 2 Mbps connectivity has also been setup at all hospitals as a redundant connection. We

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10.

11.

12.

13.

have also established Automatic switch over from TNSWAN to broadband and vise-a-versa during times when either one of them fails. A centralised web server which houses the entire database placed at a fully equipped Data center. TNHSP in coordination with Tamil Nadu Electricity Board has ensured that there are no power cuts during the Outpatient hours of the hospitals. We have also supplied UPS with 2 hours back up to all the hospitals in case of a power failure. TNHSP has requested the State Government to issue necessary orders to do away with the manual registers, so that all the hospital staff would eventually use HMS for all transactions. Continuous motivation of all the end users from the top level of the management and a daily review of the performance of the hospitals on HMS at the Directorate level ensured that the implementation was a success. Creation of a “Centralised Help Desk” to register calls/ clarify queries from end users regarding hardware/application related issues, which will also ensure coordination among various stake holders. TNHSP has posted an IT Technical coordinator at each district for the 5 districts to supervise, troubleshoot and handhold for the various issues occurring at the institutional level.

Innovations of this project: The project brought in institution level changes and provides for the following 1. Unique Patient Identification Number (PIN) 2. Unique Institution codes across all government hospitals and office 3. Unique employee numbers/ user names and passwords – for access to system 4. Re-use of drug codes (from other Central procurement agency) 5. Re- use of the treasury codes for

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Finance related information Uniform and standardized reporting formats across all institutions. 7. TNHSP has proposed to link the PIN to the UID that is to be developed by the Government of India. 8. The Lab tests results are being given to the patient with test report reference values 9. The final disease diagnosis is linked to International Disease Code- 10 10. Tamil Nadu Health Systems Project has requested the Government to issue orders for doing away with the manual registers and using the HMS for all transactions. After several iterations of requirements, uniformity and standardization of input formats were finalized and resulted in significant level of changes. Common uniform system of reporting will provide for ease of data comparison and performance monitoring across institutions. The rationalisation of some of the processes and report formats has also been done. The HMS application provides for removal of many manual processes including manual tokens for drugs, lab request slips, indent forms, etc. The day end consolidation of reports for drug issues, indents, daily census, etc. has been automated resulting in substantial saving of time for the end users. 6.

•

Sustainability of the Project: •

•

Scalability of this Project: •

•

A centralised web based solution on open source technologies designed based on factors like maintenance issues at hospital end (being situated in remote locations, lack of trained manpower at hospitals, cost of support, ease of deployment, training, etc. The servers and data storage architecture configured for ensuring scaling up with optimal additional investments only. This solution architecture has been designed for scaling up the application deployment/ access to large number of

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Institutions and to other Directorates like Medical Education and Primary Health. HMIS data entry formats fully standardized and provides for uniformity in reporting and data consolidation. Data input and collection in forms includes the data requirements for NRHM and other reporting needs at State and Central level. The Solution is highly replicable across other States in India and even other developing countries. HMIS forms easily customizable for reporting requirements. Hardware infrastructure (Desktops, LAN, UPS) fully with standardized specifications at all institutions help in quicker maintenance and troubleshooting. Existing State level infrastructure harnessed for the project with the use of the connectivity backbone set up in the State (TNSWAN) for the last mile connectivity to hospitals. Existing State Data Center facilities used to co-locate the Application and Data servers thereby creating a central repository of all health information.

•

The HMIS Solution architecture has been designed for scalability and long term sustainability. The centralised web based solution offers several advantages in terms of ease of maintenance, ease of changes incorporations, enhancements to formats, and ensuring data integrity and safety. As all data is managed centrally which ensures the availability of trained and skilled manpower at fully equipped Data Center All end users fully trained to directly use the online system for data entry. No data entry support and thereby no additional hiring of manpower envisaged. Identification of nodal teams at each hospital and at district level for training on troubleshooting and quick response mechanism

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•

for support at local level Built up the Connectivity redundancy and UPS power back up facilities at all locations as part of basic infrastructure set up. The use of State wide area network brings in additional security features of running on a secure communication link within the state. Centralised help desk set up to support end users – coordination and close follow up to ensure quick resolution of issues Applications fully scalable to meet the requirements of Tertiary care and Primary care Hospitals in the State.

Achievements of this Project: 36 hospitals across 5 districts are currently LIVE with the online system in a short period of 7 months. All respective end users are expected to use the system with no data entry support. All Registration, Stores, Pharmacy, Wards, Lab, Doctors’ Out Patient (OP) processes are fully online and no manual records are maintained. Real time data is available, 24/7 at these 36 hospitals. The doctors are making direct online entries for diagnosis, ordering lab tests and drug prescriptions. The HMIS reporting system covering Clinical, Program, Administrative including Finance, Personnel, Infrastructure modules provides, immediate online access to the Health Administrators at the Institutional level, District level and at the State Level on various critical data sets. After our successful implementation of HMIS in 5 districts, approvals have been sanctioned immediately to extend this project to 222 secondary care hospitals across the remaining 25 districts in the state. The 18 medical college hospitals across the state are also likely to be included during the Phase II implementation, which is expected to be rolled out in the beginning of 2010. It was awarded the “e -India 2009 award for category e- Health – Best Government initiative/policy for the year 2009” at the e- India event, held at Hyderabad during August 25-27, 2009.

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Saving Children Through TeleConsultation in Remote Egypt This paper illustrates an example of telemedicine applied in remote areas with limited resources through the presentation of a case-study of tele-consultation network in Siwa Oasis, one of the pristine desert environments in the world. Introduction

Sherif El Tokali ,Poverty Reduction, MDGs & Private Sector Team Leader, UNDP- Egypt

Ada Fishta ICT Specialist, UNDP- Egypt

Alexandra Gil UN University Volunteer

Khaled Shams World Health Organization, Eastern Mediterranean Regional Office

Egypt has made significant progress over the past 2 decades towards achieving the Millennium Development Goals (MDG), with particular regard to MDG 4 targeting child mortality, which have been declining significantly in the period 1990-2005. Notwithstanding the high drop percentage, in UNICEF “State of the World’s Children” Report, Egypt is ranked only 77th in terms of under 5 years old child mortality rate. Child mortality therefore remains a problem, which is primarily the effect of household economic status and availability of health services. Moreover, inequities in survival of children among different geographic areas remain a serious challenge as highlighted in Egypt Human Development Report (EHDR) 2008, which captures significant disparities among different geographic areas in under 5 years old child mortality rate. The use of Information Communication and Technologies (ICTs) in the delivery of medical care can play a critical role in achieving the ultimate goal of improving health in poor communities with limited resources. In particular, telemedicine can have a positive impact on the quality of health care provided in those remote areas with very limited access to advanced medical technologies. An example of telemedicine applied in a remote area with limited

resources will be illustrated in this paper through the presentation of the case study of tele-consultation network in Siwa Oasis, one of the last pristine desert environments in the world. Through this joint initiative, the Siwa main hospital has been connected to the Pediatric Department of the El Shatby Hospital in Alexandria. The intervention aims at improving children health care services through tele-consultation and continuous professional training of doctors by introducing e-learning techniques. The trial of this model, as reflected in the deployment and pilot tests of the project, confirms the benefits of ICT for health care provision and medical education.

Case of initiative:

Siwa

teleconsultation

The “Tele-consultation on Child Health” is a joint initiative which aims at reducing child morbidity and mortality in Siwa district, in Matrouh governorate, through teleconsultation and e-learning techniques. Siwa is an oasis that occupies a surface of approximately 1125 km2 and is situated in a remote location about 800 km from Cairo, 300 km southwest of the Mediterranean city of Mersa Matruh and 70 km east to the Libyan border. The population reaches 20,000 inhabitants living across Siwa town and several villages.

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Child health care remains one of the top priorities of the government in Egypt. The Government’s efforts in assigning a sufficient number of health care providers in the Frontiers Governorates have been crucial in improving health care in the District. Due to lack of experienced doctors and high-end treatment facilities in Siwa Hospital, difficult- to-diagnose and medically complex cases of children in Siwa are generally referred to Matrouh and/or Alexandria Hospital. The distance to these referral hospitals (more than 300 km) often causes additional health hazards and sometimes even death of patients during transit. This 1-year pilot project aims to use ehealth techniques to strengthen the capacities of h]ealth care providers and enhance knowledge acquisition and skills of medical students in Siwa Hospital. Despite being in early stage, the tele-consultation project is proving to be quite an effective tool. Regular communication conferences are being held, whereby physicians in Siwa prepare cases for which they require consultation from the pediatric department of Alexandria El Shatby Hospital. During the regular video conference, teaching staff often decide to hold specialized video conference with professors of different specialties. Health care personnel from Siwa Hospital are also participating on a biweekly basis in the scientific video conference meetings held in the pediatric department in Alexandria. An interactive mechanism is set for the teaching process and assessment of students from the Faculty of Medicine of Alexandria University. These sessions prepare students to deal with patients in real life situations. Whilst the continued medical education to the health care providers in Siwa Hospital, is implemented through e-learning packages, in form of lectures, thesis and researches on a specific station accessible to Siwa physicians or through allowing access of health care providers to the most updated medical journals from the library of Alexandria pediatric department.

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“The Siwa joint initiative is an effective partnership between MCIT (through Egypt ICT Trust Fund) support, UNDP development knowledge of the country, the technical capacity of The Child and Adolescent Health Unit (CAH) of WHO-EMRO, and the IT capability of private companies.” Effective partnership: Remarkable efforts of the Government of Egypt in ICT sector at the national level have had a dramatic effect on the diffusion of technology. The creation of an enabling policy environment is fostering technology use and is encouraging national and international investments in ICT infrastructure, development and a skilled workforce. At the implementation level of Siwa Joint Initiative, active support from the Ministry of Communication, Information and Technology (MCIT) and the Ministry of Health and Planning (MOHP) were provided. Apart from facilitating the whole implementation process, technical human resources and materials were also made available to the project. The private sector also played a significant role, since part of the funding came from the Corporate Social Responsibility (CSR) of private companies. Joining efforts with other

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stakeholders such as development agencies is crucial not only for the purpose of reducing investment costs, but also for minimizing the political risks that may exist in many developing countries. The Siwa joint initiative is an effective partnership between MCIT (through Egypt ICT Trust Fund) support, UNDP development knowledge of the country, the technical capacity of The Child and Adolescent Health Unit (CAH) of WHO-EMRO, and the IT capability of private companies.

Challenges: Lack of a legal framework: One of the main challenges of telemedicine in Egypt, is the gap in the legal framework. Telemedicine being a recent practice in the country, its development has created new legal challenges. At a global level, extensive discussions are being held concerning the risks and complex legal problems associated with telemedicine-based health care services. While developing an enabling legal framework, the Government of Egypt should foster a supportive, transparent, legal and regulatory framework that addresses the use of telemedicine in safeguarding the rights of patients. Issues concerning the privacy of identifiable health information, the reliability and quality of health data, as well as medical liability are to be considered while developing the legislative framework. Other areas that prompt concerns are the right of health professionals to exercise telemedicine, accreditation and authorization schemes to provide telemedicine services, and issues surrounding liability or recognition of professional qualifications. However, when defining the legal framework, policy makers should ensure that telemedicine does not in any way reduce the quality of the health care services provided to the public. Lack of professional development and educational opportunities: Health care personnel in remote areas are not exposed to opportunities

SPECIAL FOCUS: of professional development and training. The project seeks to provide continuous education to local medical staff through video conferencing. Moreover, efforts are being made to promote the education and training component and increase confidence and trust in telemedicine as an effective tool for education. Currently, a proposal from the Dean of the Faculty of Medicine of Alexandria University is being evaluated for encouraging doctors from Alexandria with economic incentives to carry out 10â&#x20AC;&#x201C; 20 hours/week of teleconsultation. On the other hand, hours spent on teleconsultation from Siwa doctors will form part of the traineeship required by the Master Program organized by Alexandria University. Sustainability: The sustainability of telemedicine services is a multidimensional matter that should consider technical, financial and human resources aspects. When planning the technical sustainability, easy-to-use software that require

minimum training skills and hardware that are durable and of low maintenance should be considered. The financial sustainability remains one of the most challenging aspects of telemedicine. In addition, pilot projects used for demonstrating the cost-effectiveness and benefits of telemedicine should also be made sustainable. Potential initial capital sources could be explored with the Private Sector, private donations, development agencies etc. However, sponsors of such pilot projects must have a clear plan from the start about how the project can continue after the sponsorship comes to an end.

Conclusion: This project not only showed the satisfaction of medical users both in Siwa and Alexandria about the services provided to them, but also highlighted the technical difficulties in establishing a functional teleconsultation platform that provide services on a regular basis. High cost of Internet services

SELECT PAPERS (compared to developed countries) as well as acquisition costs for computers and medical devices are major obstacles for a wider implementation of telemedicine applications. However, the first stage of this pilot project showed that teleconsultation has the potential to improve the utilization of health resources available in Siwa. Rather than simply importing expertise from outside, the local health teams are strengthened and supported through continuous training and education. Moreover, it serves as a practice platform for undergraduates students with real life situations. Finally, Siwa teleconsultation platform is reducing the disparity in the delivery of health services between the developed centers and the isolated and less assisted areas, thus contributing to improve health care for children in rural and underserved areas. In conclusion, we believe that joining efforts among various actors can be strongly value-enhancing and key for success.

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GIS-enabled Disease Surveillance Architecture

For National Disease Notification System

In Sri Lanka, lack of co-ordination of surveillance system was identified as one of the major problems. The paper describes a GIS-enabled disease surveillance system that can overcome deficiencies of the existing National Disease Notification System. Introduction

Authors Roshan Hewapathirana Post Graduate Institute of Medicine, University of Colombo, Sri Lanka

Gamini Wijayarathna Department of Industrial Management, Faculty of Science, University of Kelaniya, Sri Lanka

History of notification of communicable diseases in Sri Lanka dates back to late 19th century. The Quarantine and Prevention of Diseases Ordinance was introduced in 1897 to implement the notification system on communicable diseases in the country. The quarantine and prevention of diseases ordinance and subsequent amendments provides legal provisions for implementation of notification of diseases in Sri Lanka. All medical practitioners (in both government and private medical institutions) who attend to patients with a tentative diagnosis of diseases in the notifiable diseases list should notify the disease to proper authority. The disease should be notified immediately at the time of first suspicion without waiting for laboratory test results or confirmatory tests (Epidemiology Unit-Ministry of Health, 2005). Making the notification at the earliest possible is of paramount importance, thus enabling the field staff to start necessary preventive and control measures immediately. The traditional paper-based disease notification system followed in Sri Lanka is depicted in figure1

Existing Challenges SWOT analysis study carried out by World Health Organization in 2004 on existing disease surveillance system of Sri Lanka brought

December 2009

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several important factors to the fore. According to the study, it was evident that current system does not capture morbidity data from outpatient settings and private hospitals. Event for inpatients, a considerable proportion of the cases do not find their way in to the notification system. According to the study, only 37.5% of districts and 55% of hospitals submitted all required reports on time. A review of clinical registers of hospitals showed that Disease Case Definitions are rarely being used in the notification process. The data analysis is almost confined to the central level and other levels are merely transmitting data. Due to inherent multiplicity of reporting channels, duplication of date is inevitable in the manual system. Only 11% of hospitals and 75 % of district surveillance systems received feedback in the form of WER. Inadequate in-service training in surveillance has been identified as a major obstacle in the strengthening process. Further to the above mentioned weaknesses, it was found that there is no planned routine case-detection mechanism being operated in field level. Another problem highlighted by the survey is the fact that there are, by design, multiplicities of reporting channels. For instance, a case can be reported from more than one institution. This has a potential for duplication if care is not taken to link

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The private sector institutions, including private practitioners need to be brought into the ambit of the surveillance system. A formal system of continuing education and in-service training should be strengthened, and district-level training in surveillance established.

Methodology

reports with their respective sources. Lack of coordination of surveillance systems was identified as one of the major problems at district and divisional levels.

Project Objective Objective of this online notification architecture is to overcome the deficiencies of the existing National Disease Notification System providing computer assisted data collection, data compilation and analysis, data interpretation and feedback mechanism. Following facts, those highlighted in the SWOT analysis were also considered in designing this web based architecture – • Need for a system of surveillance that not only achieves integrated disease surveillance at the functional level for the various specific disease programmes but also starts monitoring priority non-communicable diseases. The laboratory system should • also be strengthened through networking to be able to contribute to the process of notification. The surveillance system in Sri • Lanka needs to be expanded to include outpatients and community-level case-finding using a suitable mechanism.

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The proposed architecture is a web enable notification system, based on the standard documents used in the notification procedure. Free and Open Source resources (Apache web server, MySQL database engine and Sendmail mail server in Linux environment, Google Maps API and PHP and AJAX) have been used in the development process, in order to facilitate free use of the system by any interested party. The system has several key components as shown in the Figure 2 Notification data management module has data entry interfaces based on notification forms H544, H411, H411a and H399 used in the manual disease notification (refer figure 1). It also has a duplicate entry management unit which assists system users to query database for duplicate entries, based on the name and the location of the patient and clean or merge duplicate entries. The duplicate management unit uses SOUNDEX phonetic algorithms to index names by sound to maximize the results set by minimizing the effect of minor differences found in spelling people and location names.

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Form H544 is the key input interface of the system. It carries the information about the notifying institution and the notifier (medical officer), demographic data of the case being notified, date of onset, date admitted to the institution, the probable diagnosis and laboratory investigations, and the home address of the patient (for public health inspector to trace the patient’s residence). In addition to the above standard information, the electronic H544 form would indicate ICD 10 (International Classification of Diseases) code for each notifiable disease. Once ICD 10 diagnosis is selected, the electronic H544 automatically provides SNOMED (Systematized Nomenclature of Medicine) codes compatible with the ICD code. SNOMED nomenclature was introduced to the system since SNOMED is more ‘clinical friendly’ coding system than ICD 10. The fact that the SNOMED coding system is widely supported by many other public health information systems enables the proposed system to inter-operate with wider range of health informatics applications. Further to this, Case Classification allows categorization of cases in to ‘Suspected’, ‘Probable’ and ‘Confirmed’. Notification process is strengthened with automated Case Definitions assistance, since in outbreak investigation majority of

SPECIAL FOCUS: the cases reported will have to be dependent on Case Definitions rather than laboratory procedures. When ICD code for the case is selected, system will automatically insert the ‘Surveillance case definition’ in editable manner. In addition to the standard fields of the form H544, patient’s location can be marked in a Geographical Information System (GIS) bases satellite map. Google Maps API in combination with pre-populated latitudes and longitudes for major cities are used to implement an easy focusing map interface. Each case reported using the form H544 will be notified to relevant authorities using email alerts, while the data is being fed to the central database. A special reference number will be assigned to all cases notified for future tracking and updating the information (e.g. laboratory investigations). This will ensure confidentiality of patient information. When a H544 form is submitted, a H411 form with the details of the particular patient is automatically created and can be accessed by an area PHI of the relevant MOH area. PHI can use this electronic H411 form to investigate contacts and confirm the case. Upon submitting completed H411 form by the area PHI, H411a form will be generated by the system and can be completed and submitted to the system by the MOH. When MOH submit the H411a form the details of the form can be accessed by the Central Epidemiology Unit and Regional Epidemiologist for analysis and further actions. If notification process carried out using the electronic forms in the prescribed manner, at the end of each week the system will automatically generate the H399 form and forward for MOH approval. Once approved, the H399 will be available to be analyzed by the Central Epidemiology Unit and Regional Epidemiologist. Reporting module with its subunits (plotting library, statistics library, mapping API) is responsible of generating Weekly Epidemiological Return (WER), various charts and

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ICD 10

SNOMED

Code

Title

Concept ID Description

B01

Varicella (Chickenpox). 38907003

Varicella

309465005 Varicella-zoster virus infection 314943007 Varicella contact 277644009 Congenital varicella syndrome 90433002 B01.8

Varicella with complications.

Congenital varicella infection

their 187419000 Varicella with other complications 186512004 Varicella with 186511006 complications

unspecified

187420006 Varicella with other specified complications B01.9

Varicella without 187420006 Varicella without complications complications. 186513009 Varicella with no complications

Table 3: Comparison of ICD 10 with SNOMED

graphs and spatial representation of notified cases on satellite maps. Data analysis by each level is facilitated by graphical data representation and basic statistic functions like incidence, attack rates and case fatality rates. Time series heat map based geographical information

Feedback

system are used to visualize the spatio-temporal distribution of disease. The WER generated by the system can be accessed through the Internet and a URL will be emailed to all registered user with a reminder. Administration module allows customization of the system, user management, ICD 10¬SNOMED medical terminology management and case definition management. User management includes assigning ‘trainee role’ to users allowing users to obtain hands on experience on using system. This will provide inservice training which was a major recommendation by the WHO expert group. Further to this, user management module automatically groups users based on districts, Regional Director of Health Services areas and MOH areas.

above mentioned components. The electronic version of the H544 form has introduced several key

Functional Elements of Surveillance system comprise of following areas. • Data Collection • Data compilation and analysis • Data interpretation for action The model notification system architecture possesses all of the

Figure 7: Mapping location of the case on the Google map

improvements. If the age of the patient is less than 18 years, system automatically prompts for the contact details of the guardian. It also introduced the Case Classification of ‘Confirmed’, ‘Suspected’ or ‘Probable’ which is not found in the

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Figure 8: Representing a single case on the Google map

paper based notification system. Electronic forms have several features to minimize possible variations of patient names, medical terms like automated suggestions and to minimize errors in feeding dates to the system, like pop-up calendars. The system has the ability to map ICD 10 code to matching SNOMED concept. As shown in the Table 3, a single ICD 10 code might have many matching SNOMED concepts. With reference to the above issue, database tables which hold the ICD 10 and SNOMED terms have to be designed with a one to many relationship and appropriate normalization levels to avoid data manipulation conflicts. The electronic version of H544 has the automated Case Definitions assistance as well. When notifier selects an ICD 10 diagnosis, system will automatically add the Surveillance Case Definitions relevant to the ICD 10 diagnosis code in a special editable text area. Figure 6 shows the

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Surveillance Case Definition for the ICD 10 code B01 (Chickenpox/ Varicella), â&#x20AC;&#x2DC;An illness with acute onset of diffuse (generalized) papulovesicular and/or vesiculopustular rash, appearing on the trunk and face and then spreading to extremities, without other apparent cause.â&#x20AC;&#x2122; represented in the electronic H544 form.

automatically center the map to nearest location, on which notifier can mark the case using provided additional visual clues as in Figure 7. When latitude and longitude of a case fed to the database, location of the case can be visualized accessing case details as in Figure 8. Similarly case can be viewed in relation to the cases having same diagnosis in the vicinity of a predefined radius as shown in the Figure 9. This will aid determining the extent of the spread of a disease within a shorter period of time. Density maps (heatmaps) can be used to visualize the pattern of spread of a disease over a longer period of time (spatio-temporal distribution), as shown in Figure 10. The system is capable of generating various charts based on the out put of the statistical analysis requested.

Conclusions and Further Work Plan

Figure 9: Representing related cases on the Google map

It is possible for a notifier to remove inappropriate terms in describing a particular case, and also possible to key in any other signs and symptom to describe the case. In this way notifier can save time needs to feed the notification information and allow reviewers to compare different instance(cases) of a single disease entity(diagnosis) with a minimal set of clinical features. In mapping cases to geographical locations, pre-populated look-up table has been used to find the nearest latitude and longitude based on patientâ&#x20AC;&#x2122;s residential address. When entering patients address in house number, road, village/town and city format, Google map will

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The proposed architecture could address many of the suggestions proposed by the World Health Organisation team and weaknesses of the current notification system. It was evident that this model can be used to collect and analyze disease notification data within the current disease notification framework functioning in Sri Lanka. The proposed architecture has introduced several new concepts to the system like, GIS based mapping of cases, using surveillance case definitions and SNOMED nomenclature. It also provide inbuilt facility for data analysis and data export. Automation of report generation and email alerts would be an additional advantage of using the proposed system. In future improvements of the model, authors plan to include advanced statistical analysis features to the system giving it capabilities to perform complex statistical operations. Further to this possibilities would be explored to adopt Health Level 7 (HL7) standards giving the system more inter-interoperability with other public health information systems.

1 India's Largest ICT Event

6th

INDIA

2010 4 - 6 August 2010 Hyderabad International Convention Centre Hyderabad, India

Technology Infrastructure for Public Health Transformation Challenges, Success Stories & Solutions IT@Healthcare Delivery â&#x20AC;&#x201C; improving clinical outcomes, levaraging business performance Connected Healthcare â&#x20AC;&#x201C; network infrastructure, information access & remote care delivery EMR Best Practices & Information Sharing for Integrated Healthcare Emerging Frontiers & Best Practices in Medical Imaging, RIS & PACS Innovations in Medical Electronics & Bio-Medical Engineering

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Arpan Dasgupta, M:+91 9911960753, E: arpan@ehealthonline.org Bharat Kumar Jaiswal, M: +91 9971047550, E: bharat@ehealthonline.org

www.eINDIA.net.in/ehealth

1 India's Largest ICT Event

6th

INDIA

2010 4 - 6 August 2010 Hyderabad International Convention Centre Hyderabad, India

For Sponsorship/Exhibition Opportunities:

Presenting Publication

Arpan Dasgupta, M:+91 9911960753, E: arpan@ehealthonline.org Bharat Kumar Jaiswal, M: +91 9971047550, E: bharat@ehealthonline.org

www.eINDIA.net.in/ehealth

CASE STUDY

Rapid Deployment of TrakCare Yields Immediate Benefits for United Family Hospitals and Clinics in China

United Family Hospitals and Clinics (UFH), based in Beijing, China, is the operator of 12 hospitals and clinics. With plans for expanding its network of healthcare facilities throughout China, UFH needed more from a healthcare information system (HIS) than its current solution could provide. Daniel Fulton, vice president of Information Technology Services for UFH, notes that UFH was looking for a world-class HIS solution from a vendor with the experience of international best practices, and a strong local implementation

December 2009

and support team in China. UFH chose Web-based InterSystems TrakCare™ for its match with these requirements and its ease of configuration, enabling InterSystems to supply a solution without extensive customization. Working with InterSystems, UFH completed its first TrakCare implementation in less than four months at its Guangzhou United Clinic. “The fit was in the 70-80% range,” says Fulton, “the rest came down to configuration.” TrakCare is supporting UFH’s rapid growth by providing advanced clinical and

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administrative functionality, and a shared Electronic Patient Record, within a single unified healthcare information platform. UFH is already seeing benefits at the Guangzhou United clinic. “On the billing side TrakCare is doing everything we wanted to do,” says Fulton. “We are very happy with the support for the insurance plans and with the multi-currency and multi-language support.” TrakCare also is providing easy interoperability with other information systems through its embedded InterSystems Ensemble® integration

CASE STUDY

technology. This integration capability was important for UFH to create a complete healthcare information infrastructure. TrakCare has been integrated with Disclinc’s Alphalinc supply chain system, and CMPMedica’s MIMS online drug database. “CMPMedica provides a good local pharmaceutical dataset, which is key to preventing adverse drug reactions, and takes us to a new level in providing support systems for our clinicians,” says Fulton. Alphalinc ensures efficient handling of medicines and other

“TrakCare gives us a solid platform across our network to support us in our growth plan” - Roberta Lipson, CEO, Chindex International materials, which can account for up to 40 percent of a provider’s total expenses, from suppliers to pharmacists, nursing stations, emergency rooms, patient wards, and operating theaters. UFH also is integrating TrakCare with its Oracle Financials accounting system. Roberta Lipson, CEO of Chindex

International, which owns and operates UFH, notes, “We have aggressive plans for expansion of the UFH network in China and, while our previous information platform was excellent, it could not meet our increasing requirements. TrakCare gives us a solid platform across our network to support us in our growth plan.”

InterSystems TrakCare Hospital Information System Project at Military Hospital Set to Create Electronic Clinical Registry For All of Chile’s Military Personnel Clinical and administrative modules to improve patient care and hospital management InterSystems Corporation today announced that the new Santiago Military Hospital in Chile has started to deploy a Hospital Information System (HIS) based on the InterSystems TrakCare™, connected healthcare information system. This will enable electronic clinical files for soldiers to be made available whenever they seek attention at any of the health centers across the country that comprise the Army Health Command (Cosale) Network. Once a patient receives attention at any of these centers, a unique electronic clinical file will be generated. The information this contains will then be made available for retrieval at the Santiago Military Hospital as well as all other Army primary care centers. By opting to implement an integrated health network, the Chilean army will be able to standardize and share medical information among health professionals, as well as managing preventive medicine and health-planning programs, leading to improved quality of care.

Among the information recorded within the electronic clinical file will be: the family history, the results of examinations, procedures and episodes of care, and administered medicines. The possibility also exists to optimize processes, such as the distribution and usage of medicines, security, and the reduction of duplicate exams. “The selection of InterSystems as the supplier of the Hospital Information System was the result of a comprehensive evaluation program that started with the participation of 25 companies,” explained General (ret) Aldo Cardinalli, Manager of the HIS Cosale Project. “Only five vendors participated in the bidding, and only two of them qualified technically for the final analysis. Once reviewed, it was determined that TrakCare met all the established requirements and InterSystems was awarded the project”. The TrakCare-based Hospital Information System at the Santiago Military Hospital comprises two modules, which are completely unified and share information. The

first, the Clinical Information System (CIS), groups together all the health information that supports the management of the electronic clinical file, the outpatient and inpatient episodes, as well as operating theatre and bed management. The second module supports the administration, accounting and financial management of the hospital (ERP). To deliver this, InterSystems created a strategic alliance with the Global Service Company that will provide its IconSystems software as part of the project. To support the project implementation at the national level, InterSystems will work with STG, Chile. “For InterSystems it is a great honor to have our software selected to be at the heart of one of the most modern hospitals in Chile. Winning this contract is recognition of our ability to offer innovative technology that makes a real difference to the quality of care delivered to patients”, stated Luis Volkweis, Country Manager, InterSystems Chile. Uday Bhaskarwar.

December 2009

TECH TRENDS

Keeping a Service Focus Through Mobile Point-of-Care Technologies The article focuses on mobile point of care solutions that enable hospitals to provide clinicians with secure, convenient, and ubiquitous access to electronic medical records and other digital solutions, at the bedside or other places where such access is needed.

Ashok Chandavarkar Healthcare Industry Manager - APAC Digital Health Group, Intel

December 2009

he story is familiar around the world. Healthcare costs are rising. Too many people lack access to high-quality healthcare services. Paper-based workflows introduce errors and hamper productivity. However, we still observe inefficient processes in hospitals that have deployed electronic systems including a hospital information system and electronic medical records. If a health system has to deliver world class services with a service focus, it is imperative to keep the customer at the center of the processes. The customer in this case would be the patient and the relatives of the patient, since they are the ones who would be going through the various approval processes while the patient is indisposed. Processes that would enhance the patient experience would need to transform not just the front end interactions but all the touch points that the patient experiences once he/she enters the hospital premises. While keeping this in mind, there is also a need to optimize on the efficiencies of the clinicians so that they have access to relevant information about the patient at the right time. In addition, improving the skills of the people who are staffing and using the information systems

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is vital for improving quality and throughput. Do we need separate data entry operators who are entrusted with the task of preparing the discharge summary if information is captured at point of care? Can we reduce the average discharge time of a patient thereby increasing his overall satisfaction with the hospital? Can multiple agencies like the TPA, outsourced pharmacies, outsourced laboratory etc that operate within the hospital premises have anintegrated system so that the patient or his relatives experience a seamless good experience? Let us now imagine a scenario in which the electronic systems and digital technologies, that are available today, are fully utilized. Upon admission, the patient is given a bar coded receipt that bears the patient details and the OPD number. The doctor on meeting the patient asks for this receipt and scans it to retrieve an order entry page where he can note his comments while clicking on the tests that he would like the patient to undergo. The patient walks back to the OPD counter where he just swipes his credit card or makes a payment towards the tests and is informed that the pre-conditions for each test by a technician along with the date and time when the test is to be

APPLICATION

conducted and the person to get in touch with for each of these along with the room number. The slip also contains bar codes for the various departments to peel off and stick onto the samples they collect or reports they generate. This is one such workflow that can utilize the benefits of information technology and maintaining the processed patient centric. There could be numerous other such workflows that could be reengineered and then automated to ensure that the patient is always at the center of activity. While we do this it isimportant to ensure that we also delete certain nonvalue added processes that could exist as a result of automation. There is an urgent need for hospitals to rethink their IT deployments which are largely meant to be back end functions to see how they can improve the workflow in their patient interaction areas. This is where we do see Mobile Point of Care (MPOC)1 to play a very important role. MPOC solutions enable hospitals to provide clinicians with secure, convenient, and ubiquitous access to electronic medical records and other digital solutions, at the bedside or other places where such access is needed. By doing so, MPOC investments can be essential to user satisfaction with new digital solutions and to the solutionsâ&#x20AC;&#x2122; ultimate ability to deliver their intended value. MPOC solutions enable improvements in clinical workflow through a combination of wireless networks, mobilized applications, and mobile computing devices. These improvements in clinical workflows can enhance productivity, improve quality of care, create opportunities for cost savings, and increase clinician and patient satisfaction 2.

Clinician Workflow Clinicians

experience

added

Figure 1. Mobile-optimized workflows save steps and time

convenience when entering and accessing information at thebedside or exam room. They avoid the redundant work and extra steps that occur when using a centralized PC, as well as the delays that occur when clinicians have to queue up for a PC. Clinicians who previously depended on manual processes can base their workflows on real-time information. This information can give them new power to plan and execute their work in ways that improve the quality, efficiency, and cost of care and improve their own and their patientsâ&#x20AC;&#x2122;satisfaction.

Quality of Care MPOC solutions improve care by enabling point-of-care charting, avoiding delays and errors caused by illegible handwriting and allowing patient information to be made immediately available to the healthcare team. These benefits can reduce delays in treatment planning, and shorten average length of stay (ALOS). MPOC solutions also allow clinicians to access comprehensive patient information, reminders, alerts, orders, and clinical

decision support at the point of care. Clinicians can use this information to improve treatment planning, decision making, and resource allocation, and can avoid errors or duplicate treatments caused by information that is completely missing or out-ofdate. The table has been sourced from the white paper: Mobile Pointof-Care Value Model: Building a Business Case for Clinical Workflow Improvements Enabled by Mobile Technologies.

Cost Optimization Productivity increases and efficiencies due to automation and workflow optimization can lead to cost savings. Access to real-time information may enable clinicians to avoid duplicate orunnecessary procedures, saving time and reducing materials costs. Real-time, location based asset tracking can reduce equipment loss and avoid replacement and rental charges.

Staff Satisfaction MPOC solutions enhance staff satisfaction by providing tools that are adapted to the mobile environment and workflows.

December 2009

Value Dials Simple Key Performance Indicators

Measurments

Patient Safety Adverse drug events

Percentage change in number per 1000 doses Change in number of admissions Percentage change-estimated cost of surgical error Percentage change-estimated cost of transfusion errors Malpractice expenses as a percentage of practice revenue

Admissions with an Adverse Drug Event (ADE) Incidents of Surgical errors Transfusion errors Malpractice expenses

By enabling clinicians to access medical data and decision support tools and to chart their work at the point-of-care, MPOC solutions give them more time with patients—a factor that can impact staff satisfaction and quality of care. Improvements in staff satisfaction can have a financial impact by increasing staff retention.

Patient Satisfaction Having more time with patients enhances the patient experience and generally results in greater satisfaction. Many clinicians report that optimized mobile devices intrude less on the clinical dialog than in-room PCs tend to do. In addition, reductions in length of stay tend to improve satisfaction scores. These factors can also improve the patient experience.

Patient access Overcrowding and long wait-times can increase patients’ frustration and anxiety and decreasetheir satisfaction with the healthcare system. MPOC can help improve access to care by streamlining previously inefficient processes and increasing clinician and staff productivity. HIT investments that improve asset tracking can optimize bed utilization and enhance use of other scarce resources. Patient-facing web

December 2009

portals can improve patients’ ability to interact efficiently with the healthcare system, again improving both patient satisfaction and system efficiency.

“By enabling clinicians to access medical data and decision support tools and to chart their work at the point-of-care, MPOC solutions give them more time with patients—a factor that can impact staff satisfaction and quality of care. Improvements in staff satisfaction can have a financial impact by increasing staff retention.” Reflecting Intel’s conviction that all IT investments should impact key strategic imperatives, these value dials—broad categories of benefits would determine where

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MPOC investments can deliver strategic value to healthcare organizations. Each of these value dials needs to be associated with a set of observable, quantifiable, operational metrics called key performance indicators (KPIs). Each key performance indicator is usually derived from an underlying calculation. That calculation generally has multiple variables that are built on data that hospitals typically collect to track performance, such as basic operational data, financial metrics, and clinical metrics. The Intel HIT Value Model helps organizations answer two questions: what core organizational objectives do we want to achieve, and how will we know when we’ve achieved them? The valuedials are a starting point for specifying what you want to achieve.

To know more you could visit www.healthcaregoesmobile.com a leading site for use of mobile technologies at the point of care. This is a peer community for healthcare providers, Information Technology Professionals, Administrators and Consultants who are considering implementation or upgrades of their mobile point of care technologies. The site provides you with valuable informaton including live and archived webinars, case studies, videos, blogs and forums for interaction. •

References: White Paper: Mobile Pointof-Care Value Model: Building a Business Case for Clinical Workflow Improvements Enabled by Mobile Technologies

•

White Paper : The Value of Healthcare IT (HIT): A Practical Approach to Discussing and Measuring the Benefits of HIT Investments

APPLICATION

Importance of CDSS in Clinical Practice Modern healthcare scenario is a unique synthesis of technology, doctor and patient. The availability and use of medical software technology in clinical decision support was inadequate. However, the latest development in technology including mobile communication and high speed internet connectivity opens up a golden opportunity. Proper integration of these technologies with appropriate medical software can revolutionize the healthcare delivery models globally. The article focuses on the development of clinical decision support software (CDSS) and its various applications.

Authors

Dr. Vijayabhaskar Reddy Kandula Physician, St Markâ&#x20AC;&#x2122;s Hospital Salt Lake City, Utah. USA

Dr. Sanjay Deodhar Consultant, National Rural Health Mission, Ministry of Health, Govt. of India

ajority of the people in the developing world do not have access to basic medical care. The international community is working to bridge this gap for many years without uniform, replicable success. Some inroads have been made but have not derived any system which could make a massive impact in the delivery of primary care. Medical science is changing

at a rapid pace, which has made healthcare delivery more complex, costlier and at times inaccessible to majority of the population. However, the rapid advancement in information and communication technology and its universal reach provide new opportunity to bridge this gap. Information technology has improved access to services transforming them universally, though the impact on healthcare is not felt at all levels. One of the undesirable consequences has been the increasing distance and loss of communication between the patient and the doctor. Information technology can be one of the several newer tools that could help to bridge this gap. Health industry can learn from the experiences of other sectors like microfinance and businesses to reach out to the people at the grass root level. There has been an explosion in the outreach of mobile communication in the last decade benefiting the poorest

communities in the developing world. Increasing access to mobile phones and availability of internet access on mobile platforms is fast bridging the digital divide as well. It seems logical to use this trend to bridge the large gap in access to basic health services. IT and related technologies can be the catalysts that can usher in changes in healthcare to bring basic health services to the door steps of the hither to inaccessible areas. It is wise to be cautious in embracing these new technologies and emphasize on building multidisciplinary teams represented by health, IT and management experts so that standard medical care can be developed on IT platforms in a way that is not only cost effective but also user friendly.

WHAT IS CDSS? Clinical decision support software (CDSS) are interactive computer programs, which are designed to assist physicians and other health professionals with decision making tasks. The basic components of a CDSS include a dynamic (medical)

December 2009

APPLICATION

knowledge base and an inferencing mechanism (usually a set of rules derived from the experts and evidence-based medicine) and implemented through medical logic modules. •

Characteristics A clinical decision support system use two or more items of patient data to generate case-specific advice. CDSS is simply a decision support system that is focused on using knowledge management in such a way to achieve clinical advice for patient care based on some number of items of patient data.

Drawbacks •

Purpose The main purposes of CDSS are: • To assist clinicians at the point-of-care. This means that a clinician would interact with a CDSS to help determine diagnosis, analysis, etc. of patient data. • The new methodology of using CDSS to assist forces the clinician to interact with the CDSS utilizing both the clinician’s knowledge and the CDSS to make a better analysis of the patients’ data than either human or CDSS could make on their own. • Typically the CDSS would make suggestions of outputs or a set of outputs for the clinician to look through and the clinician officially picks useful information and removes erroneous CDSS suggestions. The doctor then takes the output of the CDSS and figures out which diagnoses are relevant and which are not. • The doctor uses these systems at point-of-care to help them as they are dealing with a patient, with the timing of use as either pre-diagnoses, during diagnoses, or post diagnoses. • Pre-diagnoses CDSS systems are used to help the physician

December 2009

prepare the diagnoses. CDSS used during diagnoses are to help review and filter the physician’s preliminary diagnostic choices to improve their final results. Post-diagnoses CDSS systems are used to mine data to derive connections between patients and their past medical history and clinical research to predict future events.

•

Often these systems are standalone applications, requiring the clinician to cease working on their current report system, switch to the CDSS, input the necessary data, and receive the information. These additional steps break the flow from the clinician’s perspective, and cost precious time. Of additional irritation is that the data the clinician may need to enter is already contained elsewhere in a digital form in that hospital’s system, and some CDSSs are not equipped to automatically pull this relevant information. Clinical decision support systems face steep technical challenges in a number of areas. Biological systems are profoundly complicated, and a clinical decision may utilize an enormous range of potentially relevant data. For example, an electronic evidence-based medicine system may potentially consider a patient’s symptoms, medical history, family history and genetics, as well as historical and geographical trends of disease occurrence, and published clinical data on medicinal effectiveness when recommending a patient’s course of treatment. Furthermore, new data is constantly being published which must be integrated into the system in order to maintain its relevance.

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Why eClinician CDSS eClinician CDSS (Clinical Decision Support System) is the outcome of an ambitious project conceived 9 years ago. It is developed over the years by physicians and software developers who have successfully integrated information from standard medical text books and literature systematically. The working medical team consists of 24 medical specialists, many of whom are academic faculty members including professors in reputed medical colleges and hospitals throughout the world. In addition to these experts, the team has general physicians who ensure that the software is user friendly for general physicians. The software has been refined over several years now and is seen as an innovative tool that can improve the quality of care and decision at the point-of-care.

Advantages of CDSS •

•

Medical information is simplified such that it is ready to use at point-of-care Incorporates the latest guidelines recommended by professional medical bodies. For example, HIV and AIDS incorporates WHO guidelines, which includes extensive literature review and treatment guidelines. International Classification of Diseases (ICD 10) codes are incorporated and updated constantly to avoid nomenclature disparities which helps in data mining and to monitor standards across health care delivery sites. The program is tailored to be used by health workers with minimum or no computer expertise It is flexible enough to be adapted to suit the needs of different levels of practitioners- from general practitioners to specialist. The differential diagnosis

Table 1: Accuracy of eClinican in Generating Differential Diagnosis Differential Diagnosis Generated by eClinician

Where actual diagnosis was 2nd or 3rd in the list of differential diagnosis

88%

Final diagnosis in list Where actual diagnosis of eClinician generated was first in the list diagnosis No 40 %

100% Sample Size+ 40 (100%)

â&#x20AC;˘

module is capable of generating all probable differential diagnoses from signs and symptoms of the patient. It includes both common and uncommon probabilities in clinical diagnosis. The system helps physicians to avoid overlooking uncommon conditions and provide decision support in difficult cases. eClinician is tailor made

fundamentally focusing on Physicians who provide clinical services in rural, semiurban and even urban areas of developing countries. eClinician is an aid to medical practitioners as it is simple to use, add value to practice and provide immediate access to the most relevant medical

12%

knowledge at the point of care.

Accuracy of eClinican in Generating Differential Diagnosis We did a pilot study to access the accuracy and utility of the software. Four doctors, two general physicians, one paediatrician and one orthopedic surgeon, working in both hospital and clinic environments were selected using convenient sampling methods. Forty real clinical encounters by

these doctors were selected. The presenting signs and symptoms of these patients were entered into the software and the list of differential diagnoses generated was documented and compared with actual final diagnosis made by the doctors after investigations. The final diagnosis by the doctor in all the cases (100%) showed up

in the list of differential diagnosis generated by eClincian CDSS. In 35 cases, the final diagnoses made by the doctors were first among the list of differential diagnosis. For three cases the final diagnosis matched with the second among the list and for the remaining two it matched with third among the list of differential diagnosis generated by eClinician (Table 1 and Figure 1).

Discussion eClinician CDSS software is fairly accurate, user friendly and has high potential to not only improve efficiency in providing clinical care but also to improve quality of health care. The program is developed in flexible computing platform that can be migrated to mobile technology. Since mobile communication technology is becoming universal, eClinician system can be made available to the doctors and health practitioners anywhere in the world. In addition, eClinican can be linked to any electronic medical records so that it can be integrated into the normal patient flow stages- history taking, vitals signs, examination and lab test- and the data entered can be used as inputs for the program based on which differential diagnosis is generated. This will increase the possibility of making a more accurate diagnosis. Equally important is the ability of the software to provide instant access (with one or two clicks) to relevant medical literature which would normally require 15-20 minutes of extra time and disruption of work flow and possibly patient dissatisfaction. Other potential benefits include the possibility for general practitioners to diagnose and better manage more severe clinical conditions, which they would normally either refer to a specialist or completely miss the diagnosis. This in turn benefits the patients by healthier outcomes and reduced health care costs.

December 2009

TECH TRENDS

The New Face of Radiology Digitization of radiology departments, the need for higher resolution diagnostic images and widespread installation of picture archiving and communication systems in hospitals are providing the requisite impetus for growth of the global market for digital radiography systems.

he past few decades have witnessed consistent technological evolution in the field of radiology with the development of several newer imaging modalities such as computed tomography, magnetic resonance imaging and nuclear medicine, among others. The emergence of such computer-intensive imaging modalities have marked the advent of an era of film-less radiology. There has hence, been an augmentation in the availability of diagnostic capabilities in digital radiography domain, as well as their scope. The consequent emergence of the field of digital radiography (DR) and computed radiography (CR), has completely altered the face of the conventional x-ray imaging modality. Healthcare facilities worldwide are now following the global trend by gradually replacing film/screen radiography systems with digital radiography systems. The transition to film-less systems is being fuelled by the need to make images faster, easier and less expensive to obtain, review, duplicate, share and store. Further, digital radiography has the potential to offer greater productivity, improved efficiency and more accurate diagnoses. As per a report, the global market for x-ray systems was valued at USD 4.9 billion in 2008 and the digital x-ray systems accounted for a whopping share of 86.2 percent of this market, amounting to USD 4.25 billion. The digital x-ray systems market is even expected to grow at a higher rate of 7.1 percent between 2008 and 2015, as compared to the x-ray

December 2009

systems market which will grow at an estimated 6.7 percent annually. This will also lead to an increase in the share of the digital x-ray market to 88.3 percent of the overall x-ray market. Pertaining to the Asian market, countries like China, Japan, South Korea, Taiwan and Hong Kong are moving towards adoption of digital radiography systems at a fast pace. China, for instance is providing strong incentives to its healthcare facilities to move from conventional to digital x-ray systems. The overall market is mainly concentrated between 3-4 major players, while the rest of the players account for relatively lesser shares. In fact, the emergence of digital x-ray equipment has provided the much necessary impetus to the growth of the overall x-ray market.

The gradual replacement of film-based systems with digital radiography systems can be attributed to certain prerequisite technological advances, such as high-resolution display monitors combined with high-performance computer workstations. The subsequent emergence of electronic archives that can efficiently store data has been another key factor that supported the evolution of digital radiography. Going further, installation of high-speed electronic networks with bandwidth capable enough of transferring images anywhere also became imperative for healthcare facilities around the world.

Technology Assessment The CR and DR technology are

Advantages of Digital Radiography over Conventional Radiography Digital Radiography

Conventional Radiography

Digital radiography systems provide There is a delay in viewing the image as the immediate viewing of radiology images. film has to get developed first before it can be read. Allows the radiologist to enhance image Does not offer image enhancement feature, quality by altering the contrast, enlarging as a film once developed cannot be altered. the image, placing colour enhancements and so on. Radiographic images can be easily stored The hard copies of the images are filed on a computer and accessed any time, and stored because of which there are anywhere with the help of various available chances of the records getting misplaced. modalities. Practically eliminates the need to develop Maintaining the developing device and films and maintain them as the images are fixing the developing solution each time can directly displayed on the computer screen. be a time consuming and undesirable task. Image sharing has now become a matter of Image sharing takes time as the hard copies minutes. will either have to be scanned first before sharing the image online or sent via mail. There is almost a 70 to 80 percent reduction Potentially high exposure to radiations may in the radiation exposure as compared to prove to be hazardous. conventional radiography.

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similar as far as the digital format of the resultant image is concerned, as images obtained from both are compatible for storage in picture archiving and communication systems (PACS) and their appearance can be manipulated. However, the differences are far greater in number and involve the operation and image capture, workflow and cost, technique and dose, and image quality. The installation of CR does not require changing the conventional x-ray equipment; it is merely the addition of CR readers and cassettes. Evaluation of the conventional radiography technique, in particular, reveals several advantages offered by this imaging modality. Exceptional image quality is probably the most important feature. It also completely eliminates the need for taking any retakes as the resolution of the image once captured can be easily altered on the monitor to improve quality. Also, a single exposure offers more information as compared to that obtained on a film. Reduction in costs for processing the images as compared to conventional techniques has also been noticed as the imaging plates used by CR can be re-used 15,000 to 40,000 times, which eliminates the need for x-ray film and their processing. In contrast to CR, in DR technology, no cassettes are required as the images are recorded directly in digital format. The elimination of cassettes in this technology makes this process faster than the CR process, and provides a greater patient throughput. However, as DR technology is more expensive than the CR, it is essential to consider the advantages and drawbacks of a DR system in terms of workflow and relative costs. This may largely depend on a facility’s patient load and future growth projections. The medical imaging market is currently in a transition state as healthcare facilities around the world are now opting for digital radiography solutions over conventional radiography solutions. One of the most important reasons for this is the emergence and

DR and CR Solutions in Medicine

Dr. K Prabhakar Reddy President, Indian Radiological & Imaging Association, & Chief Radiologist, Princess Durrushehvar Children & General Hospital, Hyderabad

Digital Radiography – Changing the way we work Radiology has seen a sea change in the last thirty to forty years with the introduction of digital modalities like CT, MRI, ultrasound and mammography. Radiography is the last segment of radiology to turn digital and is currently going through a significant change across the world. Most hospitals, large to moderate and diagnostic centres are in the process of switching or have already switched to digital radiography. The primary driver for this change is not just the availability of newer technologies or it being fashionable, but the fact that digital systems significantly improve workflow, are much easier to work with and make economic sense in the longer term.

Computed Radiography (CR) CR uses a technology called Photostimulable Luminescence or the storage phosphor technology. In this method a phosphor imaging plate (IP) replaces the x-ray film and screen. The IP, when exposed to an x-ray beam, stores the pattern of xray exposure and retains it as energy for several hours. When exposed to a light source, such as a focussed laser beam, the IP releases the stored

energy by emitting light. This emitted light is captured and converted into usable electrical signals. These electrical signals are then processed to produce an image. Any latent energy still retained in the IP is then erased by exposing it to a very bright light. The IP can now be re-used to capture the next image. Essentially a CR system consists of the following components in addition to a conventional x-ray machine. Specially designed CR cassettes • with a matching IP inside A CR reader – laser scanner • connected to the workstation A computer workstation with • the image processing software The workflow of a CR system is very much akin to that of a conventional (analogue) film and screen based unit. Most part of the workflow remains similar to the conventional system except that the CR cassette is fed into a CR laser reader, instead of a dark room process.

Digital Radiography (DR) Unlike CR, DR uses x-ray detectors that directly produce an x-ray image on the computer monitor in a few seconds without the need of a laser reader. The fundamental principle behind a DR is to capture the pattern of x-ray exposure on a sensor which converts it into usable electrical signals that can be processed into an image. Since this technique does not involve physical transportation of cassettes or any scanning process, the exposure to image display is fast and efficient. Two different types of technologies are used – “Direct” & “Indirect” Detectors “Direct” Digital Radiography • – Amorphous Selenium Flat Panel Detectors (FPD) • “Indirect” or Scintillator and CCD Based Detectors “Indirect” or Scintillator and • Amorphous Silicon Flat Panel Detectors (FPD) A “direct” DR FPD is made up of an array of microscopic Amorphous Selenium sensors that are arranged

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implementation of PACS network. Subsequently, the enhancement in the clinical value of PACS has also been a result of installation of direct digital modalities. PACS was launched with an idea to collect images from all modalities to a digital archive and to allow the transmission of these images to other workstations through local area network (LAN). Further, the traditional transmission control protocol/internet protocol (TCP/IP) was gradually replaced by digital imaging and communications in medicine (DICOM) protocol, which was capable of managing any sort of medical images. The DICOM protocol hence extended from the radiology department to the entire Vendor Update Allengers Medical Systems Ltd. Agfa Healthcare Carestream Health (KODAK) GE Healthcare Jindal Photo (Fujifi lm) Konica Minolta Philips Medical (+Alpha+Medtronics) Prognosys Medical Systems (Canon) (Subsidiary of Chayagraphics India Pvt. Ltd.) Cura Medical Equipments Pvt. Ltd. Sanrad Medical (Varian Medical Systems) Shimadzu Medical India Pvt Ltd. Sun Narula Group VM Engineering Co. Pvt Ltd. (Vision Xray Systems)

Bedside and Emergency Radiography

Siemens Medical clinical department in a healthcare facility and became the standard of clinical data transmission. The increasing popularity of PACS is further driving the sale of high-end radiology information systems (RIS), a computerised system for patient registration, as text-based RIS products such as film tracking databases will be marketed with PACS solution. It is crucial to however note that in absence of a PACS of PACS like solutions, the advantages of a digital

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in a matrix of small picture elements (pixels), very close to each other. When exposed to an x-ray source, the corresponding sensors or pixels release proportionate amount of electrons causing an electron current. The electrical signal that is hence produced is amplified and processed to obtain an x-ray image. In the “indirect” method a phosphor screen or scintillator, that converts x-ray photons into proportionate quantities of light photons, is used in conjunction with either photosensitive semiconductors or photodiodes or CCD to convert the x-rays into usable electrical signals. Since X-rays are first converted to light and then to usable electronic signals, it is called an “indirect” method or indirect detectors. Primarily there are two types of “indirect” detectors commonly in use today. Some manufacturers use a scintillator coupled with a CCD panel to capture and deliver the x-ray image. Since CCD based detectors are “lossy” and inefficient compared to flat panels, they require a relatively higher x-ray dose. Moreover they are bulky and space consuming. As a result, Amorphous Silicon Flat Panels with built-in scintillators are emerging as the most popular and widely accepted technology of choice and are available in both fixed and portable formats. Amorphous Silicon with scintillator is a technique that uses a scintillator or phosphor screen that is placed directly above an array of Amorphous Silicon sensors.

Significant improvement in detector packaging technology, better management of IC power consumption and heat dissipation have resulted in

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thinner and lighter flat panel detectors that are easy to handle and are portable. This has opened up a lot of options to the clinicians and hence digital radiography can now be made available at the point-of-care. The mobile x-ray machine, flat panel detector like the one seen in the picture combine to give instant results, right by the patient’s bed side or the point-of-care. Connectivity to LAN / WAN is available and images can be pushed to a PACS network instantly. Such flat panel detectors can be integrated with various types of x-ray systems to function as a full fledged digital radiography system. Various system configurations are possible and depending on the budget and application, either a single flat panel detector or multiple detectors can be configured with them.

Detector technology - Image phosphor coupled to a-Silicon photodiode array:Different types of digital radiography technologies are available in the market today. The most popular manufacturers of flat panel solutions such as Canon, Trixel, GE, Varian and others offer a technology that involves Amorphous Silicon coupled to a Phosphor Scintillator. The X-ray scintillator in the detector is normally a thallium doped Cesium Iodide (CsI) phosphor or a Gadolinium Oxy-Sulphide (Gd2O2S). The X-rays interact with the phosphor and release light photons. The phosphor is directly coupled with the read out array. The light from the phosphor is converted into electrical charge in the photodiode array; the charge is then stored in a capacitor until the charge is then read out from each of the pixels. These are commonly referred to as amorphous-Silicon (a-Si) systems.

radiography system are lost, more or less because there is no electronic information management system to store and retrieve patient information. The printouts of digital scans offered on a film are or the scanning of x-ray films to produce digitized images are both inefficient procedures. Hence a primary requirement for installing DR and CR solutions is to first install a viable information management system to efficiently manage all the data produced in these procedures.

DR: A Better Technology than CR of this technology over the past few years?

Major roadblocks The cost-sensitive nature of the Indian market does not allow a high-end technology like DR, which is associated with huge price tags, to grow. While, the high prices of these systems may be attributed to R&D

â&#x20AC;&#x153;The cost-sensitive nature of the Indian market does not allow a highend technology like DR, which is associated with huge price tags, to grow. While, the high prices of these systems may be attributed to R&D and IT implementation, it is essential to balance the price of the technology with the product quality.â&#x20AC;? and IT implementation, it is essential to balance the price of the technology with the product quality. The general perception still is that, unlike diagnostic modalities such as PET and MRI, installing DR is a luxury and not a necessity. It has hence become imperative for manufacturers to offer the best possible product at minimum price to encourage even smaller healthcare facilities to buy this technology. Gradually, the prices of these systems are coming down, however it will still take some time before it can fit the Indian pocket.

Harish Gulhar Business Manager, Angio-, Fluoroscopic & Radiographic Systems, Siemens Healthcare

Has the emergence of digital imaging modalities had any significant effect on the medical imaging markets around the world? Is there a significant scope of growth of this technology in India?The innovation of digital radiography (DR) system has significantly improved the clinical workflow and efficiency of the department and has also helped shorten the diagnostic and therapeutic decision-making processes. Additional benefits are improved patient comfort, reduction in radiation doses, higher examination throughput (i.e. multiple examinations during one visit) and a more pleasant atmosphere in the waiting room (through shortened examination and waiting times for xray) as the x-ray images are available at any time, throughout the hospital, in a PACS environment. All represent major benefits for the patient and increased satisfaction. The technology has tremendous scope in India, primarily in the major existing as well as upcoming hospitals. The existing hospitals, both government as well as private, are upgrading themselves to this new technology due to the benefits mentioned above.

What are the major advantages these systems offer over traditional film-based systems? What has been the major trend in the development

The conventional film based system involves patient x-rays to be taken on the film and developed in the manual/automatic film processor. About 7-8 years ago, the CR system was introduced, which changed the quality of x-ray images over conventional film-based radiography. However, these CR systems involved the CR cassettes, which have a definite life of few thousand x-ray exposures. After taking the x-ray on the CR cassettes, it has to be processed in the CR reader and then the image appears on the CR workstation, so that the image can be transferred to the network or to take printouts on the laser camera. The CR system of course improved the quality of the x-ray images and improved patient workflow and efficiency, as mentioned above. In DR systems, the patient images are taken directly on the digital flat detector. So, there is no use of cassettes and the images are available immediately on the console. This has further improved the clinical workflow and the efficiency of the radiology department. Compared to the CR system, the quality of images is better in flat detector system (DR systems).

What are your major product offerings in this segment? Could you also enlist a few major customers who have purchased DR and CR systems from Siemens? We offer a complete range of digital radiography system as follows: Ysio: It is a completely new digital radiography solution. Whether for general, trauma, dedicated chest or other specialized imaging applications, for hospitals or private practices, for budgets large or small, Ysio is available in a variety of combinations. It can be used as a wall stand with an integrated detector; a wall and table system with a wireless detector (wi-D); as a mixed detector solution for high throughput and flexibility.

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AXIOM Aristos FX Plus is a multifunctional, ceiling-mounted FD x-ray system for chest exposures and skeletal radiography of the skull, abdomen and extremities. The ceiling-mounted supports can be freely positioned in the room, offering a high level of flexibility during all exams enabling lateral and oblique exposures as well as trauma applications with a single Xray system. The enhanced workflow of this system allows more than 500 organ programs for automatic system positioning making it a fast, flexible system positioning around the patient for greater comfort. A feature called DiamondView provides optimum image presentation. Lastly, it fulfills virtually all examinations with a single detector. AXIOM Aristos VX Plus is a fast and flexible imaging system with a tiltable flat detector stand, a ceiling-suspended x-ray tube stand and an optional trolley. This system accommodates imaging of extremities as well as upright and recumbent examinations. Owing to digitization, activities such as loading and transporting cassettes and material disposal have been eliminated. The optimized workflow and connectivity features further reduce waiting times for higher patient throughput.

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MULTIX Swing with its integrated mobile flat detector (mFD) enables users to access the convenience and benefits of digital radiography (DR). It virtually covers the full spectrum of general and specialized radiographic applications for both in-bucky and out-of-bucky examinations. The mFD is easy to handle and proves to be as flexible as the conventional cassettes. AXIOM Aristos MX is the universal DR system for all standard examinations, from head to the spine, abdomen and extremities. It is an ideal solution for hospitals of all sizes. The automated tracking feature in vertical, horizontal and oblique axes for faster workflow. It also allows upgradeability to tomography for expanded applications. Conceived as a multipurpose system, AXIOM Multix M covers the full spectrum of general-purpose radiographic applications from skeletal to thorax, pediatric to orthopedic exposures â&#x20AC;&#x201C; both on and off the table, as well as on the wall stand. With its DICOM standard compliance, it forms an ideal fit with existing IT and archival infrastructures and also with smaller stand-alone systems. Matching a wide application range with easy handling, AXIOM Multix M is a real time-saver in any radiology lab.

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AXIOM Vertix MD Trauma is a radiography workstation designed and optimized specifically for traumatology. It offers lateral, oblique and p.a. projections and can be upgraded with a bucky wall unit. AXIOM Vertix Solitaire M is a flexible, digital radiographic system with a ceiling-mounted X-ray tube stand, bucky wall stand and mobile Flat Detector. The system has no fixed table and is especially wellsuited for stretcher, wheel chair and routine imaging with an emphasis on trauma. The system can be configured to cover several trauma bays, allowing for immediate imaging when it counts the most.

What is the role of integrated information management systems in DR and CR technology? The Hospital information and radiology information system plays a major role in the hospital. Right from the appointment to scheduling of patient work list to reporting of images can be performed efficiently.

Which according to you is a better technology out of the two? Of course, DR system is a better technology. At the same time, this has to be evaluated on return on investment.

EXPERT CORNER

Device Innovations for Ophthalmic Surgery I-Therapeuitx, Inc., a privately held company founded in November 2006, is involved in the development of ophthalmic therapeutic products using its proprietary hydrogel technology to address unmet needs in ophthalmology and ophthalmic surgery. In addition to its first product I-Zip ocular bandage, the company is in the process of developing sustained ocular drug delivery vehicles for the therapy and treatment of ophthalmic diseases and ocular infections. eHEALTH caught up with Dr. Amarpreet Sawhney, President and CEO, I-Therapeutix, to know about his entrepreneurial ventures, device inovation and the scope of premium products worldwide. Dr. Amarpreet Sawhney President and CEO, I-Therapeutix, Inc.

Please tell us about your journey as the CEO of I-Therapeutix, Inc. Apart from the USA, which are the other countries in which you have direct or indirect marketing networks? While I was running my previous company Confluent Surgical, we were getting a lot of demands from the ophthalmologists for creating polymers for the eyes. After we sold Confluent, we decided to look into this further and charted a business plan for starting ITherapeutix. I-Terapeutix, started with a small nucleus of 4-5 people, which has now grown to almost about 300 people. The companies that I have been involved with are start-up

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companies. We find unmet needs in medicine, surgery, etc. and we try to design devices that can meet these needs. By the very nature of these companies, they start off very small as the products are first built, then approved and finally launched. The entire process from concept to stability and profitability takes about 6 years; sometimes we sell our companies and some times we continue to run them. For commercialisation, we typically look at the US market, which is the biggest for us and then Europe, which is a potentially good sized market but a little slow in adopting technology. The top 5 countries in Europe are Germany, UK, Italy, Spain and

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France. A more mature company may have a different profile as compared to a start-up company as they also focus on sales outside the US, but since our products are not registered yet we tend to focus on the US and a few countries in Europe.

What was the idea behind creating Incept and what is the model that it works on? The first company I worked with was Focal, where I was the technology founder. But I was not running the company and did not have input into many aspects of the business. I then decided to start my own company and after agreeing

EXPERT CORNER

to a one year non-compete with Focal, began Confluent Surgicals. Focal, however, retained 50 of my patents that I could not make use of. Incept was created in order to use a different model to create companies. Incept is a holding company that owns all intellectual property rights. Another reason why Incept was formed was it being an enabler. Unlike the venture capitalists, the technology founders have everything in one company and if that goes bust they are left with nothing. Finally when Incept was formed my partner Fred Khosravi and I realised that we could not scale this too much because there were just two of us and multiple things to do. We needed to create ventures and mentor one or two people to take it further. Hence we created a group of entrepreneurs who could take on more opportunities.

Which are the other entrepreneurial ventures that you have been involved with in addition to I-Therapeutix? One of the companies that I have been involved with is Market Rx. Market Rx is involved with creating software that can enable the service aspect, is faster, easier to use and more accurate based on other analytics. The company eventually became very successful and we sold it for USD 165 million. Another company that I ran in the early stages is Augmenix, which is working in the radiation oncology field. The company produces material that could be injected between two organs lying near by so that the radiation, while giving chemotherapy, doesn’t spread to non cancerous organs.

Please tell us about the in situ formed hydrogel technology behind I-Zip? I-Zip has two freeze dried droplets, to which one drop of water is added, following which they are mixed and applied onto the corneal incision in cataract surgery. I-Zip provides a liquid

“For introducing premier products it is easier to go for the highest priced markets first as the margins there are higher and the product is viewed as a premium commodity. The prices can be dropped later on in order to introduce such products in markets like India.” environment that seals the incision and also helps in holding the edges together so that the healing can be better. After about five days, the material eventually falls off and the epithelium grows underneath it. Another product that we developed is DuraSeal, which is a serum for brain surgery. DuraSeal helps in sealing the dura mater post brain surgery. Its reaction is very fast and it immediately forms a flexible membrane that stays for about a month and a half and then liquefies, during which the brain forms a new membrane.

How do you perceive the market for this technology vis-a-vis the other conventional procedures used for similar procedures? We think the market for this technology is about USD 600 million worldwide. We have recently finished a 420 patient trial and found out that the patients treated with I-Zip are more comfortable, and have less inflammation, oedema, and pain. These things haven’t existed in the past so there are no other products that can provide competition to this technology.

What is the scope of such products in India? In India, the price pressures are a lot more as any procedure that is performed here is at least 4-5 times more expensive in the US. Looking at the price constrains selling a high priced product is difficult in India if the cost of the entire cataract surgery is very less. Hence, for introducing premier products it is easier to go for the highest priced markets first as the margins there are higher and the product is viewed as a premium commodity. The prices can be dropped later on in order to introduce such products in markets like India. When we launch a product, we launch it in the US first, followed by Europe and Japan and then the rest of the world. Are there any products that are currently in the pipeline? Will they be based on the same technology? We are currently working on developing a series of drug delivery systems, starting with an antibiotic system which could deliver antibiotics post cataract surgery. This will be administered just once and will eliminate the need for taking any eye drops after that. Another product that we would be launching in the near future is for glaucoma.

Can you tell us about some of your patented technologies and the procedure that you follow to obtain these patents? Usually, obtaining a device patent is simple and its fairly easy to design around it. We try to build a patent umbrella and have multilayer protection. The first layer is of the composition or matter, the second is for the methods of the used patent, the third is for the applications type of patents and finally for patent related to use of colour in implants. Hence, there are three to four layers of patents and then patent for the delivery device.

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Challenges in Current MedicoLegal Environment in India The article focuses on the laws pertaining to the health services in India and discusses certain cases that put light on the various issues and challenges faced by the medical industry.

contractual obligation between two different distinct, equal parties. It has completely revoked the fiduciary relationship between them i.e., the doctor having an undue influence over the thinking process of patient so far.

Dr. Samuel Abraham Legal Officer, Directorate CMC Hospital, Vellore

If a person analyses the history of laws relating to health services, he can understand that no other field has undergone sweeping changes as the health sector. There is a u-turn in the concept of contractual obligations between a medical professional and his patient. For example, Section16 of the Indian Contract Act 1872, which had hitherto considered doctor-patient relations as â&#x20AC;&#x2DC;fiduciary relationshipâ&#x20AC;&#x2122;; has been completely denied its dominance because of the judgment and order in VP Shantha v/s Indian Medical Association of India. It redefined the relationship between doctor-patient as a

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Secondly, the method of adjudication of disputes relating to consumer cases has been completely changed from judicial scrutiny to quasi-judicial, i.e., a decision by a judicial person with another layman sitting in the consumer fora. Therefore, strict adherence of proof is not required in the consumer forum. No more expenses need to be incurred for filing a `money suitâ&#x20AC;&#x2122; in a non-judicial stamp paper before a civil court; a simple complaint letter from the patient is enough for the forum to take action against the service-provider. This is something a service-provider like a nursing home, hospital or medical professional did not expect. But they have to face the reality now.

How to Prevent Litigation The first step is to follow the principles enunciated from Bolam v/s. Frien Hospital Management Case. The Privy Council of Great Britain, in this case, has formulated three tests to be followed by medical professionals/hospitals. 1.

Competent Test: Whether the medical professional

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is competent to do that particular procedure taking into consideration his qualification, experience and the equipment available to him in a particular hospital. Due Care Test: Whether the medical professional has taken due care in attending the patient in question. In short, that medical professional may be an expert and might have done for example, thousands of open-heart operations; but has he applied due care while operating this particular patient. Time and Place Test: Whether the procedure which was selected by the medical professional is in vogue in that particular place and in that relevant time. Law does not expect an expert to follow a procedure which is being followed in a different country or was followed ten years back. The procedure should be practiced in that locality in that particular time.

The first test can be answered by ensuring appointment of duly qualified medical professionals in their hospitals. Hospitals/medical professionals can prove the second test only if they maintain proper medical records which will reveal various medical procedures carried out by experts in that field, according

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to medical opinion, diagnostic test results.

based

The other important factor to be considered is to obtain `informed consent’ from the patient. If such consent is obtained, patient cannot take a stand later that he was not aware of the type of treatment that was given to him by the doctor. This is called in legal jargon as “Doctrine of Estoppel”. The simple meaning is that one person, who takes a stand before a forum about a thing in a particular manner cannot take an entirely different stand in another place about the same matter. In a simpler sense, if a person claims in one petition before a court in New Delhi that he is a post-graduate, he cannot take another stand later that he is a school dropout before a court in Thiruvananthapuram. Legally, if he takes a stand, he is estopped from doing such a thing in a court of law or else, he may commit the offense of perjury which is a punishable offense. Likewise, a patient who is well informed about the medical profession, the procedure, the various risks, its percentage of risk factors and the cost of health services, cannot take another stand before a court in a later date that he did not know the type of treatment, procedure or cost involved. That is why a proper written consent form should be obtained from the patient or his relatives. The consent form is not a piece of paper which can be obtained in a stereo-typed way from patients mechanically. It is rather a continuous process wherein the medical professional and the patient sit together with the doctor explaining all details of the treatment he intends to do for the patient, while the patient interacts with the doctor and gets proper clarifications for all his reservations and queries.

Medical Professionals & Criminal Negligence In few instances, cases of criminal negligence were registered against the medical professions U/S 304 A, 326, 327 and 328 of Indian Penal

Code in different places in India. But the Hon’ble Supreme Court has come to the help of medical professional in Jacob Mathew v/s. State of Punjab, by imposing a condition to the law enforcing authorities to obtain a medical opinion from another doctor of the same specialty and if that opinion is negative, they cannot proceed further in criminal case. If the second opinion states that there is a negligence, resulting in the patient’s death/injury, the case can proceed further. Medical jurisprudence in respect of consumer litigation had a smooth sailing, till a slight set back to the medical professional and hospital managers when the Hon’ble Supreme Court of India pronounced a historical judgment in Nizam Institute of Medical Sciences v/s Prasanth S. Dhananka and others. In this case, a sum of rupees one crore was ordered to be paid to the patient by the management of Nizam Institute of Medical Sciences (NIMS), Hyderabad. The deficiency, as observed by the judges was that complete investigation prior to the actual operation had not been carried out. The attending doctors were seriously remiss in the conduct of the operation and it was on account of this negligence that paraplegias had set in. The case relates to a young engineering student of 20 years, who was referred to NIMS with complaints of recurring fever. He was diagnosed as having a mass in the left hemithrax with posterior mediastinal erosion of the left 2nd, 3rd and 4th rib. As several attempts at Fine Needle aspiration Cytology ((FNAC) under ultrasound guidance did not give any conclusive evidence as to the nature of the mass detected in the x-ray examination, he was operated for tumour. Immediately, after the surgery, the complainant developed acute paraplegia with a complete loss of control over both lower limbs. Detailed reasons

of deficiency pointed out by the National Consumer Disputes Redressal Commission (NCDRC) are given below: 1.

The hospital/medical professionals admitted to have known pre-operatively about the extension of tumour into intervertebral foramen. They should have resorted to the advice of a neurosurgery along with CT scan. Not only did the medical professional failed to utilize the available pre-operative clinical information, he also failed to conduct necessary pre-operative diagnostic tests like MRI and myelogram, which would have provided the information pre-operatively on the extension of the mass into intervertebral foramen and which information would have brought a neurosurgeon from the start of treatment. The complete case records were not submitted by the management to the NCDRC which gave negative inference of suppression of facts. After the operation was over, the doctors never informed the anxious parents that the patient became paraplegic. They straight away left the operation theater and after a lapse of five hours, after much persuasion, the junior doctors revealed the the truth to the patient and his parents. The hospital authorities failed to carryout their statutory function of exchanging opinion on the case with sister institutions in India and abroad for post-operative management to retrieve the patient from the damage to the extent possible.

Against the claim of Rs.4.61 crores, the NCDRC has ordered a total of Rs.15.5 lakhs. Aggrieved by this order, the complainant himself filed an appeal and appeared before

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the Supreme Court and argued the case by himself by sitting in the wheel chair. The Supreme Court has modified the NCDRC’s order and passed a judgment for an enhanced compensation to a tune of Rupees one crore which is the highest compensation amount paid to a patient by a hospital in India, so far.

Safety Jacket for Medical Professional by Supreme Court

sciences and must not substitute their own views over that of specialists.

New Relief in Other Areas Another notable development in labour jurisprudence applicable to hospitals has come through another judgment of the High Court of Delhi in Indraprastha Medical Corporation Ltd. v/s NCT of Delhi and others.

However, the medical fraternity can be safe and relieved because of the orders of the supreme court in Martin F. D’souza v/s. Mohd. Istfaq. It is a boon to the medical, para-medical staff members and healthcare providers in India from unnecessary, capricious and vexatious litigations against medical fraternity by the patients and the law-enforcing authorities.

Before the judgment was pronounced it was usual for all the dismissed employees who filed petitions before the labour court to take a plea with the concerned hospitals did not have a certified standing orders as provided in the industrial employment (standing orders) act 1946 because a single judge of Delhi High Court has held that the provision of the above said Act is applicable to hospitals.

The salient features of the judgment are as follows: 1. Whenever a complaint is received against a doctor or hospital by the consumer fora (whether district, state or national) or by the criminal court, before issuing notice to the doctor or hospital, the concerned judicial authority should refer the matter to a competent doctor or committee of doctors for opinion. 2. Only on receipt of an opinion that there is prima facie grounds for deficiency, notice can be issued to the concerned doctor/hospital. 3. Police officials should not arrest or harass doctors unless the facts clearly come within the parameters given by the supreme court in Jacob Mathew’s case. 4. If the police authorities arrest a doctor without following the above procedure, they have to face legal action. 5. The courts and consumer fora are not experts in medical

In all their petitions before labour courts in India filed by the dismissed employees shall hitherto attack the management that they did not have certified standing orders as provided in the Industrial Employment (Standing Orders) Act 1946 because a single judge of the Delhi High Court has held that the provision of the above said Act is applicable to hospitals.

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According to the provisions, every employer who employs more than one hundred employees, must have their own Standing Orders certified by the State Labour Commissioner. For those employers who have less than one hundred employees, the model Standing Orders in the said Act are to be followed. Because the Delhi High Court has held that the provisions are applicable, the management of hospitals all over the country found it very difficult to convince the Labour court. To add to that, the above orders were not challenged upto the Supreme Court level to convince the Presiding Officers of the Labour Courts. However, surprisingly a bench

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consisting of Justice Markandey Khatju (as he the n was) and Justice Madan B. Lokur has held that the provision of the above said Act are not applicable to hospitals in the above case. The salient observations of the honourable judges are given below: 1. The main activity of a hospital is to cure diseases and ailments and not to do washing, cleaning, generating power, cold storage, etc. The latter are only incidental activities. In other words, to determine whether an establishment is a factory or not under Section 2(m) of the Factories Act, we have to see the main activity which is being conducted in the establishment. 2. By no stretch of imagination can it be said that the main work of a hospital is cleaning, washing, packing, oiling, generating power, etc. These are incidental activities to ensure proper cleanliness etc in a hospital. 3. The decision of the Supreme Court interpreting the word `Industry’ in the Industrial Disputes Act, 1947 has no application in the Standing Orders Act. It is also a welcome sign that the High Courts of Kerala & Karnataka have subsequently given verdicts along similar lines. To sum up, the judicial pronouncements in the last five years have been positively helpful to the hospital industry as a whole. But it should be remembered that the same judiciary shall not spare a hospital where employees, by their utter negligence have caused irreparable loss to the individual, in that case courts shall go the extra mile to mitigate the suffering petitioner before it, rather than hospitals as an establishment as in the cases referred to above.

EVENT REPORT

Transforming India’s Health Care Scenario Role of Medical Technology

he Medical Technology Conference organised by CII was held on October 7, 2009 in New Delhi. This was the second edition of the conference and focused on the theme “Transforming India’s Healthcare Scenario – Role of Medical Technology.” The Indian Medical Technology industry has taken impressive strides domestically, witnessing growth in almost all areas of healthcare. Beyond high growth, it has demonstrated an ability to support the Indian healthcare industry through superior technologies and willingness to serve. Global medical technology companies now view India as a significant market as compared to the developed economies due to its large population base. The Medical technology Conference was CII’s effort of bringing forward the key issues on the medical technology sector in India. In the inaugural session, the conference kicked off with a welcome note by Chandrajit Banerjee, Director General of CII. Following which, Rohit Mehta, Chairman of CII Medical Equipment Division and General Manager and Head, L&T Medical; Anjan Bose, Conference Chairman and Vice President and Business Head, Philips Healthcare; Dr. Prathap C Reddy, CII National Committee on Healthcare and Chairman, Apollo Hospitals Group; and Ajay Pitre, Vice Chairman, CII Medical Equipment Division and MD Sushrut Surgicals Pvt. Ltd., presented

(L-R) Mr. Chandrajit Banerjee, Sri Dinesh Trivedi, Dr. Pratap C Reddy

their views on medical technology being a key factor in transforming India’s healthcare scenario and the aim of the conference to • Understand the current and anticipated Indian Medical Technology Industry landscape • Understand various demand side hurdles such as affordability, accessibility and awareness • Identify novel initiatives taken by industry participants and Government to facilitate growth and greater access to mass markets • Provide an understanding of building sustainable collaboration models to realize synergies – • Multinationals leveraging on India’s product and cost capabilities while providing Indian medical devices scope for growth and expansion on the global platform

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Come up with innovative business solutions that can increase the pace of growth in medical technology adoption

Sri Dinesh Trivedi, Minister of State for Health and Family Welfare, Government of India gave the inaugural address highlighting the role of the Government in providing the requisite impetus for the augmentation of the medical technology industry in India. In addition to the inaugural and valedictory sessions, the conference was divided into four sessions that focused on • Indigenous Manufacturing and Technology Solutions for Affordable Healthcare • Partnering with Technology to Make Healthcare Accessible • Regulatory: Ways and means to ensure quality healthcare

December 2009

EVENT REPORT

Mr. Sam Pitroda, Chairman, Natioanl Knowledge Commission

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CEOs Panel Discussion on Innovation and its impact on Patient Care

The speakers at the plenary session 1 on indigenous manufacturing and technology solutions for affordable healthcare—Dr. Ajit K Nagpal, Chairman – Executive Council of Batra Hospital and Medical research Centre and Debasis Panda, Joint Secretary, Minister of Health and Family Welfare, Government of India talked about the non availability or non affordability of healthcare services in India. They talked about how medical technology can play a crucial role in bridging this gap, however it needs to be designed keeping in mind the local needs and also at a relatively lower cost. The major focus of this session was on technology solutions, trying to arrive at a roadmap which can give a boost to indigenous manufacturing. The eminent panellists further discussed the key issues that impede indigenous manufacturing and the most probable solutions that may improve this scenario. Considering the rapid increase in demand for healthcare services that have forced the government to rethink upon the delivery model, the government is now ready to think out of the box and proactively involving private sector to increase the reach of healthcare services.

December 2009

Anecdotal evidence suggests that partnering with medical technology industry can significantly improve health indicators like IMR,MMR or providing high end diagnostic services. These models have proven to be sustainable and successful. The need of the hour is to take on these projects at a larger scale so that the number of beneficiaries can increase significantly. For successful implementation of these projects a lot of challenges need to be overcome, political will power, risk sharing mechanism to name a few. To aim of the next special plenary session was to find a way to overcome these challenges. In this session on Partnering with Technology to Make Healthcare Accessible, Sam Pitroda, Chairman of National Knowledge Commission, Government of India shared his views and ideas on partnership opportunities amongst government and medical technology industry. The other key speaker of this session was Sangita Reddy, Executive Director of Apollo Hospitals Group. While the Indian healthcare scenario is characterized by lack of standardization and ambiguity on regulatory standards a lot has been achieved in the pharma segment in terms of optimal regulation and the same needs to be replicated for the medical devices and healthcare delivery sector. Proper regulation

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can help the industry positively by harmonizing it with the rest of the world, though with local needs in consideration. The second plenary session, hence focussed on regulatory ways and means to ensure quality healthcare. The moderator of this session was Ajay Pitre, who along with a host of eminent panellists touched upon what is the sort of regulatory framework required for medical technology segment, which simultaneously ensure the cost of technology increase significantly due to regulation. The panel discussions also focussed on the role of the government and private sector in regulating this industry. Bringing key examples from the pharma segment, Dr Surinder Singh, Drug Controller General of India, Ministry of Health and Family Welfare delivered a special address on regulation of medical devices in India. The plenary session III was the CEO’s panel discussion on innovation and its impact on patient care. Several key people from the medical technology industry participated in this session and talked about how innovation has helped companies in achieving the dual objective of better patient care and increase in the market size. The conference ended with the final valedictory session focussing on changing dynamics of medical technology – addressing expectations of healthcare deliverers. The session focussed on analysing the needs and expectations of healthcare deliverers and how medical technology is shaping up to provide potential solutions for the same. The presence of several key personnel from the healthcare sector, medical technology industry and the Government made the conference and important knowledge sharing platform for all who attended it and succeeded in resolving issues pertaining to the role of medical technology and transforming the healthcare scenario in India.

EVENT REPORT

HEALTH CONCLAVE 2009 Managing Challenges of 21st Century in Healthcare Organisations

ndian Institute of Health Management Research (IIHMR) organised a two day conference “Health Conclave 2009” during November 18-19, 2009 to address and manage the key challenges of the 21st century in the healthcare industry. The conference, which was held in New Delhi was sponsored by the Government of India; National Disaster Management Authority; Quality Council of India; World Health Organization (Country Office for India); National Health System Resource Centre, New Delhi; Sulabh International Social Service Organization; IBM; and Centre for Excellence in Project Management. The conference focused on developing win-win strategies for better management of healthcare practices by networking of academicians, government officials, corporate executives and practitioners from all over the country. The Guests of Honor at the conference, Lt. Gen. JR Bhardwaj, Member, National Disaster Management Authority, Government of India and Dr. Captain (Retd.) Mozibur Rahman Fakir, State Minister of Health and Family Welfare, Bangladesh addressed the conference in the inaugural session. Lt Gen Bhardwaj emphasised the importance of appropriate capacity building in terms of infrastructure as well as human resource. He also highlighted the importance of establishing strong disaster management services for an effective healthcare system in the country as exemplified by the current H1N1 pandemic. Dr. Captain (Retd.) Mozibur Rahman

Gen. NC Vij addressing the audience

Fakir discussed the current status of healthcare services in Bangladesh and its focus on using technologies like creating community database to enable effective decision making in healthcare. The Chief Guest, Gen. NC Vij, Vice Chairman, National Disaster Management Authority, Government of India delivered the inaugural address, emphasising on the importance of climate change, disaster management education and other preventive measures in government initiatives in disaster management. The first day of the conference saw two parallel sessions – parallel session I, which comprised of the technical sessions and parallel session II, which comprised of student paper presentation. The topics of discussion for technical session in parallel session I were: • Managing Globalization and its Impact

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Forays in Quality Management • Building Effective Healthcare System The keynote speakers, of the first technical session on managing globalization and its impact, were Dr. Kevin Fickenscher, Executive Vice President, Perot Systems Corporation, USA and Dr. Shiban Ganju, Chiarman, Atrimed, USA. The focussed on what India should and should not learn from the west. The session was chaired by Dr, Ajit K Nagpal, Convenor, Task Force, health Sector Reforms, J&K State and provided key insights into the impact of globalization, financial recession and customer insights for the improvement of the health sector. The second technical session on forays in quality management was chaired by Dr. Girdhar J Gyani, Secretary General, Quality Council of India and included various presentations that focused on improvement of quality,

December 2009

EVENT REPORT

laboratory accreditation and physical environment as enabler of healthcare safety. The keynote address of this session, delivered by Mr. Nicholas G Middleton, President, Apac and Global Growth, Simpler Consulting UK, focused on lean healthcare concept, its global application and Indian perspective. The third and fourth technical sessions on day I focussed on building effective healthcare system. Dr. AK Shiva Kumar, Member, NAC and Adviser UNICEF and Mr Adesh Jain, President, Centre for Excellence in Project Management Pvt Ltd delivered the keynote addresses during these sessions. Mr. Daljit Singh, President – Strategy and Organizational Development, Fortis Healthcare provided key inputs for the development of an effective healthcare system in India. The programme for day II was segmented into three parallel sessions, two of which were technical sessions and one was the student paper presentation session. The topics of discussion for technical session in parallel session I on day II were: • Medical Counter Measures in Disaster • Special Counter Measure for CBRN Casualties • Medical Counter Measure Logistic and Supply Chain Management • Are we Prepared for Possible Disaster This parallel session focused on various topics on disaster management such as building trained human resources to improve trauma care in India, preparedness and emergency medical response to CBRN casualties and the state of public health during a disaster. A panel discussion was held during the last technical session focusing on our preparedness for a possible disaster in future. The key panellists

December 2009

(L-R) Dr. Captain (Retd.) Mozibur Rahman Fakir, Gen. NC Vij, Surgeon Rear Admiral Dr. VK Singh, Lt. Gen. JR Bhardwaj, Mr Pawan Kumar Taneja.

included Dr Shakti k Gupta, Head, Dept. of Hospital Administration, AIIMS; Dr P Ravindran, Director, Medical Relief, Ministry of Health & Family Welfare, Government of India; and Dr Rajiv Kumar Jain, Director (Health & Family Welfare), Ministry of Railways, among others. The topics of discussion for technical sessions in parallel session II were: • Clinical Governance through Health Information System • Health Insurance for Sustainable Healthcare Delivery Outcomes Considering the crucial role of health informatics, the first technical session of parallel session II focused on certain key areas in this arena, such as smarter health networks, emerging role of workflow and decision marking systems in clinical governance, open source solutions in healthcare IT management and techno managerial for highly effective health management programme. Mr Sunil Nandaraj, National Professional Officer (Health Systems Development), WHO Representative Office

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delivered the keynote address on healthcare reforms in India, in addition to Dr. Arun Sood, Prof., Computer Science, Co-Director, Laboratory Cyber Centre who spoke on security of information system for healthcare. Technical sessions in parallel session three focussed on quality management initiatives in public health. The inaugural address of this session was delivered by Mr PK Pradhan, Medical Director, National Rural Health Mission. Some of the key speakers of this session included Sh Amarjeet Sinha, Joint Secretary, NRHM; Dr. Girdhar J Gyani; Dr JN Sahay, Adviser Public HealthQuality Improvement, NHSRC; Mr JP Misra, Principal Specialist, GTZ HSS; and Dr. T Sundaraman, ED, NHSRC, New Delhi. The conference was one-of-itskind as it addressed certain key issues such as disaster management and quality management in public health. Inputs from key personnel from different sectors in the healthcare industry added value to the conference, which achieved its purpose of managing key challenges in the 21st century health system.

NEWS REVIEW

Philips Organises Conference on Sleep Apnoea Philips Respironics recently organised a conference called “wake up to sleep”. The conference was based on the current scenario and future of sleep disorders in India. 17 key opinion leaders in the field of sleep medicine were present to discuss and brainstorm on various issues related to sleep disorders. Some of the prominent names are as below: • Dr JC Suri: HOD Pulmunary critical care and sleep medicine, Vardhaman Mahavir Medical College and Safdarjung hospital, New Delhi. Also President of Indian Sleep Disorder Association. • Dr Sujit Rajan, Sr Consultant, pulmonary Medicine, Bombay Hospital • Dr. Prashant Chhajed: Fortis and Saifee Hospital, Mumbai. • The topics that were discussed were: • Limited data available on prevalence of sleep disorders in India. Hence more studies and research required in the field. • Lack of awareness among general physicians and other specialists is an issue that needs to be addressed. • Economic event of sleep apnoea was discussed, citing some examples of disasters linked to sleep disorder. • Healthcare cost containment related to early diagnosis and treatment of sleep apnoea. • Long term (hypertension, type 2 diabetes, stoke, cardiac arrhythmias) and short term effects (excessive daytime sleepiness, loss of memory, lack of concentration etc.) of sleep apnoea. • Local service infrastructure to be provided by manufacturers of sleep diagnostics and sleep therapy equipments. • Need to look into import of quality products that are US FDA approved and CE marked.

Eight New AIIMS-like Institutions to be Constructed In order to expedite the construction of eight new All India Institute of Medical Sciences (AIIMS)-like institutes in the country, Union health minister Sri Ghulam Nabi Azad announced incentives of up to Rs 10 crore for early completion of these projects. Speaking at the 37th convocation of AIIMS on Monday, Azad admitted that the institute was not able to concentrate on research, the main objective for which it was set-up, because of heavy patient load, especially from outside the capital. With eight AIIMS-like institutions across India in the pipeline, the minister is confident that it will help in reducing the patient load at the institute. The ministry is also upgrading 19 medical colleges which will have super-speciality facilities. Addressing a large gathering of students, professor and other AIIMS staff, President Pratibha Patil asked young doctors to devote a few year of their professional life to work for the rural sector and encouraged them to take up rural postings.

Narayana Nethralaya Pilots Breakthrough Telemedicine on iPhone Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore which has been involved in pediatric community eye outreach programs for over 25 years has helped evolve a unique tele-medicine software which allows screening of rural and semiurban infants for a potentially blinding condition called Retinopathy of Prematurity along with other common conditions including ocular cancers. The institute has helped provide the access of this software on the iPhone. The new pilot will run for 36 months at which time we expect TeleROP to be deployed on a much broader scale across the country and soon in other countries.

NComputing bags ‘Project Panchdeep’ deal from ESIC and Wipro NComputing won a contract from Employee State Insurance Corporation (ESIC) and Wipro for ‘Project Panchdeep’, one of the largest e-governance projects in India. The project will aim to streamline insurance and healthcare services provided by ESIC to employers, employees and state and central government workers. The initiative includes the computerization of various set-ups across the nation. It will also issue 20 million medical ID cards that can be used at any ESIC facility and will also rollout Unified Information System. Wipro had bagged the project from ESIC worth Rs. 1182 crores. NComputing’s L130 thin clients will be deployed for the project, and over 31,000 L130s will be connected to Wipro’s desktop PCs operating on Windows OS, which will then connect to the cloud computing environment in India at ESIC datacentres. December 2009

NEWS REVIEW

Carestream Health India Announces New Tabletop Laser Imager For High-Resolution Medical Imaging Printing Carestream Health India has announced the availability of its latest innovation with the high-image quality Carestream DryView5850 Laser Imager. The machine brings tabletop convenience and outstanding reliability with extra-sharp 508 pixels-per-inch resolution that makes it ideal for medical imaging applications and digital mammography. The new DryView 5850 laser imager addresses the need for affordable laser-quality film output from full-field digital mammography (FFDM) and CR-based mammography systems. It delivers extra sharp 508 ppi resolution every time on every size film. The imager, with two on-line film trays, supports DICOM printing for mammography and general radiography. With a simplified user panel and capability to change films in full room light, it is easy to operate. Moreover, the DryView technology does not use thermal print heads thereby requiring minimal maintenance. The product has been accorded marketing clearance by the US Food & Drug Administration (FDA). “The compact nature and simplicity of use of the machine will be extremely helpful for imaging centers, hospital departments, and clinics alike. Besides, the high-quality of output will result in accurate and better diagnosis and treatment,” informed Prabir Chatterjee, Managing Director of Carestream Health India. Carestream Health’s laser imagers are available in three models that range from tabletop systems designed for low to medium level output to fully featured units designed for high volume, multi-modality output These laser imagers offer output from PACS, CT, MRI, computed radiography and digital radiography systems, and other grayscale imaging applications. The company has installed more than 60,000 laser imaging systems around the world that serve radiology departments, imaging centers and small clinics, dedicated modality printing and mobile applications. Its laser imagers deliver proven great performance and earn consistently high customer satisfaction ratings. The company originated as a business unit within Eastman Kodak Company and brings from its former owner a proud history of innovation, more than 110 years’ experience in health imaging, and over 1,000 patents in digital and film imaging and information technology. As a result of its innovative product portfolio and broad global sales, service and distribution capabilities, products from Carestream Health can be found in approximately 90% of hospitals and dental practices around the world.

December 2009

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NEWS REVIEW

GE Healthcare Collaborates with InterComponentWare (ICW) to Deliver eHealth Solutions In order to further promote the exchange of clinical expertise beyond imaging solutions, GE Healthcare is delivering global solutions enabled by ehealth technology partner ICW headquartered in Walldorf, Germany. This collaboration drives eHealth solutions such as virtual and personal patient health records, and master patient index, in order to match clinical information to the right patient, as well as care and disease management IT solutions. The combination of these solutions can help to optimize workflows across vendors, care providers and institutions, and supports safer diagnoses and better patient care. The result is expected to reduce costs and enhance productivity for all parties. GE’s Centricity RIS/PACS is a web-based solution that offers an extremely fast streaming technology which enables the system to run in region-wide and multi-hospital environments even under low bandwidth conditions. Its full XDS capabilities offer the radiologist to access information from multiple systems even beyond radiology on a single desktop. On top of its embedded Maximum Intensity Projection Module/Multiple Planar Reconstruction (MIP/MPR) functionality Centricity RIS/PACS provides advanced clinical tools and 3D technology in order to easily evaluate huge sets of data. This supports cost-effective image exchange projects throughout several care providers and vendors. At the same time, fast access to vital patient information is leading to more timely and safe diagnoses for patients. GE Healthcare’s long-lasting experience in medical devices and IT has led to a series of new technologies, driving the commitment to interoperability further. It also launched a remote viewing and image sharing workstation (AW-Server) where all processing is done on a web-based server. Office PCs virtually turn into a multi-modality 2D, 3D and 4D postprocessing workstation. The efficient combination of AW-Server with Centricity RIS and PACS promotes extensive reporting capabilities, streamlined radiology workflows and a smooth collaboration between internal clinicians and referring physicians, enabling safe diagnoses and thus better patient care.

Centre to Infuse Health and Life Cover IBM Creates POC Diagnostic Test for Over Six Crore Poor Families The insurance regulator has proposed a new consolidated health and life cover for over six crore poor families that will replace all existing insurance schemes sponsored by the central and state governments. The Insurance Regulatory and Development Authority (IRDA) plans to provide every poor family a life cover of Rs 1.5 lakh and a medical cover of Rs 1 lakh. An integrated cover will cost Rs 1,500 per annum, of which the Centre will bear half the premium and the rest will be shared equally by the states and the beneficiaries. The proposal, estimated to cost Rs 12,000 crore, will cover most families in the unorganised sector and will replace all other central and state-sponsored insurance schemes. The insurer, who underwrites the policy, will also get a profit, making the scheme commercially viable. In this case, the Centre’s share of the premium works out to around Rs 6,000 crore per annum, and about Rs 30 a month for a poor family. Today, both the Centre and the states spend over Rs 4,000 crore on social insurance schemes with different claim ratios. It is believed that the insurance coverage and costs can be optimised with a well-designed scheme that integrates all the risk covers: health, partial and full disability, and death.

IBM scientists have created a one-step pointof-care-diagnostic test, based on an innovative silicon chip, that requires less sample volume, is significantly faster, portable, easyto-use, and can test for many diseases, including cardiovascular disease. The results are so quick and accurate that a small sample of a patient’s serum or blood, could be tested immediately following a heart attack, to enable the doctor to quickly take a course of action to help the patient survive. The diagnostic test uses capillary forces to analyse tiny samples of serum, or blood, for the presence of disease markers, which are typically proteins that can be detected in people’s blood for diagnostic purposes. IBM scientists have encoded the forces of capillary action on a microfluidic chip made of a silicon compound, similar to those used in computer chips, thus leveraging IBM’s vast experience in developing and manufacturing silicon semiconductor wafers. The chip, which measures 1 x 5 centimeters, contains sets of micrometer wide channels where the test sample flows through in approximately 15 seconds, several times faster then traditional tests. Uniquely, the filling speed can be adjusted to several minutes when the chip requires additional time to read a more complex disease marker. IBM scientists designed the chip with flexibility in mind in both its form and uses. Due to its small size the chip can be embedded in several types of form factors, depending on the application, including a credit card, a pen or something similar to a pregnancy test. Besides diagnosing diseases, the test is also flexible enough to test for chemical and bio hazards.

Tata Elxsi and Narayana Hrudayalaya Enter into Strategic Alliance Tata Elxsi Ltd and Narayana Hrudayalaya announced the signing of a MoU to mark their strategic alliance to develop affordable, high quality healthcare solutions. The partnership brings together Tata Elxsi’s technology and design expertise and Narayana Hrudayalaya’s domain knowledge to develop medical devices for the mass market. While Tata Elxsi, through its industrial design division, IDE, will undertake the entire design and development work of the devices, Narayana Hrudayalaya will provide support for problem identification, domain knowledge and clinical trials.

December 2009

Lifeclinic International Forays into India Lifeclinic International, Inc., the world’s leading manufacturer and distributor of automated blood pressure monitors and Health Stations has launched nationally here in Hyderabad through its Indian partner Lifeclinic India. Lifeclinic’s products are FDA approved and meet AAMI (Association of Advanced Medical Instrumentation) and WHO (World Health Organization) standards. Lifeclinic’s entry into the national market brings a critical service which will allow individuals to engage in their own health and wellness. The Lifeclinic Automated Health Stations provide tools for a natural transition into self-healthcare and chronic disease management. It helps identify early risk factors and prevent progression. The machines can be ideally installed in any public place like: airports, bus terminals, railway stations, super markets, shopping malls, health clubs, corporate offices and large medical stores. Railway stations and metro railways can keep these health stations in waiting rooms, ticketing counters; star hotels for their guests, corporate houses for the benefit of their employees. In addition to its unique, self-testing technology, its new Web-enabled health stations provide healthcare professionals and employees with data-tracking and management tools to enhance program effectiveness. Lifeclinic’s blood pressure monitors, health stations and health management systems make it easy for individuals to take an active role in their healthcare while enabling corporate management to reduce healthcare costs and improve the health and productivity of their employees. More than one thousand employers have installed several thousand Lifeclinic self-testing health stations at worksites as a part of their Corporate Wellness Program. The Lifeclinic LC500 provides automated measurements of blood pressure, pulse, weight, body fat, Blood Oxygen and BMI. Peripheral input ports interface with various personal health devices, including glucose meters and pedometers. The LC500 is Internet-ready for secure, HIPAA-compliant, connection to health and wellness tools.

news round-up of the whole week...

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December 2009