eHealth February 2013

asia’s first monthly magazine on The Enterprise of Healthcare

volume 8 / issue 02 / february 2013 / ` 75 / US $10 / ISSN 0973-8959

Dr K K Aggarwal VP, IMA

‘Coca Cola, Pepsi have Reached to Rural India but Healthcare has not’

iNdian

ultrasound

Strides in mapping within The fervent doer Sameer Khan, CEO, Rockland Hospital

A Pancreatic

eHealth Magazine

Surgeon’s Vision Dr Shefali Agrawal Senior Consultant Hepatobiliary & Pancreatic Surgery, Apollo Hospital, New Delhi ehealth.eletsonline.com

volume

issue

contents

ISSN 0973-8959

Dr K K Aggarwal MD, Padmashri & Dr B C Roy National Awardee, National Vice President, Indian Medical Association (IMA)

cover story Ultrasound The Game Changer tech trend Managing Information: Your Lab’s Biggest Asset!

exclusive PSRI sets the stage right for Indian healthcare

speciality Changing Face of Radiology Radiology of Today and Tomorrow Radiology Outsourcing: The Next Big Thing?

22 20 30 32 34 36

zoom in Chronic Disease Management Takes a Turn CDSS Blends Evidence with Expertise

42 52 57

38 62

46 44 64

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Dr PS Reddy, Chairman, SHARE (USA) Dr N Ramakrishnan AB (Int Med), AB (Crit Care), AB (Sleep Med), MMM, FACP, FCCP, FCCM, Managing Director, Chennai Critical Care Consultants

in focus ICT-Empowering Patients “Early Diagnosis is Imperative” Healthcare Scenario in India

expert corner

case study Palisade’s Neural Tools Helps Replace Gadolinium for Brain tumors

60 66

expert speak

Dr Arun Nair, Consultant in pulmonary diseases, Narayana Hrudayalaya Hospital, Bangalore

in conversation Dr Shefali Agrawal, Sr Consultant Hepatobiliary & Pancreatic Surgery, Apollo Hospital, New Delhi

policy ‘Coca Cola, Pepsi have Reached to Rural India but Healthcare has not’

asia’s first monthly magazine on The Enterprise of Healthcare volume

issue

February 2013

President: Dr M P Narayanan

Partner publications

Editor-in-Chief: Dr Ravi Gupta group editor: Anoop Verma

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editorial

A New Perspective on Healthcare It has been in the news that the Congress President, Shrimati Sonia Gandhi, is going to launch a new childcare initiative in Palghar, town, situated on the outskirts of Mumbai. The programme assures a package of health services for all children up to 18 years of age. A part of the National Rural Health Mission (NRHM), this child health screening and early intervention programme has been named the Rashtriya Bal Swasthya Karyakram. The programme will be extended to cover all districts of the country in a phased manner, ultimately hoping to cover 27 crore children. There is no doubt that a country like India needs this kind of a scheme. The advent of latest technologies in healthcare has made it possible for many more people in the country to access healthcare, but there still exists a large section of the population, the urban and the rural poor, who are unable to avail proper treatment. In the current issue of eHealth, we are focusing on the different facets of ultrasound diagnosis. Today it is difficult for us to even think of treating ailments without going for an ultrasound procedure. In the article, we have taken the views of some eminent doctors on how the ultrasound technique is benefiting the patients. In addition, eHealth February edition is enriched with insights from Dr KK Agarwal, VP, Indian Medical Association (IMA). He has spoken about the elements that are hindering the growth of the Indian healthcare and also has suggested ways to improve the scenario. Feature on Laboratory Information System (LIS) will give you the technology updates that the healthcare sector needs. Also there are a whole lot of other elements, including articles on Radiology, which is a compact story on the present status of Radiology in India. I am glad to introduce new sections in the magazine that are expected to serve our valuable readers’ interests more. The section on newly launched product has been named ‘Launch Pad’ and I hope you would like reading the Last Page of the magazine too, which is a fresh initiative from the eHealth edit team. On 6th March, 2013, we are going to organise the eOdhisa event in Bhubaneswar, Odhisa. The Government of Odhisa is the host partner of the event. The one-day occasion will also have a powerful track on Healthcare, along with those on e-Governance and Education. Eminent stakeholders of all the three verticals of Health, Governance and Education will grace the occasion. We hope to see you at the eOdhisa event to participate in discussion on ways by which we, the people of this country, can have access to worldclass healthcare.

Dr. Ravi Gupta ravi.gupta@elets.in

february / 2013 ehealth.eletsonline.com

volume

issue 2

february 2013

asia’s first monthly magazine on The Enterprise of Healthcare

Social Circle Prof Jeff Karp @Prof_Jeff_Karp tweets, SMART card containing your genetic information and medical history to diagnose / treat diseases at ATM-style kiosk http://shar.es/Yapsq Lisa Gualtieri @lisagualtieri tweets, mHealth is more relevant in India than eHealth w/900 million mobile phoneshttp://ehealth.eletsonline.com/2011/11/ state-of-mhealth-in-india/ via @ehealthonline cc@ fionajasmine Samit Biswas @samit2009 tweets,Genes and obesity: Fast food isn’t only culprit in expanding waistlines -- DNA is also to blame http://newsroom.ucla.edu/ portal/ucla/genes-and-obesity-fast-food-isn-242332. aspx Beams Hospital@BeamsHospital says,Take some time out from your busy schedule and walk! See what a 30 minute walk, five days a week can do for you? http://fb.me/1RwprTpRb @DellHealth Physicians and other #healthcare providers must be especially careful when using social media http://del.ly/hcsm Dell Healthcare@DellHealth tweets a question: Should doctors and patients be Facebook friends? #WSJ -http://del.ly/6017nBsx Orange Healthcare @OrangeHCare tweets 80 percent of IT executives agree that EHR-based systems will improve patient care. The healthcare IT challenges for 2013: http://bit.ly/TDLJrS Facebook Like of the Month

Tanvi Chauhan Presently dentist at family healthcare hospital Studied at Indian Institute of Health Management Research

inbox Readers Speak Anonymous commented on “Leading the Way in Indian Healthcare” Technology is a blessing in every industry. I’ve seen it in hospitals, especially during my all-too-frequent trips to the ER. I’ve been stuck waiting in hospitals that had old, outdated systems. These slow and cumbersome systems had everyone waiting longer than necessary. Once, I took a friend to the ER at a hospital that had a large screen that was constantly updating itself with the latest statuses of all the patients and whether or not certain rooms were occupied. One glance was all it took for a nurse to know exactly where he or she needed to take the patient and what needed to be done. We were out of there in no time. Christian louboutin wedge commented on “India’s first heart implant training centre” Interesting intriguing write-up. One other problem is that mesothelioma cancer is normally attributable to the breathing associated with fibres coming from asbestos, which is a positivelly dangerous content. It is frequently seen amid individuals inside the engineering industry who’ve extended contact with asbestos fibers. It’s also brought on by moving into mesothelioma insulated complexes for a long time of time, Inherited genes takes on an important role, and a few people are more susceptible to the threat than other individuals. Ajay commented on “Do we need managed care in India?” Managed Health Care, From which stage of a Persons life do we start managing the Healthcare? If we start managing the healthcare of a person from the day he/she comes into this world , then it makes more sense and is sustainable. Preventive Healthcare has to be managed. Baby & Mother need to be given correct food,nutrients,vaccines on time ,this needs to be monitored.(will definitely reduce the ailments which crop up due to the miscare at this age).If the care is tracked properly and periodic checkups are conducted the baby & Mother will be healthy and happy(The family will save on time,money,tensions and enjoy a happy life). Productivity of the other members of the family will improve. This management of the healthcare would lead to general good health across the population. Even if people fall sick the cost & Time to recover will be less, as the disease id diagnosed at a very early stage and treatment generally at this stage is Cheap and fast., rather than coming to a hospital at a very later stage when the disease had progressed and the cost of curing has gone up. Make preventive healthcare compulsory to claim advance healthcare treatments

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cover story

Ultrasound

The Game Changer Indian ultrasound story has walked ahead from black and white equipments to 3D color dropplers. Experts say more are there in store, a closer look!

iagnosis is the first step of treating any disease and ultrasound is one of the most commonly used diagnosis process for curing a disease. Itâ&#x20AC;&#x2122;s a safe, painless method for examining the internal organs that avoids the use of radiation. Instead, high-frequency sound waves are generated and the echoes that result from their bouncing off the soft tissue structures are used to measure size, to detect structural abnormalities etc. Doctors recommend ultrasound test for a various uses. In obstetrics,

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to monitor growth of the baby and check that there are no abnormalities. In urology, for diagnosis of urinary bladder, scrotal, prostatic and kidney disease and the like.

How it works Ultrasound examination is a painless procedure that takes between 15 minutes to one hour to complete. Usually, a lubricating gel is used to help conduct the sound waves into the body. This is applied on the skin by the lab person then a probe is held against

the skin and moved over its surface. While the ultrasound scan is in progress, the images are displayed on a video monitor. Permanent copies of the examination results can be produced as still pictures or as a video recording. For more specialised kinds of ultrasound examination the probe is inserted into the body. For example, the probe can be swallowed into the gullet (oesophagus) in order to obtain detailed pictures of the heart valves.

Indian Ultrasound Market is Growing Fast Dr Sanjay Arora

Managing Director & Founder, Suburban Diagnostics

ndian ultrasound market is one of the few markets in the healthcare industry that has emerged profitable during the economic downturn in 2008-2009. India is one of the fastest growing regions for the ultrasound market, marking an expected compound annual growth rate (CAGR) of about 15 percent between 2009 and 2016 as observed by Frost & Sullivan. The reason behind this growth is high population, booming economy, Governmentâ&#x20AC;&#x2122;s efforts to decrease maternal and infant mortality rate and high-end, user-friendly machines. There is a rise in demand for ultrasound machines designed for specialities such as cardiology and radiology and in the knowledge of the advantages offered by the portable color ultrasound systems. Increasing awareness about screening for breast cancer has driven the number of ultrasound procedures. Advanced technology such as echocardiography has evolved into a non-invasive method for imaging, driving further growth. Diagnostic success rates, a decreasing price trend, improved handling of the devices and the use of ultrasound as a primary screening method for breast cancer are key factors influencing the volume of ultrasound procedures in India. Advancing technology has freed ultrasound users from the physical restrictions of cart-based systems, making it easier to bring the imaging to the patient instead of bringing the patient to the imaging and that too without sacrificing image quality. The total ultrasound market revenue in India in 2011 was estimated to be nearly USD120 million and the

market is expected to double by 2015; while the global market for ultrasound equipment is projected to reach USD 6.9 billion by the year 2017, driven by applications in new segments, such as administration of emergency medicine and introduction of portable, handheld ultrasound devices. While demand for ultrasound equipment from developed regions is primarily expected to emanate from replacement demand, strong economic growth and increas-

The ultrasound market in India is growing at a steady pace mainly because the Government is implementing schemes to reduce mortality rate. Central schemes like the Janani Suraksha Yojna have been launched so that the rural women can avail professional medical care during pregnancy and have deliveries in primary health centres and hospitals, rather than at home

it dominates Indian ultrasound market with a 12.9 percent growth in revenues.

Mid-end color doppler Mid-end Color Doppler equipment is the most preferred purchase, with sales of 1456 units, valued at `220 crore. High acceptance of mid-end ultrasound equipment by the medical fraternity with its increasing usage in obstetrics/ gynecology, regional anesthesia, pain management, oncology, rheumatology, and various surgical applications has led to an impressive value-wise and unit-wise contribution of 44 percent in this segment.

Portable ultrasound machines Portable ultrasound segment is expanding rapidly as the functionality of these systems has approached that of the cart-based systems. With total sales of 780 units, portable segment is valued at `57.6 crore.

Black and White ultrasound systems

ing healthcare spending in developing markets are expected to fuel demand for new equipment. Asia Pacific constitutes the fastest growing regional market with a CAGR of 9.4 percent in 2011.

The sale of black-and-white ultrasound equipment is gradually declining every year. A 10 percent decline in portable and a 15 percent decline in standalone were seen in 2011.

Market status

Growth promoting factors

According to Frost & Sullivan, ultrasound equipment market in India stood at `600 crore (USD 120 million) in 2011, with total sales of 4431 units. Color Doppler continues to edge out their black-and-white counterparts, increasing their dominance to 93 percent. With 3341 units of Color Doppler sold in 2011

The ultrasound market in India is growing at a steady pace mainly because the Indian Government is implementing schemes to reduce mortality rates during pregnancy. Central schemes like the Janani Suraksha Yojna have been launched to encourage more rural women in the poor strata

february / 2013 ehealth.eletsonline.com

cover story

Strict compliance with the PNDT Act may impede the installation of ultrasound equipment to avail professional medical care during pregnancy and have deliveries in primary health centers and hospitals, rather than at home. The Government is also providing cash benefits and free antenatal checkups for expectant mothers through such schemes. Ultrasonography is now finding applications in several medical specialities. In cardiology, it is possible to analyse the rate of blood flow and narrowing of blood vessels by measuring the frequency of reflected waves. Realtime scanners can capture moving images like the heart beating. They also aid physicians in conducting biopsies by guiding the fine needle into the tissue mass. Recent advances also allow for guided antenatal procedures like amniocentesis, which is done to detect disorders like Downâ&#x20AC;&#x2122;s syndrome, etc. Smaller, high-resolution ultrasonic probes also find applications in the study of small organs like thyroid, salivary glands, etc. These are also used to detect hemorrhages and other anomalies in the human eye. In India, mobile medical units with portable ultrasound machines go to smaller towns and villages to provide prenatal checkups and cancer screenings for the breast, cervix and prostate, etc. With these additional, more specialised medical applications coming up every day, the market is growing rapidly, becoming more technologically advanced and user-friendly.

Challenges Despite the development of the ultrasound market in India, there are certain factors that have the potential to restrain this growth. High import duty The high import tax levied by the Gov-

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ernment on ultrasound machines and this cost is passed on to the customers and patients end. The steady influx of low-cost machines from China and Korea has resulted in a price war in the competitive market environment in India, with major players being forced to reduce their margins to stay in the game. PC-PNDT Act On the forefront of all challenges is PCPNDT Act, which had been genuinely enacted to prevent deliberate

female infanticides. It prohibits advertisements relating to prenatal determination of sex and prescribes punishment for its contravention. All places using pre-conception and sex selection techniques/procedures and any place having equipment capable of detecting the sex of the fetus and those related to genetic counseling need to be registered. All genetic counseling centers, genetic laboratories, and genetic clinics, include sonography centers, mobile sonography vans, and those having imaging machines and advanced versions of ultrasound machines require registration. Infertility/sterility clinics and IVF centers also have to be

registered. Strict compliance with the PNDT Act may impede the installation of ultrasound equipment. This has led to a restriction in free movement of ultrasound systems. Safety concerns Ultrasound machines may be relatively safe, but they can still have a mechanical or thermal effect on tissue, especially when a machine uses increased output. Regulations on these machines have not changed the ways in which they can be used in a medical setting, but they have placed the onus on the operator of the machine, rather than the manufacturer to ensure that a diagnostic test is done safely.

Technological advances Point-of-care ultrasonography ultrasound is used across the board to guide or monitor vascular access for procedures. Intravascular ultrasound (IVUS) is primarily used to view the coronary arteries from inside, with the help of high-frequency sound waves this produces cross-sectional images and yields information about the composition of plaques that may have formed on the vessel walls. In fusion imaging real-time ultrasound images are fused with the high resolution, contrast enhancing images produced by modalities like computerised tomography scans, and magnetic resonance imaging. Advanced 4D images in ultrasound allow for the capture of a moving realtime video that markedly improves treatment success rates. Earlier, a major disadvantage of ultrasound testing was that it was very operator dependent; but the recent 4D capability reduces the risk of operator errors and increases user-friendliness and ease of handling. Elastography is another recent trend in ultrasound machines, which can be used to detect tissue elasticity to ascertain the boundaries of tumor masses and check if tumors are malignant.

Advances in Ultrasound What is the size of ultrasound market in India? Who are the dominating players?

What are the market segments of ultrasound machines in India? Which segment is dominating the market?

The approximate size of the ultrasound market is `7 billion for the year 2013. The major players are Siemens, GE, Philips, Mindray and Samsung.

Ultrasound machines are available in premium, high end, mid-range and low-end segments. Mostly, low-end and the mid-range are the two segments sold maximum in India.

What is the percentage of growth in recent years?

What are the new technology advancements in the ultrasound space?

The market is currently growing at 12 percent CAGR.

How crucial is the role of an ultrasound report in treating a patient? Ultrasound is the most economical method of tissues related patients. the treatment depends sound report alone.

common and scanning soft Major part of on the Ultra-

Is it true that the accuracy of ultrasound reports is mostly dependent on the skill of the practitioners? It is true to a large extent that the accuracy of ultrasound reports is mostly dependent on the skill of the practitioners. Recently, courses have been introduced

Ashis Dey

Business Head-Ultrasound, Siemens Healthcare in Government and private centers for getting trained in Ultrasonography.

What is your take on the heavy import duty costs on ultrasound machines in India? Ultrasound units should be more affordable to the needs of India to cater to the large population in rural areas. This will further result in reducing the cost of treatment and the patients will be benefited.

Accuracy Matters How opportune is Indian ultrasound market in terms of growth? Relatively lesser than the other European countries in this regard.

How crucial is the role of an ultrasound report in treating a patient?

Dr Rajkumar

MBBS, DMRT, Radiologist, Bishop Benziger Hospital, Kollam

As far as india is concerned, not every patient is rich enough to do an MRI/CT for evaluation. USG is available at affordable cost and free of radiation hazards and at bedside almost

Virtual-Touch ARFI, Matrix Array Transducer are some of the latest developments.

What are your offerings in this space? Virtual-Touch ARFI is offered by Siemens. Acoustic Radiation Force Impulse (ARFI) technology in Ultrasound was exclusively introduced by Siemens. ARFI technology has been very well accepted worldwide and has also made a revolutionary difference among the Indian user fraternity, for whom early diagnosis of some fatal disorders such as Liver Fibrosis was a challenge.

in every corporate hospital. Most of the times a proper USG report is sufficient to for further treatment.

What are the new technology advancements in the ultrasound space? Elastography, 3D, 4D, Contrast enhanced USG, Harmonics.

What is your take on the heavy import duty costs on ultrasound machines in India? If the import cost comes down it will be good for the radiologists to buy a machine and do the service at a reduced rate.

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cover story

‘Portable Ultrasound is

Expected to Grow at a Steady Pace’ How opportune is Indian ultrasound market in terms of growth? What is the percentage of growth in recent years?

this crisis. In every ten minutes, one Indian dies on the road and ten others get injured. Amongst them, 7 to 10 percent are critically injured, and about 30 percent are disabled for life, either partially or totally.

Due to an increased investment in the healthcare infrastructure, the market of portable ultrasound equipment is growing across the dimensions of the country. It is expected to grow at a steady pace.

What are the common usages of ultrasound in India? How crucial is the role of an ultrasound report in treating a patient? The use of Point-of-Care (POC) ultrasound is not limited to departments traditionally focused on clinical imaging. With technological advancements, point-of-care ultrasound systems have found wide applications such as emergency, critical care, anaesthesiology, sports medicine, pain management, rheumatology, paediatric, dermatology, surgery, oncology, cardiology, and trauma etc are relying on it for diagnosis and assistance with clinical procedures. Indeed, portable units have made the cost for ultrasound technology affordable to more healthcare providers overall, including numerous hospitals and medical facilities throughout India. Point-of-Care ultrasound has many proven advantages. This technology has the potential to transform the way in which Critical Care Units

Nikhil Hiremath

MD, Anesthesia, Inamdar Hospital (CCUs) function. By consolidating and speeding up healthcare delivery as well as minimising patient transports, such technologies can significantly improve patient safety, reduce costly hospital stays, and enhance healthcare quality.

What are the market segments of ultrasound machines in India? Which segment is dominating the market? Traditional applications dominate the Indian ultrasound market; for example in the year 2011, cardiology, radiology and obstetrics and gynecology together were estimated to account for 87 percent of revenues. While, trauma also continues to be one of the major causes of death in India, and the country is beginning to recognise the need to address

It is true that the accuracy of the ultrasound technique and results also rely on one’s skills, experience, education and training 14

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Is it true that the accuracy of ultrasound reports is mostly dependent on the skill of the practioners? In this regard, how Indian medical colleges have been offering courses? Learning a new ultrasound technique or procedure can be challenging and it is true that the accuracy of the ultrasound technique and results also rely on one’s skills, experience, education and training. Courses are designed to teach those who have little or no experience in the use of ultrasound in their daily practice.

What is your take on the heavy import duty costs on ultrasound machines in India? What are your suggestions to deal with the situation? Import duties on ultrasound scanners have increased over the period in India. This cost is passed on to the end customers and patients. All such restraints and challenges hamper the purchase of the equipments.

What are the new technology advancements in the ultrasound space? The most talked about technological trends in the market are the miniaturisation of ultrasound probes.

cover story

â&#x20AC;&#x2DC;Colour Droppler is Dominatingâ&#x20AC;&#x2122; What is the size of ultrasound market in India? Who are the dominating players?

Government authorities. On the other hand there is a paucity of financiers also to facilitate the purchase of the machines, especially in tier II and tier III cities.

The size of ultrasound market in India is currently around USD 120 million, and is growing at not less than 14 percent per annum. Major players are Siemens, Phillips and Toshiba cornering 70 percent of the market.

What are the market segments of ultrasound machines in India? Which segment is dominating the market?

What is the percentage of growth in recent years?

The main market segments are black and white machines, colour dopplers and the laptop ultrasounds. At present colour dopplers are dominating.

India is a growing market for ultra sound segment. Estimated growth is 16-18 percent.

What are the common usages of ultrasound in India? How crucial is the role of an ultrasound report in treating a patient? Common usages of ultrasound in India are diagnostic and guiding interventions of various pathologies of abdomen, pelvis, musculoskeletal, neurosonography, obstetric imaging, Doppler studies etc. Ultrasound is many times the first mode of imaging modality, easily available, can be carried out relatively fast and in experienced hands has a very good accuracy rate. ultrasound does not involve any ionising radiation and often has a crucial role in the management of patients. It is nowadays used more as a screening tool.

Is it true that the accuracy of ultrasound reports is mostly dependent on the skill of the practitioners? In this regard, how Indian medical colleges have been offering courses? Yes, it is true that the accuracy of ultrasound is largely dependent of the skill of the operator. Various institutions do provide short term courses in ultrasound training particularly private institutions.

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What are the new technology advancements in the ultrasound space?

Dr K Kamlakar

CEO, Premier Hospital, Hyderabad

The new technology advances include high resolution 3D, 4D USG, contrast imaging, Elastography of breast, thyroid, liver and prostate.

The ultrasound course materials vary from institution to institution and are not standardised How relevant and effective are these course materials? I guess, they are relevant. However, ultrasound has a long learning curve. Unfortunately the course materials vary from institution to institution and are not standardised. Finally, the accuracy of ultrasound depends on the expertise and experience of the sonologist.

What is your take on the heavy import duty costs on ultrasound machines in India? What are your suggestions to deal with the situation? Being a part of the healthcare delivery system, reduction in import duty may be considered by the appropriate

Miniaturisation of probes, high resolution ultrasonic probes for small organs like thyroid, salivary glands, intra vascular ultrasounds to assess stenotic blood vessels and Fusion Imaging are some advancement in the offing.

What are your offerings in this space? As an accreditation assessor I look at regulatory and statutory compliances of the facility and resources, internal quality control and external quality control of the reporting. Training of the sonologists, credentialing and privileging of radiologists is another area for monitoring.

cover story

MRgFUS

The “New-wave” Surgery Dr Shrinivas B Desai, Director of Imaging and Interventional Radiology at Jaslok Hospital, Mumbai shares interesting insights about the latest technology in ultrasound. In conversation with Nikita Apraj, ENN

naesthesia, incisions, sutures and scars may soon be a history in the field of surgery. Here arrives the MRgFUS – MR Guided Focused Ultrasound, a new non-invasive technique of performing surgeries. The technology which is no less than a magic allows a doctor to see inside the patient’s body, find the tumor and treat it without incisions. It’s no wonder that the technology has revolutionised the traditional approach to different diseases. It is a novel treatment alternative for treating tumors.

No scars, no incisions In this totally new revolutionary technique, the patient lies in the MRI machine. The tumor or part of the body to be treated is mapped under MRI. Under the MRI table, placed is a High Intensity Focused Ultrasound (HIFU) source. The HIFU then destroys the tumor. This is done without touching the patient, without any general anaesthesia, radiation, scar or incision. The HIFU source burns the tumor; it focuses the ultrasound energy to a small peanut-sized spot inside the tumor and heats the spot sufficiently to cause cell death. During the treatment, MRI enables the physician to ‘see’ the tumor and its surrounding organs in

3D, obtain real-time feedback about temperature changes in the treated areas and observe what has been treated, in a totally non-invasive manner.

Fibroids, cancer and even brain tumors At present, Jaslok Hospital performs surgeries of uterine fibroids, adenomyosis, prostate cancer, bone metastasis with MRgFUS. 25-30 percent of Indian women suffer from Uterine Fibriods. Until now, treatment for Uterine Fibroid would often include a surgery. Now, women have the option of choosing a nonsurgical, outpatient method of ablating fibroids using MRgFUS that preserves the uterus and enables them to return to normal activity within one or two days. MRgFUS is FDA (Food &

Drugs Authority) approved modality for treatment of uterine fibroids. “We are also planning to start treatment of breast cancer with this revolutionary technology,” says Dr Srinivas Desai. Jaslok is aiming high with planning to install a brain module on the machine which certainly will be a milestone in Indian Healthcare. “It will enable us to perform brain surgeries without even touching the patient. Different surgeries of the brain can be performed using MRgFUS without opening the skull. MRgFUS brain module will perform surgeries of brain tumors, Parkinson’s Disease tremors, curing epilepsy, debunking, inoperable tumors, and psychotic disorders,” Dr Desai informs proudly.

It just takes a lunch time! Dr Desai cites an interesting case of uterine fibroids. An employee of Jaslok Hospital was suffering from uterine fibroids for many years. She was advised to undergo the regular surgery to get rid of the condition. The lady was not ready to undergo the surgery and was avoiding it. When she learnt that Jaslok has started the MRgFUS procedure, she visited the department during her lunch hours with a hope to find a solution. It took only two hours to complete the treatment and after the procedure, she even went back to her job. It just took a lunch time to get rid of the problem! “We can say this is an out-patient surgery, however we keep the patient overnight in the facility under observation,” says Dr Desai.

Fit for unfits Theoretically there is no contradiction in this surgery. On the contrary, a patient who cannot undergo a regular surgery is an ideal candidate for MRgFUS procedure. It does not require general anaesthesia. It makes it viable and safer for patients with kidney or heart problems who are unfit for general anaesthesia and on the same ground, face problems while undergoing regular surgeries.

february / 2013 ehealth.eletsonline.com

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Ziqitza Aims to be The Top Ambulance Company in Developing World Sweta Mangal, CEO, Ziqitza Health Care Limited (ZHL) reveals the journey of Dial ‘1298’, in conversation with Nikita Apraj, Elets News Network (ENN)

tarted with 10 Ambulances in Mumbai seven years ago, ZHL today runs 868 Ambulances across the country with more than 4500 people working with the company. The name ‘Ziqitza’ comes from words – ‘jigyasaa’ (quest for more knowledge) and ‘chikitsa’ (medical treatment). Born with a vision to serve India’s Ambulance need, Ziqitza has served around 20 lakh people, out of which 6261 were babies delivered on-board.

The business ZHL serves three verticals – a Public Private Partnership model- Ambulance service ‘108’ under NRHM, its proprietary Ambulance service ‘1298’ and outsourced Ambulance services to hospitals. ZHL operates ‘108’ services in Rajasthan, Bihar, Kerala, Punjab and is soon expanding its services in Odisha from 5th March 2013. 1298 model works on cross-subsidy wherein customer pays based on the destination. A patient going to private hospital pays the full fare and those who choose a Government hospital, pay subsidised fare. “This is based on an assumption that people going to government need subsidised services,” Sweta Mangal, CEO, Ziqitza Health Care Limited (ZHL) explains. Besides these two numbers, ZHL also provides services to any hospital that wants to provide their patients an ambulance service.

Expertise and training “Being totally inexperienced in ambulance business, we decided to take help from those who are best in the world,” Mangal adds further, after a long pursuit, the London Ambulance Service

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(LAS) decided to help ZHL start similar services in India. Entire working of 108 under ZHL and 1298 is based on LAS model. Emergency Medical Services Corporation (EMSC), US has helped us in terms of processes, protocols and training standards, etc”.

Pioneer in ambulance industry “Back in 2005, Ambulance was not an industry in India. It was confined to NGOs and political parties. ZHL put out a standardised Ambulance service with standardised prices. ZHL Ambulances have rate card and users pay as per their usage,” she says. “Transparency and ethical values makes us stand out, whatever we have built till date is done without taking any shortcuts and we are proud of it,” she adds.

First Responder Programme “Saving life is a function of multiple stakeholders. In an emergency, a person can help you immediately may be a person standing next to you. However, they can only help if they know what to do,” she unfolds the genesis of First Responder Programme (FRP) which recently entered Limca Book of Records for successfully training 5143 participants in six months. “We launched free FRP camps in schools and colleges of Mumbai, Rajasthan and Kerala because running an Ambulance services without educating people will be futile,” Sweta adds.

‘1298’ helpline for women and senior citizens “We have tied up with 75 NGOs to help women in distress. These NGOs are doing very effective work in their field; however women in distress are not able to reach them many times. We act as a bridge between women in distress and these NGOs.” she adds. The senior citizen’s helpline works closely with 10 prominent NGOs in the field. Any senior citizen requiring assistance can Dial 1298 which will connect them to a counsellor who is available 24 x 7 to assist them.

Future plans

“ZHL put out a standardised ambulance service. Any ambulance in Ziqitza’s caravan is same and provides same quality care.” Sweta Mangal, CEO, Ziqitza Healthcare Ltd

She reveals, “In near future, we want to be the top ambulance company in the developing world. We also want to provide our services in more states of India. The knowledge we have gained over the years running this business in India is very valuable. We would like to utilise this knowledge in other developing countries.”

EXCLUSIVE

PSRI Sets the Stage Right

for Indian Healthcare With undaunted focus on quality healthcare, Pushpawati Singhania Research Institute (PSRI) for Liver, Renal and Digestive Diseases believes the ambiance of the hospital also crucial in healing human body and mind. To explore the mission, vision, achievements of the hospital, eHealth team speaks to the Endoscopic Ultrasonography (EUS) department specialists, PSRI hospital and digs out the following excerpts on different subjects. g

By Sharmila Das, ENN

Tell us about your journey at PSRI. What changes you have noticed during the long stint you have here. What are your views on the current state of Indian healthcare? There are tremendous changes I have seen in the last 15 years. The healthcare sector has progressed quite a lot. fifteen years back there were no hospitals offering specialised services. The advantages of having one to two specilased services are that there is no crowd and secondly you can give more time and attention to patients. Disadvantages are also there! If you stay at one place then patient who are admitted in the hospital may come for a consultation at anytime, may be at some odd hours. At PSRI, the first thing I like most is that management never pushes you for any unethical work and that’s a very big thing. Secondly they treat you gently which is also very rare to experience. Indian healthcare is in shambles; because healthcare is not a priority of the Government. They don’t bother that public health is an important part. If we talk about Government hospitals, they are so poor that most patients will

february / 2013 ehealth.eletsonline.com

Dr (Col ) Arun Kumar

VSM, MD (MED), DM (Gastro), AIIMS, Senior Consultant, Gastroenterology, Liver Diseases & Endoscopy go and die if we know that what type of treatment is given there. The Government has not done anything; they don’t have strategy for the same. They don’t understand 95 percent of health problems are common problems like cough, cold, pneumonia etc.

Don’t you think health insurance can solve this situation if Government intervenes?

Government insurance scheme in Andhra Pradesh is a good example to quote here. YSR Reddy did very good job by providing facilities for heart, kidney transplant, heart surgery for the below poverty people. It worked very well there, but again corruption comes here. Government needs to pay attention to the health sector, must identify what the sector needs. We need to treat common problems first, try to get proper emergency treatments; we need to give value to life

Do you think telemedicine can help treat these issues? To treat a patient with telemedicine is very difficult, because some doctor has to see the patient. If patients are coming to you, you should welcome them. You should make sure that there is no unethical practice. Don’t treat them just as revenue earner; give them good care so that more patients come. See the huge number of patients coming from Afganistan, Nepal and from many more countries. Pay attention to them, give them facility and treat them properly and honestly and I am sure they will generate a lot for

Brief us about Endoscopic Ultrasonography (EUS) being introduced at PSRI Hospital.

Dr Manoj Kumar

MD, BHU, DM (Gastro), SGPGI, Lucknow, Currently Senior Consultant at Pushpawati Singhania Research Institute (PSRI)

Tell us about your journey at PSRI. What are the changes you have seen that technology implementation has brought in the different verticals of PSI? I would say when I joined PSRI, it was the first phase of the hospital. There were around 60 to 70 beds at that point of time, now there are 120 beds. Third phase of the hospital is now and we are planning to introduce 100 plus beds and probably liver transplant, cardiology and other things would come up. We have primarily two specialties, one is gastroenterology and another is kidney related treatments. If I talk about gastroenterology, we had huge scope when I came. Gradually, within 2-3 years, we introduced new software, new kind of endoscopy. When I joined, there was hardly an ICU, now we have 14 bedded state-of-the-art ICUs. These ICUs are competitors to any best ICUs in the world so these are the developments. Overall, PSRI is a progressive hospital. As far as gastroenterologist concerned, we were after to get the EUS at PSRI Hospital and

Endoscopy Ultrasound is a very new technique and very few cities and hospitals have it. Like in Delhi, there are only 4 to 5 centers which have introduced this machine. Reason being, the machine is very costly, it costs around `1 crore. To run this machine you need a skilled person. In Delhi, gastroenterologists are may be around 150 to 200 in numbers, but only 5 to 6 are capable of performing this test. Even EUS is not available if you go to other states like Haryana, Bihar and Punjab. For investigating organs which are placed deep inside the body and where the ultrasound

probe canâ&#x20AC;&#x2122;t reach well, EUS performs better. With EUS, the investigation is more accurate and easier.

How Indian healthcare is aware of using EUS? In India awareness level is very low. The need of performing a diagnostic test is not decided by a patient but by the treating doctors. The doctor will understand the need of this kind of therapy and they will refer to patient.

What is your suggestion to increase awareness about EUS? Writing and publishing it in different media platforms. Let the public, the doctors and let the community read about it.

last September we finally got it. The scope of EUS is though very huge but the utility has not been so much. However, we are trying to change this. The reasons are lack of awareness and cost of the machine.

What are the benefits of undergoing EUS test? There may be very small stone that can be missed out by routine ultrasound. ICT never picks up this stone; even MRI can miss almost 10 to 15 percent of stones. With EUS, you cannot miss a Single stone. Lot of unnecessary surgery/Scans can be avoided

Who provides training to do a EUS procedure? It depends. Either you can go abroad for the training sponsored by the manufacturer company from whom you buy the machine. Because of the high cost of the machine, these training are conducted by them. However, going abroad for EUS training is not a good idea. Indeed Mumbai serves the hub of endoscopic ultrasound and Mumbai was the first place to start giving EUS training in India. I preferred taking necessary training on EUS from Mumbai instead of going abroad.

Dr Suddep Khanna

MD (Med), DM (Gastro), AIIMS, Senior Consultant Gastroenterologist, Specialist in Endoscopy, Liver, Pancreas, Intestinal Diseases & Obesity february / 2013 ehealth.eletsonline.com

Tech Trends

Managing Information

Your Lab’s Biggest Asset! Today’s laboratories are privileged to be able to take advantage of the latest Laboratory Information Management Solution (LIMS ) to operate with the highest level of efficiency, effectiveness, and quality g

By Shally Makin, Elets News Network (ENN)

f you have been in the business of running labs, you must have faced the need to manage larger volumes of data, while complying with stricter regulations and achieving higher quality and efficiency levels. In other words, your lab is a complex operation with many functions and priorities. It requires a Laboratory Information Management System (LIMS) that can multitask. LIMS is designed to help you meet all your information management objectives, manage complex processes, take the headache away from regulatory compliance and give users exactly the information they need, at the right time and in the right format. The past decade has seen an explosion in the number of samples generated for research and analysislargely due to the increased focus on translational medicine and epidemiology. In addition, a significant increase and focus on high quality sample yields and how they are accurately and efficiently managed is now a top concern for researchers who are often charged

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with managing enormous volumes of both samples and their relevant data. This sharp rise in the number of samples researchers are expected to handle along with cost pressures, regulatory compliance, tracking needs and limited storage space have led to significant laboratory streamlining initiatives, and often outsourcing of sample management activities to third-party biorepository or biobank networks, which can more efficiently manage samples and also free up researchers’ valuable time. The real challenge is to find the right solution that meets both your immediate requirements and future needs. As your business grows, your operation must be continually supported without having to “build in” your new process needs, by painfully applying ad-hoc systems or hiring costly external consultants who may not fully understand your business, operation, and legacy systems.

What is Lims? LIMS is designed for the process plants to help run the laboratory efficiently. A fully-featured lab management software makes lab data easily accessible, thereby improving the effectiveness of the laboratory, and meets demanding IT requirements for security, support, and low total cost of ownership. LIMS manages lab samples from scheduling to analysis, manages test methods and product specifications, tracks qualifications to perform tests, records test results against specifications, handles historical data for as many years as desired, and makes lab data available to other systems. It is used by laboratory management staff and technicians, engineers, and operators. LIMS manages lab data with customizable user interfaces designed specifically for laboratory staff. Lab data can be entered directly by technicians, interfaced from test equipment, or imported from another LIMS. Authorised laboratory personnel can record test results, reclassify products, issue certificates of analysis, and take other actions typical of any laboratory.

Benefits LIMS is used for biobanks and biorepositories in advancing today’s discoveries by providing relevant biospecimens to pharmaceutical, clinical, academic and biosciences research, as well as medical and contract research organizations. It is specifically designed to address the unique challenges of managing biospecimen collection, locations, online requests, chain of custody and patient demographics. Organisations that take advantage of our rapidly growing set of informatics tools and technologies aimed at biobanks and biorepositories will realise the benefits of enhanced sample integrity, tracking and audit trail. Hundreds of labs and organisations rely on LIMS to guarantee regulatory compliance and adherence to SOPs. This software makes it more conveni-

Benefits of LIMS • Well organised, accurate and timely availability of data provides both scientific and business users with meaningful information used in the discovery and in the daily decision-making process • Preconfigured to facilitate data capture and specimen management • Facilitates chain-of-custody and handling assurance needs that improve operational efficiencies • Supports organisation-wide inventory control—whether storing or tracking whole blood, tissue, cellular lysates, DNA, RNA, or proteins • Web interface provides centralized global access in a secure environment • Built-in proprietary graphical workflow utility tool allows organizations to easily extend capabilities and tailor the solution to the needs of each laboratory’s unique data capture, result management, storage and specimen handling requirements • Automated sample management module ensures that biological samples are stored safely • Provides renowned analytical equipment, instruments, consumables, reagents, media, services and informatics software • Sample management products and services address the scaling needs of biobanking laboratories worldwide. The critical nature of biobank samples make permanently-attached 2D barcodes for secure sample tracking and chain of custody a superior choice over traditional labels.

ent than ever to: • Document that a sample was appropriately handled and that the analysis was performed by a properly trained, qualified technician • Store and manage equipment and maintain histories • Validate analytical methods • Enhance the credibility of testing practices and data quality to customers and regulatory authorities, and accelerate the validation process

Potential Regardless of the range, volume and complexity of the data you produce, LIMS gives you a complete picture of the processes and products of your lab. There are software which present data in intuitive graphic formats, so users can quickly understand and respond to emerging trends and other essential information. The graphic executive dashboard shows the exact data and information that is relevant for each role. LIMS increases laboratory effectiveness and responsiveness to business requirements by making the lab part of

the process plant automation solution. It improves the process plant efficiency through timely access to quality lab data for production management, product quality, advanced process control, and other essential functions. It has a specific functionality for pharmaceutical, bio-analytical, environmental and many other applications and dramatically reduces implementation, training, validation and maintenance costs for a lower total cost of ownership. Intuitive, application-focused interfaces create high end-user acceptance. Every process plant uses quality data, and most have a laboratory that analyzes samples to certify products for shipments, track material properties, help balance the books, and aid analysis. A laboratory information management system, or LIMS, ensures that tests are performed properly and quality lab data is available for essential functions such as production management, advanced process control and performance monitoring.

Design The LIMS is designed to dramatically increase the efficiency of scientific

february / 2013 ehealth.eletsonline.com

Tech Trends

processes and staff and to secure the future value of your data by properly archiving each and every data point that your organisation collects. One can accomplish these tasks by customising LIMS product to match the specific requirements, interests and workflows of the organization. In general, client system customizations account for an increase of only two to four weeks in delivery time and only 10 percent in price. Informatics solutions are tailored to manage your organisation’s critical information across multiple laboratory facilities in order to optimize productivity and share knowledge more effectively. Companies deliver configurable-offthe-shelf solutions for a variety of functional laboratories focused on research, development, quality management, biobanking and environmental monitoring just to name a few.

LIMS products are power packed with innovative features presented in a simple, clean and enjoyable graphical interface. The software is easy to use, quickly learned, and can be modified to suit your preferences. LIMS products are designed by lab managers and coded by experts for reliable everyday use without compromising advanced features. Coding process has resulted in robust, flexible, and configurable software capable of supporting any lab type. Product design provides for rapid setup and configuration, an interface that allows users to save their settings, and the ability to keep clients up to date with the latest technology. This modular nature allows users to provide a truly integrated suite of products, or fully capable independent product modules. Individual modules can be updated or customised without impacting the entire program.

Informatics Solutions are tailored to manage your organisation’s critical information to optimise productivity and share knowledge more effectively

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LIMS continues to redefine enterprise laboratory informatics with its leading combination of functionality, flexibility, and technology in one platform. It helps organization model in specific workflows, seamlessly integrate with instruments and business applications and meet government regulations to increase productivity, reduce operating costs, and improve overall quality. With LIMS, your enterprise-wide information management is accomplished with intuitive data entry from any Internet or Intranet access device and easy integration to third party instruments and systems, workflow and process automation through a simple user interface, and compliance with internal standards and government regulations through programmable rules and electronic signature. LIMS helps laboratories meet their scientific, performance and business goals. Apollo LIMS has been successfully implemented in toxicology, pain management, public health, clinical, environmental, and hospital laboratory environments in the United States and Caribbean. Its features include: • Rules-Based, Configurable Off The Shelf (COTS) Application • Standard and Customizable Reporting • Instrument Interfaces • Foreign System Integration with HL7 and other protocols • Modular configuration for maximum flexibility LIMS is committed to supporting your informatics needs both today and into the future. With flexible and easyto-use configuration tools, the solutions can be quickly tailored to specific roles within the enterprise, adapted to changing business needs, and extended to other areas of the organization, while also reducing ongoing validation costs. Moreover, for organizations with worldwide operations, LIMS combines a powerful informatics platform with support to deliver the most complete, versatile, multi-site and multi-language backbone for your laboratory enterprise.

Tech Trends

Standard

Inter face Needed and implementation as a technology game, not as a clinical process improvement.

Need for lab process consulting

Dr Santosh Pawar

Head - Sales (India Pvt Sector) 21st century

ith an experience of automating more than 200 labs-both private and public clinical labs, whether standalone or chain of labs in different cities of India and abroad- 21st century is upbeat on the LIS market in the Indian Laboratory space. We found that, irrespective of the market, size, geography, specialty and service offering, almost all clinical laboratories recognize that their goal is to ensure the accuracy, turnaround time and quality of testing in order to be successful and they need to do better service. In addition to that, laboratoriesâ&#x20AC;&#x2122; major challenges are patient privacy, referring physician satisfaction, regulation and compliance, time and logistics constraints, operational efficiency and finally rising cost and competition. However, there are challenges, with respect to the mindset that some stakeholders still treat IT planning

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There are cases where LIS applications are procured and installed as it is and lab decision makers do not consider with the outcomes of automation and change management with respect to clinical process excellence. Rudimentary, duplicate, manual and administrative processes in the lab need to change to automatic and patientcentric processes. If IT systems are implemented in alignment with the existing processes as it is, they will just bring an aura of pseudo-efficiencies. At the end of the implementation there should be a role to change management and a transformation in the care system should be felt by patients and users of the system.

Interface to equipments Today, most of the popular lab instruments and analyzers are capable of being interfaced to a LIS. Whether uni-directional or bi-directional, interface to the instruments definitely enhance data flow and elimination of transcription errors means faster and more accurate reporting of results. In addition to that, using one standard HL7 interface for the entire lab reduces implementation, training, maintenance cost and attains interoperability with any third party applications also. The application systems will make sure that the output of samples analysed , tracked, tested and results reported automatically. It should generate reports that allow pathologist to track turnaround times of all the events and workflows,

samples completed per unit of time, samples re-run or repeated, and if any exceptions. The scheduling feature increases efficiency of control routine sampling, analysis, and instrument calibration and maintenance tasks. Here the objective is to develop an integrated workflow in the lab processing to data management for each clinical specializations such as Biochemistry, Haematology, cytology and microbiology and people/users attached to each specializations considering the hierarchy of users. Effective laboratory workflow with efficient amplification, sequencing, and analysis of samples greatly enhances throughput capabilities, decreases unit costs, and significantly impacts the amount of time. A significant advantage can be derived if the workflows are designed in consideration of modern advances in technology like web booking/reporting with integration to payment gates or device like pneumatic shoots for sample transport. This will further benefit laboratory processing and data review by the lab technicians and doctors sitting at geographically dispersed centres. Finally, a LIS application with capability of user definable configurable screens, workflows, policies, alerts-alarms, dashboard, documents and reports will be one best system for maximum end user satisfaction with the system. Once the LIS application is deployed based on the business process mapping and improvement blue-print, implementations do have quick and visible benefits for the organisation, once the system is deployed and proper training is provided, it retrieves specific information from vast amount of data using the personalised reporting for key users such a lab technicians, pathologist and lab administrators. The system should eliminate a significant amount of paper records (near to 100 percent), and thereby the occurrence of loss or misfiled data, files and worksheets.

A Need for Diagnostic Chains

aboratory Information System (LIS) streamlines workflow in the laboratory and eliminates time-consuming paperwork. A LIS is a complex system where it will integrate with all instruments within the laboratory. It is also incorporated with other hospital based information systems such as Hospital Information Systems (HIS), Electronic Medical Record (EMR), Radiology Information Systems (RIS), and Picture Archiving and Communication Systems (PACS). As diagnostics chains are mushrooming in the country there is an increasing demand for LIS which can facilitate in carrying out sample collection and investigations in various centres. The patient can collect results from the various sample collection centres as well. LIS can provide facility to capture results to the computer System directly from diagnostic equipment through lab interfacing. There is increasing trend

Naeem Ahmed

Manager - Projects, Healthcare IT Practice, Akhil systems of instant comparison and statistical analysis of tests like Turn Around Time (TAT) etc. Also, there is the facility of online appointment and registration, checking online lab results, SMS, E-mailing the lab results. Over years after gaining rich 17 plus years of experience Akhil Systems provides both cli-

ent-server based and web â&#x20AC;&#x201C; based LIS which can facilitate all these through a single solution. The increasing trend for medical tourism, the demand for realtime web enabled LIS, considering the possibility of replacing barcodes with RFID at labs and incorporating bioinformatics testing are all important factors that LIS vendors need to consider in the coming years. The diagnostic landscape in our country is highly fragmented. Still largely populated by unorganised players, approximately 10 percent is constituted by organised entities. Thus, in an effort to match the increasing demand, large players have endeavoured to increase pan-Indian presence, by building national networks, over the last few years which calls for growth in the demand for LIS. Also, small diagnostics centers with enough funds, now a dayâ&#x20AC;&#x2122;s demanding LIS.

LIS Offer Real Time Analysis and Reports

he majority of LIMS solution available today in the market is point solution which takes care of various functions/departments of a laboratory, such as registration, billing, pharmacy solution etc. However the need is to have a complete integrated enterprise level solution which helps the laboratory to not only automate various processes but also helps to provide real time analysis and reports. The need for enterprise level system which includes modules like human resource, inventory management, finance management and activity-based costing combined, with need of having bi-directional information exchange between clinical and non-clinical activities is forcing

Suchet Singh

CEO, Srishti Software

laboratories to move away from traditional LIMS and opt for a completely integrated LIMS. Today, most of the laboratories have branches spread across over different geographies and the key challenge they face are in the areas of standardization, optimization, and control processes across the chain of Laboratories. LMIS with multi-location capability of handling the information/data intelligently across the geographies can certainly bring about a change the way LIMS has been used till date. Adoption of LIMS is definitely on the rise and the current trends coupled with the future technologies in the pipeline could go a long way in defining the future of LIMS.

february / 2013 ehealth.eletsonline.com

Tech Trends

LIS is Imperative for

Better Quality of Services

ncreasing complexity of healthcare business and services as well as the increasing awareness and demand for quality services has become pressing. Quality demands better operational efficiency, monitoring and control; and in real-time. With this fast evolving healthcare market, healthcare IT has also reflected developments. The concept of Enterprise Resource Management (ERP) has now advanced to healthcare in the forms of hospital, healthcare and lab information management systems. India’s market is ripe for healthcare IT and it is the fastest growing market in Asia with an expected growth rate of 22 percent. As far as the LIS is concerned, one needs to look into the market of

Ajit Dixit

VP-IT, Metropolis Healthcare Ltd diagnostics itself. As against hospitals or pharmaceutical industry; the diagnostic industry is fragmented to a large extent. For the smaller labs the processes that are to be managed through an LIS are much simpler, whereas for larger organised diagnos-

LIMS Needs to Be

Well Integrated

R Vishwanathan

Business Unit Head - LIC PCS Technology

february / 2013 ehealth.eletsonline.com

ot many years ago, barring few, most of labs and diagnostics centre’s were stand alone, operating individually. These labs were well equipped with processes and complied with necessary standards. LIMS was built either around them or upgraded to their needs. With the “take-over” syndrome catching up, bigger labs have started acquiring labs that are either sick or want to grow with a merger. This has given the birth to the ever increasing need for real time data and information. Most of the LIMS providers follow the decentralised approach, where the data is merged at the end of the

tic companies the complexity is ever increasing. In most cases the smaller labs wouldn’t even want to invest in any kind of LIS. This scenario is set to change, as the concept of accreditation of diagnostics labs strengthens. As accreditation becomes increasingly important, along with all other developments, healthcare IT will emerge further and so will its demand. Similarly, as the regulations related to patient healthcare records are made stringent, healthcare IT will have a major role in data confidentiality and transfer. Healthcare IT’s growth is dependent on sector growth of hospitals and labs. The sector’s want for quality and control will be a great booster for the demand for healthcare IT.

day. This approach has lot of lacunae in terms of providing the information to the provider’s real-time. There are lots of issues viz: source of the sample , where it is registered, where it is processed, change of processing centre’s etc. Tracking of samples real-time becomes a big challenge that gives birth to other issues like missing samples, timely services, customer queries etc. Current LIMS should accommodate local differences while retaining the ability to analyse at global level. It should be able to provide similar interfaces but different levels of access throughout the organisation. It should be compliant to standards like NABL, CAP etc, accommodate Nation-Wide Patient ID, seamlessly integrate the new mergers and acquisitions, accommodate different analyser’s at different locations performing same tests.

advertorial

Enabling Modern Solutions for Laboratory g

By Baskaran A, Managing Director, Dhii Health Tech

n the current globalised scenario, Laboratory Information System (LIS) has to cater to global requirements by making the system adhere to many international standards including CLIA, CCHIT, ANSI, HL7, HITSP, and LOINC and the continual pressure to reduce costs, customisable functionality, scalability and a high level of adaptable connectivity for both institutional EMRs and physician access. Laboratory informatics has evolved as a solution to these healthcare challenges by providing an information technology based application aimed at optimising laboratory operations.

LIS The technology applications in diagnostic laboratories are required to achieve quality and accurate clinical outcome. LIS is a software-based multi-disciplinary strategy to research, develop, optimise and capitalise on technologies in the laboratory and information management system. It offers a set of key features to support modern laboratory’s operations enabling new and improved processes. The research conducted by laboratory automation professionals help in developing new technologies to increase productivity, elevate experimental data quality, reduce lab process cycle times, or enable experimentation that otherwise would be very difficult. The existence of diagnostic laboratories that are committed to activities such as high-throughput screening, clinical chemistry, automated analytical testing, large scale bio repositories, etc., is made more convenient with the advancements in LIS.

Current trends in LIS LIS has evolved with great features

from simple sample tracking to an enterprise resource planning tool that manages multiple aspects of laboratory informatics. Some of the basic functions of LIS include order entry for lab tests, specimen/sample collection, entry and reporting of results, sharing/transferring data to other information systems, and verification of results. Existing LIS employs barcode labels to track specimens. Errors may arise with sample identification by barcode due to human or if the optical reader fails to read the barcode. Radio frequency identification tags are newly developed as a new approach to overcome this limitation. These tags serve as an aid to read/analyse several samples simultaneously then sequential analysis as with barcode are also cheaper to implement due to lowered production costs. Research is in pipeline to integrate these tags with micro-sensors to give realtime, detailed physical and chemical composition of a sample, in addition to the sample identification for clinical applications. The key features of LIS include workflow and data tracking support, flexible architecture, and smart data

exchange interfaces, which fully support its use in regulated environments. LIS in diagnostics not only integrates all instruments within the laboratory, but is also incorporated with other hospital based information systems such as hospital information systems, electronic medical record, radiology information systems, and picture archiving and communication systems. Apart from sample management, instrument and application integration, and electronic data exchange, there are numerous other LIS manageable operations that include audit management, customer relationship management, compliance, manual and electronic data entry, instrument calibration and maintenance, personnel and work load management, quality assurance and quality control reports management, time tracking, traceability and workflows. As a technology advancement cloud based web LIS with effective communication standards so that the history of patient’s clinical tests can be accessed by authorised hospitals across the country. If an individual undergoes two different parametric tests at two different diagnostic labs, with the help of the web-enabled LIS, both the diagnostic labs will update the patient’s results. On the approach of a patient, these reports can be accessed by a physician at different hospitals at some other location through web-enabled LIS, conserving both the patient’s time and money. The increased medical tourism, in the aim to get the good medical facilities at affordable costs, forces the LIS to be capable of transferring patient data across different nations, a need for speeding the turnaround of data and increased access to information resources.

february / 2013 ehealth.eletsonline.com

specialty

Changing

Face of Radiology Dr Pramod Lonikar, Secretary, Maharashtra State Branch of Indian Radiological & Imaging association and Treasurer, Indian Radiological & Imaging Association, New Delhi shares his insight on the recent development Indian radiology has witnessed

eleradiology, a part of broad specialty of telemedicine, has gone far ahead of its umbrella fraternity in last few years. Teleradiology is interpreting or reporting of images like X-rays, CT scan, MRIs, sonography, Colour Doppler and 2D Echo Studies from remote places. A radiologist sitting at a place away from hospital or clinic interprets radiological images with help of computers, Internet and specialised software.

From traditional to digital The technique of teleradiology is commercially available worldwide since

Pramod Lonikar

february / 2013 ehealth.eletsonline.com

the 1980s and has evolved over the time with the advancements in technology. In India, initially, use of teleradiology was limited to reporting of CT and MRI cases from home, especially at night times. The Internet connectivity was slow, specialised software were not commercially available at those times, most machines were not Digital Imaging and Communications in Medicine (DICOM) compatible. These factors limited the growth of the specialty in India, apart from limited expectations of clinicians from radiologists. Before advent of cross sectional imaging, ultrasonography and colour Doppler, traditional radiology was limited to X-rays, angiographies and some contrast studies which were also part of X-rays. So in emergency room X-rays were most of the times interpreted by clinicians and on next day morning were reported by radiologists. Of-course operations were most reliable mode of diagnosing the diseases. However, technological advancements in sonography, color doppler, CT and MRI broadened the scope of knowledge. As technology advanced and subspecialities like neurology, nephrol-

ogy developed, it demanded more expertise from the field of radiology. At this juncture demand of radiologist was on rise. Surgery as a diagnostic tool started becoming an obsolete method. Sonography, color doppler, CT, MRI were more helpful to diagnose more accurately. These new techniques changed the face of radiology services worldwide. Information Technology was

a sunrise sector then, thus, it was natural that India got first-movers advantages in the field of teleradiology. Skilled manpower, time zone difference for serving emergency hours, cheaper remunerations as compared to their counterparts in USA, UK, and willingness to work on weekends played pivotal role in the development of outsourcing of these services to India. Lexicon Nighthawk â&#x20AC;&#x201C; reporting

during night hours has increased as the number of hospitals increased, dayhawk - services during day hours have also increased and created a huge business opportunity.

Serving the un-served Today, USA, UK and Singapore are the main countries outsourcing to India. Many companies are involved in this enterprise; these are mostly

owned by radiologists. Off late some major companies have entered this field, which may lead to a major leap due to funds infusion. Every year there is increase in number of radiologists by two percent whereas demand for radiologists is increasing by 15-20 percent annually. With the increased penetration of health services in India, there is a huge demand for teleradiology services. Many hospitals cannot afford full time radiology services, so they avail teleradiology services. People in remotest of places can now get expert opinions in diagnostics. Cheaper technology and net connectivity has helped thoroughly. This is a win-win situation for hospitals, patients and radiologists. With increased penetration of health services across India, especially as many big hospital chains expanding their services to tier II and tier III cities, need of teleradiology is bound to increase. There are no set standards for teleradiology in India. To perform final reporting of a radiology assignment originating from USA, Europe, Singapore, concerned-board certified radiologists are needed. American College of Radiology has formulated a set of norms in this regard. As an Indian context is considered, there are no set norms for in-shore work and there are no any statutory guidelines. The growth story of India in this domain has been contributed by the private players, though there is a high potential at government level as well. Government hospitals at all levels, from public health centers to district hospitals- are facing scarcity of radiologists and use of teleradiology can benefit in a big way. Government partnership and private players can change the face of healthcare facilities in the remotest place of India. Teleradiology is growing in-shore in India; though the exact size of market is not known it is estimated to be proportionate to growth of healthcare and health insurance sector in the country.

february / 2013 ehealth.eletsonline.com

specialty

Radiology of

Today and Tomorrow What began from a simple X-ray has now evolved into more sophisticated modalities like ultrasound, CT, MRI and 2D Echo and it doesn’t stop here. A perspective on the journey of radiology g

By Nikita Apraj, Elets News Network (ENN)

echnology has helped radiology in making diagnoses faster, much safer and as close to surgical gross findings and pathology as possible. Emergence of newer imaging modalities like CT angiograms have almost replaced diagnostic catheter angiograms, intraoperative ultrasound and MRI, emergence of fusion imaging like PET-CT and more recently PET – MRI.

Radiology to Interventional Radiology Radiology has come a long way today. From the gloomy days of dark room radiography where a radiologist had to spend hours in a dark room devel-

february / 2013 ehealth.eletsonline.com

oping films, to the present day where brand new advances are happening almost every month in various modalities like CT, MRI, PET and Interventional Radiology. “Interventional radiology has come to stay and we see the presence of interventional radiologists in most big hospitals in the country, doing excellent and life saving work, obviating difficult surgeries in most cases. The advent of teleradiology has increased the reach of radiologist services to remote places and in non office hours. This has been made possible by improved bandwidths, widespread penetration of internet and willingness of the clinicians and radiologists alike

to upgrade to the new technology,” says Dr. Eshwar Chandra, Consultant Radiologist, Kamineni Hospital, Hyderabad. There are multidetector slice CTs which quickly scan a patient with less radiation and enable multiplanar viewing. There are also newer advances in MRI with functional imaging and fusion imaging catching up in a big way. Advances in radiology include elastography, microbubble, ultrasound contrast study and 4D imaging. Many centres with their own mini cyclotron are doing PET scans in India. “Interventional Radiology is an exciting new field. Various aneurysms, fistulae, varicose veins can be treated in

a minimally invasive way. Newer modifications in terms of catheter design, coils, embolising materials are coming up every day. It really is a challenge for a radiologist to keep abreast of the various changes that are happening,” says Dr (Prof) Kishore Taori, Chairman, Maharashtra Medical Council.

“Functional surgery such as real-time MRI will revolutionise radiology. MRI HIFU will be one of the major trends in radiology in future.”

Challenges ahead

Dr Kishore Taori, Chairman, Maharashtra Medical Council

Dr Eshwar Chandra feels the need for Public Private Partnerships in delivering radiology services to rural and underserved areas is also need of time. Technologists need to be trained in accordance with the latest advancements in ultrasound, CT and MRI in addition to already existing X-rays. Accreditation board for technologists and accreditation for diagnostic centres on the lines of NABL (National Accreditation Board for Testing and Calibration Laboratories) should also be set up, adds Dr Chandra. Dr Taori expresses need to make the MRI procedure more patient-

Technological advancements in radiology have increased the opportunities and, at the same time have created new challenges: • Developing low cost radiology techniques • Serving underserved areas through PublicPrivate partnership • Training technologists for latest advancements • Making MRI machines more patient-friendly to reduce claustrophobia • Setting up an accreditation board for radiology • Sealing loopholes in PCPNDT

“Teleradiology will continue to play an important role. Group practice and subspecialties of radiology would gain pre-eminence. More availability of interventional radiological services and decrease in the hardware costs would enable its much wider use.” Dr N Eshwar Chandra, Secretary, IRIA

friendly in terms of reducing claustrophobia, reducing scan time and newer sequences. “Ground level studies need to be carried out to gauge the implementation of PC-PNDT (PreConception and Pre-Natal Diagnostic Techniques) act and to find any loopholes and seal them,” Dr Taori raises another important point.

Future trends With continuing shortage of radiologists, Dr Eshwar Chandra forecast that teleradiology will continue to play an important role. “We have always followed the West in terms of acquiring technology and the way we practice. New technology will find takers in India almost as simultaneously as in the rest of the world. As the costs come down, we can see technological advances reaching smaller cities much earlier than the present,” Adds Dr Chandra. MRI HIFU (High Intensity Focused Ultrasound) will be one of the major

trends in radiology in future, as Dr Taori observes. At present, MRI HIFU is available only at a few centres in India and is used in treatment of uterine fibroids, adenomyosis, various prostatic conditions, benign tumors of the bones, etc. Dr Taori expects teleradiology catching up in a big time. Functional surgery - using imaging while operating – such as real time MRI in surgery of pituitary tumors, using elastography to predict tissue composition, detecting and analysing fetal lung maturity, and brain maturity in uterus would also be an important future trend. Fusion imaging - PET CT and PET MRI and robotic intervention would also be future trends in radiology. As the time marches ahead, radiology will evolve into more sub-specialties like teleradiology and MRI HIFU. Technology will take radiology beyond existing limitations of medicinal science and geographies, making it more patient-friendly.

february / 2013 ehealth.eletsonline.com

specialty

Radiology Outsourcing:

The Next Big Thing?

Teleradiology has helped improve patient care as it allows radiologists to provide services without actually having to be at the location of the patient. But, how big can this market grow? g

By Nikita Apraj, Elets News Network (ENN)

eleradiology works on standardised network and is particularly important when a sub-specialist such as a MRI Radiologist, Neuroradiologist, Pediatric Radiologist, or Musculoskeletal Radiologist is needed, since these professionals are generally only located in large metropolitan areas working during day-time hours. Teleradiology allows for trained specialists to be available 24/7. India, in addition to being a hub for IT-related outsourcing, is also catering to radiology outsourcing assignments from foreign, especially Western countries. However, the future of radiology outsourcing is still debated among experts. To understand the argument in depth, we spoke to two eminent experts in the field, Dr Arjun Kalyanpur, one of the pioneers of teleradiology in India & CEO of Teleradiology Solutions: & Dr Bhavin Jankharia, Editorin-Chief, Indian Journal of Radiology & Imaging.

february / 2013 ehealth.eletsonline.com

Understandig the market

Major hindrance is the lack of doctor-radiologist face-to-face interaction. Communication is the essence in case-solvingâ&#x20AC;? says Dr Bhavin Jankharia, Editor-in-Chief, Indian Journal of Radiology & Imaging

Radiology outsourcing business in India can be divided into two segments â&#x20AC;&#x201C; international and domestic. Estimating the size of the market is difficult as it is highly fragmented. Dr Kalyanpurâ&#x20AC;&#x2122;s Teleradiology Solutions is the major player in the international arena. Teleradiology Solutions provides reporting services across 20 countries including the USA and Singapore. Other providers do report international relationships as well. As Dr Kalyanpur explains, the value proposition lies in being able to provide a high quality specific service such as emergency nightshift reporting, sub-specialty reporting or value segment reporting, such as X-rays, where the volumes exceed the capacity of the radiologists on site. A number of regional radiology groups and centres, including Teleradiology Services, provide domestic reporting services within India. In this case, the services are typically provided to centres in smaller

towns and rural areas where there is no radiologist available. The USA, Singapore, Indonesia, Thailand, Maldives, Tanzania, Nigeria, Djibouti, Netherlands, Denmark are major countries that outsource their radiology assignments to Teleradiology Solutions.

Why outsourcing? According to Dr Kalyanpur, shortage of radiologists resulting in long waiting times for reports and day night time play to our advantage. This is of particular value to the US, where the night shift translates into a day shift in India, which makes for a better quality service, he explains. Also important are requirement for sub-specialty expertise and credibility of Indian medical education system, based on outstanding physicians of Indian origin having migrated all over the world. Lower cost of reporting from India due to lower cost of infrastructure and support staff also plays a role, however as Dr Kalyanpur sees, this is fast eroding and cannot be a sustainable factor if the reporting quality is not of the highest level. Dr Jankharia explains, a radiologist must be US Board-certified or certified from the board of the country from where the outsourcing assignment belong. In India, we still face shortage of such qualified radiologists. Company should have necessary infrastructure and should be able to provide accurate reports with accuracy rate of 90 percent or above. Report quality is the primary thing; it is paramount, and essentially determines the credibility of the provider. Turnaround time is important as well, given emergency nature of healthcare profession. The turnaround time may vary from 30 minutes to 24 hours, depending on the clinical requirement, Dr Kalyanpur says. He adds further, security compliance and HIPAA is a very important factor as protection of patient health information is of highest importance in the Western countries. International

accreditations such as Joint Commission definitely provide added value. Responsiveness to complaints and issues are an important factor once service is established, as lack of this will rapidly result in client dissatisfaction.

What lies in the cards? Dr Jankharia feels that the market for international radiology outsourcing is very limited and the wave will soon fade. The main reason he sees that would cause hindrance in development

Radspa have emerged that will enhance radiologist productivity and enhance their quality of life, as workloads increase. Dr Kalyanpur also expects entry of hospital groups and chains into teleradiology providersâ&#x20AC;&#x2122; market. Given that this is seen as an attractive opportunity/space, larger hospital groups see it as something they would like to enter, he explains. Outsourced radiology is being seen and will continue to be seen as an attractive investment opportunity

Long waiting times for reports in foreign countries and day-night time play to our advantage. Credibility of Indian medical education system, based on outstanding physicians of Indian origin having migrated all over the world also plays important roleâ&#x20AC;?, says Dr Arjun Kalyanpur, CEO, Teleradiology Solutions of this market is the lack of doctor-radiologist interaction. It is necessary for a doctor to be able to discuss the case with the radiologist face-to-face. While this is possible if both are on the same soil, it may prove difficult when a doctor and his radiologist live in different time zones or continents, explains Dr Jankharia. Communication is the essence of any case-solving, he says. Dr Kalyanpur is optimistic about greater international acceptance and utilisation of teleradiology outsourcing. This will lead to growth in the field. As he observes, greater sub-specialisation is a trend that all radiology is heading towards and teleradiology is no exception. However, he also points to decreasing reimbursements with increase in competition following the rules of market economics. Emergence of new workflows and technologies to improve efficienciestechnologies such as TeleradTechâ&#x20AC;&#x2122;s

for investors. Dr Kalyanpur expects greater role of private equity and financial markets in the space. Dr Jankharia sees future market growth in domestic teleradiology outsourcing. There is significant infrastructure gap between urban and rural areas in the country. Dr Jankharia says teleradiology would help serve the unserved areas.

Way ahead Teleradiology is an excellent example how technology has brought the world closer to transform it into a global village. With just help of a high-speed internet connection and specialised software, radiology images can be interpreted from any corner of the world. Though there are differences of opinion on growth of teleradiology in international boundaries, experts agree that teleradiology is going to bring transformation in the domestic market.

february / 2013 ehealth.eletsonline.com

case study-radiology

Palisade’s Neural Tools Helps

Replace Gadolinium for Brain Tumors g By Dr Tapan Biswas, Member of the Indian Radiological Association & Founder Biswas X-Ray and Scan Centre

sansol-based Biswas X-Ray and Scan Centre is a dedicated imaging and research laboratory that specialises in brain tumours. Dr Tapan Biswas, a member of the Indian Radiological Association and founder of the Biswas X-Ray and Scan Centre, had been keen for some time to establish a protocol that would allow his centre to determine the pathological changes in brain tumours without the use of the injected contrast dye intravenous gadolinium. The contrast agent has been linked to the development of nephrogenic system fibrosis, a serious condition of the joints, skin and internal organs. It is highly toxic despite it being widely used in MRIs to enhance or discriminate brain tumours.

Neural tools Using a contrast agent like gadolinium is a valuable tool that allows Dr Biswas and his colleagues to have improved visibility of internal body structures. gadolinium is a paramagnetic substance, that has small local magnetic fields which cause a shortening of the relaxation times of the surrounding atoms ultimately improving tissue discrimination in MRI. This can give a higher or lower signal between two tissues enabling them to be better differentiated. However, considering the adverse effect that gadolinium can cause, Dr Biswas wanted to create the same enhancement to the brain tumour that gadolinium would give, but without actually using it. This led to research

february / 2013 ehealth.eletsonline.com

that would help determine the probability of the ability to produce an enhancement-like effect of the brain lesions of MRI images mathematically without intravenous injections of gadolinium. Dr Biswas chose Palisade’s NeuralTools for the research. It’s a software with neural networks analysis able to intelligently predict outcomes based on multiple pieces of input data. It works directly in Microsoft Excel, it could create accurate new predictions based on patterns in known data that were easily accessible, and simple to read.

Neural tools helped in intelligent predictions Using various historical magnetic values of tissue, both brain and tumour pre and post-gadolinium injection, were used as data inputs. Dr Biswas followed the standard steps for designing neural networks to predict the signal and gray shade values

of unknown tissues in four application areas: function fitting, pattern recognition, clustering and time series analysis. After understanding the data, NeuralTools worked through the following steps: analysis of the data, training the network on the data provided, testing the network for accuracy and lastly making intelligent predictions. These predictions consisted of forecasted values for the magnetic signal of the unknown tissue. The partial (input) data known about the target tissue was its T1 value, or spin-lattice relaxation time. The predicted signal values could then be translated into a gray value of 256 possible shades. In effect, the mathematical analysis of the predicted values from the NeuralTools analysis enabled Dr Biswas to create an MRI-like image of brain lesions without the dangers of using gadolinium contrast dye. A neural network and without a Gandolinium IV contrast was possible. Dr Biswas commented, “The result of this study means contrast enhancement like simulation of brain tumours can be done accurately. Using NeuralTools, and specifically its Live Prediction feature, we have been able to stop using gadolinium, whilst the discrimination of various brain tumours pathology can still be made.” Palisade Corporation is a software developer that produces decision support tools for professionals in many lines of work. Its range of software serves fields from finance to pharmaceuticals.

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zoom in

Chronic Disease

Management Takes a Turn Many diseases and conditions cannot be cured by existing medical treatments. When a medical problem can’t be cured or healed, then the goal is to manage & to make sure both the patient’s longevity and quality of life are maximised by managing the problem g

By Anil Nayak, Co-founder, Kartavya Healtheon

here are many diseases and health problems that people deal with everyday. Dealing with a chronic disease can be much harder. A portion of your time is always consumed in treating the disease or going to the doctor. The healthcare industry in India is providing organised cure but was lacking organised care. There is a continuous gap in chronic care and lifestyle conditions awareness, screening and behavioural modification. In order to control over the chronic diseases, this concept of remotely managed disease management/patient management is certainly picking up in India. This is because access to information and disease awareness is very low and healthcare cost is rising. Many diseases and conditions cannot be cured by existing medical treatments. When a medical problem can’t

february / 2013 ehealth.eletsonline.com

be cured or healed, then the goal is to manage it to make sure both the patient’s longevity and quality of life are maximised by managing the problem. Many of the diseases and conditions that must be managed are considered ‘chronic’, which means they last a long time (that is more than three months), even through the rest of one’s life or they recur over and over again throughout one’s lifetime. Chronic diseases are generally long duration diseases and generally have slow progression. It is a type of illness that is persistent or long-lasting and also recurrent. It is controllable, but in many cases can’t be cured. They include diseases such as HIV, arthritis, diabetes, cancer, cardio-vascular, Hepatitis B and respiratory disease, and are among the most costly and common of all health conditions around the world. Chronic diseases

are a leading cause of increasing healthcare costs. More than half of all population of the world have at least one chronic condition. Disease management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. It may reduce healthcare costs or improve quality of life for individuals by preventing or minimising the effects of disease Patient management is an integral component of chronic disease management. People living with chronic diseases are educated to live independently. One important aspect of disease management is its goal of preventing another disease from developing. People with diabetes are at the risk of developing heart, nerve or eye problems, therefore one goal of chronic disease management is preventing

the extra problems from occurring. Chronic disease represents one of the most important challenges facing healthcare systems. Many people with chronic illnesses survive for a considerable period of time, but they need ongoing care. Risk factors such as obesity, smoking and lack of exercise are prevalent, so without significant and sustained policy intervention chronic disease rates will continue to rise. Chronic disease affects anyone. Around 70 percent of deaths globally are due to chronic diseases and the rates are high in low and middle income countries. The count rate of deaths occurring are too high and the leading cause is that many people are infected with chronic illnesses which cannot be cured easily. Cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases are increasing rapidly across the country. It accounts to 53 percent of all deaths in India. Healthcare industry in the country is providing organised cure but was lacking organised care. There is continuous gap in chronic care and lifestyle conditions awareness, screening and behavioural modification. In order to control over the chronic diseases, disease management brought this concept of remote controlled disease management/patient management, which is certainly picking up in India. But having a close look, many people are not aware about the concept. This is because access to information and disease awareness is very low and healthcare cost rising day by day. Disease management programmes organise care in multidisciplinary programmes with many components, using a proactive approach that focuses on the whole course of a chronic disease includes the coordination of healthcare, pharmaceutical or social interventions designed to improve outcomes for people and cost effectiveness. It recognises that a systematic approach is an optimal and cost-effective way of providing. As healthcare costs have been rising for years and as per the expert

predictions, the trend will continue, disease management tries to reduce healthcare costs and improve quality of life. The individuals benefit from it as it prevents or minimises the effects of a disease, usually a chronic condition, through integrative care. Disease management programmes are instrumental in assisting patients

Anil Nayak

Disease management programmes

are instrumental in assisting patients to handle their disease effectively and lead a normal life as far as possible to handle their disease effectively and lead a normal life as far as possible. The patients, after enrolment, are offered information and education about their disease and the means to handle them through booklets/literature, regular counselling, health tips, diet books and recipes, as well as medication reminders at regular in-

tervals with a free SMS alert service or a pill reminder machine - a kind of alarm clock that can be set to remind the patients when it is time to take their medicines. Disease advisors are run by retired nurses, doctors while psychologists also assist the patients. They visit homes of the patients to check their progress and advise them on the way forward. This, in turn, reassures the patients that they are in safe hands and would receive the required care as and when necessary. Thus, disease management system has several advantages – cutting hospital time for patients, reducing the bed patient imbalance, educating and helping the patients handle their disease effectively, assisting the doctors post diagnosis – to name a few. Disease management programmes can benefit the patient, employer and health insurance carrier. The goal for disease management is to make the patient understand his condition and ensuring that he regularly visits his primary-care physician. Care premiums, which ultimately pass through to the patient/employee as well. After identifying a patient with a chronic condition, a clinical care manager attempts to speak with the patient to assess her/her condition. This assessment traditionally occurs by telephone but may occur face-to-face. The assessment is a series of questions about the patient’s current condition; lifestyle and behavioural actions to determine his/her risk level. Based on the assessment answers, the care manager develops, in conjunction with the patient, a care plan for the patient to follow. The disease management care manager and patient will have ongoing meetings with a frequency determined by risk level – the more high-risk the patient is, the more frequent will be number of discussions be. At these sessions, the goal is to educate the patient and improve his health and lifestyle. Non adherence to medication is a major impact for poor therapy outcomes and treatment for chronic disease.

february / 2013 ehealth.eletsonline.com

event report

HP Joins Hands with SHARE India In order to make healthcare accessible to the remotest of the villages in the country, HP has inked a pact with SHARE India to deploy the company’s cloudenabled healthcare solutions in rural Andhra Pradesh HP intends to transform an existing rural health center in Aliyabad, located 45 kilometers from Hyderabad, into an eHealth Center by deploying a fully integrated cloud technology solution. The solution will connect the medical equipment deployed at the eHealth Center with an eHealth Cloud and collect basic patient health data to enable better medical diagnosis. The eHealth Center will also provide remote consultation using built-in video conferencing options. “This cloud-based e-health solution is a potential game-changer and reaffirms HP’s vision that innovating technology can strengthen healthcare systems and improve access to medicines, quality treatment and better care”,

said Dr Jaijit Bhattacharya, Director, Government Advisory, South Asia HP. He further added, “We want to pick up more domestic manufactured equipment. It will help in integration”. Dr PS Reddy, Chairman, SHARE India said it is important to expand the gamut of tele-medicine. “It is important to take tele-medicine in most interior villages”. SHARE India, a NGO is recognised as a Scientific and Industrial Research Organization (SIRO) by the Ministry of Science & Technology, Government of India for its work to improve healthcare awareness and facilities to the underprivileged in India through affordable community welfare initiatives.

The eHealth Center is expected to give close to 20,000 people across 10 villages an opportunity to receive quality diagnosis and treatment from doctors seated at a telemedicine studio in SHARE India - MediCiti Hospital at Ghanpur Village in Medchal Mandal, Ranga Reddy district of Andhra Pradesh. The patients will have direct interface with doctors remotely through a video conferencingfacility and will be assisted on-theground by interns, paramedics and nurses from the MediCiti Institute of Medical Sciences (MIMS). MIMS will also provide weekly supplies of medicines and other consumables to the eHealth Center.

Dr Jaijit Bhattacharya, Director, Government Advisory, South Asia HP, speaks to Aparajita Gupta about HP about the company’s telemedicine models What are the things, which you think are crucial for telemedicine practice? HP is focused on helping the state and central governments achieve what they want. Very clearly, from Indian perspective, healthcare is an important issue. The first initiative we took was Tatkal Kaksha, which was launched in 2011. We thought of doing a similar thing in healthcare. We have done a detailed research of 10 years in tele-medicine. We found out that the vital statistics of the patients are not provided, in such practices. We decided that the first step towards having a complete remote medical consultation is to make sure that the equipment is integrated back to the health cloud for collecting health data and for that the data should be available to the doctor to actually make the

february / 2013 ehealth.eletsonline.com

Pradesh and Maharashtra and now in Andhra Pradesh. It is happening parallelly. We have the plan to roll out 25 more as part of the CSR initiative. A few of them will be in the Northeast India as well, like in Assam. We are still learning and that is the reason we are not rolling out the service at too many places.

diagnosis. We have built the complete solutions based on that.

Which are the places where it has been already rolled out and what your future plans? This has been rolled out in Haryana so far. It is being rolled out in Uttar

What is your model for execution of tele-medicine project in Maharashtra and Uttar Pradesh? We are now looking at strong partners, who will roll out first 4-5 of these solutions, so that the system does not fail. So far, we have not partnered with any company. We have partnered with social workers both in Maharashtra and Uttar Pradesh.

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IN FOCUS

ICT-Empowering

Patients

Cloud solutions are offered in multiple areas like telemedicine, electronic medical records, medical imaging and patient management, which could be integrated by healthcare providers, payers and customers g

By Sumanth Tarigopula, VP, Apps Global Delivery India, Enterprise Services, HP

ealthcare is a capital-intensive industry where the cost of healthcare is increasing more rapidly than the reimbursements resulting in cost economics driving the industry. The industry is highly fragmented resulting in inefficiency in the revenue cycle. Due to these reasons, historically, the US healthcare industry has been a laggard in adopting latest technologies. Lately, the healthcare industry is undergoing a paradigm shift for technology adoption with the Patient Protection and Affordable Care (PPACA) Act and Health Information Technology for Economic and Clinical Health Act (HITECH) being implemented. The provisions in the acts provide massive funding for the adoption of latest technologies in Electronic Health Records (EHR) and the consumer-based services. One of the major areas where the industry is seeing traction in transformation of service delivery is through cloud services. This trend represents the convergence and synergy of cloud computing, mobility, and social media. The cloud offers multiple advantages to the healthcare industry by reducing the capital expenditure and leveraging the existing assets, increasing the speed and flexibility of developing new applications. Cloud solutions are offered in multiple areas like telemedicine, electronic

february / 2013 ehealth.eletsonline.com

Sumanth Tarigopula medical records, medical imaging and patient management, which could be integrated by healthcare providers, payers and customers. These solutions are offered on cost per transaction model, transforming the industry from capital intensive to cost-optimised model, providing limitless scalability and enabling the business to grow by offering additional services.

Health information exchanges An EHR is systematic collection of electronic health information about individual patients or populations. Patientsâ&#x20AC;&#x2122; treatment often happen at multiple locations like initial investigation with a primary care provider, lab tests with a lab provider and pharmacy intake with the pharma providers. Due to this distributed care the care records are

stored in multiple systems or as paper records resulting in limited access to the records when a provider has to review past records to provide treatment. Health Information Exchange is a digital platform where electronic health records of the patients can be accessed by healthcare professionals from multiple facilities. The technology building blocks for HIEs are already available, and the impediment until now has been putting together all the disconnected systems with incompatible formats. Earlier providers have to coordinate with multiple vendors for infrastructure, applications, security, etc and thereby overwhelming the healthcare IT departments and stretching their budgets then. The cloud solutions are integrated, end-to-end, standards based solution with automated and streamlined workflows that enables collaborative care coordination for the patients. By implementing the Health Information Exchanges, the healthcare industry is eliminating multiple impediments such as limited access to clinical patient information, increasing the cost of healthcare, increasing inefficiency and decreasing quality of healthcare delivery.

HPâ&#x20AC;&#x2122;s mobility based diabetes management solution HP has mobility based Diabetes Management solution that would be a

LandingScreen

BloodGlucoseLevel

component of telemedicine solutions. As per the Centre for Disease Control (CDC) the diabetics epidemic is sweeping the USA and by end of 2020, an estimated 52 percent of the general population will be having either diabetes or pre-diabetes from 40 percent today and a leading factor in escalating the out-of-control healthcare costs. The cost of treating diabetes and related illness is going to reach USD 500 billion by 2020. Given the heavy cost of diabetes, patient self-management is a critical element of treatment for diabetes. Patients with diabetes are encouraged to receive education and counseling about diabetes self-care from a certified diabetes educator and nutriGlucose

Glucose Level History

BloodGlucoseLevel With Keypad

Home

tional counseling from a registered dietitian. Patients are instructed to self-monitor their blood glucose using a handheld glucometer, meter strips and lancets. Patient self-management may also require additional healthcare visits to review these activities and to adjust medications accordingly. Patients are also advised to pursue screening exams for high blood pressure and cholesterol, kidney tests, eye tests and foot exams. HPâ&#x20AC;&#x2122;s Diabetes Management Solution is a mobility based solution that directly fits in to the tools that enable the patient self-management as part of the diabetes disease management programme. The key trackers for patient in a self-management proGlucose Level History

Enter Calorie

gramme are controlling the glucose level and the calorific intake of the food for each meal. Though there are multiple solutions available in the market to cater to the tracking glucose level or food intake, there is no single solution that would combine the two trackers as unified solution. In addition, HP solution will provide the ability for health plans to post the reading materials and videos about diabetes management directly to the userâ&#x20AC;&#x2122;s devices through analytics. The application is platform independent and majorly targeted for iOS and Android platform. The application covers three major functionalities like tracking the blood glucose level, calorie intake and weight tracker in the personal profile. Blood glucose level monitor is integrated with the standard FDA approved solutions to get the real time data from the measuring equipments to help avoid the data entry errors made by the users in a traditional setup. The process is more user-friendly helping the users to adhere to the programme tracking requirements. The calorific intake counter is a more user-friendly solution that would help user to evaluate the food intake needs. The user will have the ability to reevaluate the food calorie intake by increasing or decreasing the food portions. Additionally, the analytics behind the solution will help the users to get the recommended food calorie intake for the members based on his history of glucose levels and the food intake in the past.

Conclusion Technology adoption has been slower when compared to other industries in the past, with lot of incentives have pushed the industry to adopt latest technologies like cloud, mobility and social media in multiple areas like health information exchange, telemedicine, etc. The adoption will transform the industry in to a more efficient one in controlling the cost and quality of care.

february / 2013 ehealth.eletsonline.com

LAUNCH PAD

Siemens Introduces

ACUSON X700 Ultrasound System

iemens has launched ACUSON X700 ultrasound system in the mid-range segment, providing excellent image quality and diagnostic confidence for a wide range of clinical applications. Diagnosis of difficult to scan patients like obese, old people, children or accurate diagnosis of difficult ailments like tumors, abnormalities with the foetus, etc. was possible only on premium ultrasound systems that come with very advanced technologies and transducers. By and large these machines are installed at hi-end diagnostic centres or hospitals, which are not always affordable to the masses. Siemens has thus introduced the ACUSON X700 ultrasound system, which incorporates these advanced technologies so that midrange hospitals and diagnostic centres can provide the same facilities like the hi-end healthcare providers. ACUSON X700 is a powerful system that offers image quality, advanced technologies and intelligent workflow solutions at an excellent price/performance ratio. It comes with the dynamic tissue contrast enhancement technology

Suburban Diagnostics Unveils ImmunoCAP Suburban Diagnostics presents ImmunoCAP, an allergy blood test machine that can help detect whether a patient has allergies and diagnose the exact cause of it. Based on the results the doctor can craft an individual action plan and prescribe simple measures to reduce exposure to the identified triggers (For example: excluding specific foods from the diet) A correct diagnosis goes a long way in diminishing the symptoms, the risk of a severe allergic reaction and the need for temporary medication. It is a first step for an allergy patient towards a healthy life.

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that improves borders and reduces speckle/noise, facilitating subtle tissue differentiation, thus allowing faster examination with accurate diagnosis. Another hi-end feature is, tissue grayscale optimisation technology that provides instantaneous, one-button image optimisation by automatically adjusting the image brightness to the tissue type being imaged. The ACUSON X 700 systems also features workflow solutions that support workflow, ensure exam consistency and enable high patient throughput required by various clinical departments. Moreover, the system features a new design for improved usability, including a 20-inch LED display that allows relaxed viewing of images with detailed information. Ashis Dey, Business Head-Ultrasound, Siemens Healthcare says, â&#x20AC;&#x153;Siemens is an innovation leader and has always introduced innovative healthcare solutions for healthy future. With ACUSON X700, we are targeting the mid-range customers, who will be able to experience hi-end performance for faster diagnosis and better patient careâ&#x20AC;?.

Philips Brings ClearVue 650

Ultrasound System for Women ClearVue 650 is a new 3D/4D ultrasound system from Philips specifically designed for women’s health. To start with, the design is sleek, with smooth, graceful lines. It functions elegantly with features such as intuitive 3D/4D imaging that set it apart from other ultrasound systems. A new dimension ClearVue 650 is equipped with Active Array technology. The machine produces 2D and 3D/4D images with the clarity and detail resolution you need. ClearVue 3D/4D capabilities are designed to be easy to use and easy to learn, so that 3D/4D fits seamlessly into your routine clinical workflow. Philips puts

3D/4D made easy 3D volume renditions and dynamic 4D displays are presented with incredible clarity and detail resolution. 3D/4D imaging powered by Active Array technology Proprietary next-generation Active Array technology integrates key imaging technologies into all ClearVue transducers and is now also available on the V6-2 and 3D9-3v transducers for superb 3D/4D image quality in a small, lightweight and highly reliable system. Auto Face Reveal Captures a

clear 3D view of the fetal face to enhance visualisation of potential facial defects while enhancing 3D/4D exam time. The Auto Face Reveal feature is an automatic segmentation method for sculpting away the overlying tissues and noise in front of a fetal face in an acquired 3D/4D volume by detecting a sphere for the skull. Fetal STIC To evaluate fetal heart anatomy and function in 3D, ClearVue offers trimester-optimised Spatio-Temporal Image Correlation (STIC).

this technology within reach, both financially and from a day-to-day workflow perspective.

liability and environmental sustainability show this is a system built on the Philips imaging legacy.

A brilliant level of performance

Designed for your everyday success

The ClearVue 650 offers brilliant ease of use, advanced imaging modes, including 3D/4D imaging, and best in class automation features. This versatile system is designed for superb image quality to enhance diagnostic confidence, and for intuitive workflow with features that are sophisticated enough to be simple. ClearVue 650’s forward-thinking performance in re-

The intuitive design of ClearVue 650 puts the controls, which are needed most often precisely where they should be. A sleek control panel designed to help speed image acquisition and management. The elegant design of ClearVue 650 hints at the reduced complexity of the system. The modular design and lightweight cart means enhanced portability and maneuverability.

Dr APJ Abdul Kalam Inaugurates CARE Outpatient Centre Dr APJ Abdul Kalam has inaugurated ‘CARE Outpatient Centre’, India’s integrated out-patient centre, in Hyderabad. CARE Hospital has announced the addition of this milestone. A free-standing out-patient centre provides a wide array of outpatient services in a single, dedicated location, creating a space optimised for out-patient consultations. One of the key services provided by the centre is the ambulatory surgery. An ambulatory surgery or day care surgery is a procedure wherein post-operative observation

is uneventful. Such surgeries have now become possible due improved technology and have become an accepted method of treatment for a number of patients as overnight hospital stay is not required. ‘At the Care Outpatient Centre I feel compassion and hope for the patient. This is a place which conveys comfort to the ailing heart. CARE Hospitals always strives to serve the people and is silent in its approach’ said Dr APJ Kalam, who is also the chief mentor for the hospital chain

february / 2013 ehealth.eletsonline.com

expert corner

Pulmonary Care Needs

Specialisation

Pulmonary Arterial Hypertension is a serious medical condition which the average person may not have heard off, but if untreated it can be worse than having cancer g

By Dr Arun Nair, Consultant in pulmonary diseases, Narayana Hrudayalaya Hospital, Bangalore

ulmonary Arterial Hypertension is a progressive disease of the blood vessels of the lungs which get stiffened, narrow and damaged to the extent that blood flow through these important channels get increasingly difficult. This results in a strain on the functioning of the right side of the heart and eventually leads to failure of the struggling heart and causes death. There are several challenges when it comes to an early diagnosis of PAH as the initial symptoms of breathlessness, fatigue and weakness are very non-specific and patients are often misdiagnosed to have asthma, anaemia, heart failure and chronic obstructive pulmonary disease (COPD). Untreated from the time of diagnosis, a majority of patients with this lethal lung disease would live around 2.5 to three years. For those who do find their way to a trained pulmonary hypertension lung specialist at a dedicated centre, the survival is improving remarkably due to advances in targeted drug therapies which have evolved over the last 15-20 years. While continuous intravenous prostacyclin based drug therapies remain the trail blazer in terms of improving patient outcomes, targeted oral drugs have been developed over the last 10 years which make effective treatments more patient friendly.

february / 2013 ehealth.eletsonline.com

There is increasing recognition that this complex lethal disease has several causes (connective tissue disease, congenital heart disease, liver disease, HIV, etc.) and this was highlighted by the updated data point clinical classification from 2008. What is also clear is the fact that not all forms of PAH can be suitable for treatment. Further, inappropriate treatment can make the patient worse and even lead to premature death. Internationally, care for this rare relentlessly fatal condition is provided at specialised units who have the requisite skill mix and experience to manage this condition. The Pulmonary Hypertension Service at the Narayana Hrudayalaya Group of Institutions will be the first dedicated

Dr Arun Nair

specialised unit in the management of pulmonary arterial hypertension within the state of Karnataka and possibly India. The Echocardiogram (if done systematically by a trained personnel) remains the best simple test to screen for this rare condition. At this new centre, the first priority in newly diagnosed patients will be to assess the extent of the damage done to the pulmonary blood vessel and heart by doing a right heart catheterisation. This procedure which is performed by introducing a small catheter through the large blood vessel in the neck allows him to accurately measure the pressure within these large blood vessels and provides valuable information on the function of the heart. This procedure is often followed by testing the ability of the blood vessels to dilate in response to a inhaled drug called nitric oxide which helps him assess the ability of the blood vessel to open up in response to vasodilator drug (drugs which help dilate the narrowed pulmonary artery blood vessel). This helps identify a small group of patients (around 20 percent) who would respond very well to simple treatments called Calcium Channel Blockers. The assessment process which is carried out as an inpatient is far more detailed and includes other tests to measure the patientâ&#x20AC;&#x2122;s exercise capacity, heart function from

Echocardiogram, lung function, CT/ MR scans amongst others. The key focus remains to accurately assess the cause and extent of the disease process so that appropriate treatments may be provided when necessary with arrangements for periodic follow up. There is increasing recognition of Chronic Pulmonary Embolism (a disease caused by the presence of recurrent/persistent blood clots within these large blood vessels within the lung) which if left untreated can lead to critical reduction in the blood flow to the right heart, increasing the pressure within the pulmonary blood vessels eventually causing the right heart to struggle to pump the blood forward into the left side of the heart and over time causes heart failure and death. This condition which is known as chronic thromboembolic pulmonary hypertension (CTEPH) if recognised early can benefit from surgery to remove these organised blood clots by a pro-

Care for this rare relentlessly fatal

condition is provided at specialised units who have the requisite skill mix and experience to manage this condition. The Echocardiogram remains the best simple test to screen for this rare condition

cedure called Pulmonary ThromboEndarterectomy (PTE). This surgery is a life-changer for a majority of patients with CTEPH, and therefore, the gold standard when it comes to treatment if the patient is assessed properly. Dr Devi Shetty and his colleagues are the surgical experts in this critical procedure and have already performed more than 400 such procedures successfully at Narayana Hrudayalaya. In general, while patients may never be able to achieve the same levels of exercise when compared to their pre disease fitness levels, we

have certainly seen a lot of patients who were previously bed bound now able to walk with a phenomenal increase in their overall quality of life and a new perspective on life on treatment. Current advances do mean that we can control the disease a bit better, but as yet we canâ&#x20AC;&#x2122;t cure them. On the bright side, there are exciting research programmes internationally which we would soon hope to contribute to which may bring the prospect of cure closer to reality in years to come and yes there is a glimmer of light at the end of this tunnel.

february / 2013 ehealth.eletsonline.com

host partners

Department of IT Government of Odisha

Towards A Digital Economy 6th March 2013, Swosti Premium, Bhubaneswar

chief guest

Guest of Honour Shri Raghunath Mohanty

CONFERENCE EXPO • AWARDS

Minister of IT, Housing & Urban Development & Law, Govt of Odisha

Shri Naveen Patnaik Hon’ble Chief Minister of Odisha

Shri Bijaya Patnaik Chief Secretary, Govt of Odisha For

Sponsorship Enquiries Contact: Manjushree Reddy, manjushree@elets.in; +91-9910998064

partner publications

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Organisers

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*Hosconnn.com –Online Healthcare Consultancy Portal aims to use Internet Tech-know-logy • To simplify the Inherent complications in various strata of Healthcare • To provide Value based decision-making, and • To provide Expert advice available and accessible to the medical fraternity throughout the Nation

HOSCONNN is dedicated to a MISSION to Optimize the Resources and Minimize the Wastages At Hosconnn, we strongly feel that “Hospitals should be built not only as per the Market Potential but also as per Clients Competency, Capability, Adaptability & Resource Mix” And last but not the least…. not only Entry Plan but also there should be an Exit Plan.

* Relevance of Online Healthcare Consultancy On-line “Case Studies Driven” Healthcare Consultancy is “relevant” in changed Perspectives (Competitiveness, Quality, Commercials, Cost, and Technology etc) becaus • It would bring in fresh perspectives to the issues to be undertaken and prevent Intellectual &Creative Inertia • It would keep CCP (Cut, Copy & Paste) Syndrome in check • Lack of Experienced Consultancy Professionals across Nation • On-line Consultancy is beyond Infrastructural Limitations, and • On-line Case Studies driven Consultancy would allow Thinking out of Box and healthy debate & Cross Examination among the Experienced Professionals

* Our Approach Through online route we offer advisory consultancy and solutions to the Clients, and provide guidance to the team Implementing and Executing the project on behalf of the client. On implementation issue, we wish Clients to have more Comfort Levels, Ease & Leverages vis a vis their Resource Mix. Our key responsibility would be to advise Client to manage/optimize project cost.

* Perceptual Balancing Over the years knee-jerk /adhoc responses (to the Issues, Challenges and even Opportunities) have been quite common across various strata of healthcare. Through Expert & Experienced knowledge pool of Hosconnn. com, we would strive to “Analyze & Grade” the Operational & Opportunity issues and “Calibrate” the Strategies”.

* Speed is the need Our Online Status would enable us to have more time & sharper focus resulting into Quality Deliverables in 2-4 weeks irrespective of issues/locations february / 2013 ehealth.eletsonline.com

In conversation

A Pancreatic Surgeon’s Vision Dr Ravi Gupta and Shally Makin had a candid conversation with Dr Shefali Agrawal, Senior Consultant, Hepatobiliary & Pancreatic Surgery, Apollo Hospital, New Delhi on how her surgical skills are impacting medical care in India. She talks about the need in India for skilled physicians with specialty training in complex pancreatic surgery Tell us about the global magnitude of the problem of pancreatic cancer.

What are the techniques used to diagnose a tumour in the pancreas?

Pancreatic cancer is the fourth leading cause of cancer-related deaths. Surgical resection is the only potentially curative treatment. Estimated incidence and deaths from pancreatic cancer in the United States is 45,220 and 38,460, respectively for the year 2013. Based on incidence from 2007-2009, 1.47 percent of men and women born today will be diagnosed with cancer of the pancreas at some time during their lifetime. This number can also be expressed as 1 in 68 men and women will be diagnosed with pancreatic cancer during their lifetime. These statistics are called the lifetime risk of developing cancer. Pancreatic cancer is usually diagnosed at a late stage when most patients are not candidates for curative surgery and the five-year survival for patients with inoperable tumors is less than five percent.

The most important investigation for the diagnosis of pancreatic cancer is a contrast - enhanced CT scan of the abdomen. All patients diagnosed with a pancreatic tumour require a pancreatic protocol triphasic CT scan to assess the characteristics of the tumor and the extent of its spread as it is highly accurate in the assessment of tumour resectability. • A Magnetic Resonance Cholangiopancreatography (MRCP) may be used for the evaluation of the pancreatobiliary ductal system or pancreatic cysts in addition to a CT scan. • Endoscopic retrograde cholangiopancreatography (ERCP) - ERCP may be used to visualise the ampulla, obtain biopsy or place endobiliary stents to relieve jaundice. • Endoscopic ultrasound (EUS) utilizes a thin tube with a camera

Dr Shefali Agrawal, MS, FACS is a surgical oncologist who focuses on the surgical management of hepatobiliary, pancreatic and gastrointestinal cancers. She is trained in Hepatobiliary and Pancreatic Surgery from the world-renowned Johns Hopkins University School of Medicine, Baltimore, USA and prior to joining Apollo Hospitals she was an Assistant Professor of Surgery at Temple University of School of Medicine, Philadelphia, USA. Dr Agrawal has several publications in prestigious surgical journals including Annals of Surgery, Annals of Surgical Oncology, Cancer, Journal of Gastrointestinal Surgery Journal of Surgical Oncology and contributions to book chapters. She is a member of several professional societies including International Hepato-Pancreato-Biliary Association, Society of Surgical Oncology, Society for Surgery of the Alimentary Tract, Association of Academic Surgery and American College of Surgeons.

february / 2013 ehealth.eletsonline.com

and light on one end and maybe required to evaluate pancreatic abnormalities which remain indeterminate on CT scan or MRCP. • Laparoscopy may identify tumour deposits not seen on imaging and avoid major operative intervention in patients with unresectable pancreatic cancer. • Needle biopsy of the pancreatic tumor is required prior to the administration of chemotherapy or radiation therapy however, it is not necessary prior to potentially curative surgery.

How effective is the treatment for pancreatic cancer? Multimodality therapy combining chemotherapy and radiation therapy with complete resection of the tumour prolongs survival in pancreatic cancer. Survival depends upon the stage of the pancreatic cancer at the time of diagnosis and the best outcomes are achieved with a multi-disciplinary approach utilising a combination of surgical removal of the tumour, chemotherapy and radiation therapy. Curative surgery involves resection or removal of the tumourbearing part of the pancreas with negative pathologic margins. There are various types of pancreatic resections and the two most commonly performed operations for pancreatic cancer are the Whipple surgery or pancreaticoduodenectomy and distal pancreatectomy depending on the location of the tumour. The Whipple surgery is performed for tumours located in the head of the pancreas and distal

pancreatectomy for tumours in the pancreatic tail or body. As the head of the pancreas lies in close association with the first portion of the small intestine (duodenum), lower part of the stomach and bile duct, these structures need to be removed in continuity in a Whipple surgery to avoid tumour spillage. Allen Old father Whipple (18811963), Chair of Surgery, Columbia University Medical Center, New York reported the first three successful two-stage Whipple operations in 1935 and his biographers Johna and Schein state, “To the abdominal surgeon a successful Whipple operation is what a first combat mission is to the fighter pilot: a symbol of competence- the fruits of prolonged training”. The Whipple operation is a highly complex operation requiring skilled surgeons with specialty training in centers of excellence for the best post operative outcomes. The acceptable mortality for a Whipple operation is 2 percent worldwide.

As it sounds complicated and challenging, what should be the ideal protocol for performing a Whipple surgery? Patients diagnosed with pancreatic cancer require evaluation and treatment at a tertiary referral hospital with multi-disciplinary excellence in surgery, anesthesia, radiology, pathology and gastroenterology for optimal outcomes. There may be a role for regulatory bodies like the Medical Council of India (MCI) to ensure that the patient is informed correctly of the operation performed and provide him with copies of the discharge summary, operative and surgical pathology reports. The patient should be made aware about the expected survival after a curative operation such as a Whipple versus a biliary bypass operation, which relieves the jaundice providing symptomatic improvement but does not remove the tumor and is therefore, associated with tumor progression and poor survival. The 5-year survival after a Whipple sur-

About Pancreatic Cancer

Whipple surgery is performed for tumours located in the head of the pancreas and distal pancreatectomy for tumours in the pancreatic tail or body. As the head of the pancreas lies in close association with the first portion of the small intestine (duodenum), lower part of the stomach and bile duct these structures have to be removed in continuity in a Whipple surgery to avoid tumor spillage.

gery and completion of postoperative chemoradiation is 25-30% and for unresected pancreatic cancer it is a few months. This is important because not infrequently, the patient may have the impression that a curative operation was performed whereas in reality only a biliary bypass had been performed. Health insurance companies of the patients are legally authorised to evaluate the medical records of the patient and audit bills submitted for financial reimbursement by the physician and hospitals to confirm that they are commensurate with the procedures performed.

cancer may present with non-specific abdominal symptoms. • Early referral to a pancreatic surgeon once the diagnosis of a pancreatic tumour has been established on imaging studies. • Limitations in resources include diagnostic facilities and specialised physicians particularly, pancreatic surgeons. We have undertaken several initiatives dedicated to fighting pancreatic cancer in India including the website www.pancreatic-cancers.com the goal, of which is to serve as a portal for patients with a pancreatic cancer to gain a focused understanding of their diagnosis, treatment options and expected outcomes. We have launched the Pancreatic Cancer Network India on facebook for promoting awareness about early diagnosis and treatment options with the objective of improving patient outcomes in India.

Do we have trained physicians in developing countries to operate this deadly tumour? How do you help in spreading awareness about this disease? Specialty training in the implementation of complex treatment algorithms of such a deadly cancer is imperative without which the treatment itself will be associated with high patient morbidity and mortality. In developing countries like India, there are three major areas where improvement is required to improve patient outcomes: • Avoidance of delay in diagnosis for example, persistent upper gastrointestinal (GI) symptoms should be evaluated with a CT scan as pancreatic

Dr Shefali Agrawal

february / 2013 ehealth.eletsonline.com

In Focus

“Early Diagnosis

is Imperative”

Empowering women with knowledge of awareness and early detection has resulted in the addition of its fifth Mammomat Van for breast cancer detection in Punjab

OKO Cancer Charitable Trust is an initiative of the MKC Trust, UK. ROKO is a charity which engages itself in breast cancer awareness and early detection from past six years now. We have points of presence in 17 states of the country and focus on spreading knowledge and reducing ignorance and myths about the disease cancer. ROKO also joined hands with Hewlett Packard (HP) and HP as part of its social sustainability initiatives made a contribution to society by sponsoring for a month long camp in the various villages of rural Haryana. ROKO has also been currently working with O P Jindal Grameen Jan Kalyan Sansthan which is an initiative by Member of the Parliament Naveen Jindal for the health and the upliftment of women in the rural areas. Health is a major focus point for this Sansthan and ROKO has partnered with it for taking this cause ahead. The inauguration of this camp took place on the 25th of July in Chausala, village in Kaithal, Haryana. ROKO Cancer would also be holding camps in Kurukshetra in villages namely,

Pehowa, Ladwa, Gandhinagar, Peepli, Shahbad, Rajaud, Keorak, Fatehpur and Sewan in the following weeks. OP Jindal Grameen Jan Kalyan Sansthan was instrumental in the arrangement of this camp.There were 207 breast examinations, out of which the suspected cases which were 22 cases were sent for mammograms, blood pressure monitoring for 60 patients were done with sugar estimation and ECG for 15 people. Amongst this, 14 high blood pressure cases were detected and four cases with diabetes. Till date ROKO has examined more than two lakh cases and done more than 50,000 mammograms with cases being positive across 17 states of India in the different villages. Another reason, which environmentalists bring up, is the green revolution in Punjab. Due to the Green Revolution, there has been rampant use of pesticides and different chemicals and as a result, cancer cases have increased and children have been born with abnormalities. There is now growing recognition for the need of early diagnosis through screening through social mobilisation initiatives with the community as a critical stake holder, comprehen-

sive and treatment facilities and well recognised treatment protocols. According to the Chairman, APS Chawla, he says, “Cancer is a deadly disease but does not mean death. It is a myth that people have, that if they get cancer they are going to die. This is another myth that got busted. Cancer if detected and treated at the right time, some cancers arecurable. Awareness and early detection is very important for empowering them with knowledge and information about the disease.”

Read ehealth magazine online at

ehealth.eletsonline.com

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events.eletsonline.com

Ushering Transformative Practices in Governance, Education & Healthcare

Eve n t s

Events Event

Month

digital LEARNING State 7 - 8, February, 2013 Education Summit Punjab 2013

City

Hometel Chandigarh

6 March, 2013 Swosti Premium Bhubaneswar, Odisha Towards A Digital Economy

8 March, 2013 The Oberoi New Delhi

3rd Annual 23 - 24 April, 2013 Le Méridien digital LEARNING New Delhi world education summit 2013

2nd Annual 26 - 27 April, 2013 Fariyas Lonavala Maharashtra

Steering e-Inclusive Economy

16 - 18 May, 2013 The Lalit Srinagar, J & K

Sr i nagar

June, 2013 New Delhi

PSU Summit

9th July, 2013

india’s premier ict event

HICC Hyderabad Andhra Pradesh

30 August - 1 Sept 2013 The Leela Kovalam, Kerala 10th

November, 2013 Mahatma Mandir Gujarat india’s premier ict event

Contact : Elets Technomedia Pvt Ltd, Stellar IT Park, Sector- 62,

Calendar 2013 Focus

Education

Host Partner

Key Participants

Sarva Shiksha Abhiyan Authority, Government of Punjab

Stakeholder of Education ecosystem of the state, MHRD officials

egov Department of IT, Government of Odisha and Odisha Computer Application Centre

All IT departments of other states and GoI, Stakeholders of Education & Healthcare ecosystem

egov

CERT IN, MoD, MHA, Central and State PSUs

Department of Science and Technology and Department of Electronics and Information Technology, Government of India

Education AICTE, NCERT, NAAC, UNESCO

Stakeholder of Education ecosystem of the world, MHRD Govt agencies in Education, Major Universities, Colleges and Schools

egov Department of IT, Government of Maharashtra

All IT departments of other states and GoI, Stakeholders of Education and Healthcare ecosystem

egov Department of IT, Government of Jammu and Kashmir

All IT departments of other states and GoI, Stakeholders of Education and Healthcare ecosystem

egov SCOPE, Department of Public Enterprises, Government of India

Central and State PSUs, Regulatory bodies including DPEE, BPRAC, etc.

egov, Education, eHealth Department of IT, Government of Andhra Pradesh

Global Stakeholders of Governance, Education and Healthcare ecosystem

egov Department of IT, Government of Kerala

All IT departments of other states and GoI. Stakeholders of Education and Healthcare ecosystem

egov, Education, eHealth Department of IT, Government of Gujarat

Global Stakeholders of Governance, Education and Healthcare ecosystem

Noida - 201309, Ph : 0120-4812600

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in focus

Healthcare Scenario in India The healthcare ecosystem in India is at an inflection point. While the outlook for the healthcare industry is optimistic, there is a need to move towards an integrated healthcare delivery system, which leverages technology and has the patient at its center g

By Nilaya Varma, Partner, Health & Public Services, Accenture India

he growth of a nation is not just about tallying its industrial, agricultural and services balance sheets. It is equally about tallying its performance on the human development indices. The state of its healthcare is one of the critical measures of how a nation state is performing. For a country the size of India, that is even more important. The Indian healthcare industry is all set to grow to over USD 280 billion by 2020, which is a growth of over ten times from 2005. This growth has been driven by several factors, including demographics, increase in awareness levels and availability of medical care in India.

Rising affordability: In the past decade, India has witnessed a rapid increase in levels of wealth and disposable incomes. Coupled with a better standard of living and health awareness, this has led to an increase in spending on healthcare and wellness. Increase in lifestyle diseases: Lifestyle-related diseases comprised 13 percent of total ailments in India, according to a 2008 data, and this number is expected to increase to 20 percent by 2018. This is expected to trigger an additional demand for specialised treatment, which in turn,

Changing with the times Conducive demographics: While the population growth rate for India has steadily gone down, it is still at over 1.3 percent and is not expected to go below one percent in the near future. Also, it is interesting to note that our population aged above 60 years is projected to grow to around 193 million, compared with over 96 million in 2010. This change in the population pyramid is expected to fuel the demand for healthcare in general, particularly lifestyle diseases.

Nilaya Varma

will lead to increased margins for hospitals since these diseases lie at the high margin end of the spectrum. Health insurance and medical tourism: While out-of-pocket spending remains the mainstay of healthcare expenditure, health insurance is gaining momentum in India.The increasing penetration of health insurance is expected to significantly increase the affordability of healthcare services, driving up the demand for preventive healthcare and curative services. Medical tourism is also driving the healthcare market in India. The fact that the treatment for major surgeries in India costs approximately 20 percent of that in developed countries; coupled with the high quality of care in Indian tertiary and specialty hospitals makes medical tourism attractive for patients from developed as well as emerging economies.

Challenges to growth Despite such strong factors working in the industryâ&#x20AC;&#x2122;s favour, there are several systemic challenges that also need to be addressed. Dual disease burden: Even as the incidence of lifestyle diseases is steadily on the rise, a vast majority of rural and poor patients still suffer from infectious and acute diseases. Low penetration of insurance and other payer mechanisms: The overall quantum of health insurance may have increased, but it is largely limited to urban areas. In other areas, especially rural, people continue to spend from their own pockets. Inequity in infrastructure: While the urban India is witnessing a mushrooming of world-class medical facilities, the rural areas are bereft of even basic healthcare facilities. This has resulted in severe inequities between the urban and rural areas across all major health indicators. Low levels of healthcare spend: The per capita spend on healthcare (both public and private), as well as the healthcare spend as a portion of

february / 2013 ehealth.eletsonline.com

in focus

overall GDP, are amongst the lowest of the comparable economies, and way below global averages.

Patient/consumer centric healthcare Given the nature of the healthcare ecosystem in India, several hospitals and other health facilities are waking up to the need for â&#x20AC;&#x2DC;patient-centric careâ&#x20AC;&#x2122;. At the core of this approach is the customer or the patient. It links multiple levels of care management, coordinates services and encourages

professional collaboration across a range of care delivery. Integrated healthcare is another approach that is being increasingly used. It is not about structures or common ownership or bearing insurance risk, but about networks and connections, often between separate organisations, that focus the continuum of healthcare delivery around patients and populations. The models of integrated healthcare vary from entailing contracts with private providers to legislation driven approaches. Whatever the approach, the objective is to ensure that the most appropriate and efficacious care is provided where and when it is needed. Common among all these approaches are significant initiatives to share information on quality, costs and outcomes across healthcare deliveryâ&#x20AC;&#x201D;the core of connected health.

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The connected health ecosystem This approach to healthcare delivery leverages the systematic application of healthcare information technology to facilitate the accessing and sharing of information, as well as to allow subsequent analysis of health data across systems. The ambition of connected health is to connect all parts of a healthcare delivery system, seamlessly, through interoperable health information processes and technologies so that critical health information is

available when and where it is needed. By structuring and exchanging healthcare information to center care delivery around the patient or a defined population, connected health facilitates improved care coordination, disease management, and the use of clinical practice guidance to help reduce errors and improve care.

The journey to connected health There are three milestones on the journey to connected health: 1. Healthcare IT adoption: The planning, construction and use of a digital infrastructure. 2. Health information exchange: The exchange of captured health information between clinicians, across administrative groups and with patients. 3. Insight driven healthcare: The

use of advanced analysis of data to better inform clinical decisionmaking, population health management and the creation of new care delivery models. As the functionality and adoption of connected health increases across the health system, so does the potential for increased benefits and the creation of greater levels of value. Clinical efficacy: Early benefits from healthcare IT adoption and Health Information Exchange (HIE) include reduction in duplicate tests, quicker access to vital patient information and reduced costs. Shared knowledge: Deepening connectivity can help reducemedical errors and improve carequality, for example through druginteraction alerts, greater use of evidence-based care protocols and new capabilities in managing population care, which increase the potential for preventive and lowcostcare for chronic conditions. Care transformation: Advanced analysis of data captured and exchanged in the first two stages informs clinical decision-making population health management and the creation of new care delivery models, including patient self-management and better care coordination across settings. Although there is close alignment between the stages of the journey, the groups of connected health functionalities and the levels of value creation, each demands careful, dedicated planning, management and expertise if the benefits of connected healthare to serve the interests of clinicians, healthcare organisations, patients and society as whole. It is advocated that organisations or systems that are embarking on the connected health journey begin with a clear assessment of their own current healthcare IT functionalities as well as their own capabilities and external factors that will influence their journey. We believe that the six dynamics of connected health success provide a solid basis for such analysis.

EXPERT speak expert CORNER

SHARE India Climbs High

with Telemedicine Dr PS Reddy, Chairman, SHARE (USA), SHARE Medical Care & SHARE INDIA, MedCiti Institute of Medical Sciences, Hyderabad, India spills the beans to Aparajita Gupta, ENN about the telemedicine initiative his organisation has taken How has been the journey of SHARE India so far?

How well equipped is our country to adopt telemedicine?

I enjoyed as much as probably mountaineers climbing Mount Everest would enjoy with all its coldness and tribulations. Good news is I was not killed by an avalanche.

Country is well equipped to experiment with telemedicine and find out how best it can be adapted.

Now you are focusing on telemedicine in rural region, what is your plan for telemedicine in the future?

The future is in telemedicine only. Even in advanced countries like the US, e-medicine is enormous. Earlier in many treatments we used to admit patients in the hospitals for five days and seven days but now most of the times we send them back in one day. In future medicine, there are no rooms for hospital beds. There will be only intensive care units, but there will be no regular beds. For disease like pneumonia and others we no longer need patients to be admitted in the hospitals. We need to admit a patient when somebody undergoes a bypass surgery, when somebody needs to be intensely monitored then we need intensive care unit and one is needed to be admitted. Among all the hospitals, 90 percent and over are regular beds, there is no future for those beds. It will be taken over by the telemedicine.

Rural people have an easy access to Registered Medical Practitioners (RMPS) who are easily accessible but not so well trained and also do not have easy and affordable access to technology. Telemedicine should make modern tools for diagnosis available and affordable to remotest areas. These can be used by welltrained low cost healthcare personnel. Intelligence can be built into the system to guide the worker for immediate referral or for consultation. Availability of consultant for consultation is key integral part of the system. Accessible and affordable modern tools, with built-in intelligence, low cost well trained health workers to acquire the signals and available consultants for telemedicine are required.

What are SHAREâ&#x20AC;&#x2122;s thrust areas? SHARE strives to improve healthcare of rural population using information technology, telemedicine and low cost well trained health workers.

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What is the future of telemedicine in India?

How appropriate is telemedicine for our country? If telemedicine is the future for industrialised place like the US, it is much more appropriate for our country. In India, in villages there is no infrastructure at all. In India, we are doing

it in the other way round. In the US, they have beds and everything, they are planning to close it, but here we do not have anything, instead of opening it, we are leap-frogging to the technology of e-medicine. Our industrial cities will go through it, but villages do not have to. This is where the transformation is taking place. The only question is, whether the e-medicine is ready for all sorts of diseases? No, we are at the beginning of it. Still we are taking baby steps. Apollo Hospital was the pioneer, which started with e-medicine 10 years ago. But its project was not very successful. So people have learnt over last 10 years what it takes to translate this visionary telemedicine into practice. If you set-up a remote centre, you have to obtain the signals for the pulse rate, the respiratory rate, etc. Infrastructure has to be in place.

Is telemedicine a threat to the present day hospitals? If the hospital beds vanish due to telemedicine, wouldnâ&#x20AC;&#x2122;t that be a deterrent for the hospitals? There is no immediate threat. Initially requirement for beds may increase. Telemedicine in the long run when it fully matures can decrease the number of hospital beds, but that is distant future.

Do we have indigenous tools to support telemedicine in India? Most of the tools are available in India.

How will the spurt of telemedicine in the country help medical science as a whole? Quality of medical care accessible to people living in remote areas can be increased.

How will you segregate between diseases, which can be treated through telemedicine and those cannot be? There are algorithms, which can be also built into intelligence systems of telemedicine, can decide and consultants available at the other end can also decide.

What is the acceptability of telemedicine among the people in India so far? Do they feel that it lacks personal touch?

ulations to make early diagnosis, treat/ cure and prevent complications.

Are you planning any new unit inside Andhra Pradesh or outside? After gaining enough experience, we plan to experiment with another unit in the remotest village of Rangareddy district in Andhra Pradesh.

How many doctors and specialists are involved with SHARE India? Is it enough for the number of patients you get or are you recruiting more doctors? Presently we plan to have just one doctor at the remote station who will be supported by more than 100 specialists at the Medical College- Mediciti Institute of Medical Sciences.

What will be SHAREâ&#x20AC;&#x2122;s future plans? Experiment and demonstrate Rural Effective Affordable Comprehensive Health care delivery systems (REACH) to rural population.

It is not tried enough to make any judgements. In certain circumstances telemedicine cannot replace personal touch. On the other hand a known case of high blood pressure or diabetes will be happy to have his/her blood pressure and sugar checked at home and tele-consult the health care provider for advice based upon the results.

What is the way to popularise it and to take it to the next level? Low cost systems well integrated with consultants.

How far telemedicine is taught in medical curriculum in India and how much more should it be included in the future? Telemedicine is not being taught in India. It should be taught when the systems are put into practice in many places and its degree of utility and limitations are well worked out.

What are the new areas SHARE is looking at to make healthcare facilities better and affordable for the masses? Using healthcare workers and low cost laboratory tests plan to screen the pop-

Dr PS Reddy

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CDSS Blends Evidence with Expertise CDSS helps healthcare professionals to work efficiently with good turnaround g By Gp Capt (Dr) Sanjeev Sood, Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh

hen a lawyer approaches a legal case, he has a reasonable time to refer to his library of legal books and recent judgments and then present his case in the court. When a financial analyst has to review a company’s performance, he has volumes of reports and technical analytic tools to scour to finally give his opinion. However, doctors are not so fortunate. They are knowledge workers who have to memorise large amounts of medical information, lab results, treatment options and recent updates. This ever growing knowledge has to be interpreted in light of various other factors like patient genomics, co morbid conditions and then applied at point of care often in highly complex settings where time is critical and any error can have serious consequences.

What is a CDSS? This challenge can be best managed by an IT application called Clinical Decision Support System (CDSS). Simply put, a CDSS is an application that analyzes patient data to help healthcare professionals make clinical decisions. A CDSS is an active knowledge system, which uses two or more items of patient data (like signs, symptoms and lab results) to generate case-specific advice. Healthcare professionals use a CDSS to prepare and to review the diagnosis and treatment as a means

of improving the final outcome. A working definition given by Dr Robert Hayward of the Centre for Health Evidence is, “CDSS links health observations with health knowledge to influence health choices by clinicians for improved healthcare”.

Objectives of CDSS The main purpose of modern CDSS is to assist clinicians at the point of care. It enables the clinician to interact with the CDSS utilising both the clinician’s acumen and the CDSS to make a better analysis of the patient’s data than either could make on their own. The software tries to reduce misdiagnoses by presenting doctors with a comprehensive list of possible conditions. CDDS systems also direct doctors to helpful information, such as medical journal articles with the latest research. CDSS does not replace human expertise, it only enriches it with myriads of possibilities and brings the right ones to the attention of doctors at the right times. The doctors may lose sight of small facts or rules among the myriad of tasks they need to perform. It thus prevents failure to consider reasonable alternative diagnosis and possibility of uncommon events, a common human limitation called ‘Premature closure or Cognitive failure’.

The science behind CDSS Most CDSS consist of three parts, the knowledge repository, inference engine, and mechanism to communicate with the provider. The knowledge base contains the rules and associations of compiled data which most often take the form of IF-THEN rules. Using another interface, an advanced provider could edit the knowledge base to keep it up-to-date with new developments. The inference engine combines

Gp Capt (Dr) Sanjeev Sood

the rules from the knowledge base with the patient’s data. The communication mechanism will allow the system to display the results to the provider as well as have input into the system. Systems without a knowledge base, on the other hand, rely on machine learning to analyse clinical data.

Requisites of successful CDSS The CDSSs should completely integrated into the clinical workflow of the physician, so as to provide right information, delivered to the right person, in the right intervention format ,through the right channel and at the right point in workflow

Challenges & barriers to implementation Though CDSS has proven effectiveness, there are several challenges to be overcome for its successful adoption and usage. A 2005 systematic review by Garg et al of 100 studies concluded that CDSS improved practitioner performance in 64 percent of the cases. A CDSS must be integrated with a healthcare organisation’s clinical workflow, which is often already complex. Most CDSSs are standalone products that lack interoperability with reporting and EHRs. The sheer number of clinical research and medical trials being published on an ongoing basis makes it

A CDSS must be integrated with a healthcare organisation’s clinical workflow, which is often already complex The CDSS can intervene in clinician’s workflow in following ways(a) Documentation forms/templates: Complete documentation for quality/continuity of care, reimbursement, legal, complete orders, reduces errors of omission, provides coded data for other CDS (b) Relevant data presentation: Optimise decision making by ensuring all pertinent data are considered, organise complex data collections to promote understanding of overall picture and to highlight needed actions. (c) Order creation facilitators: Promotes adherence to standards of care by making the right thing the easiest to do. (d) Reference information and guidance: Address information needs of patients and clinicians. (e) Alerts and reminders: Provides notification of errors and hazards related to new data or orders or passage of time. Helps enforce standards of care.

difficult to incorporate the resulting data. Each one of these studies must be manually read, evaluated for scientific legitimacy, and incorporated into the existing system in a seamless manner. In addition to being tedious, integration of new data can sometimes be tricky to quantify or incorporate into the existing schema, particularly in instances where research may appear conflicting. Furthermore, incorporating large amounts of data into existing systems places significant strains on application and infrastructure maintenance. Generally extra steps are required of the clinician which then causes a disruption in workflow affecting efficiency. Another source of contention with many CDSSs is that they create large amounts of alert. When systems produce high volume of warnings (especially those that do not require escalation), aside from the annoyance, clinicians may pay less attention to warnings, causing ‘Alarm Fatigue’ and potentially critical alerts to be missed.

Some existing CDSSs CADUCEUS was a medical expert system developed in the mid-1980s by the University of Pittsburgh .This was developed with intent to improve on MYCIN - which focused on bloodborne infectious bacteria .CADUCEUS eventually could diagnose up to 1000 different diseases. CADUCEUS has been described as the ‘most knowledge-intensive expert system in existence’. Another CDSS software, Isabel (named after software developers daughter who nearly died due to misdiagnosis), was tested in a study published by the UK’s Medical Protection Society. In the study, Isabel Healthcare considered 88 cases of doctors’ misdiagnoses or delayed diagnoses. The software made correct diagnoses in 69 percentof the cases using it patternmatching technique, as opposed to keyword searches. These CDSSs are available for PDAs and other mobile devices.

Current status of CDSS adoption Some of the Indian hospitals are using CDSS based on machine learning in some departments. PGIMER, Chandigarh is using one CDSS as a part of its Telepsychiatry project to evaluate and manage patients based on computerised inventory developed by TCS. The software has proved to be valid and the application has benefitted several patients in remote areas who otherwise have no access to psychiatric consultation Nevertheless, the use of CDSSs is expected to increase in light of the Health Information Technology for Economic and Clinical Health Act 2009, which stipulates that healthcare providers must adopt and demonstrate the meaningful use of health IT by 2015. Furthermore, as the technology becomes mature and doctors become more involved in the development of CDDS, the system may become more desirable and its adoption more widespread.

policy

‘Coca Cola, Pepsi have Reached to Rural India but Healthcare has not’ Dr K K Aggarwal, MD, Padmashri & Dr B C Roy National Awardee, National Vice President, Indian Medical Association (IMA) goes candid in identifying the lethal elements of Indian healthcare. In conversation with Sharmila Das, ENN What is the current status of Indian healthcare? We have over 15 lakhs of deficient doctors, nurses and paramedical staffs in the country. 80 percent of the country’s healthcare is being taken care of by the private sector and 20 percent of the people are living in urban areas who are getting healthcare. Fact is that Coca Cola, Pepsi have reached to rural India but healthcare has not yet. Government says, doctors are not willing to go and work in rural areas. But there are young interns going to Saudi Arabia for two years to work in primary healthcare. If these young interns are ready to go to Saudi Arabia for two years, he should be ready to go to rural areas provided you give

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them the same facility. In Saudi Arabia they get tax free salaries, so if they get similar kind of offerings like free accommodation with free food and tax free salaries income then the entire scenario would have changed.

How to improve the scenario? One is compulsory insurance for everybody. Today if you can’t drive your car without insurance, then how can you take your body out without any insurance. Government should help people who can’t afford a health insurance. Instead of opening new hospitals, Government should pay for the health insurance for people who can’t afford. In

India needs five lakh more doctors, 10 lakh more nurses, 64 lakh more paramedics and 7.5 lakh more beds. It is only possible by building more private and Government medical educational institutions lakh more paramedics and 7.5 lakh more beds. It is only possible by building more private and Government medical educational institutions. The role of MCI should be to help recognising a medical college and not focusing on its derecognising.

What is your suggestion to deal with low doctorpatient ratio in India?

Dr K K Aggarwal buying insurance, Government should encourage a system where the insurance buyer for example a farmer can offer potatoes to buy health insurance. Government can take this potato and sell it and pay back the insurance seller on behalf of the farmer. For people under below poverty line, Government should be able to pay the insurance money.

What steps IMA is taking to safeguard the standard and quality of medical education in India? Medical education in India is controlled by Health Ministry through Medical Council of India (MCI). Ever since the MCI has been dissolved, it is controlled by Health Ministry through a Board of Governors. IMA is fighting for reconstitution of autonomous MCI. The present MCI is trying to make a BSc Community Service course which is in long run not in the interest of the medical profession. If the Government wants to fill the gap of the dearth of medical professionals in the country, they should increase MBBS seats and also nursing seats.

How do you think shortage of medical and paramedical staff can be addressed in India? India needs 5 lakh more doctors, 10 lakh more nurses, 64

Minimum infrastructure requirement is one hospital bed for 150 people, one dentist for 30 people, one doctor for 1500 people, one nurse for 500 people, one Personnel Service Company (PSC) for 10000 people, one pharmacist for three doctors, one midwife for 50 births and one health visitor for 3000 persons. The only way to control is to open more medical colleges both undergraduate and postgraduate. Attractions should be provided so that Indian doctors do not go abroad. Most of the doctors in India try to go to Arabian countries for a couple of years to earn tax free income so that they can start their clinic in India. Indian Government should think of providing the same facilities in rural areas. That means if a doctor wants to serve in a rural area for two years, he should be given free boarding and lodging and income tax free salary. Similarly, nurses should be encouraged to stay in India on similar terms.

Lately a lot of news have come up that showed the poor standard of patient safety in India. What do you think where are we lacking and how this can be rectified? Patient safety today is a matter of concern. Over 1,00,000 people die in US alone every year because of human error. Sometimes back, there was a medical strike in California during that period number of deaths reduced but at the cost of increased morbidity. Improving morbidity will always beat the cost of increase in some mortality. We should understand difference between magnitude and standard of care. Magnitude of care may differ but the standard of care should be the same. A person should be able to get uniform medical care irrespective of medical establishment he or she attends. Every medical institution in the country should be certified by NABHs. Job of NABH should be in assisting recognition and not derecognition. The Government and the MCIâ&#x20AC;&#x2122;s job should be to create awareness about patientâ&#x20AC;&#x2122;s safety. The only way Government can do it is to involve IMA with a membership of over 2.2 lakh, over 1680 branches and 29 state branches.

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expert speak

Tele-ICU to the Rescue Dr N Ramakrishnan AB (Int Med), AB (Crit Care), AB (Sleep Med), MMM, FACP, FCCP, FCCM, Managing Director, Chennai Critical Care Consultants, speaks to Sharmila Das, ENN, on how Tele-ICU can help Indian healthcare Is the change in disease burden profile in India changing the demand of critical care? India’s healthcare sector is very unique. As we all know the average lifespan of a person is increasing and the need for critical care is high in the last twenty percent of our life. Most elderly people require hospitalization in Intensive Care Unit (ICU) in the last two years of their life and that is one part of the burden. The other very unfortunate aspect is that we see a lot of young people admitted to ICU because of trauma and adverse effects of lifestyle diseases like diabetes and hypertension. In the years to come, the number of young and elderly patient we treat in the ICU will only multiply. We do not have enough manpower to manage the situation and have to look at innovative solutions.

Do you think technology can come handy in addressing the crisis? Absolutely. The Medical Council of India (MCI) has recognised critical care as super specialty. The first set of institutions offering DM (Critical Care) will create only 8-9 critical care specialists (Intensivists) after three years. Even if more institutions start offering such training, the numbers would not be adequate for several years. We have to use the existing manpower very resourcefully so that expertise is available to more people. And here, technology has a role to play. With technology, ‘Geography is now History’ as we can

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Dr N Ramakrishnan

increased both among the general public and healthcare professionals. In today’s world everyone would want their child seen by a pediatrician and any chest pain managed by a Cardiologist. So, why settle for anyone other than an Intensivist to manage a critically ill patient? We also need to understand that providing critical care is truly a multidisciplinary concept and the Intensivist needs to be supported by appropriate trained staff.

What is India’s position in delivering quality critical care? reach any part of the world through remote monitoring.

What are the current challenges facing critical care in India? The very definition of critical care units is itself questionable in several parts of India. There are no standards or guidelines for ICU designs or level of care that they could provide. To a common man, this leads to confusion that any critical care unit could handle even complex medical problems, which is not the reality. The second challenge is the non-availability of skilled manpower. It is not about the availability of qualified critical care doctors alone, the system has to be supported by trained critical care nurses, physiotherapists, clinical dietitians and nutritionists.

What are your suggestions to deal with the situation? First of all, awareness needs to be

We should be very proud of the fact that nothing is impossible in India. I am currently the Vice President & Educational Coordinator of Indian Society of Critical Care Medicine and it is great to have 5, 500 strong members active in Indian critical care. Our professional society is focussed on education & training in critical care and we are pleased with the enthusiasm of existing members in updating their knowledge and also the enrolment of several new members every year who are keen on furthering their training in this field. While the society has developed guidelines and position statements we need support from quality accreditation organisations like the National Accreditation Board for Hospitals & Healthcare Providers (NABH) to help implement these. Collaborative effort of the society & NABH will redefine critical care and ensure high quality & patient safety.

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news

Narayana Hrudayalaya Rededicated MMI Hospital to The People of Chhattisgarh Narayana Hrudayalaya Hospitals rededicated its Raipur hospital to the people of Chhattisgarh at a ceremonial function in the presence of the State Chief Minister Dr Raman Singh, presided by Dr Devi Prasad Shetty, Chairman Narayana Hrudayalaya Hospitals. A 17-month transformation has turned the 56-bed hospital into a 150-bed one. Health check packages have also been introduced to emphasize on the importance of preventive health. Along with a radiology department equipped with the latest technology, the hospital has a 26- bed dialysis unit, one of the largest in the state of Chhattisgarh. The emergency and trauma centre at the hospital was upgraded with a specialised team of trained orthopaedic and neurosurgeons to handle any type of medical emergency.

India to Launch Cancer Screening Project

The Centre will soon launch a programme to screen the people for different cancer cases in select districts on a pilot basis. The programme will be launched in 30 districts and screen the people for different cancer diseases including oral, breast and cervical cancers. The Government will provide required equipments for mammography and other tests to the selected health centres in these districts, a senior Health Ministry official said. Besides the screening, the Government is planning to set up eight more hospitals for treating cancers in states like West Bengal, Orissa, Rajasthan, Uttar Pradesh, Haryana and Chattisgarh. The aim is to have at least specialised hospitals with 200 beds in 20 states. The existing financial assistance for the cancer hospital also will be raised from the current levels of `6 crore to `45 crore, the official said.

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India, Sweden to Begin Joint Programme in Health Research Under the ‘Strategic Indo-Swedish Cooperative Innovation Programme’, India and Sweden will soon begin joint research to support long-term Indo-Swedish research and innovation collaboration in the field of health. The research will focus on broad scientific areas such as determinants of health and disease prevention, developing treatments and treating disease; medical diagnostics; innovative food, improving health promotion and disease prevention; medical devices; and antimicrobial resistance – innovative treatment, diagnostics and preventive strategies. The approach is to establish and strengthen collaborative industry and research networks between India and Sweden by funding joint research and innovation projects, exchange visits, demonstration and proof of principle. For this programme, the Department of Biotechnology (DBT), Government of India and the Swedish Governmental Agency for Innovation Systems (VINNOVA) and the Swedish Research Council (SRC) have invited proposals from the eligible scientists. The programme is open to Indian and Swedish partners from public, private and non-profit organisations that perform R&D and innovation activities.

Rockland to Expand its Chain of Hospitals Delhi- based Rockland Group plans to expand its chain of hospitals by opening new hospitals in Manesar in Haryana and Greater Noida in next couple of years and expand the existing unit in Qutab Institutional area in Delhi. “Besides, the group will create a network of over 4,000 doctors across the country to provide advanced healthcare,” Rockland Group Chairman and Managing Director Rajesh Srivastava said. The multi-specialty 505-bed hospital in Manesar opened on January 24. The second unit of the Rockland hospital in Qutab Institutional area in Delhi will be operational by the middle of this year. “Our fifth unit will be in Greater Noida. It will have over 500 beds and will open in 2015,” he said. Currently the group runs two hospitals – one in the Qutab Institutional Area and another in Dwarka in the national capital.

news

SIRO Clinpharm Deploys Office 365 to Improve Productivity SIRO Clinpharm, a leading clinical research organisation recently deployed Microsoft Office 365, in order to simplify employee communication, gain business insights and share experience across its offices. Using Office 365, SIRO Clinpharm has enhanced its communications and collaboration infrastructure to ensure increased productivity amongst employees by offering them unified experience across the PC, phone, and browser. After a comprehensive evaluation process between Office 365 and Google Apps, the company chose Microsoft Office 365 to serve their long term needs. “We constantly strive to make our business robust by improving our organisational IT health, and Office 365 deployment is yet another step towards that goal. We chose Microsoft for its enterprise expertise across its services and products,” SIRO Clinpharm CEO Gopakumar Menon said. Microsoft Office 365 offers a solution that perfectly integrates with our enterprise environment and provides the best user experience across multiple devices and platforms, he added.

Core Diagnostics to Begin India Operation UK-based Core Diagnostics, a clinical laboratory focused on next generation diagnostics for disease stratification and therapy selection, is planning to launch operations in India. ‘We will launch a high-end diagnostic laboratory in Gurgaon. We will make those high-end diagnostics tests available in India, for which samples used to go to the US and other countries,’ Co-Founder of the company Arghya Basu said. Earlier, patients had to wait for long for the results of their diagnostic tests but now with high-end laboratory there will be no wait for them,’ Core Diagnostic Director, Zoya Bra said. ‘Effective treatment for any disease begins with an accurate and timely diagnosis. Our aim at Core is to bridge the diagnostic deficit,’ company’s CEO Mohan Talwar said.

Heart Patients from AHI Also Ran Mumbai Marathon

99 heart patients from Asian Heart Institute (AHI) ran the Standard Chartered Mumbai Marathon organised on January 20th. Of these 79 ran for dream run, 18 for half marathon and 1 for full marathon. And none of them needed any kind of medical help. AHI, the medical partner to Standard Charted Marathon has been providing medical aid and help since last ten years. AHI had set up 10 medical aid stations along the Marathon route. The stations were set up to provide first aids for the participants. AHI had also set up two base camps at the start and the finish. The base camps were equipped to handle all emergencies. The camps were deployed 10 Ambulances with a doctor and nurse and 350 doctors, nurses, paramedical and support staff from Asian Heart institute are on duty. Since last year, the team also has 6 medics on motorbikes to patrol every part of the course, to pick up injured runners even sooner. The project was headed jointly by Dr Vijay DSilva, Medical Director to AHI and Dr Aashish Contractor, Medical Director to the marathon itself and Head, Cardiac Rehabilitation Department at AHI.

DM Foundation Sets up Preventive Healthcare Centre in Kerala DM Foundation, the non-profit charitable arm of the leading healthcare conglomerate in the Middle East and India DM Healthcare, in association with Ashraya Charitable Trust (ACT) has launched an Early Disease Detection and Cancer Screening Centre in Harippad, Kerala titled ‘Healing Touch’. The Early Disease Detection and Cancer Screening Centre will offer advanced diagnostic services free

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of charge with the aim to have immediate results to help tackle fatal diseased without delay. Focusing on cancer screening and prevention programmes, the Center will actively work on creating awareness through related research and statistics done in view of the current economic, socio, occupational and geographical scenario. The facility comes as aid to those

who were required to travel to cities to get tests and scans done. Offering advanced diagnostic services, the Centre is equipped with a full-fledged consultancy, scans, X-Ray, mammograms, lab tests and other diagnostic facilities for men and women. The Centre will also offer structured screening camps and educational programmes led by Ashraya Charitable Trust volunteers and staff and doctors of ECDDC.

news

Royal College of Surgeons, Indian Hospitals to Come Closer Indus Health Joins Hands with Apollo Hospital Pune based preventive healthcare firm, Indus Health Plus has entered the southern market by tying up with Apollo Hospitals to set up its 55th centre in Hyderabad .The firm currently has a tie-up with 15 odd hospitals, providing specially designed healthcare packages through 55 centres. It offers four packages to suit different age groups, with a uniform price tag of between `3,000 and `17,000 across its network. The package best suited for people above 40 years covers 21 different tests related to cardiac, hypertension, diabetes and cancer symptoms, including CT scan of heart, MRI Scan, Screening Tests. Apollo Hospital Hyderabad is a 350bed multi-specialty hospital with over 50 specialties and super-specialties. Sharing their expansion palns, Indus Health Joint Managing Director, Amol Naikawadi said, “We also wish to extend our reach from the present number of 29 cities to 50 cities in a couple of years. In the next ten years we aspire to have a pan Indian presence.”

Britain’s Royal College of Surgeons (RCS) would soon begin exchange programmes with hospitals across India to share knowledge and bring about improvements in the field of surgery. “We want to encourage internationalisation of surgery and are at present in talks with public and private hospitals,” RCS President Norman Williams said. As a result, RCS has ‘opened up’ its examination and the Membership of Royal College of Surgeon (MRCS) course would be made easier with the RCS thinking of waiving a part of the exam for doctors holding a Master of Science (MS) or Diplomate of National Board (DNB) degree. The MRCS is an entry level course to determine whether a doctor is good enough to complete the core training.

Vijayraghavan Appointed Biotechnology Secretary National Centre of Biological Sciences, Bangalore Director Prof K Vijayraghavan has been appointed as Secretary, Department of Biotechnology. Numerous awards winner Prof K Vijayraghavan replaces Dr Maharaj Kishan Bhan. Professor K Vijayraghavan has Bachelor of Technology degree in Chemical Engineering and Master of Technology degree in Bio-Medical Engineering from Indian Institute of Technology, Kanpur. He holds a PhD in Molecular Biology from the Tata Institute of Fundamental Research, Mumbai. In recognition of his many contributions as a developmental geneticist and neurobiologist Infosysawarded him with Life Sciences award in 2009.

Infosys Designs Cloud-Based Portal for US Diagnostic Firm Consulting and IT major Infosys has designed an innovative cloudbased user portal for the US-based diagnostic service provider NovaSom to test Obstructive Sleep Apnea (OSA), a medical condition affecting over 40 million Americans. The new portal ‘MeditrackR’ provides physicians with a single, easy-to-use interface that speeds up the orderto-delivery of devices, processing of diagnostic data and management

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of insurance claims. The portal also provides web interfaces with third party applications to access and analyse patient data received online from the sleep test at home. The software helps NovaSom’s sleep customers to deliver faster diagnoses to patients and hasten their treatment. The diagnostic solution also leverages NovaSom’s AccuSomR, the first and only FDA-cleared wireless home

sleep testing device. With over 18 million moderate to severe cases of OSA in the US, NovaSom’s cost-effective home sleep testing solution is delivering benefits to patients, health insurers, and specialty and primary care physicians. NovaSom unveiled in 2012 AccuSom solution as a customised turnkey solution to enable specialists to provide at-home sleep testing into their practice on a large scale.

Kerala to Revamp Primary Healthcare Sector

The Kerala government is preparing to strengthen the primary healthcare system of the State by revamping the structure, reworking the role of healthcare providers, and by envisaging a greater role for local communities. The state has proposed a Universal Health Coverage (UHC) project to the Centre for approval to implement it on a pilot basis. The project proposal has been included in the Plan Implementation Programme of the National Rural Health Mission (NRHM) this year. The State has already received approval for a Rs 96 crore e-Health initiative from the Centre, to support the pilot project. Utilisation of information technology to build up a health database of communities; equipping field workers with tablets or PDA devices for data collection; and creating portable workstations with Wi-Fi connectivity to ease workflow are being envisaged under the project. The PHCs are to be equipped with more facilities and manpower to deliver most of the healthcare requirements of the community. Every PHC will have at least three doctors and four staff nurses. Nurses will have a more pro-active role, on the lines of ‘nurse-practitioners’ of U.K.’s NHS. Team work, multi-tasking, skill development and a better use of technology are some of the watch words here.

Govt Sop for Medical Graduates from Foreign Institutions The Government of India is planning to amend the Medical Council of India (MCI) Act to allow Indian doctors, who have a graduate degree from foreign institutions, to practice in India without the mandatory tests and clearance. The Union Health Ministry is planning to introduce a Draft Bill for it during the Budget session of the Parliament, Union Health Secretary P K Pradhan said.

Since 2002, students who have studied medicine abroad have had to appear for a screening test conducted by MCI, the regulatory authority for medical education. Only those who clear the test, administered by the National Board of Examinations, get certificates from the State Medical Council permitting them to do a yearlong internship in a university or hospital in the state.

Aster Medcity to be Commissioned by Oct 2013

The first phase of Aster Medcity in Kochi is likely to be commissioned by October this year, DM Healthcare Chairman Dr Azad Moopen said. Aster Medcity is coming up in a 38-acre land on the banks of Periyar river. Stating that the Aster Medcity will boost medical tourism in India Dr Moopen added that the group is currently investing `500 crore for the Aster Medicity, `250 crores for Wayanad Medical College and WIMS Hospital and `100 crore for a 200-bed multispecialty hospital in Kannur For the second phase of Medcity and expansion plans of Malabar Institute of Medical Sciences (MIMS), the group will pump `1,200 crore. Envisaged as a township of healthy living, first phase comprises a hospital of 550 beds, six excellence centers, 500-seater medical convention centre, accommodation for medical and paramedical staff, four-star hotel and serviced apartments and a topclass residential development with an expected population of 10,000. While the second phase will house another 500 beds and three more centres of excellence. Aster Medcity will offer tertiary to quaternary care facilities in almost all medical and surgical specialties including oncology and cancer treatment, radio diagnosis, robotics, minimally invasive procedures, organ transplantation.

Moolchand Healthcare Acquires Agra’s Largest Hospital

Leading healthcare services provider, Moolchand Healthcare, has acquired the Agra based Pankaj Apollo Hospital. This is the largest private tertiary

care hospital in Agra with a capacity of 200 beds. “The acquisition enables us to strengthen our footprint in the NCR and adjoining areas. The asset is an extremely high quality hospital and is an excellent fit strategically. In addition, it provides Moolchand an early mover advantage as leading hospital groups are largely absent

from the Agra market,” Moolchand Healthcare Managing Director Vibhu Talwar said. “We intend to bring the best of healthcare services available in Delhi to Agra and Western Uttar Pradesh. Many of our leading clinicians will now also be available at Moolchand Agra.

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The Fervent Doer

Dr Sameer A Khan, CEO, Rockland Hospitals was earlier Director of Fortis Healthcare. He started his career with Border Security Force as a Doctor, thereafter he moved to Apollo Group to help start the Apollo Clinic. g

By Sharmila Das, ENN

Best thing ever happened to you Choosing Sainik School Rewa; I did my schooling from there which made a man out of me.

People closest to you My family and a few very close friends.

Various facets of your professional career I have worked across all facets of healthcare sector and have covered business, strategy, technology and in my current role I have an opportunity to put all this together and create something which is worthwhile and enviable.

View on Indian healthcare sector Healthcare as a business is growing and changing very rapidly. The issue is not on the demand side but on the supply side. The challenge will be to contain cost and increase the reach.

Life’s turning point When my son Abuzar was born

Favorite outdoor activity Playing tennis

Your last vacation Nubra Valley, Leh

Most recent purchase iphone 5

Your motto in life No inhibitions, no worries. Do what you want to do as ‘you live only once.’

One thing that sets your pulse racing Challenges of any kind, something which others have tried and not succeeded gives me the kick and yes fast cars do pump in the adrenaline.

Your favorite restaurant and your most relished dish Restaurant Bukhara and favourite dish is Tandoori Raan.

One thing you would change about yourself I love myself. So there is nothing to change

One line self description

february / 2013 ehealth.eletsonline.com

I work real hard and play even harder and I never mix professional and personal life.