UNIVERSALISING HEALTHCARE-Telemedicine promises to revolutionise healthcare: June 2008 Issue

v o l u m e 3 | issue 6 | J UNE 2008

A Monthly Magazine on Healthcare ICTs, Technologies & Applications

Cover Story: Universalising healthcare through telemedicine eHEALTH

Page 8

Industry Speak: Technology for Connected Care Yugal Sharma Country Manager - India Polycom

Page 18

Industry Speak: Telemedicine for All Shivaram Malavalli, President, TeleVital India Pvt. Ltd. Page 20

Industry Speak: Star Performer R. Guru Moorthy Executive Director Karishma Software Ltd.

Page 22

In Conversation: Solutions for Transformation Patrick Downing Product Unit Manager Microsoft Healthcare Solutions

Page 38

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ISSN 0973-8959

Rs. 75

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

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

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

w w w . e h e a l t h o n l i n e . o r g | volume 3 | issue 6 | June 2008

CONTENTS Cover story

Universalising Healthcare Through Telemedicine eHEALTH

WORLDVIEW

International Development and Evolving Dimensions in Telemedicine

F. Lievens Board Member and Secretary/Treasurer, ISfTeH, Switzerland

M. Jordanova Solar-terrestrial Influences Laboratory, Bulgarian Academy of Sciences

INDUSTRY SPEAK

Technology for Connected Care Yugal Sharma Country Manager - India Polycom

20 Telemedicine for All

Shivaram Malavalli President TeleVital India Pvt. Ltd.

Star Performers

R. Guru Moorthy Executive Director Karishma Software Ltd.

EXPERT SPEAK

Universal Solution to the Healthcare Challenge

June 2008

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

w w w . e h e a l t h o n l i n e . o r g | volume 3 | issue 6 | June 2008

POWER HOSPITAL

Fortis Hospital Mohali

eHEALTH

APPLICATIONS

Connect Now for Easy Health Claims

IN CONVERSATION

eHEALTH

Solutions for Transformation

Patrick Downing Product Unit Manager Microsoft Healthcare Solutions

spotlight

Service With a Smile

Naresh Chaudhary Chief Operating Officer Smile Foundation

PerSPECTIVE

New Age Healthcare Information Assurance for All

ZOOM IN

Health Without Frontiers

Prof. K. Ganapathy President - Apollo Telemedicine Networking Foundation Ms. Aditi Ravindra Biomedical Engineer - Apollo Telemedicine Networking Foundation

K. Srikanth Co-founder, COO Prognosys Medical Systems Pvt. Ltd.

expert corner

V. Krishna Prasad Co-founder, President Prognosis Medical Systems

New Age Diagnostic Miracle

RE G U L AR SE C T I O NS BUSINESS NEWS

india news 40 wORLD NEWS 46 NUMBERS events diary

In conversation with 21st Century Health Management Solutions Satish Kini Chief Mentor Aniruddha Nene Principal Consultant Imaging Technologies Devesh Rajadhyax Solution Architect Tele-radiology Portal

www.ehealthonline.org

IN-BOX Thanks for the link to your magazine I have been reading eHEALTH magazine for some time now, (www.ehealthonline.org), I will add it to my reading list for and think its a tremendous effort. I wish to congratulate the my students! entire team for this. Dr Anil Khetarpal, MS, FAIS, FICS Dr Chris Paton BMBS BMedSci Lecturer in Health Informatics, (Laparoscopic, Endoscopic And Bariatric Surgeon) Director Otago University, Dunedin, New Zealand eHEALTH team is doing a fine work. I complement all of you on the layout and overall organisation of the matter. Aniruddha Nene 21st Century Healthcare Solutions

This is one magazine I make sure to read each month. The magazine covers important topics in healthcare IT and Medica Equipment. Abhijit Sane, Manager Business Development manager Designtech System Pvt. Ltd.

I am sure that your magazine and content will help me out with the latest trends in the Healthcare industry. Srikant Patro A very good initiative to cover healthcare IT. Business Development Specialist Keep up the good work. Healthcare And Lifesciences Dr. V. Desai, Director SYNTEL, INC. HOSMAC India Pvt. Lt.

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

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

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

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

www.ehealthonline.org

Volume 3 | Issue 6 | June 2008

president

Dr. M P Narayanan editor-in-chief

Ravi Gupta group directors

Maneesh Prasad Sanjay Kumar Sr. manager - PRODUCT DEV EL OPMENT

Dipanjan Banerjee mobile: +91-9968251626 email: dipanjan@ehealthonline.org research A ssociates

Susan Thomas Sarita Falcao Sales executiv e

Arpan Dasgupta mobile: +91-9911960753 email: arpan@ehealthonline.org Sr Graphic Designer

Bishwajeet Kumar Singh Graphic D esigners

Ajay Negi Chandrakesh Bihari Lal (James) Om Prakash Thakur web

Zia Salahuddin Santosh Singh subscriptions & circul ation

Manoj Kumar (+91-9210816901) manoj@ehealthonline.org editorial correspondence

eHealth G-4 Sector 39, NOIDA 201301, India tel: +91-120-2502180-85 fax: +91-120-2500060 email: info@ehealthonline.org printed by

Vinayak Print Media, Noida Gautam Buddha Nagar (U.P.) India does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors.

EDITORIAL Need to get a head start into the future of healthcare? Rising costs and dearth of medical personnel have put pressure on public healthcare providers the world-over to explore the possibility of electronic delivery of services across distances and borders in the shortest possible time. This situation, coupled with the high and fast paced uptake of ICT in India has opened up opportunities for India to become a major outsourcing hub for medical diagnostic and telemedicine services to healthcare facilities both within and outside of India. ‘Telemedicine’ or as some experts now call it, ‘ehealth’, is the use of information and communication technologies (ICT) to provide medical information and services”. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at two distant locations, using video conferencing equipment. Despite the opportunity knocking at our doors, there are several problems impeding the growth of telemedicine services by Indian service providers. A recent report by the Planning Commission revealed that the large variation in the quality of medical professionals produced by institutions across the country is a major constraint in receiving recognition from overseas medical authorities; add to this malpractice policies, liability insurance and jurisdiction issues for settling disputes that may arise. These roadblocks need to be removed - beginning in India itself to inspire confidence. Within India, an oft heard complain from ehealth providers is low bandwidth, power shortage and lack of technical support. The public sector too can ride on this telemedicine wave and drive further innovation by acting as technologically demanding first buyers of new R&D. Adequate ICT infrastructure, would assure improved healthcare delivery, and in turn, better diagnosis, mapping of public health threats, training and sharing of knowledge among health workers and support in primary healthcare. The latest trend of online personal health records being offered to a techsavvy populace of the 21st century, only suggests a larger uptake of ideas such as telemedicine, where the patients are in charge of their health data and dictate who can or not access it, without barriers such as geography. In this Telemedicine special issue, we have tried to present a multi-dimensional perspective of this concept of ‘Telemedicine’. The cover story includes an overview of three key telemedicine projects in India – those of the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Narayana Hrudayalaya and Sankara Nethralaya. Together, they have benefited over 2 lac patients. Key players from the Indian healthcare IT and telemedicine companies too share their enthusiasm of the changing landscape of the healthcare delivery system. Prepare for the ehealth revolution.

is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. is published by Ravi Gupta on Behalf of Elets Technomedia Pvt. Ltd. Printed at Vinayak Printers E-53, Sector 7, Noida, U.P. and puiblished from G-4, Sector-39, Noida, U.P. Editor:Ravi Gupta © Elets Technomedia Pvt. Ltd.

Ravi Gupta Ravi.Gupta@ehealthonline.org

May 2008

COVER STORY

Universalising healthcare through telemedicine Millions of people in India do not have access to essential healthcare. Can telemedicine be the answer?

hough the Indian pharmaceuticals industry began expanding in the 1980s, only about 33% of the Indian population has access to modern medicine.1 Also, accurate estimates are hard to come by, but studies indicate that 50 to 80% of Indians do not have access to all the medicines they require.2 One reason for this in rural areas is the absence of qualified doctors and medical stores. Only 38% of our primary health centres (PHCs) have all the required medical personnel. In smaller towns and villages, patients are often at the mercy of unqualified Registered Medical Practitioners (RMPs). A recent report by the Planning Commission stated that essential therapeutic drugs are not supplied in most public health institutions with the exception of some states and adds that an essential component of strengthening primary health facilities will be a system of guaranteeing essential care.” Pharmaceutical companies’ expansion into rural India could have a significant impact on the availability of drugs. The pharma industry has come up with a novel plan of penetrating the rural market – by using post offices to sell over-thecounter drugs. A presentation to this effect has been made to the Planning Commission’s Deputy Chairman, Montek Singh Ahluwalia. Industry experts, however, say the move would help increased sale of drugs that are not even allowed in some of the developed countries because of the harmful side effects.

With expenditure on healthcare in rural India on the rise and improving infrastructure facilities, pharma companies are looking to invest in rural markets in a big way. The government announcement of a five year tax holiday for hospitals in rural areas, will further help in facilitating basic healthcare amenities. One must however keep in mind the currently limited purchasing power of rural India. The Bhore Committee report understood this way back in 1946 and recommended that no person should be denied medical care because of the inability to pay for it. Today, the three-tier plan to provide comprehensive preventive and curative care lies in shambles. The scenario is grave and complicated with rampant corruption adding to unaffordability and inaccessibility. A majority of illnesses and deaths are due to poverty and unavailability of life-saving drugs. The disparity in access to drugs between urban and rural areas is reflected in the marked difference in the number of children (12–23 months) who received all vaccinations (31% rural and 51% urban). Tuberculosis, respiratory infections, malaria and diarrhoea are amongst the main causes of death in India, and are all treatable. Treatment of TB is supposed to be free, through the state. Whilst steps such as these will help to solve the problem of unavailability of medicines, there is a need to simultaneously boost rural purchasing power, especially in economically backward regions.

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E-medicine or telemedicine is “the use of telecommunication to provide medical information and services”. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at two distant locations, using video conferencing equipment. There are vast asymmetries in information in the doctorpatient relationship, as well as vast differences in the access to healthcare within the population. Although nearly 75% of Indians live in rural villages, more than 75% of Indian doctors are based in cities. Over 60% of the 300 top-selling drugs are not even approved by the National List of Essential Medicines (NLEM).3 This general problem is exacerbated in rural areas with high illiteracy. A study conducted by the Indian Institute of Public Opinion in 2005 found that 89% of rural Indian patients have to travel about 8 km to access basic medical treatment, and the rest have to travel even farther.4 Apart from this, it is common for women to ‘normalise’ their health problems and ignore serious diseases which even hamper their daily routine. Speaking at a national level conference in Udaipur, Rajasthan recently, Marzio Babille, head of health at UNICEF India said that the problem is that people do not know much about the government programmes and the authorities are not doing enough to make them popular. He said the ASHAs are also not well trained and are overburdened. “India never lacks manpower but trained manpower is a concern here.” It is not surprising then that 60% of under-5 deaths are preventable. If healthcare is to become universal, there is a need for committing much greater public resources and radical structural adjustment to the National Health Policy. The National Rural Health Mission (NRHM) has identified 18 ‘low-performing’ states in terms of institutional deliveries. These are Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Chhattisgarh, Rajasthan, Madhya Pradesh,Orissa and Jammu and Kashmir. Bimla of Duhiya village in Gwalior District, Madhya Pradesh is an Accredited Social Health Activist (ASHA). As an ASHA, she is paid INR 600 for every pregnant woman she is able to take to a government hospital for delivery. All she can remember of her “training” is that she, and others like her, were told that they would be paid if they took pregnant women to hospital. A kutcha road links Duhiya to Gwalior city. Bimla is supposed to serve a population of 1,000, but serves two Panchayat areas with a total population of 2,000. Sometimes, Auxiliary Nurse Midwives (ANMs) refuse to even touch pregnant women of lower castes, let alone attend to their needs. June 2008

Can telemedicine provide an answer? Poor infrastructure of rural health centres makes it very difficult to retain doctors in villages, as they feel professionally isolated and outdated if stationed in remote areas. In addition, poor Indian villagers spend most of their out-of-pocket health expenses on travel to the speciality hospitals in the city and for stay in the city along with their escorts. E-medicine or telemedicine is “the use of telecommunication to provide medical information and services”. It may be as simple as two health professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at two distant locations, using video conferencing equipment.5 Telemedicine promises to be one of several possible solutions to some of the medical dilemmas facing India and other developing countries. Chhattisgarh, Rajasthan and Karnataka are among the states that have used telemedicine to a great extent. The North-Eastern states have a high incidence of cancer, but the region lacks adequate hospitals for treatment. In response to this, the Dr. B. Barooah Cancer Institute (BBCI) in Guwahati, Assam, one of the largest institutes in the region, started a telemedicine initiative in 2003. Now, patient’s suffering from cancer in the region can access an expert at their doorstep. The objective of the telemedicine centre is to:  Improve access to cancer care and cancer initiatives in undeserved areas.  Reduce cost of cancer care delivery. (Patients earlier had to go to Mumbai and other metros.)  Standardise and ensure practice of Evidence Based Medicine.  Export clinical expertise and increase the availability of cutting edge cancer protocols and procedures to all affiliated facilities.6 Roadblocks: There remain several challenges to the implementation of telemedicine on a large scale:  Day to day maintenance becomes difficult if there is a lack of technical support. It can take a long time for any technical snag to be fixed as technical support is hard to come by in remote areas.  Low bandwidth and lack of interoperability standards

COVER STORY

He a l t h S AT Encouraged by the steady growth of its telemedicine programme, ISRO launched HealthSAT - an exclusive health satellite in 2005, to bring telemedicine and medical education needs to the poor on a larger scale. The satellite would not only serve remote areas of India but also those in other poor countries in Asia and Africa. HealthSAT is expected to cost only between INR 600 million to INR 1 billion. Each receiving terminal (where patients and rural doctors are present for audiovisual conferences) in the villages is expected to cost about INR 0.5 million. This telemedicine service will save the cost that patients would have spent on travel and accommodation. The aim of the HealthSAT network is to connect rural hospitals to specialist centres in the cities. for software.  There needs to be in place a critical mass of patients who will utilise the telemedicine facility; along with hardware, software and connectivity infrastructure; technical support manpower; treaties between linking institutions with support from link providers.  There is the possibility that telemedicine will not be used to augment the quality of care to the underserved, but to provide a minimum care from a distance instead of care that should optimally be provided in person.  Privacy and confidentiality are critical issues, not unique to telemedicine, but important in this context Moreover, rigid data processing laws and difficulty in accreditation of Indian telemedicine providers have also prevented telemedicine from making a headway until now. The Planning Commission, in a recent report, stated that the wide variation in the quality of medical professionals (both at the graduate and post-graduate level) across India has impeded the expansion of services. About 75% of our doctors practice in urban areas and 23% in semi-urban areas. This leaves just 2% of the qualified doctors, who are attached to about 23,000 primary health and 3000 community health centers, to attend to 70% of the rural population. For example, nearly all 6000 opthamology surgeons chose to practice in urban areas rather than rural areas where the prevalence of speciality eye disease is high. In the north-eastern region, this dependence on medical diagnosis and treatment from outside is even more pronounced. In Himachal Pradesh too, over 55% of villages do not have linkages through all-weather roads, making access to medical facilities very difficult. 18% of the villagers have to travel at least 10 kilometres to reach a hospital. Telelinks appear to be the only feasible way to address the crisis. A promising future Telemedicine is becoming increasingly popular all over the 10

world for its tremendous potential to provide cost effective health care delivery. Though in its infancy (with only pilot projects initiated thus far), telemedicine has become increasingly plausible due to a confluence of ongoing technological advances in multimedia, imaging, computers and information systems as well as in telecommunications. The Telemedicine Society of India was formally launched in Lucknow as recently as 2006. It objectives include:  promoting, encouraging developing and advancing research in telemedicine  to encourage and promote application of telemedicine technology in clinical care, education and research  fostering, networking and collaboration, among health care providers, policy makers, NGOs and industry in telemedicine technology  to develop and implement national standards and recommend guidelines for licensing, certification and authentication. Telemedicine links between Tripura and Kolkata and the Andaman and Nicobar Islands and Chennai have cut patients’ travel expenses and ensured quality medical advice. In recent years, low-cost inputs have been developed. However, a far more serious attitude and greater dedication of funds and resources is required to take healthcare and medicines to every part of India. References: 1. World Medicines Report, 2004;World Health Organisation 2. Dr. Amit Sen Gupta, IMPF Policy Notes for Parliamentarians on Access to Medicines 3. S. Srinivasan & Dr. Anurag Bhargava, IMPF Policy Notes for Parliamentarians on Access to Medicines 4. Rao R (2005 May) Taking health care to rural areas. I4d. 5. http://www.themanager.org/Resources/Telemed.pdf 6. http://www.cbhi-hsprod.nic.in/listdetails.asp?roid=123 www.ehealthonline.org

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BUSINESS DEVELOPMENT PROFESSIONALS (BD) We need motivated & result oriented business development professionals to market our state-of-the-art HIS & Clinical IT solutions for Hospitals & Healthcare chains. Candidates should have 5 to 25 years experience, proven track record of successfully marketing Consulting /ERP solutions to top & operational management in corporates and SME segment. Good candidates with experience of marketing high end Medical equipment and services to Hospitals can be considered. Those capable of building professional trust-based business relationships with corporates and quality conscious clients will find 21st Century Health a great place to work. Can be on full time or part time basis. Earning will not be a limitations for performers. Can be resident in Mumbai, Ahmedabad, Delhi, Kolkata, Hyderabad, Chennai & Bangalore. PROJECT LEADERS / PRODUCT SPECIALISTS FOR HIS /LIS/EMR/AIS (PL/PS) We require Doctors, MHAs, MBAs and CA and Cost Accountants with 3-20 years Hospital experience as consultants to carry out BPR, change management and project management in our Hospital Projects. We also require reliable service oriented people as Prod Specialists & Help Desks to implement & support our ICT solutions at our client sites in India & overseas. Candidates should have 2-7 years experience in using/implementing/trouble shooting HIS/Clinical IT solutions in Hospitals in front office, billing, insurance claims, Pharmacy, Labs, Imaging Wards/ICU, OTs, Purchase, Stores and MRD. Candidate should have good understanding of the healthcare domain and be a smart user of IT. If you feel you have the fire in the belly and feel excited enough to be part of 21st Century Health’s movement to transform Healthcare, then please indicate your field of interest (BD/PL/PS) and mail your CV to satish.kini@21chms.com with cc to ravi.mani@21chms.com and joe@21chms.com

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COVER STORY

Some stellar telemedicine projects in India: SANKARA NETHRALAYA Project inception: 2003  Total number of patients benefited: 196,444 • Sankara Nethralaya (SN), a unit of Medical Research Foundation has served more than 1.75 lakh patients under the Teleophthalmology project, thanks to the support from various sources. With a majority of medical resources, including workforces, concentrated in the cities, SN’s effort stands as a beacon of light for those suffering millions in the rural pockets. The Rural Mobile Teleophthalmology unit has an air-conditioned consultation room equipped with state of the art equipment for a comprehensive eye check-up. In addition, it has the facility to transmit digitised images of the posterior and anterior segments of the eye to the Main Hospital Hub at Chennai via Satellite connectivity provided by Indian Space Research Organization (ISRO), Bangalore. Facilities exist for Teleconsultation to interact between the Super Specialist at Chennai, Hub and the patient along with their Optometrist in the unit at rural areas of Northern Tamil Nadu and Southern Andhra Pradesh. Through its 2011 camps, Sankara Nethralaya conducts free: • Eye Awareness Programs • Continuing Medical Education Programs for doctors in rural areas • Training of teachers for vision screening program • Comprehensive eye examinations in rural areas at patients door step. It has performed 37,157 teleopthalmology consultations and 151000 patients have been thoroughly examined so far. SN collaborates with Essilor, ISRO, MSSRF, Mehra Eyetech Pvt. Ltd., World diabetes Foundation, Government of India, Topcon, Microvision, Campaign Sight First II and Intel to provide services. It has 80 Tele Screening Camps and 949 Tele Ophthalmology Consultations (Tamil Nadu, AP, Karnataka and Maharashtra).

NARAYAN HRUDAYALAYA • Project inception: 2006  Total number of patients benefited: 12,000 One of the largest telemedicine networks in the world, sponsored by the Indian Space Research Organisation (ISRO), the Narayanan Hrudayalaya Telemedicine Network runs through 26 locations in India and abroad, offering video consultation round-the-clock, primarily for heart patients from remote areas. Using ordinary telephone lines, a large number of ‘family physicians’ are networked with NH for early diagnosis of heart attacks. The tele-medicine project is a non profitable project sponsored by Asia Heart Foundation (AHF), Kolkata and Narayana Hrudayalaya (NH) Bangalore, Indian Space Research Organization (ISRO) and state Governments. Asia Heart Foundation at Kolkata and Narayana Hrudayalaya at Bangalore are the main hubs for Telemedicine linking the seven states. The specialists at both the institutions offer their services for this project entirely free. Coronary Care Unit Network A coronary care unit is set up in semi urban or rural area and linked to Narayana Hrudayalaya. Each CCU is equipped with beds, medication, defibrillators, ECHO machines, ECG machines, & videoconferencing equipment & technical staff who are trained to operate the equipment. In addition, NH trains the doctor at the CCU to take care of acute cardiac emergencies to avoid the delay in critical treatments before referring the patient to a speciality centre. Teleconsultation Network The basic infrastructure of telemedicine is provided in remote locations whereby the remote centres can interact directly using audio and video support with the specialist using digital communication (DICOM) link. The software to transmit data is provided to the remote centres to transmit the basic data of the patient to the specialist location before the schedule of teleconsultations. Family Physicians ECG Network Narayana Hrudayalaya provides cardiac support to general practitioners with the use of TTECG. A software developed by SN Informatics is used to scan and transmit ECG via a web connection. An ECG device is provided to the GP along with the software and the report can be transmitted and received through a normal telephone line. This can be supported through an internet service and an IP line. The entire process of receiving and sending the reported ECG will take 10 minutes. 12

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SANJAY GANDHI POSTGRADUATE INSTITUTE OF MEDICAL SCIENCES • Project inception: 1999  Total no. of patients benefited: 1543 SGPGIMS, Lucknow in collaboration with the Uttar Pradesh State government and DIT has taken up the initiative to set up a School of Telemedicine and Biomedical Informatics in its campus. It will house different laboratories in the field of e-health such as Telemedicine, Hospital Information System, Biomedical Informatics, Medical Multimedia and Image Management, Medical Knowledge Management, Artificial Intelligence, Virtual Reality and Robotics. The objective of the School is to create various resource facilities, conduct structured training programmes, research and development and providing consultancy to government and private healthcare organisations in collaboration with technological and medical universities in the country and abroad. Number of Personnel employed: At present there are 18 personnel employed in different government sponsored projects and working at School of Telemedicine and Biomedical Informatics and its network partners. They worked in the capacity of project coordinator, network engineers, project assistants and telemedicine technicians to look after the organizational, managerial and technical responsibility of the projects and in creation and maintenance of website (sgpgi-telemedicine.org , telemedindia. org.) Infrastructure at the SGPGIMS Telemedicine Centre consists of several independent telemedicine work stations equipped with tele-radiology, tele-pathology and videoconferencing units with large display devices. It can carry out medical data transfer and videoconference with six remote locations simultaneously. The communication set-up consists of six Integrated Services Digital Network (ISDN) lines, one Ku band Demand Assigned Multiple Access (DAMA) and one extended C band Very Small Aperture Terminal (VSAT). All telemedicine sessions are real time and interactive in nature. The operation theatres of SGPGIMS are equipped with high resolution video camera to transmit live telecast of surgical procedures. Two auditoria of 700 and 120 seating capacity are networked through optic fibre backbone to the telemedicine centre to enable interactive live telecast of proceedings of seminars, workshops and conferences to different locations in India and abroad. With the completion of intra-hospital telemedicine network as an infrastructure component of upcoming School of Telemedicine, all HIS nodes will be made potential telemedicine nodes.

According to the Telemedicine Act, 2003 the Medical Council of India (MCI) is the apex telemedicine authority in India with the duty of protecting the interests of patients. • You can practice telemedicine only with authorisation by MCI. • The Act recommends that your application should describe your experience or expertise, if any, with delivering telemedicine services via telecommunications media. • MCI has to inform you whether your application has been accepted or rejected within 45 days of receiving it. • MCI has the power to authorise the practice of telemedicine at a lower level that the one you applied for. • MCI can revoke your permit if it is found that you no longer possess the required qualifications or if they find that you are unable to practice in a reasonably safe manner/without adversely affecting the health of the patient. • As a practitioner of telemedicine, you must maintain records of all transactions and submit an annual report to the authorities. • The service you provide is no different from healthcare delivered directly, face to face. A conference between the telemedicine doctor and the doctor treating a patient is a direct interaction between the patient and the telemedicine doctor (this is even if the interaction occurred due to an emergency situation where the doctor was forced to comply).

June 2008

WORLDVIEW

International Development and Evolving Dimensions in

Telemedicine

hich is the correct terminology- eHealth, Telemedicine or Telehealth? Up till mid 1990’s the word ‘telemedicine’ was accepted without questions. But now many authors are trying to differentiate between telemedicine and eHealth. For some, telemedicine and eHealth are synonyms. For others- eHealth is a broader term and includes telemedicine. A third group believes that telemedicine incorporates telecardiology, teleradiology, telepathology, tele-ophthalmology, teledermatology, telesurgery etc., while eHealth comprises of e-Santé, ICT-Health, all types of health communication services, PACS, patient information systems, e-education, e-prescription, etc. With more involvement of the electronic communication systems, the major international organisations such as, World Health Organisation (WHO), European Union (EU), International Telecommunication Union (ITU) and European Space Agency (ESA), have officially adopted the denomination “eHealth”. “eHealth refers to the use of modern information and communication technologies to meet the needs of citizens, patients, healthcare professionals, healthcare providers, as well as policy makers.”1

“

eHealth is brought to life by contemporary changes of our world and summarises the entire range of services that are at the crossroad of traditional healthcare and information technology. eHealth affects the entire health sector-from general practitioner to the hospital manager, from nurses to software specialists, from social security funds to patients.

“

eHealth includes eCare, eLearning, eSurveillance and eAdministration. In the attempts to distinguish between various aspects of eHealth, several other terms have also been introduced: • mHealth or mobile health, i.e., efficient high-quality healthcare services for mobile citizens; • uHealth or ubiquitous healthcare, focusing on eHealth applications that provide healthcare to people anywhere at any time using broadband and wireless mobile technologies. • One more term is used lately as an even broader description for eHealth, i.e., telehealth.

lieved that eHealth can help in solving critical issues of rising costs, care for the ageing and housebound population, staff shortage. It is a feasible tool to provide routine as well as specialised health service as it has the potential to improve both the access to and the standard of care. Its ultimate beneficiary is the Patient/Citizen via the Healthcare Professionals. In a broader sense, eHealth is not only an application of technical achievements in healthcare, but it is also a state-ofmind, a way of thinking, an attitude, and a commitment for networking at all possible levels. eHealth is a global thinking plus the ambition to contribute to the improvement of health services at local, regional, continental and worldwide level by wide application of information and communication eHealth is brought to life by contemporary changes of our technology. world and summarises the entire range of services that are at the crossroad of traditional healthcare and information techeHealth definitely acts at various levels – within each counnology. eHealth affects the entire health sector - from general try (local, regional, national activities and actors), between practitioner to the hospital manager, from nurses to software countries or at continental level as well as at a global level. But specialists, from social security funds to patients. It is be- who are the main actors in eHealth? It is not easy to enumer14

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nursing Role Survey, performed in 2004-2005, gives more information on tele-nursing. The goals of this survey were to identify where tele-nursing is developed, whether tele-nursing is accepted, effective and whether tele-nurses are satisfied with their work. Results from 39 countries reveal that typical tele-nurse is white, female, married, with children, working full-time in telenursing. Telenurses experience less than average role stress, role ambiguity, and role conflict, and have the same work satisfaction as other hospital-based nurses. The most important factor contributing to telenurses’ work satisfaction are autonomy and interaction. Tele-nurses are happy with this less physically demanding situation and are sure that they are able to deliver, manage and provide better patient education, keep patients out of the hospital, provide better outcomes, decrease hospitalizations, save time, etc. 59% of International telenurses stated that they are more satisfied with their telenursing position than “regular” nursing positions they had! 3

ate the players at various levels as the group is quite dynamic. At national levels these are various associations and societies, institutions, governmental and non-governmental organisations and foundations, Telecom and IT companies, military structures, etc. Everyone knows some of the most prominent international players – WHO, ITU, EU and EC (European Commission), United Nations Office of Out of Space Affairs (UNOOSA), United Nations Educational Scientific and Cultural Organization (UNESCO), United Nations Children’s Fund (UNICEF), associations and societies, international telecom and IT companies, etc. In addition, let’s not forget the unique role of science and research as well as the impact of business structures, industries (medical, pharmaceutical, etc.) and administration players. But only WHO is fully dedicated to health issues. All other organisations deal with health issues amongst several other activities, therefore WHO has the ultimate coordinating responsibility in eHealth. With so many players and so many actors, it is not always easy to have a broader view on the eHealth field and to visualise which the new streams are. In the following paragraphs we will try to outline them. 1. Tele-nursing: this is the eHealth application to professional nursing practice. Tele-nursing has developed much in the last decade.2 A very good example is the US. Despite the fact that most health care services are reimbursed on a “per visit” basis and thus the use of tele-care has not been heavily embraced, there is a 600% increase in tele-nursing in less than 5 years. It is expected that tele-nursing will develop even more rapidly internationally, especially where socialised medicine provides a financial impetus for tele-care. However, with the demanding requirement to deliver the best care at the least cost, the increase to tele-nursing applications will be even more evident in the years to come. The International Tele16

2. Tele-psychiatry: this refers to the use of telecommunication technologies with the aim of providing psychiatric services from a distance, most often via videoconferencing in real-time. Thus, the patient and the therapist can see and hear each other in real time, via direct TV-transmission. Telepsychiatry connects patients and health professionals, permitting effective diagnosis, treatment, education, transfer of medical data and other activities related to mental health care. Several studies demonstrated high reliability and patients’ acceptance of telepsychiatry. Telepsychiatry is extremely helpful in moving towards a communitarian outpatient approach. An example to follow is the pilot project for tele-assistance of mental diseases in the city of Sao Lourenco do Sul, Brazil.4 Immediately after the staff that works with mental health patients overcame their initial skepticism and the method was validated through daily practice, the results became evident. The decisions about the therapeutic interventions are adopted immediately, avoiding unnecessary hospitalisations. The preliminary results showed that telepsychiatry can play a significant role in the management of mental diseases. 3. Tele-psychology: which is the provision of psychological services in a technology-assisted environment, including telephone, Internet media (written, voice and digital pictures) and video conferencing. No doubt this is the future of psychology due to two key reasons. • The obvious trend of increasing of psychological disorders in the years to come and the heavy burden that these kinds of disorders place on individuals, families and communities all over the world. No country is immune to them, although some disorders may differ in frequency. • While many people suffer from a variety of psychological disorders, care is not available to all who need it. A simple example is depression. According to WHO5 in only the European Region, 33.4 million people per year have been estimated to suffer from severe depression, which means 58 out of 1000 adults. Of all the disability-adjusted life-years lost, depressive disorders account for the www.ehealthonline.org

largest share. Care providers recognise the problem in less than 50% of all depressed patients seeking medical care. Only about 18% of such patients get correct and specific treatment. And this is in Europe, where the situation with human resources is much better than in other regions of the world, with about 3.0 psychologists and 2.4 social workers per 100,000 of the population. 4. Application of Short Messages Services (SMS): for management of chronic diseases is another emerging area. Most of the mental and behavioral disorders are associated with a considerable risk for relapse after reaching the state of recovery. Unfortunately, once finishing the inpatient treatment most of the patients never seek after-hospital help. GSM and Internet offer easy and user-friendly ways to support these patients during the recovery period at home. A success story is the “On Cue” 2002 project in South Africa sending SMS reminders to patients with tuberculoses for drug regimen compliance. SMS were sent out every half hour within a chosen time-frame to remind patients to take medicine. As of January 2003, the city of Cape Town has paid only US$ 16/ patient/year for SMS reminders. In this pilot, only 1 patient out of 138 was non-compliant (99.3% compliance rate). This is something worth trying. Besides management of chronic diseases, eLearning, sharing eHealth intellectual property, fostering health security are also in the pipeline. Within the world of eHealth, it is crucial for all the players to be aware what is going on globally. Therefore, cooperation and networking are important factors. Let’s focus on a few specific networking enabling initiatives: The International Society for Telemedicine and eHealth (ISfTeH, www.isft.net) is a not-for profit membership organisation of national, regional, international associations and other institutions, organisations, corporations, individuals and students, established under the Swiss law. ISfTeH is the international representative body of national and international Telemedicine and eHealth organisations and is dedicated to broadly promoting telemedicine, telecare, telehealth, eHealth around the world. ISfTeH supports the start up of National Associations or Societies and facilitates their international contacts. Its aim is to disseminate knowledge, information and experience and to provide access to recognized experts in the eHealth field worldwide. As part of ISfTeH educational activity, a Working Committee “Education” is now functioning, chaired by Prof. M. Mars, South Africa. The mission of this Committee is: • Listing existing programs on eHealth • Establishing basic eHealth templates for fundamental training programs • Coordinating eHealth educational efforts around the Globe • Assisting the setting up of new courses in eHealth • Defining the needs of universities and specialists for basic and continuous education. • eHealth science, practice and market need a meeting June 2008

place. Such a place is Med-e-Tel (The International Educational and Networking Forum for eHealth, Telemedicine and Health ICT http://www.medetel.lu/index.php). eHealth is no more an optional choice. It already is a must, a fantastic challenge for the future but it requires cooperation and coordination at all possible levels. The main challenge is to be sure that these options are used optimally and in a coordinated manner to ascertain that the desired effects do come through and that resources are indeed not diverted away from basic needs. References: 1. (European Union Ministerial Declaration, eHealth 2003, High Level Conference, Brussels 22 May 2003, http://europa.eu.int/ information_society/eeurope/ehealth/conference/2003/doc/min_ dec_22_may_03.pdf). 2. (L. Schlachta-Fairchild “International Telenursing: A Strategic Tool for Nursing Shortage and Access to Nursing Care”, Med-eTel 2008, www.medetel.lu). 3. (For more information refer to L. Schlachta-Fairchild, D. Castelli, R. Pyke International Telenursing: a Strategic Tool for Nursing Shortage and Access to Nursing Care, pp. 399 – 405; R. S. Gundim, R. Q. Padilha Research Project: A Remote Oncology Nursing Support at Hospital Sírio Libanês, São Paulo – Brazil, pp. 406 -408; D. Castelli, L. Schlachta-Fairchild, R. Pyke Telenursing Panel: Telenursing Implementation Strategies and Success Factors pp. 409-414 all In Jordanova M., Lievens F. (Eds.) Global Telemedicine / eHealth Updates: Knowledge resources, Vol. 1, Publ. Luxexpo, Luxembourg, 2008). 4. (F. Resmini et al. Telepsychiatry: A New Tool for Remodeling Mental Health Assistance in South Brazil, In Jordanova M., Lievens F. (Eds.) Global Telemedicine / eHealth Updates: Knowledge resources, Vol. 1, Publ. Luxexpo, Luxembourg, 2008, pp. 395-398). 5. [The world health report 2001: Mental health: new understanding - new hope http://www.euro.who.int/mediacentre/PressBackgrounders/2001/20011128_1]. F. Lievens International Coordinator, Med-e-Tel, Belgium Board Member and Secretary/Treasurer, ISfTeH, Switzerland medetel@skynet.be M. Jordanova Solar-terrestrial Influences Laboratory, Bulgarian Academy of Sciences, Bulgaria Coordinator Educational Program, Med-e-Tel, Bulgaria mjordan@bas.bg 17

INDUSTRY SPEAK

Technology for Connected Care Q. What are the potential application areas of

teleconferencing equipment and solutions for the healthcare and medical service sector in India? A. The use of communication technology in the practice of medicine may change the face of health care in India by improving access to dispersed expert medical information, diagnostic tools, and consultations. Increasing demand on practitioners’ time and the increasing complexity of patients’ education and management have created a demand for creative solutions. Telemedicine can answer some of those needs and since not long ago, it has become an essential component in the delivery of modern medical care. Telemedicine will facilitate solutions for emergency medical assistance, long distance consultation, supervision, assurance, education and training for health-care professionals and providers. It will also help in combating tropical diseases, more so in a country like India with diseases and illness that require monitoring at regular intervals. Today, patients and providers alike are taking advantage of the benefits of video conferencing. Live digital video and high-speed satellite connections enable specialists to evaluate and diagnose illnesses in real time, without requiring patients to travel long distances. Hospitals are leveraging the power of IP video networks to link clinics, consultants, specialists and patients, extending the reach of health care into remote areas. Medical professionals enjoy the convenience of accessing professional development classes, certification programs, and training through video conferencing.

Q. Having achieved a very healthy growth rate for Polycom

from the corporate and government business verticals, how do you foresee the growth from the booming healthcare industry of the country? A. Healthcare is, and will always be, one of the most important focus areas for Polycom. We believe that the best way to improve the quality of healthcare is to improve real-time interactive communication in healthcare environments. Polycom understands the problems and challenges that are faced by the healthcare providers and our solutions are developed offering the best level of care, controlled costs, addressing staffing shortages and serving rural patients. It is our dream that within the next few years there will be telemedicine kiosks throughout the length and breadth of suburban and rural India. No Indian should be deprived of a 18

Yugal Sharma Country Manager - India Polycom

specialist consultation wherever he/she is. This is not impossible. We see it as a way of repaying the society. Telemedicine is not a great money-spinner, but it is a great way of reaching out to the masses.

Q. The healthcare industry typically requires very high end

video/imaging devices, how equipped are your products for delivering medical grade resolutions, display and data transfer capabilities? A. Healthcare industry does require superior video imaging for display and data transfer. Polycom is well positioned to address this market due to its advancement in technology and high end video devices. Polycom’s VSX™/HDX™ Practitioner Cart delivers real-time interactive voice and video communication capabilities in circumstances when maximum mobility is required within minimal storage areas. Equipped with easy connectivity to medical peripheral devices for quality medical interactions, it is compatible with the award-winning VSX series as well as the HDX series, Polycom’s most advanced and sophisticated solutions which provide the greatest visual, audio and content detail in a multimedia collaborative meeting. Polycom VSX 7000 group conferencing system has been effectively used by Partners Healthcare in Boston, www.ehealthonline.org

which devotes 30% of all conferencing needs to administrative purpose. Partners, doctors and nurses welcome Polycom solutions because they are self-contained, affordable and user friendly. Adding to that, today’s networks are well equipped to deliver multimedia telemedicine conference systems where there is simultaneous use of text, sounds, images, color & Motion and Polycom plays a very important role where technology can be shared between both Video & Data together in the equipment. Polycom’s solutions for the telemedicine industry: Polycom offers the industry’s most powerful and robust conferencing capabilities that doctors can use. Polycom’s VSX 7000 products are incorporated with technology such as Siren 14 technology delivering crisp, crystal clear audio with an integrated speaker and subwoofer. The product also provides exceptionally real, smooth motion video for an extraordinary video conferencing experience. Also, People+Content software allows content display in a video call. The VSX™ series span a wide range of products. For lowmaintenance video conferencing system in your doctor’s private consulting room, the VSX 3000, a desktop solution is perfect. For those looking for a highend system that approximates the scale of an important medical conference, Polycom maximum performance VSX 8000 uses the industry’s most advanced video technology, Pro-Motion for outstanding clarity and fidelity. The RSS 2000 allows users to easily start recording from any type of video conferencing endpoint, using simple DTMF commands such as Start, Pause and Stop. Up to 900 hours of stored content can be accessed from any IP endpoint or PC, enabling employees to easily access valuable company knowledge at their convenience.

for their telemedicine venture. Escorts, Narayana Hryudayalaya, Apollo, TeleVital are some of the hospitals that are using Polycom’s VC solutions. We have seen large scale deployment wherein thousands of patients located in remote parts of the country benefit from the solution, and in time this number is going to multiply. We have major plans to reach out to the masses and create awareness by providing healthcare at affordable costs through telemedicine tie ups with Reliance Webworld

Q. What is your healthcare sector client base in the foreign

and international market? A. Our client base worldwide is categorised into Healthcare Administration, Medical Education and Tele-medicine. Polycom’s presence in these sectors are largely in US, Canada, Australia and other geographically dispersed countries. Medical Missions for Children (MMC), New Jersey a non-profit organization dedicated to serving the medical needs of catastrophically ill children in under served areas of the United States and the world, enables volunteer physician specialists in the U.S. and Europe to help sick children around the world using donated Polycom video collaboration solutions. To support this effort, Polycom has donated products and funds, including a recent installment of Polycom high definition (HD) HDX™ video solutions. Northwest Research and Education Institue bridges the gap in the healthcare delivery and communications that plagues the largely rural and sparsely populated State of Montana with the Polycom’s flagship VSX™ group video conferencing systems; the Polycom Practitioner Cart medical and healthcare video solutions. To name some more international users for Polycom solutions in Healthcare are NBN Telethon TeleHealth Center, Australia; Inland Northwest Health Services, US; Kentucky Telecare health Network (KTHN); New ZeaQ. Web-based video-n-audio conferencing is getting land Telepaediatric Service; University of Vermont College of increasingly popular, and it is also finding use in telemedicine Medicine, Panacea Pharmaceuticals, US and many more. applications. Does it have any implication for business like yours? Q. What is the business case for any typical healthcare A. Video Conferencing is an integral part of all telemedicine service provider for adopting videoconferencing solutions, applications. Telemedicine requires optimal face-to-face com- based on cost-saving and effectiveness model? munications for any kind of medical diagnosis or treatment. A. Of course, we have revenue models. When a telemedicine Video conferencing enhances the experience of meeting over centre is opened, the doctor there charges around 450-600 video than in person, making the meeting seamless and in- (350 in cases) for a check-up. Part of the money is given to tegrated. our specialist as his fees, but it is of course less than what he Polycom provides a collaborative communications plat- would have charged otherwise. form ranging from voice, video and data conferencing soluFor the patient, it’s a great benefit. Statistics have shown tions and is therefore at an advantage. that only 15% of the patients treated through telemedicine actually had to come to the hospital for further treatment. So Q. Which are your major clients and/or target customers while he saves on costs of traveling to the hospital, he gets the among private and public healthcare establishments in same benefits of being treated by a specialist on an immediate India? basis. This also allows a possibility of medical consultations A. Polycom has provided solutions to a number of hospitals with more than one subject experts. June 2008

INDUSTRY SPEAK

Telemedicine for All Shivaram Malavalli President TeleVital India Pvt. Ltd.

Q. The experience of serving different customer bases such as an

army hospital, health insurance firm and rural villages must be very different from each other. What has been the level of success in each of these areas? A. Yes, TeleVital has the largest installation base reaching out to different customer bases, each with their different requirements and approach. The Army’s requirements are clearly defined and cater to the networking of secondary and speciality hospitals for enhancing the specialist support to secondary hospitals and catering to the healthcare requirements of soldiers in the remote border areas like Siachin. They have a strong protocol and high level of discipline achieving high level of success. In case of Healthcare Insurance firms, it is in the initial level of acceptance and adoption. It is primarily based on the concept of sickness management but if it takes a paradigm shift from sickness management to wellness management there will be a high level of success. Only 25% of India’s specialist physicians reside in semi-urban areas, and a mere 3% live in rural areas. As a result, rural areas, with a population approaching 700 million, continue to be deprived of proper healthcare facilities. Further the availability of hospital facility is very low in rural areas. However, the early successes of telemedicine pioneers have led to increased acceptance and proliferation of telemedicine. Healthcare is a state subject in any country, especially so in a developing country like India. The role of the Government both state and federal is high. They have to be a facilitator rather than an implementer. The State of Karnataka has become the role model in the country implementing telemedicine, networking all districts. At this juncture we have to commend the role played by ISRO in creating and sustaining the movement of speciality healthcare support to rural areas through telemedicine. Now it has spread to other states in the country. The success and popularity of the concept has now reached even Africa. TeleVital through Telecommunication Corporation of India Limited (TCIL) is implementing the Pan-African telemedicine project. Success, especially in providing healthcare cannot be measured by sporadic success but by reaching out to each one of the rural populace where there are no healthcare facilities and providing healthcare support consistently and effectively. This will be achieved by high level of acceptance by Doctors, providing higher bandwidth at the point of 20

care and outsourcing maintenance to eliminate downtime, which cannot be accepted while delivering Healthcare.

Q. You have recently been assigned to establish eHealth Technology

Business Incubator (TBI) promoting Technocrat Entrepreneurs in the areas of ICT solutions for healthcare. Please elaborate on the nature of this project. A. I was involved in the establishment of India’s first Science and Technology Entrepreneurs Park (STEP), in my capacity as its first Director, which went on to bag the ‘BEST STEP’ award instituted by the Department of Science and Technology (DST) Government of India. Based on this valuable experience and the support of DST we prepared a blueprint that would see the launch of India’s first-of-its-kind Technology Business Incubator (TBI) in the health space soon. The e-Health TBI is an industry-institute partnership that is aimed at leveraging the earlier experience of nurturing entrepreneurs. The STEP experience has helped in preparing and formulating the eHealth TBI. e-Health TBI will operate out of the PESIT Tech Park in Bangalore, where a centralised facility of 1,500 sq ft, consisting of facilities for R&D, Testing and Quality Assurance is being established to be utilised by aspiring Technocrat Entrepreneurs. Apart from this each entreprewww.ehealthonline.org

neur will be supported and mentored by strategic, business and team to develop and implement individual strategic plans to support building inputs. Though eHealth TBI will encourage ideas, entreprenational goals and objectives. neurs would be required to make an initial investment, to pledge their • Create awareness among private sector healthcare providers that commitment and take it to the Proof-of-Concept stage. We do have reaching out healthcare to rural areas through telemedicine is no idea-level incubation, wherein, the direct funding option can be exerlonger philanthropy but is a business model enhancing traffic to cised but we have to make the model a sustainable one. For this, 2% of their hospital. Encourage them to work in tandem with health the profit will have to be ploughed back by the entrepreneur. eHealth insurance providers to come out with innovative insurance prodTBI seeks to nurture entrepreneurs, both on campus and off campus, ucts with a paradigm shift from sickness management to wellness by mentoring them. It will also facilitate venture capital linkage, as the management. projects attain the maturity stage. The uniqueness of this TBI is that, it will be manned by entrepreneurs. Q. What new areas do you see TeleVital providing its telemedicine solutions to? How do see the scope of telemedicine grow in this reQ. TeleVital has several successful telemedicine projects running gion in the next five years? the world over. What are the unique challenges you face in operating A. The healthcare segment’s contribution to the economy has been in India? What are the challenges related to some of the peripheral on the rise and is expected to continue doing so for the next couple requirements for the implementation of telemedicine here? of years. India’s healthcare industry contributed 5% to the GDP and A. For effective telemedicine, IT use in hospitals should be increased to employed approximately 4 million people during 2002. By 2012, this improve computer literacy. Telemedicine systems should be integrated industry is projected to contribute 8.5% of GDP. Healthcare spending into the traditional working environment. Adequate training should is expected to double over the next 10 years. It is expected that private be provided, and key personnel should be trained. Telemedicine is healthcare will form a large chunk of this spending, rising from US$ meant to augment - and not replace - traditional practices and chan- 14.8 billion to US$ 33.6 billion in 2012 (Source: www.indiainbusinels of medicine, but several doctors tend to feel threatened by such ness.nic.in). new technology-based approaches. Legal liability issues, especially for An enormous amount of private capital will be required in the comtrans-border communications, are not easily resolved. ing years to enhance and expand India’s healthcare infrastructure Information and communications technologies tend to be dismissed to meet the needs of a growing population and an influx of medias expensive - but a well-developed solution using these technologies cal tourists. Currently India has approximately 860 beds per million is sometimes the only economically viable solution. population. This is only one-fifth of the world average, which is Sustainability of telemedicine projects - many of which do not go 3,960, according to the World Health Organization. It is estimated beyond a pilot project stage - is a key concern, and care needs to be that 450,000 additional hospital beds will be required by 2010—an taken to ensure private sector participation in such issues. investment estimated at $25.7 billion. The government is expected Some of the peripheral requirements for the implementation of tele- to contribute only 15-20% of the total, providing an enormous opmedicine are proper bandwidth for streaming videos and DICOM Im- portunity for private players to fill the gap. (Emerging Market Report: ages; awareness among beneficiaries; high level of acceptance among Health in India 2007 – PricewaterhouseCoopers). the medical community and trained manpower availability in the reFurther, the Insurance Regulatory and Development Authority gion to sustain the activity. (IRDA) eliminated tariffs on general insurance as of January 1, 2007, and this move is expected to drive additional growth of private insurQ. There are 258 telemedicine centres, with 215 remote hospitals, in- ance products. In the wake of liberalisation, health insurance is procluding 8 mobile units, connected to 43 speciality hospitals in India jected to grow to US$ 5.75 billion by 2010, according to a study by today. What are your expectations from the government for further the New Delhi-based PHD Chamber of Commerce and Industry. The promotion of telemedicine in India? IRDA believes that eliminating tariffs will encourage scientific rating A. Apart from acting as a facilitator the central Government should and adoption of better risk management practices, and lead to indehave a national strategy that would establish near and long-term na- pendent pricing for each line of business, so that premiums will be tional goals and objectives to ensure the cost-effective development based on actual risks and costs. The implementation of the new policy and use of telemedicine. In addition, the proposed strategy should also will encourage the development of innovative practices and cusinclude approaches and actions needed to tomer-friendly options for policyholders, boosting penetration. Establish a means to formally exchange information or technolIndia’s thriving economy is driving urbanisation and creating an • ogy among the Central government, state organisations, and pri- expanding middle class, with more disposable income to spend on vate sector; Foster collaborative partnerships to take advantage of healthcare. While per capita income was US$ 620 in 2005, over 150 other investments; million. Indians have annual incomes of more than US$ 1,000, and Identify necessary technologies that are not being developed by many who work in the business services sector earn as much as US$ • the public or private sector; 20,000 a year. While this is a fraction of the income that their US peers Promote interoperable system designs that would enable tele- earn, it is the equivalent of more than US$ 100,000 per year when • medicine technologies to be compatible, regardless of where they adjusted for purchasing power parity. are developed; These factors give new direction to Televital to focus on transition Encourage adoption of appropriate standardised medical records from Doctor centric approach to Citizen centric approach in provid• and data systems so that information may be exchanged among ing IT solutions to Healthcare Delivery leading to Home care reaching sectors; the health care/wellness options at the doorsteps of the individuals Encourage Central Government agencies and State departments and family. • June 2008

INDUSTRY SPEAK

Star Performers R Guru Moorthy Executive Director Karishma Software Ltd.

Q. Karishma Software has been recently awarded with the IBM Pub-

lic Sector Top Star Award under global healthcare and life sciences Sanjeeva- Telemedicine System, ManageHealth– Clinic Mancategory. How do you feel about being acknowledged with such a agement System and MARCH- Medical Access for Rural and prestigious award? What do you think gives Karishma Software the Community Health. competitive edge over others? Q. How does your business partnerships/alliances with leading venA. Being recognised as a significant player in the global health- dors such as IBM, Intel and Oracle help in delivering value for your care and life sciences domain is a fantastic achievement, espe- clients?

cially for an Indian IT product company. Being in the company of world’s largest healthcare IT firms gives us a sense of arrival. Our dedicated team and our clients’ best wishes have resulted in this honour. The competitive edge that Karishma has over others includes many things such as the terrific implementation record that we maintain; we help hospitals standardise their processes more effectively; our strong focus on EMR and Clinical pathways specifically for Oncology, Cardiology, Orthopaedics, Ophthalmology, HIV and OBGYN; we make sure that quality clinical processes and decision support systems are used extensively; our products have better architecture and easier GUI; our clients vouch for increased productivity, efficiencies and revenues.

A. These relationships primarily help the clients in reducing

cost of ownership, getting better value for money and access to current technologies. This also helps create a user group forum to exchange ideas and experiences from different countries. IBM is a big player in healthcare consultancy, Intel’s focus on digital health is now getting more attention, Oracle HTB is striving hard to get acceptability, and hence, value proposition for client will come from different directions and different initiatives. As people who engage the client, we play a central role, extremely critical and important.

Q. Even large hospitals today spend only 2% of their turnover on IT. What is the role you foresee for Karishma Software given the current scenario of limited IT adoption in the Indian healthcare industry?

A. We believe over the next three years the IT spend will inQ. Health IT market in India is estimated at US$ 3 billion and expect- crease to 3–4% for large hospitals. The need to have better

ed to grow over the next 3-5 years. What is your perception about control, accurate data, standardised processes, consolidation the level of preparedness for IT uptake among healthcare service of information and data integrity will propel these clients to look at IT adoption more seriously. The cost of storage has providers in India?

A. We have seen many changes in the perception of health- come down, images are getting digitised more often now, care entities towards IT, including an increase in the level of preparedness. In future, due to spiralling staff cost, shortage of staff, high attrition rate in hospitals and the urge to benefit from clinical processes, stakeholders will be pushed to use IT progressively more than the current levels. Usage of data for better marketing and quality is now becoming essential. Also, the younger people coming into the field have better pre-disposition towards computers and technology.

Q. Which parts of the globe are you focussing on as potential geogra-

phies? What are the key products Karishma Software has to offer the healthcare industry in India?

A. We have had substantial breakthroughs in Tanzania, Kenya,

Malaysia, Indonesia, South Africa, Bahrain and UAE. From a 1300 bed hospital in Dar-es-Salaam to a network of 120 clinics in Malaysia, we have been very successful in delivering significant value to our customers. Our Software, managing 25,000 beds daily and more than 3 million OP visits per year has given us a good standing. Our focus over the next three years will be India, Africa, Middle East, South Asia and the USA. The product suites Karishma offers today are Jeeva- Hospital Information system, 22

clinical pathways or some kind of guidelines will become essential as time goes by, revenue leakages and wastages will become more unaffordable, hence IT will come to the fore. The decision-making with reference to IT is a major problem and attention span of decision makers is low. Our role is to engage them in their professional environment more often and strike relationships, which they can fall back on, in case of problems. The advent of MHAs, and corporatisation will compel these organisations to look at IT more seriously because every PE investor is demanding, thus, we are looking at exciting times and we will play a greater role. The differences that exist are due to the importance given to IT and the role it plays in good governance. The solutions also reflect the same. For example, tertiary care hospitals in India or in other regions have now started behaving in a similar fashion. The reason is increased dialogue and exchange of ideas and also medical tourism. However, smaller hospitals have a tendency to look at administrative functions more seriously. Training needs differ significantly. Being a product company we customise versions across the markets to suit the demands of the region. www.ehealthonline.org

EXPERT SPEAK

Universal Solution to the

Healthcare Challenge enabling and encouraging patients to become more proactive and better informed in furthering their own and others’ health (aided by health websites); enabling the old, frail and chronically ill to lead more independent and at the same time less isolated lives; and reducing the exploding costs of what is a good health care system to make it sustainable, by improving communication between health care providers and thus avoiding unnecessary repetition of procedures. Q. What groundwork do you think is required for the successful implementation of telemedicine in a country like Germany? A. I shall take “successful implementation” to mean imple-

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

Q. Please share with us your vision of using telemedicine for the bettering of healthcare facilities in Germany? A. I don’t think anybody’s vision for Germany is as exciting

as a vision for India can be. However, I envisage telemedicine

June 2008

mentation that is widely used in clinical routine. The success of telemedicine depends strongly on factors that can vary widely, even between seemingly similar countries, so I shall limit my answer to Germany. The necessary groundwork includes at least: • Interoperability of patient data between health care facilities, or a universal electronic health record; complete interoperability or a complete universal electronic health record is not a prerequisite, nor is it a realistic short term goal, but increasing use of telemedicine needs increasing interoperability. • Proof of net benefit (in terms of change in patient outcomes and/or costs) of a significant range of telemedicine applications. • Changes in the reimbursement rules to enable health insurers to reimburse costs of telemedicine technology adequately. • Acceptance of telemedicine by those who are to be involved - the patients and health care workers. In Germany, developing the electronic health card (a smart card) and its accompanying infrastructure is currently a prime telemedicine activity and one which is intended, in the long run, to give access to an electronic health record, and thus indirectly support all other telemedicine activities. As regards the electronic health card, acceptance among patients is fairly good but not on the part of doctors.

Q. How different would the groundwork have to be in a country as large and diverse as India? A. The interoperability and EHR requirement holds for India

too, in the same relative sense as for Germany. Proof of net benefit of telemedicine applications: In a country like Germany, in which the whole population is fairly well cared for already, this can be very difficult. But in a country like India with a vast underserved rural population, if telemedicine provides care in certain situations to people who could not access any care in those situations before, then it is obviously beneficial. That is why I find visions of telemedicine in India much more exciting than in Germany. Reimbursement: If telemedicine is to improve the health care of India’s huge underserved rural population in a sustainable manner, it must enable a large number of health care workers to earn some money by contributing to this improvement. (I know several people, who regularly provide health care services free to the needy, and I believe there are many such people, particularly in India; but I suspect that even in India there are not enough of them to bridge the urban/rural health care divide on this basis alone.) As I understand the situation in India, the problem as regards reimbursement of costs of telemedicine technology is not a problem of existing counterproductive rules, but reimbursement is nevertheless an important issue. Acceptance: I have been pointed by several people to the reluctance of rural people in India to accept opinions and people from outside their community, and the fact that this cannot be overcome by training someone from the community as a doctor because almost inevitably the person thus trained will soon move to a city. Sustainable telemedicine solutions need a health care worker who is accepted by the community. Q. What factors according to you contribute to the overall success or failure of telemedicine projects? A. I am not familiar enough with the situation in India to an-

swer this question in relation to India, so I shall answer it by examples from Germany and the USA: Lack of standards: technical communications standards; standards for the representation of patient data. Cost of technology (both in Germany and USA): in the USA this is offset by a national law (universal service) to use part of the charges for advanced telecommunications services to support underserved sections of the population. Laws that prohibit or discourage some forms of telemedicine - licensure laws in the USA, reimbursement laws in Germany. Lack of acceptance by health care workers because of disruption of established workflow processes - this is a familiar problem in IT development in general, not just in the health care domain. This seems to be a list of factors that contribute to failure, but of course anything that overcomes these problems contributes to success. And there are several examples of people who have been instrumental for success by a very positive attitude towards a project or by being warm-hearted and dependable. 24

The reluctance of rural people to accept opinions and people from outside their community cannot be overcome by training someone from the community as a doctor because the person thus trained will soon move to a city. Q. What should be the government interventions, in terms of policy, regulations and financial support, in order to facilitate telemedicine based public healthcare delivery? A. As regards the “ground work” issues discussed above, the

government can support the development of solutions for the interoperability / EHR requirement and implement appropriate legislation; it can address the reimbursement issue by giving financial support for telemedicine infrastructure that can be used by individual health care workers (for example by doctors in private practice); it can address the problem of acceptance in rural communities by training women in the community as auxiliary health care workers who will remain in the community with their family. Q. Please share with us some insights and new learnings you may have received, during your stay in India on telemedicine projects undertaken by public and private sectors in India. A. In the first six weeks of this year, I had conversations with

many people all over India, from both the public and private sectors, about telemedicine in India, and discussions about possible ways forward. I have not yet had time to follow up all this information, so cannot claim to have a balanced view and shall limit myself to one observation: I am very impressed by reports on the Aravind Eye Hospital, including its sustainable non-profit business model, which supports 70% of the patients with the fees of the other 30%. At first sight I took this to be ‘just’ a successful telemedicine project; on closer inspection I found telemedicine came in at a fairly late stage, as a means of screening people in their communities for oncoming blindness in order to get them to the hospital if (and only if) they needed an operation; before that, the founder had, among other things, worked out a process which makes maximum use of the few available ophthalmologists by having all steps that do not require this qualification done by other workers. Maybe this is a good illustration of the fact that, for a telemedicine project to be successful, usually a lot of thought and work has to go into many facets; so mature ventures, in which many problems have already been solved, can be particularly good candidates for applying telemedicine. Finally, I would like to thank all the people who shared their time and insights with me, and stress that I am a beginner as regards familiarity with telemedicine in India. If I have misunderstood anything, I shall be very grateful to anyone who enlightens me.

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POWER HOSPITAL

FORTIS HOSPITAL MOHALI

ortis Hospital, Mohali, Punjab, set on a sprawling 8.22 acres of land, is the largest Cardiac Care Hospital in the region. The hospital is a 215-bedded cardiac and multi-speciality hospital, and was the first facility of its kind in the region. The hospital has been designed and equipped with the latest technology, Information Technology systems, a telemedicine programme and carefully selected doctors, nurses and support staff. Bringing breakthrough technologies to the operating room, the hospital is continuously setting the highest International standards in as many as 26 Medical specialities. Taking the concept of personalised care to the next level the hospital maintains 1:1 patient to nurse ratio in ICUs and ICCUs. The hospital, which was awarded the Best Design Award by the American Institute of Architecture in 1999, has the following facilities: • A Multi-speciality Medical Centre with day care facilities. • Out patient care to fulfill the local demand • NABL certified path lab • State of the art blood bank • State-of-art Operation Theatres with laminar flow with shadow less lighting • A 24 hours Emergency Ambulance service • A dedicated Emergency and Trauma center • Mohali’s only 24hr Chemist Shop • Free home collection of Pathology Samples The hospital received the US-based Joint Commission International (JCI) accreditation in the year 2001. The accreditation is considered the highest form of recognition in the health world and was conferred in recognition of Fortis Hospital Mohali’s empathetic patient care programme. JCI, the gold standard in global healthcare standards, focuses on areas that directly impact patient care. The focus areas include: Assessment of patients, utmost care of the patients, patient and family rights, strict infection control for the safety of the patients, education and documentation. June 2008

<<< Multispeciality Services Fortis Hospital Mohali uses “tracer methodology” – an evaluation method to “trace” a single patient’s experiences within a healthcare organisation to ensure utmost comfort for the patient from the time s/he registers into the hospital till s/he is discharged. IT Backbone Fortis Mohali has one of the biggest IT infrastructures of its kind in the country, with fibre optic as a backbone for their IT network, Dedicated Lease lines to different Fortis group hospitals. As IT infrastructure they have 15 servers for different applications, 450 Desktops, 100 printers, S8400 server based AVAYA Telephone Exchange. 10 Cisco switches for internal networking. The infrastructure is fully based on Client Server Architecture. HIS Fortis Mohali operates on Trak - a complete Hospital Information System (HIS) solution. This is a totally webbased system connected to centralized server. Different modules like BILLING which is used in OPD and IPD for patient billing, PHARMACY which is used for dispatching medicines and medical consumables to out patient and inpatients, INDENTING module is used by nurses for indenting medicines to the patients. DISCHARGE SUMMARY modules used for making discharge summary of patients, which is integrated with their LMS server for lab reporting. The Pathology Lab for all inpatient and out patient lab reports uses LMS. The finance module is based in Prodigious, which is completely integrated with Trak modules for all MIS and other reporting purposes. Clinical Technologies The hospital works regularly to put Clinical technologies into a system, which can be integrated with their HIS. They are working on RFID as

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Cardiac Services Cardio Thoracic and Vascular Surgery Invasive Cardiology Cardiac Anesthesia Paediatrics Special Clinics Dietetics Physiotherapy

Diagnostics & Investigations Radiology Nuclear Medicine Lab Medicine Non-invasive Cardiology Urology Lithotripsy Lab Pulmonary Lab Audiometric Test Lab

Facilities Area Cardiac Operation Theatres Mutispeciality Operation Theatres Cardiac Cath Labs ICU’s - 5 High Dependency Unit Private/General Wards (A1, A2, A3) Dialysis Unit Endoscopy Suite ER Triage Day Care Cath Area

Nos. 3 4 2 84 Beds 23 Beds 115 Beds 9 Beds 1 4+2+1 Beds 12 Beds

technology, which can be used very effectively for clinical purposes. They plan to use mobile devices, which can be integrated with their HIS, which can facilitate doctors for online reporting. Currently doctors are using HP remote link for viewing clinical details of ICU patients. Fortis Initiatives Telemedicine is being used as a tool to cross consult be- Corporate Social Responsibility tween different Fortis Hospitals. They are also working on a • Sarthak - Cancer support group Public Private Partnership (PPP) model and are hopeful about • Sahayak - Dialysis support group taking this concept ahead very aggressively in the near fu• Chetna - Programme for the girl child ture. • Act fast - AIDS awareness campaign • Out reach OPD’s • Golden Age Club Services • Friends of Fortis Programme Multispeciality Services • School Buddies Anesthesia Neurology Governance through Collaboration (Hospital Committees) Cosmetic & Plastic Surgery Nuclear Medicine • Quality Steering Committee Dermatology Medical Oncology • Safety Committee • Infection Control Committee Endocrinology Ophthalmology • Blood Transfusion Committee Gastroenterology Orthopedics • Pharmacy and Therapeutics Committee General Surgery ENT • Code Blue Committee Gynecology Pulmonology • Medical Audit And Mortality Review Committee Internal Medicine Transfusion Medicine • Credentialing & Privileging Committee Nephrology & Dialysis Urology • Staff Selection and Appraisal Committee Neuro Surgery • Staff Welfare Committee June 2008

> >

APPLICATIONS

Connect Now for Easy Health Claims

ealth insurance claims processing in India is not in the best of shape. Patients and/or their relatives end up having to spend a lot of time, effort and resources on filing requests, following up payments and in many cases also having to deal with faulty billing. There is a strong need for healthcare reform and greater health insurance uptake. Revenue cycle leaders are struggling with tighter budgets, increasing scrutiny over billing and collection practices, new legislation, rapidly evolving technology, and payers’ changing rules. The industry also has to deal with the rising numbers of the uninsured and underinsured patients, shrinking reimbursements, and to add to this rising costs amplify these challenges. Issues that are most likely to impact the health insurance sector over the next five years include unpaid care (e.g., write-offs, bad debt), policy/regulatory issues, and delayed payment for services. The Solution A group of professionals belonging to HealthSprint Networks Pvt. Ltd., Bangalore have designed iSprint Health Insurance Electronic Claims Network, the first of its kind network in India for insurance claims processing. The aim of this network is to provide patient friendly health insurance transaction platform, which enables smooth transfer of health insurance related data with complete privacy and security. One of the most important service offerings of this team is focused on making Patient/Payer/Provider communications more clear, correct, concise, and patient friendly. The ultimate goal of the network is to ease the experience of patients and their families, but hospitals and medical groups also benefit in the process. Providers adopting the network experience considerable operational and financial improvements, due to the standardisation and inter-operability. Product Development HealthSprint Networks began its work by conducting surveys of focus groups of patients, payers and providers around the country. The participants’ message was loud and clear patient billing is a significant problem for both patients and providers. Participants said they saw the patient bill as confusing and over-charging; they found the billing process timeconsuming and frustrating. Consumers today expect to participate in their medical care and to be better informed about all aspects of their health. As the amount paid by consumers for medical care increases, patients more than ever demand and deserve financial information in a comprehensible format. Even though many organisations and entities are comfortable with the concept of paying bills online, healthcare lags behind many industries in adopting electronic billing options. 28

Important Components of HealthSprint Statement Clear: All financial communications should be easy to understand. Providers and payers should be able to quickly determine what they need to do, with the communication enabling quick decision-making.  Correct: The bills or statements should not include estimates of liabilities, incomplete information, or errors.  Concise: The bills should contain just the right amount of detail necessary to communicate the message.  Patient Friendly: The needs of the patient and their family members should be paramount when designing administrative processes and communications. The software and network components cover all important aspects of Cashless Claims processing namely, e-Preauth – which eliminates the need to fax pre-authorisation forms and shrinks turnaround time dramatically; e-claims - which sends the information related to billing and necessary medical information to validate a claim, thus eliminating the communication issues after the discharge of the patient. It dramatically helps to improve the Payer – Provider relationship which is the need of the hour and helps providers build effective Customer relationship management; e-Payment Gateway - after validation of the electronic and physical claim, iSprint enables seamless payment gateway secured through Unit Trust of India (UTI) Bank payment gateway to enable electronic fund transfers /RTGS to providers. Benefits of the Network  Some of the immediate expected benefits of implementing the network are:  Improved satisfaction, operational efficiencies, and revenue cycle metrics  Patient satisfaction with the billing process  Days in accounts receivable  Cash collections improvement (cash collections such as revenue and bad debt expense)  Changes in bad debt and account aging  Change in billing/service calls per account  Readability of financial communications. www.ehealthonline.org

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BUSINESS

Medtronic to surf Europes ‘wave of telemedicine’ The US-medical device manufacturer Medtronic is planning to extend its presence as a telemedicine provider in Europe. CareLink was introduced in Europe in 2007, but so far in pilot projects only. This will change in 2008, according to Medtronic’s CEO Bill Hawkins. He said 2008 will be the year for Medtronic to get into Europe with its telemedicine solutions on a bigger scale. At the heart of the company’s telemedicine initiative is the CareLink platform, an internet-based solution for remote medical device monitoring and remote patient monitoring. CareLink has been available in the US since 2004. The platform is currently used for the remote monitoring of patients with implantable defibrillators (ICD) or pacemakers, and for web-based continuous blood glucose-monitoring. The new product line-up includes new generation ICD - and pacemaker systems that are capable of wireless data transfer without the need of an antenna to collect the data. The devices will also have an automatic alert function for pulmonary oedema, which Medtronic refers to as ‘OptiVol’. It measures electrical currents in the thorax and generates an e-mail or short message-alert for the physician in case a pulmonary oedema is developing in the patient.

Computer Sciences Corp forms healthcare unit

GE Healthcare in joint venture

Computer Sciences Corp. has launched a new business unit dedicated to healthcare. CSC’s Healthcare Sector will focus on the information and service needs of healthcare providers, health plans, pharmaceutical and medical device manufacturers and allied industries globally. Deward Watts, who has been with CSC for 12 years, will serve as president of the new unit. “Organizing CSC’s global healthcare resources into a single vertical organization better positions CSC to help our clients use information to transform healthcare,” said Watts. “Our main focus will be delivering IT-based innovation that improves patient outcomes and the decision making of providers, payers and life sciences organisations. “ The Healthcare Sector will leverage core intellectual property to help clients innovate new or enhanced clinical and business processes, including processes related to supply chain management, revenue cycle management, claims processing, document management and clinical trial management, CSC officials said. In addition, application management services and business process outsourcing are supported by CSC’s healthcare centres in Bangalore and Chennai, India. The company said the new unit will be bolstered by CSC’s acquisition last year of First Consulting Group, a healthcare IT consulting company, and also by the acquisition of Covansys, which adds offshore domain expertise and an additional market channel.

GE Healthcare, the US$ 17 billion (Dh62.3bn) healthcare business of General Electric Company (GE), has announced the formation of a joint venture, GE El Seif Healthcare Arabia. The new company, which has a 51:49% ownership between GE and El Seif Development, will drive the sale of GE Healthcare’s products in Saudi Arabia. GE Healthcare has been operating in Saudi Arabia for more than 25 years and together with strategic partner El Seif Development Company it has been making the latest innovations available to healthcare providers in the country. GE El Seif Healthcare Arabia will bring GE Healthcare’s extensive portfolio ranging from innovative diagnostic and imaging equipment, patient monitoring and data systems to network storage systems and software for healthcare professionals across Saudi Arabia. It will also complement the earlier joint venture between GE and El Seif Medical Services, demonstrating the commitment of both companies to transform the healthcare delivery in the Kingdom. “GE believes in strong ties such as the one we have with our partner El Seif Development,” said Richard Di Benedetto, President and CEO of GE Healthcare, International - EAGM region.

Apollo DKV health insurance in ties with InsuranceMall Apollo DKV Insurance recently announced its tie-up with Bonsai Insurance Broking Pvt. Ltd., a leading Insurance Broker in the General Insurance segment for online insurance shopping through its website www.Insurancemall.in. The tie-up would offer customers a comprehensive solution for purchasing health insurance products over the internet. This tie-up is yet another step towards offering unparalleled product range and value to its customers. The company plans to have a national presence across 25 cities by the second year of operations and spread to over 100 locations by 2010. The tie-up will provide the common man with indigenously developed ‘quote-engines’ to compare, choose and buy Insurance online. The website also offers complete portfolio management (renewal auto-reminders to advisory) and claims assistance on policies purchased. The site also endeavours to give the common insurance buyer complete power of information and decision making.

June 2008

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Tatanet grabs contract from TCIL for telemedicine Tatanet, a division of NELCO Ltd., has announced that it has received a multi-million dollar order for supply of Satcom equipment from Telecommunications Consultants India Limited (TCIL) for a e-Network project providing telemedicine. TCIL is implementing a multi-million dollar pan-African e-Network project on turnkey basis, funded by the Ministry of External Affairs. The network will provide telemedicine and tele-education services to 53 countries of African Union and VVIP connectivity (VoIP and Video Conferencing) among the heads of states. Tatanet would build a satellite hub station with a full-fledged Data Centre at Dakar, Senegal and a studio in India along with other facilities to connect seven Indian University Centers, including IGNOU, to cater the student communities in Africa. The network will also have 12 super speciality hospitals in India to provide tele-consultation and Continuing Medical Education (CME) services. “This project has many firsts and provides us the platform to showcase our skills in the field of System Integration and Satcom project. We are confident of our ability to deliver a robust network, which will be a benchmark for such initiatives in the future,” said Kaushik Mandal, vice president - Sales (Enterprise & Turnkey Projects) and Program Management, Tatanet.

Global healthcare IT firm enters Pune US-based healthcare information technology services firm Eclipsys has set up its second India unit in Pune to support its cleint base in Europe, US and Australia. With a headcount of more than 25 in Pune, the company will provide integrated softwares, advanced clinical content and professional services to hospitals, research institutes and related establishments located in US and Europe to a large extent. Eclipsys CEO Andrew Eckert said, the company has set up its fully functional unit inside a notified special economic zone (SEZ) in Kharadi, Pune. With 13 development centres spread across the globe, the company has invested INR 45 crore as capital investment for its Pune unit. “Service sector in India is growing at the fastest possible rate. The same is accompanied by availability of skilled manpower in medicine and techincal aspects. This has made us focus on India for research and development activities along with services,” said Eckert. Eclipsys India President Nitin Deshpande said the company would recurit technicians and medicine professionals from local market only. `“While more and more hospitals and clinical establishments are now depending on information systems, software development and services support in this sector is all set to grow. India is being looked as one of most important and efficient service provider on global perspective. Eclipsys India will address the global needs through IT support in healthcare sector,” Deshpande stated.

EMIS in JV with Ireland’s Helix Health EMIS has announced a joint venture agreement with Ireland’s largest healthcare IT provider, Helix Health Ltd. The agreement sees the two companies selling each other’s products in their respective market areas. The new EMIS Dental system, as well as software components for primary care will become available in Ireland through the Helix sales and support network, while Helix will gain access to EMIS’ sales and support network to distribute and support its QicScript range of pharmacy management software applications across the UK. Both companies will gain access to each other’s research and development expertise, in addition to software knowledge. They will also localise their products for each marketplace, incorporating features and functionality that will benefit their respective customers. Sean Riddell, EMIS’ Healthcare Managing Director comments: “The joint venture gives us the opportunity to extend our product offering into new markets, as well as working closely with Helix to bring benefits to our respective customers at a local level.”

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2008

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New Intel software connects health networks better

British health insurer set to foray into India

Intel Corporation announced Intel® SOA Expressway for Healthcare, software that provides an efficient way to exchange healthcare information inside hospitals and with health information networks. The product will allow healthcare providers to connect more easily with one another so that each can provide better care while benefiting from reduced integration costs. Based on Service Oriented Architecture (SOA), Intel SOA Expressway for Healthcare offers a cost-efficient solution to this problem by providing an efficient and scaleable way to translate, process and connect any data format across a healthcare network. In addition, Intel has created a group of validated independent software vendors (ISVs) that provides best-of-breed capabilities to deploy a complete health network powered by the Intel SOA Expressway. The validated ecosystem helps complete next-generation SOA architecture for healthcare data interoperability. Intel SOA Expressway for Healthcare provides the performance of a hardware appliance in a software form factor that offers native message acceleration for rapid data exchange, workflow management and translation to enable data exchange to and from any original format. In order to make Intel SOA Expressway for Healthcare as versatile as possible, Intel designed it as a flexible product offering that can stand alone as the gateway to and from a community health information network or can be bundled as part of an ISV solution.

Britain’s largest private health insurer, British United Provident Association (BUPA) is set to enter India to cash in on the booming healthcare services demand, driven by rapidly rising population and growing affluence. The UK healthcare giant is said to have teamed up with Max New York Life for its foray into the country, and plans to plough some of the £1.44 billion raised from the sale of 25 of its UK hospitals last year, sources said. BUPA is already present in 190 countries and has over 8 million members in Hong Kong, Thailand, Australia. It recently opened an office in China. Last year the company earned revenues of £3.8 billion from insurance in the UK alone and £2.3 billion from international insurance. BUPA has bases in three continents and operates over 300 care homes spread across the UK. To this end, BUPA had teamed up with Mumbai-based Wockhardt Hospitals over five years ago. Wockhardt is on BUPA’s emergency international network of participating hospitals. With less than 10% of the population covered by medical insurance, the Indian government has taken up the noble cause to provide the same to the country’s 300 million poor, most of whom work in the unorganised sector and are thus deprived of quality healthcare.

Atos Origin awarded Gematik contract International IT services provider Atos Origin has signed a 5-year contract with the Gesellschaft für Telematikanwendungen der Gesundheitskarte mbH (gematik) for the implementation of the German electronic health card. Atos Origin will be in charge of the design and implementation of the Directory Service in the IT infrastructure, and will be responsible for the organisation of the service rights in the eHealth card central IT network. The electronic health card will extensively simplify the administration of medical data in Germany, thus reducing costs in the healthcare system. It enables a simple and secure exchange of important data between insured persons, doctors, pharmacies and insurance companies. With the contract for the implementation of the Directory Service, Atos Origin now extends its commitment that began in December 2007 with the acceptance of the bid for the installation of two central elements of the infrastructure – the Time Service and the Name Service. The Time Service synchronises the time settings of all central and distributed hardware and software components. The Name Service handles the conversion of domain names to IP addresses so that the assignment of the name to the storage location will be possible.

Novartis in record Swiss deal Pharmaceuticals company Novartis is acquiring a potential $39bn (25bn) stake in eye care group Alcon in what could be the biggest Swiss acquisition of a US company if the (optional) second stage of the deal goes through. In the first stage of the deal, Novartis has agreed to a 25% stake on Alcon from Swiss food group Nestlé for US$ 11bn in the second half of this year. Goldman Sachs advised Novartis, while Nestlé was advised by Credit Suisse. Cravath, Swaine & Moore was legal advisor to Nestlé. Alcon was acquired by Nestlé in 1978, and Credit Suisse, alongside Merrill Lynch, led Alcon’s initial public offering when it was partially spun off in 2002 on the New York Stock Exchange. Credit Suisse and Lazard also advised Nestlé last year on its US$ 5.5bn acquisition of Gerber, the baby food business from Novartis, which was advised by Goldman Sachs. Gordon Dyal, who runs the Goldman’s global M&A business has a strong relationship with Novartis. Novartis said it intends to finance the purchase of the 25% Alcon stake in the first step from internal cash reserves and external short-term financing, with borrowing needs currently estimated at US$ 5.5bn. If the deal increases to US$ 39bn, it will be the second largest cross-border health care M&A deal on record, according to Dealogic.

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European firms sign global e-health deals

IBA wins £5 million deal with General Healthcare Group

Two large European e-health suppliers have announced new deals to conduct healthcare work internationally, in the last month. Netherlands based Gemalto and Belgium-based Agfa HealthCare will be undertaking large projects in Algeria, Azerbaijan and Canada respectively. Gemalto has begun rolling out a two-year e-health project in Algeria (CNAS), consisting of 7 million smartcards, known as Chifa, in five regions of the north African country, to be used by healthcare beneficiaries and providers. The aim is for hospitals and other healthcare institutions to manage patient records securely and to verify patient benefits, whilst keeping the data secure. The Chifa is intended to simplify administration by removing paperwork from submission claims to the authorities. Gemalto has also been chosen as a prime contractor for the National E-Health Programme in Azerbaijan. They will supply 3 million microprocessor-based smartcards to the continue, with the project expected to last two years. In Canada, Agfa HealthCare has been awarded a contract to deliver a Diagnostic Imaging Repository (DI-r) to New Brunswick, one of Canada’s provinces. The project is part of the province’s One Patient One Record e-health strategy, and will provide the infrastructure and functionality required to capture, store, view and link patient information for its 740,000 residents. Agfa HealthCare will create the DI-r based on its IMPAX DataCenterconcept radiology information system software, for consolidating images and radiology reports into a central system. The data can be retained for the lifetime of a patient, and staff can use a secure login to access the information regardless of where it was acquired. The project aims to help clinicians make informed decisions about care, as well as reducing costs for healthcare facilities, such as those due to repeat imaging procedures caused by lost paper files.

Australia’s largest listed health information technology company announced that the largest provider of independent healthcare services in the UK, General Healthcare Group (GHG) has appointed iSOFT as a strategic health information technology partner. Further, GHG will license and implement iSOFT’s patient management systems at its 47 BMI Healthcare private acute care hospitals and its Netcare centres in a deal worth £5 million over six years. Additional services will be provided over the life of the agreement for development, implementation and deployment services. The agreement also provides the framework for licensing and implementation of additional iSOFT products. The agreement provides a strategic framework for GHG and iSOFT to work closely together as iSOFT makes available its “next generation” of products. In addition, GHG has appointed iSOFT as its preferred supplier for clinical IT systems, to include order communications and results reporting as well as other systems to support its highly successful and growing business. iSOFT will be working closely with GHG as a partner to ensure fast-track deployment of these critical business solutions. As the largest provider of independent healthcare services in the UK, GHG is upgrading to iSOFT’s iPM Patient Administration System as part of its overhaul of IT systems and infrastructure. The GHG group will implement iPM across its national network of BMI Healthcare hospitals as well as its Netcare centres, integrating patient management, billing and back-office functionality within a single suite of software. iPM will streamline the current patient administration processes, reduce dependence on paper records and include core theatre and billing data into a single electronic record. This repository of information will form the basis of a patient’s “Electronic Health Record” for the GHG network of facilities. GHG includes BMI Healthcare, the largest independent provider of acute surgical services in the UK.

European firm buys Dabur for INR 880 cr Dabur is exiting the pharma business. The Burman family, promoters of FMCG major Dabur, has sold the oncology drug manufacturing company - Dabur Pharma - to European healthcare major Fresenius SE for about INR 880 crore. The Burmans, along with some key stakeholders, have agreed to sell their 73.27% stake at a price of INR 76.50 per share, a 10%s premium over the current market price. The deal values Dabur Pharma at INR 1198.75 crore. Dabur Pharma is one of the leading players in the field of oncology in India and is among the top generic oncology companies in various markets, including in Thailand, Philippines, Malaysia and India. Besides being present in more than 40 countries, the company has a strong base in the US. It has a substantial market share in Paclitaxel and Irinotecan injections used in the treatment of rectum cancer. Dabur has 12 generic drugs pending for approval in the US market. It has already received four approvals. “Dabur is an FMCG company and the move of the Burmans to exit from the pharma business is aimed at focussing on the high investment intensive FMCG business,” said Sujay Shetty, associate director of PricewaterhouseCoopers.

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Karishma Software wins IBM Global Public Sector Top Star award for 2008 Karishma Software Ltd. is a winner of IBM Global Public Sector Top Star award for 2008, announced recently. The Indian company is one of five Business Partners recognized with this prestigious award by the Global Healthcare and Life Sciences industry. IBM’s Public Sector channel sales teams and industry executives selected business partners from government, education and healthcare/life sciences who consistently demonstrate the “Best of the Best” qualities that help to ensure a successful partnership with IBM, as well as success in the marketplace. These qualities are - unique, innovative solution; a significant win in 2007 that has been or can be replicated; loyalty to IBM; strong adoption of IBM platforms and open architecture; strategic commitment to partnership with IBM; significant involvement and help in closing strategic deals. Karishma Software, a major player in the healthcare IT field, delivers solutions for Hospital Information System, Telemedicine, Clinic Management System and Decision Support System across seven countries. It has over 200 healthcare organisations as its clients. Karishma’s healthcare systems manage over 20,000 beds in over 60 hospitals including Hospitals such as Jaslok, Jupiter, St. Stephen’s, St. Ann’s, Muhimbili National Hospital, Ruby Hall and Image Hospital. Commenting on the occasion R Guru Moorthy, Executive Director, Karishma Software said “Our focus in healthcare IT has made significant difference in the way IT systems are being used in the hospitals and clinics across seven countries. We believe our patientcentric EMR strategy with focus on clinician’s documentation will evolve into innovative business processes.” Other Healthcare/Life Sciences Top Stars were: BlueWare, Inc., Vocera Communications, Inc., Carefx Corporation, Cerner Corporation and Karishma Software, Ltd.

Trivitron’s Med Tech Park ready to commence construction Trivitron group of companies, one of India’s largest medical technology companies laid the foundation stone for the construction of their much-awaited Medical Technology Park at the SIPCOT Industrial Park, Irungattukottai, Sriperambadur adjacent to Hyundai Car factory. The Medical Technology Park is first of its kind initiative in India and will be having collaborations with the world-renowned medical technology companies. Trivitron has signed three Joint Ventures with Aloka from Japan, Biosystems of Spain, and Brandon Medical a UK based company to manufacture Black and White Ultrasound Systems and Colour Dopplers, Wide Range of Diagnostics Reagents and Shadowless High End Operating Theatre Lights. The Trivitron’s Medical Technology Park (TMTP) is spread over an area of 23 acres and will see an investment of over INR 250 Crores in the first phase of the project. Trivitron plans to invest INR 170 Crores in the project and the remaining 80 crores will be raised through various joint ventures. The upcoming facility will be built on par with international manufacturing standards and the layout abides the FDA and CE norms. Trivitron is also exploring the option of converting the park into SEZ after acquiring another 2-acre land in the same location. Trivitron will focus on manufacturing of medical equipments in the areas of Critical Care, Cardiac Care, Imaging and routine labortaory diagnostics. For the initial phase, it will manufacture products with the support of its in-house technology and R& D department which would include products like X Ray Machines, C arm, ECG Machines, Stress Test Systems and Holter Monitors, Syringe and Infusion Pumps, Haematology Reagents, Haemodialysis Concentrates etc. All products manufactured in the TMTP will be CE and US FDA approved and will be sold in all the emerging markets across the world apart from India. “Our aim is to position India as an alternate viable low cost manufacturing hub in the global manufacturing map of medical technology products.” said Dr. G S K Velu, Managing Director, of Trivitron group of companies. The products manufactured in MTP will be priced 30 to 50% less than the current MRP” Initially, Trivitron will use 15 acres of land for manufacturing its products through Technology transfer arrangements and remaining 10 acres will be allotted to its JV Companies.

IBA Health’s eHealth Network growing IBA Health Group Limited - Australia’s largest listed health information technology company has announced two new Australian private health insurance funds, HBF and GMF Health funds will connect to its expanding eHealth network for real-time, point-of-care electronic health claiming and payment services. With more than 900,000 members, HBF is the leading provider of health insurance in Western Australia. Also based in Western Australia, GMF Health provides health insurance to more than 60,000 members across Australia. IBA now has agreements with 30 health funds, which collectively represent 98% of privately health insured Australians. Privately insured Australians can settle their accounts on the spot with their health insurer and health care professional through connectivity to IBA’s HealthPoint claiming service. HealthPoint gives healthcare professionals and their patients an efficient, easy-to-use single point solution for EFTPOS, patient claims to health funds and, where appropriate, Medicare claims. By automating and streamlining the entire health claim and payment process, IBA’s solutions are enabling health fund insurers to lower costs while providing more efficient and effective services to their members. Both HBF and GMF are expected to go live with IBA’s HealthPoint service from August/September this year with claiming for optometrists, dentists, chiropractors and physiotherapists.

June 2008

in conversation

Solutions for Transformation Patrick Downing Product Unit Manager Microsoft Healthcare Solutions Group

Currently, the healthcare industry across the region seems to be in a race to catch up with IT uptake and adoption of technology. What has been your observation in this regard and what do you think are the reasons behind this lag?

Transforming healthcare is a complex problem with no easy answer and certainly no quick-fix solution. With the Asia Pacific region experiencing increasing challenges and escalating healthcare costs, healthcare organisations are continually threatened by an insufficient allocation of technology, resources, and capabilities for their efforts. Technology has a very real and proven ability to drive transformation—arming healthcare workers, plan administrators— and most importantly, consumers, with the best knowledge for real-time collaboration and decision-making. We believe this will chart the path to better, more efficient healthcare outcomes. At Microsoft, we firmly believe in software’s ability to make a positive impact on the healthcare ecosystem worldwide. However, no one company can solve it alone. We are taking the long view in our approach to enabling transformation across the healthcare system - it will be a marathon as opposed to a sprint.

able Microsoft technology, makes this a great addition to our portfolio of health enterprise products as we look to power developing and emerging hospital systems around the globe. The GCS solution has allowed the Bumrungrad facility manage scheduling demands, multiple languages and medical records so efficiently that the average waiting time to see a doctor is only 17 minutes.

Up till now, Bumrungrad International is known to be the one lone success story of GCS in Asian region. is supposed to have expanded capabilities for both the Given that from now, your solutions will be offered under companies, while creating superior value for customers. Microsoft’s brand name, how do you foresee business prospects in the near future? Kindly reflect on this.

Q. Microsoft’s acquisition of Global Care Solutions (GCS)

The acquisition complements Microsoft’s already strong portfolio of health solutions and will provide hospitals across international markets with a new alternative to achieve improved workflow and patient safety through information technology. Global Care Solutions’ impressive state-of-the-art health information system has enabled complex facilities such as the Bumrungrad International hospital in Bangkok achieve amazing outcomes related to improved workflow and patient safety. The international, fully integrated nature of the GCS technology, and the fact that it is built from the ground up on scal38

A. The success of Bumrungrad is a sterling example that we foresee other hospitals and medical facilities modeling their technology deployments on. The synergies between GCS solutions and Microsoft’s health solution portfolio and the future innovations will further strengthen the product offering to new and existing customers globally. GCS’s successes also extend to 6 other customers outside of Bumrungrad International. We have HIS systems installed at Franco-Vietnamese Hospital in Vietnam, Asian Hospital in the Philippines and Assunta Hospital in Malaysia. In addition to this, we have been very successful in the Singapore market www.ehealthonline.org

with Changi General, KK Women and Children’s and Singapore General Hospital with a combination of PACS systems, medical records document imaging, and image distribution for the SingHealth cluster of hospitals and Polyclinic (these facilities comprise 49% of Singapore healthcare).

Q. The recent launch of Amalga PACS under Microsoft banner promises a new beginning in enterprise healthcare solution. What technological and functional specialties are built-in Amalga, and how does it bring in a differential advantage over other PACS?

A. Microsoft Amalga RIS/PACS is an integrated Radiology In-

formation System (RIS) and Picture Archiving and Communication System (PACS) that is available as a stand-alone imaging system or a seamlessly integrated component of Microsoft Amalga Hospital Information System (HIS). Amalga RIS/PACS is part of the Microsoft Amalga Family of Health Enterprise Systems, a portfolio of enterprise-class health solutions that provides rich integration, giving clinicians and executives quick access to valuable, up-to-the-minute information across their health enterprise. The clear winners are doctors, administrators, and patients. Most companies don’t integrate their PACS and RIS software, translating into a forced fit between the systems. This often imposes the manual matching of studies between the PACS and RIS. The Integration of Microsoft Amalga RIS/PACS provides a powerful, truly seamless system that can deliver quick, highquality data to any department, which, in turn, can help hospitals increase patient turnaround time and enhance the patient experience. Integration also improves data integrity between PACS and RIS, can reduce transcription errors and duplication of data entry, and optimizes report turnaround. The system fully supports paperless, integrated workflows and facilitates easy access to patient medical information and order, scheduling, and study information. The new Amalga family is built on widely used and supported Microsoft products to deliver important benefits, including security, high availability, scalability and full audit capabilities. Amalga also offers simplified deployment and improved supportability through streamlined administration, configuration and self-service tools for users.

Key benefits are: • Automatic order management integrated from EMR and RIS • Automatic scanning and attachment of hard copies to study orders • Image manipulation tools include 3-D cursor location • Multiple language support provides patient demographic and screen label data in any Unicode language • Integrated database ensures patient medical information is accessible directly from the PACS • Template-driven options include reporting and voice recognition • Intuitive Report Editor accepts written or dictated reporting June 2008

The Integration of Microsoft Amalga RIS/PACS provides a powerful, truly seamless system that can deliver quick, high-quality data to any department, which, in turn, can help hospitals increase patient turnaround time and enhance the patient experience.

• Preference for radiologist worklist studies are customizable • Instant Study assignment to radiologist at time of ordering • Warning system provides real-time notifications to prevent radiologists from reporting a study that is being reported by another radiologist • Online Historical studies make historical studies available for quick retrieval, regardless of study age • Unlimited Study revisions save any or all key images, window-level settings, and image annotations • CD creation for PACS studies, Reports, and Electronic Medical Record. Options include DICOM and JPEG images, reports, and all or selected portions of a patient’s EMR.

Q. The major bottleneck for mass adoption of Health IT

is the ‘technology averseness’ of doctors. Does Microsoft have plans to increase technology friendliness of doctors through education programs?

A. One major reason for the bottleneck is the healthcare indus-

try’s own conservative attitude and reluctance to change. For example, it currently takes 17 years for a new drug to be fully approved. It does not help that the advancement in healthcare is often inextricably tied to a government’s agenda, which puts additional consideration in areas like political sensitivity, employment issues and so on, giving greater reason for highly conservative attitude. At Microsoft, we believe that we are in a unique position to deliver solutions that span from the hospital to the physician’s office to the patient’s home. Our willingness to partner with other leading industry vendors further expands the reach of the Microsoft platform in Health IT. With a friendly, consistent user experience and rich set of services, we believe that doctors will more readily accept Microsoft-based healthcare solutions than older, legacy products. As mentioned before, we are taking a long-term view in our approach and it will require significant effort to inform and educate healthcare providers about our solutions. Events such as our upcoming participation in the HIMSS APAC exhibition are an example of the kind of outreach that we will engage in over the next several years. 39

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news review

INDIA

Medsynaptic’s WebPACS installed at Solapur hospital

ISRO extends Telemedicine project across Karnataka

Medsynaptic announced recently that it has completed the installation of its Enterprise WebPACS system - Medsynapse at Ashwini Hospital in Solapur, India. The system manages all images from MRI, CT, Cathlab, Echocardiography, Ultrasound, Endoscopy and C Arm. This is one of the first hospitals in India to connect all modalities including non radiology equipment using Medsynapse PACS to provide a seamless experience to its physicians. Ashwini Hospital is a 300 bed multispeciality hospital and tertiary care center and one of the largest in Western India. In addition to making all images available throughout the hospital via a web browser, the system also allows images to be manipulated using advanced tools and to be viewed remotely from outside the hospital. “Medsynapse PACS has allowed us to view multimodality images through a Central Worklist, provided the most advanced image manipulation tools and generally increased our efficiency and ability to deliver quality medical care” said Dr S Iyer, Radiologist of Ashwini Hospital. Uniquely, Medsynaptic has also connected the ICU/CCU central monitoring system allowing cardiologists to view the patient parameters in real time from anywhere, using a simple internet connection.

The Indian Space Research Organisation (ISRO) has extended its telemedicine project to 14 more districts in Karnataka. With the inauguration of Karnataka Telemedicine Project Operational Phase II, the entire state is now covered under the project, senior ISRO officials said recently. In the first phase, the telemedicine project was operational in 12 districts in the state. G Madhavan Nair, chairman, ISRO said that the benefit of the project has now reached to 300,000 people. Till now, 300 hospitals have been connected across the country through the telemedicine project. This includes 255 rural hospitals and 40 super-speciality hospitals in major cities. Started in 2001, ISRO’s satellite based telemedicine network aims at linking rural district hospitals with super-speciality hospitals in major cities via INSAT. While ISRO provides the software, hardware and communication equipment as well as satellite bandwidth, the speciality hospitals provide the infrastructure, manpower and maintain the system. Using the telemedicine network, the consultation is being provided free of cost, and only when a patient needs a higher-level treatment, he/she has to visit a hospital. States like Chhattisgarh, Rajasthan and Karnataka are among the states that have used telemedicine to the greatest extent.

Satyam sets-up Life Sciences CoE Global IT giant Satyam Computer Services recently announced the setting up of its Life Sciences Centre of Excellence (CoE). The facility was inaugurated by Satyam’s Founder and Chairman, B. Ramalinga Raju on the sidelines of RxCellence, the life science’s conclave that Satyam hosted at its stateof-the-art Satyam School of Leadership in Hyderabad. The theme of the conference was ‘Faster, safer and smarter strategies for life sciences industry’. Thought leaders, CEOs, business leaders, consultants, analysts, scientists and senior executives from different parts of the world attended the event. Some of the eminent dignitaries were from the advisory board comprising ex-senior executives /ex-CEOs of leading life science companies. The Life Sciences CoE will showcase Satyam’s domain expertise and thought leadership in the industry. It will house solutions cutting across the value chain, addressing a number of industry pain points. The CoE solutions will provide necessary frameworks with flexibility and ease of customisation enabling faster implementations and therefore a better RoI. The CoE addressed industry needs in the areas of clinical drug accountability, drug counterfeiting, cell line management systems, high throughput analytics, clinical development, bioinformatics, supply chain, CRM, key opinion leader portals etc. 40

US$ 350k MacArthur grant for Goan public health NGO Sangath, a Goa-based public health institution focussing on 350 million children and youth, is one among eight organisations in six countries that has won the MacArthur Award for Creative and Effective Institutions. Announcing the award recently, Chicago based John D. and Catherine T. MacArthur Foundation said Sangath would use its US$ 350,000 grant to build a new centre for its clinical, training, and research work. Foundation president Jonathan Fanton said, “These imaginative and influential small organisations have an impact altogether disproportionate to their size. They are addressing problems and injustices, finding fresh solutions, and proving themselves as leaders and innovators.” The MacArthur Foundation is a private, independent grant making institution dedicated to building a more just, sustainable, and peaceful world. Goa based Sangath’s mission is to carry out innovative research to promote healthcare. Sangath also directly provides services, counselling, and models of healthcare for Goa residents. Sangath is now the largest and most successful health-related NGO in Goa, with more than 80 employees providing services, conducting research, and running training programmes. Landmark research studies include work on the link between maternal depression and child malnutrition. These findings and other research carried out by Sangath, have led to policy change at the World Health Organisation and other UN agencies concerned with maternal and mental health.

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India’s first Magnetom Essenza at Aatmajyoti MRI Center Siemens Medical Solutions will install Magnetom Essenza, a 1.5 Tesla magnetic resonance imaging system (MRI) at Aatmajyoti MRI Center, Surat — also the city’s first hi-end, affordable MRI. Surat Manav Seva Sangh (popularly known as Chhayando), a charitable trust, has set-up this MRI Center in the premises of New Civil Hospital in Surat. Magnetom Essenza is a powerful 1.5 Tesla system with technological innovations like Tim (Total imaging matrix) technology, IsoCenter Matrix Coil, etc. incorporated into it. Tim technology has revolutionised MR imaging around the world by dramatically changing the workflow as well as improving patient comfort. The advantage of IsoCenter Matrix Coil is that the user does not need to carry large, heavy spine coils any more and the patient preparation time is shortened. Till date, MRI facility was unavailable at the New Civil Hospital, owing to which many poor patients either opted for private MRI centres paying high scan costs or often avoided MRI scanning. Speaking to the media about the installation, Mr. Bharat Shah of Chhayando said, “Chhayando is committed to provide healthcare services to all sections of society, especially the lesser privileged. We believe that lack of funds should not be a hurdle for people to avail hi-end medical facility. Not only are we offering much lower rates for MRI scans but the centre will also perform free scans as per the MoU with the Government of Gujarat, for those patients referred by the New Civil Hospital”.

Over 800 rural hospitals don’t have a single Transasia Bio-Medicals Ltd. awarded ISO doctor 13485 There was a shortage of 4,833 primary health centres (PHCs) across India and over 800 rural hospitals were functioning without a single doctor, Health Minister Anbumani Ramadoss told parliament recently. “A total of 807 PHCs are working without a single doctor,” Ramadoss said in a written reply to the Lok Sabha. There are a total of 22,370 primary health centres functioning across the country, and the shortfall is of 4,833 PHCs, he said. Ramadoss said there are only 15,546 female health assistants against a requirement of 22,370. PHCs function as the first contact point between villagers and medical officers. They render curative, preventive, promotive and family welfare services to rural Indians. Giving details about the status of community health centres, the minister said there is a shortage of 2,525 CHCs across the country. He said 449 buildings are under construction and 199 buildings need to be constructed. Ramadoss said there are only 5,117 specialised doctors working in these CHCs but the requirement is a whopping 16,180. In both PHCs and CHCs there is a requirement of 50,685 nurses and midwifes but only 29,776 are in position. CHCs are established and maintained by the state governments. A CHC has at least 30 indoor beds and provides facilities for emergency obstetrics care and specialist consultations. June 2008

Transasia Bio-Medicals Ltd, leader in the Clinical Diagnostics Segment across the Indian health care sector, which aids in diagnosing life threatening diseases faced by the humankind such as, AIDS, Tuberculosis, Cancer and Diabetes etc. has been awarded ISO 13485 (Quality Management Systems for Medical Devices) by UL India, a certifying body to foster quality assurance and improvement. UL India is an affiliate of Underwriters Laboratories Inc., USA., which is one of the world’s largest Conformity Assessment Service Provider. Transasia Bio-Medicals Ltd is one of the few Indian companies which has been awarded the ISO 13485. The certification has reinforced the vision of the company to provide quality medical diagnostic products & services at Affordable prices, through Cost and Quality conscious systems of Materials and Process Control. Transasia has always recognized Quality & R&D as the prime drivers of innovation and leadership and strives to be among the top ten diagnostic players in the world. Transasia’s young and enthusiastic team of experts in software, mechanical engineering, electronics and embedded software and Bio-chemistry has built an impressive track record of successful projects. The Research and Development department, a team of 90 research and development engineers, bring out products with appropriate technology and features to meet the changing customer needs. 41

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spotlight

Service with a Smile How significant are the multi speciality hospitals for 72% of India’s population who are living in rural areas and for more than 70% of urban population who are underprivileged are living on less than a dollar a day? Smile on Wheels is a national level mobile hospital programme from Smile Foundation, catering to the underprivileged children and women in remote rural areas and urban slums.

Q. How large is your current fleet of mobile hospital vans and what is the strength of doctors and nurses? A. Smile Foundation has 5 mobile hospitals which are operational from many stations such as Pune (Maharashtra), Cuttack (Orissa), Bhilai (Chhattisgarh), Roorkee (Uttarakhand) and Kolkota (West Bengal). Two new projects for the slum population of Delhi and Chennai are ready to be operational from May 2008. Each vehicle carries a qualified medical team. However, the team at times changes composition, expertise wise, making it responsive to community health needs. Usually the team consists of 2 Doctors - 1 general practitioner in routine manner and the other doctor being either a gynaecologist or paediatrician or dermatologist or ophthalmologist etc; assisted by 1 nurse/ANM, 1 social/health worker, and the driver.

Q. Does Smile Foundation work with ANMs and ASHAs? A. Smile Foundation has tied up with NGOs, corporate trusts and charitable hospitals which are very active in their respective locations in health related activities. These organisations implement the ‘Smile on Wheels’ projects in the field by recruiting the required medical staff, tying up with local medical practitioners, local civic bodies etc. Hence the tie ups with ANMs and ASHA’s or village health workers are done through the respective implementing partners in these locations.

Q. What is the system for procuring and distributing

medicines? A. The local partners of Smile Foundation have got their static and charitable hospitals at all locations. Medicines are procured regularly as a part of the ongoing healthcare activities at these hospitals. Requirement for Smile on Wheels projects are also made from the current sources. Local medical practitioners as well as government health departments are also approached for procuring medicines. Smile Foundation has been getting cooperation in most of the cases as Smile on Wheels is supplementing health services where the same is not adequate owing to various reasons. As a strategy, Smile Foundation ties up with very renowned local organisations which are headed by medical doctors and has good professional linkages. Hence the operations are managed with efficiency and professionalism. The medicines are distributed either free or at a much sub42

Naresh Chaudhary Chief Operating Officer Smile Foundation

sidised rate to the patients during the regular OPDs during the visits by the Smile on Wheels.

Q. How often is a location visited and for what length of time? How is the follow-up conducted? A. The locations are fixed on a weekly basis for about 3-6 hours at a time. Locations which are far off are visited fortnightly. Urgent cases are referred to either the static hospitals or other charitable and government hospitals. Follow-up is crucial and is meticulously designed through raising a cadre of community-based volunteers and workers, who are properly trained or oriented and linkages established with local Government facilities. Also Smile on Wheels team is kept informed of any eventuality or special needs for services which remain functional in vicinity - not very far from cases needing follow-up care and advice.

Q. Are the mobile hospitals linked to one another

and to any government or private hospital? Where are patients referred to in case they need advanced treatment? A. Establishing referral network with nearby governmental and private health care facilities is an intrinsic component of the programme to the extent that possible facilitation is also www.ehealthonline.org

done to help people avail of needed services from such outlets. Governmental as well as private and charitable outlets in vicinity with specialized facilities (TB/Leprosy/ RTI/STI etc.) are referred to. As Smile on Wheels mobile hospitals are operational in different locations across different states hundreds of miles apart from each other, linking each other does not make any sense. However, necessary technology is being developed centrally at Smile Foundation for online tracking of movement of the mobile hospitals and also computer facilities being installed inside mobile hospitals for concurrent information feeding.

Q. Does Smile Foundation have a tie-up with any

corporate to provide medicines and/or equipment? A. Negotiations with various corporate and pharmaceutical companies are on for possible partnership and strategic tieups for multiplier effects; resulting into resources mobilization in the form of financial, technical and expertise. June 2008

Q. Is ‘Smile on Wheels’ integrated with ‘HEALTH with

SMILE’, your other initiative, in any way? A. Smile on wheels so far has been confined to very specific locations providing for comprehensive medical healthcare services. Health with Smile is a camp based approach and a short term intervention initiated in locations where Smile Foundation has its own regional office or various other projects. Depending upon similarity or proximity in locations, Smile on Wheels and Health with Smile Programmes are integrated occasionally. However, as Smile on Wheels as well as other programmes of Smile Foundation expand gradually to locations which are common or nearby, both these projects will be integrated.

Q. What are the future plans for Smile on Wheels programme? A. Smile Foundation aims to run 30 mobile hospitals under

Smile on Wheels Working Model Smile on Wheels operates by taking well-equipped medical van along with specialized doctors, nurses, medical staff, equipments and medicines to the identified villages/slums in a systematic manner. Smile on Wheels vans cover the rural or slum areas in the vicinity where either no governmental health care facilities exist or the same is not sufficient for the population. Each unit is covering the vicinity of up to 25 kms from its centre and visiting 2-3 villages a day on a regular basis. The mobile hospitals offer preventive, promotive and curative medical expertise to the needy children and women in remote rural areas and urban slums. In deserving and life-saving cases, it functions like a referral clinic and ambulance. Each van is stationed in an urban centre usually with a static hospital, which acts like a referral medical centre. The team also carry out awareness activities on health and hygiene in order to achieve health seeking behaviour. Smile Foundation has been recognised with GE Healthcare–Modern Medicare Excellence Award as “NGO of the Year” for innovative contribution towards healthcare services for the poor and needy. Phase - I: Launched in June 2006 Chief Minister of the Govt. of NCT of Delhi, Mrs. Sheila Dikshit flagged off the five mobile hospitals under Smile on Wheels from the Delhi Secretariat. Vehicle make: Tempo Traveller / Force Motors. Five vans under the first phase of Smile on Wheels has been reaching out to 1.5 lakh beneficiaries in a population area of 7.5 lakhs covering 249 identified villages across five Indian states. These are Orissa, Chhattisgarh, Uttarakhand, West Bengal and Maharasthra. Stations: Cuttack (Orissa), Bhilai (Chhattisgarh), Roorkee (Uttarakhand), Kolkata (West Bengal) and Talegaon (Maharasthra). Phase - I I: Launched in May 2008 Vehicle make: Ashok Leyland Two more mobile hospital projects under Smile on Wheels programme would be operational for the slum population of Delhi and Chennai from May 2008. The mobile hospitals in phase – II are one and half time bigger than the hospitals as in Phase – I and are completely air conditioned. These are also equipped with dark rooms, advanced X-ray machines and a few additional facilities. Stations: Delhi and Chennai Smile Foundation launched the programme as part of its endeavour to introduce healthcare awareness and contemporary healthcare services seeking behaviour among the rural masses and the underprivileged. Services Provided: The services provided are OPD, Ante-natal/post-natal services, identification of difficult pregnancy and referral for institutional care, Immunization - Mother & children, Minor surgery, BP examination, X-ray, ECG, First Aid, Distribution of Iron Folic tablets, Vit-A Prophylaxis, Treatment of mal-nutrient cases, etc. Children and Women’s health is one of Smile’s prime concerns. A referral service network for them also needs to be developed. Future Outlook Smile Foundation aims to run a fleet of 30 fully equipped mobile medical vans under Smile on Wheels programme reaching out to around 35-40 lakh beneficiaries in coming five years. “This is a very ambitious and wonderful project which is going to benefit children and women in the outreach areas. I would congratulate Smile Foundation for that.” She added, “Consistent follow-up and concentration in a particular are necessary in health programmes which would hopefully make this programme a success.” - Ms. Sheila Dikshit, Chief Minister of Delhi Smile on Wheels programme across 30 locations covering almost all needy states in India. Smile Foundation is also working on an online MIS [management information system] which links the field information to strategic management. Thus, it will help Smile Foundation in monitoring the programme and ensuring efficiency. Smile Foundation is also working on making customized mobile hospitals according to the requirement of specific locations. Very soon, all Smile on Wheels mobile hospitals could be monitored through advanced global positioning system [GPS] which is going to put the programme at par with international standard. 44

Q. Reason for stationing the mobile hospitals in cities

or urban centres? A. Stationing mobile hospitals in a city town is done for strategic reasons like repair and maintenance of vehicle, taking varied medical and health expertise from urban to rural areas, drugs and equipments availability etc. Also the fact that mobile hospital comes back to the city, acts as a motivating factor for medical experts who remain wary of rural stations for obvious reasons. Doctors and other medical staff work in the rural areas living in urban centres.

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news review

WORLD

Smart fabrics for health to be piloted by EU team

Berlin University opens telemedicine centre

A cluster of EU research projects, collectively known as the SFIT Group, are piloting garments which can measure a wearer’s body temperature or trace their heart activity. The European Commission scheme, known as Biotex, is focused on supporting the development of smart textiles. Miniaturised biosensors in a textile patch can analyse body fluids such as sweat, and provide an accurate assessment of the wearer’s health. The idea is that a fabric would be embedded with numerous sensors, constantly monitoring vital signs. If danger signs are detected, the garment could be programmed to contact the wearer’s doctor or send them a warning text message. Jean Luprano, a researcher at the Swiss Centre for Electronics and Microtechnology (SCEM), and coordinator of the project, said medicine was one of the main areas the technology could be applied. Luprano said development work included a suite of sensors that can be integrated into a textile patch, incorporating both a sensing and processing unit that could target and respond to different body fluids or biochemistry. The system uses no power, thereby reducing the power demands of the system and the weight of a battery pack that the wearer would have to carry.

The Charité University Hospital, part of Berlin University, has opened a centre for cardiovascular telemedicine that will carry out research and provide services to patients. The new centre will carry out clinical research on telemedicine for cardiovascular patients and act as a telemedicine call-centre for patients on home monitoring programmes. The hospital is already engaged in international telemedicine consultations, for example as the academic centre of excellence for the telepathology network of the International Union Against Cancer, and as a telemedicine partner of Shanghai University Hospital. To open its own call centre was the next logical step, said Ganten. The first big project at the new centre began a few weeks ago with the ‘Partnership for the Heart’ project, a clinical study on telemonitoring for patients with chronic heart failure. “If successful, telemedicine in heart failure patients will finally be reimbursed on a regular basis within the German public insurance system”, said Köhler. This would be a major breakthrough, since it would mean that every doctor with heart failure patients could issue a “prescription for telemedicine”.

Sweden launches national e-health strategy The Swedish government has launched a new citizen-centred national e-health strategy designed to ensure the provision of information to where it is needed, to support improvements in care. The new e-health strategy focuses on the need to use information and communication technologies (ICT) to achieve improvements for patients, health professionals and decisionmakers. Setting out the future strategy for e-health in the country, the government says it will use appropriate ICTbased tools to ensure care professionals can devote more time to patients and adapt care provision to individual needs. “ICT will be used as a strategic tool at all levels in the care sector, and health care resources as a whole will be utilised more efficiently and effectively” says the strategy. This will include, providing citizens with access to personal data on their own care, treatment and health status. It says citizens “must also be able to contact care services via the internet for assistance, advice or help with self-treatment”. Healthcare professionals meanwhile should have access to efficient, interoperable eHealth solutions that support them in their daily work,” the document says. 46

Philips provides speech-recognition to Oslo hospital Philips has signed a new deal to deploy SpeechMagic across the Ulleval University Hospital in Oslo, Norway’s largest clinical centre. The hospital will roll out SpeechMagic to more than 1,000 physicians across all medical specialities. Once completed in early 2009, Philips says the implementation is expected to be the world’s largest deployment of front-end speech recognition at a single hospital site. The hospital expects to increase the quality of medical reports, speed up documentation workflows and reduce administrative costs, which should contribute to improved patient care. The hospital-wide deal, which came through the local Philips Speech Recognition Systems partner Max Manus, follows a successful pilot in Ulleval’s radiology department, where report turnaround time was reduced by 96%! “We are expecting to save tens of millions of Norwegian crowns each year thanks to more accurate, convenient and efficient information capturing. SpeechMagic has been implemented in more than 8,000 sites worldwide, sold by over 200 Philips partners. “Norway is probably the world’s most advanced country to adopt speech recognition-based information capturing in healthcare. The scale of this latest deployment proves that speech recognition-based information capturing in electronic health records has become a reality.

www.ehealthonline.org

Siemens introduces laptop-based ultrasound system

Nottingham univ hospitals to deploy Cisco network

The Siemens Acuson P50 is a new laptop-based ultrasound system with integrated echocardiography software. The system is designed for mobile applications in cardiology, musculoskeletal and vascular imaging, as well as in the operation theatre and anaesthesiology departments. The P50 offers ultrasound with a complete range of transducers, communications and computer functionality - such as office software and Internet access, in one mobile system. The system provides high image resolution in B mode and in colour Doppler mode. It also includes an integrated stress echo function. It can run several cardiology application packages, including Siemens’ syngo Velocity Vector Imaging and syngo Arterial Health Package, which can be used to determine a patient’s vascular age. Together with syngo Auto Left Heart, these applications simplify and accelerate the workflow in echocardiography and vascular diagnosis. Siemens also recently introduced its Acuson P10 handheld ultrasound device. The P10 weighs 700gm and fits easily into a lab coat pocket. It is intended for complementary initial diagnostic care and triage, particularly in emergency care, obstetrics and cardiology.

The Nottingham University Hospitals’ NHS Trust has signed a multi-millionpound agreement to use Cisco technology to provide a state-of-the-art network infrastructure across hospitals. The new network is expected to help reduce costs, improve access to healthcare information, and provide patients with services faster and more efficiently. The choice was made following a significant period of research by the Trust’s IT team, which included a visit to St. Olav’s University Hospital in Trondheim, Norway, widely regarded as a flagship ‘connected hospital’ in Europe. The project is expected to be completed by March 2010 and will be implemented and supported by NextiraOne UK, a Cisco Gold Certified Partner. The Cisco Medical-Grade Network will include many of Cisco’s portfolio of products, including foundational networking technologies delivering highly secure, high-performance fixed and wireless networking, centralised Wi-Fi, Unified Communications Software, collaboration tools, network security products, and location-based services. The solution will support a broad range of applications to help improve the delivery of healthcare services. A wireless network will provide real-time access to information at the bedside and help ensure that clinicians can be contacted anywhere on campus.

Electronic methadone dispensing for UK prisons Prisons in England will be provided with biometric-based computer controlled methadone dispensing systems (CCMDS) under a framework agreement between the Department of Health and NEC UK. Under the agreement, NEC will deliver CCMDS to up to 100 prisons in England, with ongoing technical support and consultancy for five years. Phase I, in which CCDMS will be implemented in 72 prisons, started in December 2007. The system includes biometric software, the network infrastructure, computer hardware and a methadone dispenser, and is being delivered in conjunction with partners Methasoft UK Ltd. and Human Recognition Systems Ltd. CCMDS enables the accurate and controlled dispensing of prescribed methadone to prisoners addicted to heroin, according to the requirements outlined in their individual treatment record. It uses a combination of biometric identifiers, such as a fingerprint or iris scans, to identify the correct person and access the prisoner’s treatment record before dispensing methadone. Participation in CCMDS is not mandatory for prisoners, although uptake is high, and there is no infringement of personal security or human rights as the system does not physically store ‘images’ of biometric data, only the coding which enables an individual to be identified.

June 2008

Open source health IT solutions in Europe The open source developer community, Open Health Tools (OHT), has announced a collaborative effort to develop common healthcare IT products and services. Its 26 members consist of national health agencies, government-funded organisations and agencies, major healthcare providers, international standards organisations and companies from Australia, Canada, the UK and the US. Formed in November 2007, OHT’s mission is to provide software tools and components that will accelerate the implementation of electronic health information interoperability platforms, which improve patient quality of care, safety and access to electronic health records (EHR). The results will be available under an open source agreement so anyone may use them to provide interoperable healthcare platforms that will link clinics, hospitals, pharmacies and other points of care to make healthcare systems more efficient. OHT’s health interoperability framework will use standardised, open interfaces and a set of reusable software components that can be assembled into systems and products by health systems and vendors. OHT is open to membership from any organisation and the results of member efforts are made available under a commercially friendly open source license. Research points to a potential annual savings of US$ 77.8 billion in the United States alone from the introduction of healthcare information exchange and interoperability. 47

PERSPECTIVE

New Age Healthcare -

Information Assurance for All

ith the rapid proliferation of hundreds of health information websites, e-health publications and commencement of use of electronic health records, we in India, are now in an era of information dissemination. This is actually leading to information overload!! The end user - the health care consumer, formerly known as a patient, is now deluged with too much information. Public access to specialist information, the cornerstone of accountability, is only a mouse click away. It is estimated that 75% of Internet users surf the Net for medical information at some point in time and almost all feel that they get the information they are looking for. How many of them know that most of the information on the net has not been peer reviewed, authenticated and is not always reliable? Information Assurance (IA) in healthcare therefore becomes crucial. IA involves ensuring authenticity, credibility and reliability of the information, which the end user has access to. For the purpose of this discussion, information assurance will also include maintaining the sanctity of a patientâ&#x20AC;&#x2122;s individual health information, considered strictly confidential and sacrosanct. Most stakeholders are still oblivious of the concept of IA. Malpractice and litigation not yet being a major problem, awareness of privacy and security issues in health information is also not high. IA refers to the practice of managing information, protecting confidentiality and ensuring integrity and availability of data. IA also ensures that delivery systems deliver the necessary information only to authorised personnel. These goals are relevant whether the data are in storage, processing, or transit, and whether threatened by malice or accident. Information Assurance means much more than assuring Information Security. IA emphasizes strategic risk management over tools and tactics. It includes corporate governance issues such as audits, business continuity, compliance, disaster recovery and privacy. IA draws from multiple fields, including Fraud Examination, Forensic Science, Management Science, Systems Engineering, Security Engineering and Criminology. Assurance is a measure of confidence, with security features, practices, procedures and architecture of an Information System, that accurately mediates and enforces the security policy using assured software. Assured Software is software that has been designed, developed, analysed and tested using processes, tools and techniques that establish a level of confidence, in 48

Prof. K. Ganapathy, a Neurosurgeon and pioneer in introducing telehealth in South Asia, he is a co-founder of the Telemedicine Society of India. Member of National Task Force on Telemedicine and the Planning CommissionW working group on Telemedicine. Currently President, Apollo Telemedicine Networking Foundation. e-mail: drkganapathy@gmail.com

Ms. Aditi Ravindra, a Biomedical Engineer with an M.Phil in Health Systems Administration, is currently working with Apollo Telemedicine Networking Foundation. e-mail: aditiravindra@gmail.com

its trustworthiness, appropriate for its intended use. IA therefore is essentially the process of ensuring that the right people get the right information at the right time. IA in the health care industry is a very recent phenomenon, even globally. What constitutes â&#x20AC;&#x153;Health Informationâ&#x20AC;?? Who should be authorised to update this? How often should this be updated? Who will be the ombudsman overseeing this? To whom should this information be directed? What should be the mechanism for updating? Where should this be done? For whom? Is one justified in resorting to simplification at the cost of scientific accuracy. These are just some of the many, many questions that need to be answered. The average user is not sophisticated enough to critically analyse the loads of different information now easily available and give appropriate weightage to them. www.ehealthonline.org

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How do we assure that the medical information necessary for a patient to aid him or her in the decision making process is factually correct and more important, is relevant to the specific situation? When providing information to a patient about a proposed surgical procedure, is it necessary to mention the rarest of the rare complications as well? The Supreme Courts of India and USA among others have opined that while obtaining consent from a patient, the physician can use his/her judgement in deciding what information need not be stressed. Even with a medical background this is often difficult. Experience and wisdom cannot always be broken down and fitted into a decision making tree. The onset of the 21st century has witnessed a steady increase in the number of stakeholders responsible for an individual’s healthcare. They include medical students, interns, technicians, nurses, staff of the medical records department, hospital administrative staff, hospital pharmacy, immediate family, colleagues, employers, interested third parties including insurance companies and credit card companies and often in the case of VIP’s - even the press. Do all these various groups of people need to have access to the health information of an individual? Should this be on a need-to-know basis? A few decades ago knowledge about the health of an individual was strictly confined to a paper medical record which was available only to the family physician. Today, more often than not, it is a team of specialists who are collectively involved in the management of a single patient. One’s personal health information can theoretically be hacked. In the Indian setting, the concept of EMR is just emerging. Creating awareness, sensitising stakeholders and training the end user about IA in health care should be the 50

first step in implementing Information Assurance. Ensuring suitable policy framing and enforcement of legal measures will automatically follow. However, social, ethical and legal solutions are unlikely to keep up with technology. The legal aspects of privacy of health information, the rules and limits on who can have access to an individual’s health information have to be culture sensitive and relevant to the needs and local milieu. Information today is not confined to paper records or electronic records. Sensitive information about a patient can be computed, stored and transmitted using various devices that may or may not interconnect with a network. Security measures implemented should be based on local milieu, facilities available and degree of security required. Creating awareness, studying cost containment and feasibility of implementation issues, and sensitizing and training the end user about privacy and security issues should be the first step. This should be followed by suitable policy framing and enforcement of legal measures. These are as important as using the technology itself. It was Confucius who once remarked that, ‘A journey of a thousand miles begins with the first step’. The time is now ripe for India to take the first steps in implementing Information Assurance in healthcare. www.ehealthonline.org

ZOOM

Health without frontiers Definition Telemedicine is defined as the use of electronic Information and Communication Technologies (ICTs) to provide and support health care when distance separates the participants. The delivery of healthcare from a distance uses exchange of electronic patient information and medical data using computers, medical equipment, videoconferencing, the Internet, satellite, and wireless communications. For telemedicine to be successful there must be an ability to clearly transmit a clinical situation, including clinical information of diagnostic quality, to a clinician located far from the point of need, and the ability for that clinician to effectively communicate concerns, additional requirements needed for diagnosis, or the provision of a diagnosis back to the point of need. Aims • Improved and increased access to speciality medical care for geographically isolated patients • Move the information rather than the patient • Enhance the quality and continuity of medical care • Expanded utilisation of specialty expertise • Faster access to patient records and reduced intervention time • Reduced cost of patient care • Eliminate unnecessary travel • Continuing Medical Education for isolated health care providers Objectives • Capture and upload patient information, waveforms & images from remote location to centralised server and get expert opinion / review instantly. • Real time transmitting of ECG and other vital sign data for expert opinion during cardiac and other emergencies. • Providing instantaneous expert advice within the network (intranet) as well as after hour Consultation, review and reporting outside (internet) • Share resources optimally and increase efficiency and throughput Market Definition - Telemedicine • Consultation services between the consultant in the Department and resident at a distant location • Improvements in quality of care in rural and underserved communities • Faster delivery of required information and services • Easy access to their specialists from any locations • New business and marketing opportunity • Single referral hospital can handle multiple nodal centers simultaneously through telemedicine • Telemedicine services envisaged in the country should be available for the benefit of all people located in rural, remote and inaccessible places

Telemedicine in India Telemedicine has been recognised as one of the potential application area of Information Communication Technology to address the issue of inadequate quality health service for the rural and remote population of India. A number of initiatives have been taken to set up pilots scheme to evaluate the impact and benefit of this application for patients in these remote areas. Telemedicine in India provides insight into the growing telemedicine market in India. With a rural population nearing 700 million, India will benefit enormously from digital data transmission related to healthcare. Both public and private June 2008

Present System - Healthcare Access to Doctors : Trained Staff : Time to Intervene : Cost of treatment : Distance Traveled : Monitoring Mechanism : Statistical data :

     Haphazard Minimal

Telemedicine Access to Doctors : Trained Staff : Time to Intervene : Cost of treatment : Distance Traveled : Monitoring Mechanism : Statistical data :

     Centralized Complete

entities are aggressively pursuing the use of telemedicine to hasten diagnostics and treatment of a variety of diseases. The Ministry of Communications and Information Technology, Government of India, has classified “Telemedicine” as one of the thrust areas for development in the country. In sync with the policy, the Government initiated a project called “Development of Telemedicine Technology”. Availability of necessary telecommunication infrastructure, crucial for success of telemedicine programme, is drawing special attention in India. Department of Space is mooting the idea of launching a satellite dedicated to Tele- health in the near future. Initiatives of both public and private sector telecommunication players to lay a huge backbone of fiber optical network covering large part of country in addition to the existing infrastructure like POTS, ISDN, etc. to provide further impetus to application of telemedicine in India in its vision to have a countrywide hierarchical telemedicine network. Some facts: • In India, 80% of the population live in the rural areas whereas 80% of the medical experts live in the big cities. Thus, about 11% of the world’s population, which reside in the rural areas of India, remain devoid of quality healthcare. • Exponential growth in Information and Communication Technology and plummeting telecom cost making India highly competitive • ISRO has been instrumental in providing telemedicine solution in over 200 locations using VSAT communication protocol to linkup Dist Hospital, Community centers and PHC’s to Tertiary care hospitals. • The Ministry of Communications and Information Technology, Government of India, has classified telemedicine as one of the thrust areas for development in the country. • NRHM and various State Government has taken telemedicine initiative 51

•

to linkup remote rural health centers with District and Medical college Hospitals. Indian Railways who have one of the best communication platforms is planning to linkup all zonal, regional hospitals in all their zones.

About Prognosys Prognosys Medical Systems, based in Bangalore, specialises in developing and integrating high quality solutions in Healthcare. Our combined experience and domain knowledge helps us to design solutions that use cutting edge information technology and telecommunication engineering in the areas of Telemedicine and Tele-health to connect people, processes, systems and technology in a modern medical enterprise. Our ability to adopt technology, understand customer needs and a willingness to work with the medical fraternity to customise products and continuously improve solutions, makes us unique. It has helped us reach technological leadership in a very short period of time. Prognosys’ constant endeavor to deliver the finest and the latest solutions in Healthcare Technology has been the driving spirit behind innovative products like the Remote Patient Monitoring Systems (Real-time) for Ambulances and ICUs. In addition, Prognosys has further enhanced its solution offerings through strategic business partnerships. Prognosys has recently tied up with Canon, Japan – a world leader in Digital Radiography to bring the best in class DR solutions to India. Coupled with Prognosys’ Tele-radiology/ Mini PACS solution, DICOM images can be viewed and reported from anywhere, anytime. Experience Prognosys is a subsidiary of Chayagraphics (India) Pvt. Ltd, which has over 20 years of experience in the diagnostic imaging business. Chayagraphics works with many leading international businesses. Chayagraphics is an ISO 90012000 manufacturing company and exports its products to 17 countries and offers its services to over 5000 customers across India. Significant Achievements • Over 350 installations in 4 years. • Leading solution provider for the telemedicine business in India. • Identified as a technology partner of choice by organizations like ISRO, Konkan Railways and many OEM partners • Recognized as a leader in innovation in telemedicine • Most Renowned hospitals in the country use Prognosys solution • Implementation of the largest telemedicine network in the state of Rajasthan in association with ISRO. • Strategic partnershwip with Larsen & Toubro Ltd for promoting emergency medicine and REM-ICU solution. • Installation of DR systems in two most renowned institution of the country.

K. Srikanth Co-founder and COO Prognosys Medical Systems Pvt. Ltd. e-mail: k.srikanth@prognosysmedical.com V. Krishna Prasad Co-founder and President Prognosis Medical Systems e-mail: krishna.prasad@prognosysmedical.com 52

PRODUCT PROFILE PRODUCT APPLICATION EHR EX-04

Electronic Health record

TELEMEDICINE SUITE

BRIEF DESCRIPTION EX-04 web based electronic health record solution allows the clinicians / specialists to work and access patient information from anywhere, anytime

CX-04

Cardiology

The CX-04 provides a simple, effective and efficient recording, monitoring and simultaneous transmission of 12-leads of ECG data, in real time and allows the cardiologists to view and report

IX-04

Radiology, Ophthalmology, Dermatology, ENT, Pathology

This solution allows transmission of diagnostic-quality X-ray / CT/ MRI films into digital format using Scanners / Digitizers or Digital cameras or using any video outputs from medical devices like Ophthalmoscope, Slit lamp, Fundus camera, CCD camera, Otoscope or from microscope

HX-04

Home Healthcare

Solution provide disease monitoring and management, patient support using Glucometer, blood pressure device

PATIENT MONITORING FROM AMBULANCE EMX-04 Emergency Records, monitors, stores and transmits vital Medicine signs like 12 Lead ECG, SpO2 and NIBP in real time. REMOTE ICU MONITORING REM-ICU

Remote ICU Monitoring

PACS & TELE-RADIOLOGY PROPACS PACS & Tele-Radiology

Solution offers 24 /7 Vital Sign Monitoring to remote ICU patients across a single or multiple hospitals in real-time. A cost effective PACS & Tele-Radiology system that’s designed to meet the needs of a modern day diagnostic and Radiology practice that lets you work anywhere!

Digital Radiography

CXDI 40 EG CXDI 40 EC CXDI 50 G CXDI 50 C

Prorad – Finest and the most versatile range Flat Panel DR Solutions from Canon.

Prorad CXR Range

Full Room DR System

Complete DR Solution with Ceiling Suspended Tube, High Frequency Generator of choice, Digital Radiography Flat Panel Detector – Both Single and Dual Detector Systems in any combination, Vertical Bucky, Horizontal Table(s), Remote Control, Auto Positioning, Tracking, Tomography and Workstation.

Choice of 32, 50, 65 & 80 KW Generators

Prorad URS Range

Universal DR System

Complete DR Solution with Universal Radiography System, Flat Panel Detector, Choice of 32, 50, High Frequency Generator, Mobile X-ray 65 and 80KW HF Table, Remote Control and Workstation. Generators with a Ideal for Emergency / Trauma rooms and single FPD of Choice. smaller General Radiography Rooms. Option of battery powered generators also available

Prorad MDR Range

Battery Mobile DR System

Fully integrated battery mobile solution with motorized movement and a choice of HF generators and Portable FPD. Can Battery Mobile with store over 3000 images on board, instant a choice of 20, 32, preview and over a 100 exposures with 40 and 50KW High one full charge. The most versatile soluFrequency Generation for all round use – ICU, Bedside, tors coupled with the Emergency, OT and Rad Room. CXDI 50G or CXDI 50C. www.ehealthonline.org

EXPERT CORNER

New Age Diagnostic Miracle eHEALTH in conversation with 21st Century Health Management Solutions about latest trends in Teleradiology

Q. 21st Century Health is a major player in health

consulting and IT solutions space in India with your own indigenously designed solutions for HIS, LIS, EMR and AIS/PACS. You have been closely observing rapid changes in the healthcare sector for the last 1012 years. How do you view emerging technologies like telemedicine, their impact on healthcare in India and your own contribution in this new arena? A. Satish Kini: We in 21st Century Health have adopted the vision 2020 espoused by our former Hon. President Dr A P J Abdul Kalam i.e. to achieve “Healthcare for All by 2020”. Dr Kalam has repeatedly mentioned that Telemedicine has to play a very significant role if we have to achieve this difficult goal. In India we have about 5 lakh doctors, even though as per WHO norms, we need an additional 15 lakh more doctors to service our population of 1.1 billion. As if that was not skewed enough, 70% of our population lives in villages or small remote towns while 30% live in metros and cities. But 75% of doctors live and practice in cities and big towns. In fact, a lesser-known but shocking fact is that 98% of medical specialists are available only in state capitals. Let us not forget that we also lose many trained doctors to advanced countries like US, UK and to oil rich countries of the Middle East. This mismatch of demand and supply of healthcare resources is impossible to be bridged by traditional methods of healthcare. The real challenge here is to see how doctors can continue to live in cities and yet provide expert medical services to people in the remote places without wasting time and money on traveling. The solution we think is telemedicine because when people can’t travel, images and information can.

Q. You have made a very good case for telemedicine; but these statistics are not new, so why is telemedicine being talked of now? A. The three factors that make telemedicine feasible and have impact are technical feasibility, time and cost. Today, communication and Internet in India are very affordable and have already reached the remotest areas in the country. Coincidentally, most modern medical equipment used for diagnosis give digital output (ECGs, XRays, CTs, MRI machines) which can be transmitted across time and space; the first two factors are in place in India, it is time to June 2008

Satish Kini Chief Mentor

Aniruddha Nene Principal Consultant - Imaging Technologies

Devesh Rajadhyax Solution Architect - Tele-radiology Portal

take the next big step to activate this fantastic innovation of telemedicine. If we can set up the infrastructure and technology to effectively use telemedicine in small towns and villages, millions of patients and their relatives (mostly poor) can be spared the cost, time and agony of traveling hundreds or miles just to see a doctor. It will also save valuable time for doctors who can give expert advice on patients’ conditions without having to travel large distances. Besides saving millions of lives and suffering, this can save crores of Rupees for the national economy by way of saving lost man-days of productivity. Telemedicine is indispensable in case of emergencies and accidents where even if you have the money you may not have the time to save lives. A CT scan of a patient with skull injury in a remote place can be seen at any given time by a radiologist remotely at his home and in a matter of minutes correct action can be taken to save that life. This in fact has happened. It sometimes makes me wonder why we can’t make people to adopt these processes faster. Perhaps, we have to spread greater awareness about such technologies and prove that it can be put in place with minimal investment.

Q. 21st Century Health specialises in teleradiology.

Can you explain a little more about teleradiology, its importance in modern day diagnostics? A. Telemedicine is an umbrella term used when using telecommunication medium for providing medical services. Even a telephonic consultation between doctor and patient can be loosely called telemedicine. Teleradiology is transmitting radiology images (X-rays, CT scans, MRI scans etc.) across space via telecommunication. Imaging plays a very critical role in modern day diagnosis. 53

Our imaging team is very strong in their understanding of how radiologists use imaging to diagnose and have designed interfaces with 100+ modalities from all big suppliers of modalities like Philips, Siemens, GE, Agfa etc. Aniruddha: There should be no doubt about the need for Tele-radiology. It is a well-known fact that the radiologists are too few in number compared to the increasing patient load all over the world. The reason why it took off suddenly is because of the sudden rise of ‘flatteners of the world’ as described by Thomas L. Friedman in his famous book “The world is flat”. These include: • Superb connectivity of Internet across continents. • Conformance to standards by digital imaging equipment that unshackled the world of radiologists from the clutches of proprietary technologies. And with this we really see the distance between the Referring clinician and the Diagnostic centre from the radiologist disappearing.

Q. Are there different applications of Teleradiology

that make it necessary and viable? A. Devesh: Today, almost every hospital or diagnostic centre practices remote reporting of radiology images in one form or another. The situation in which teleradiology is warranted and useful is obvious but let us lists some of them: • When radiologists are not available on site, such as at night, or when they are on leave • When on site the institute does not employ services of a radiologist, either because there is a scarcity of radiologists or because the services are too expensive and outsourcing the services is the only viable option like in case of western countries. • When a radiologist is available on site, but higher skills are required to diagnose an exam. • When the examination load increases, and on site radiologist cannot cope with the load. • When the on site radiologist would like to take another opinion on the report. • When a chain of health institutes wants to pool the radiologists in the group. • When a region lacks qualified radiologists, such as parts of Africa. Looking at the list, it seems natural that the health institutes routinely carry out teleradiology. There are many ways in which it is practiced: • Analog/Manual: The traditional way of printing films and then delivering them by hand to the radiologist. Though it looks archaic, this practice is prevalent in most hospitals for night reporting, when the films are carried to the radiologist’s home. • Digital/Manual: Here, digital images are carried manually (in form of a CD/DVD). • Digital/Networked: The digital images are transferred over a network. Of course, it is the third type that is teleradiology that we will discuss, but one must keep in mind that the first two are followed because of lack of a standard and infrastructure for teleradiology. 54

Q. Most of the image archive solutions, more

popularly known as PACS claim to have built-in teleradiology. How do you see this utility for various scenarios you discussed? A. Devesh: If you take a review of how the health institutes practice teleradiology of the third type that is Digital Network, we will see many variations: • The most expensive method is to implement a PACS and allow VPN connections to radiologists. This is teleradiology looking from the hospital’s side. Secure, but highly restrictive in nature. • A stripped down variation of the above has a small scale DICOM and Web Server implemented in the hospital. The radiologist logs on to the web application and uses it to report. • Point-to-point transfer programs transfer the images from the institute computer to the radiologist’s computer. There are many providers of teleradiology solutions in the industry, including the big PACS providers and the smaller scale regional providers. The PACS-VPN solutions address only one situation of teleradiology need – when a hospital wants its regular radiologists to access exams from outside. This method of teleradiology assumes a long term and concrete contract between the hospital and radiologists, so that the hospital allows the radiologist an access to its internal network. All other situations call for more flexible and universal method to transfer exam and report between a source of images and a radiologist. Though there are many solutions in use, no standard method is available, which is very similar to the story of e-mail or Instant Messaging that will drive us to a true teleradiology portal.

Q. Before we go to the details of these advanced

portals, can you give us some idea of the challenges one faces while implementing such solutions? A. Aniruddha: Of course, ultimately it is the implementation of a good concept that matters. While the ‘flatteners’ have provided us with the unique situation of a Global level playing field, it is up to the users to quickly adapt to the change to exploit full benefits of the situation. The first challenge, at least in India, is the soft copy viewing by radiologists. While there are umpteen number of DICOM viewers available, not all radiologists are actually used to this process. Softcopy reading with today’s technology is as good in quality of the image and much superior in terms of the tools to process the image! Fortunately most of the new generation radiologists in India are aspiring to be global teleradiologists and are adapting to softcopy reading fast. The second hurdle is connectivity to the modalities, which of course is easily surmountable if the modalities are ‘DICOM 3’ ready. But it may require a visit from the engineer from the vendor’s side to enable this data transfer. It is a thankless task to get a non-DICOM machine to hook on to the digital portals. A portal solution must be plug-and-play. If it requires any installation/support effort on site, the growth of this model is impacted. All that the Diagnostic Centre/Hospital needs is an www.ehealthonline.org

ordinary PC and very good Internet connectivity. Ideally such solutions ought to be in the form of downloadable/browser based software solutions so it has least dependency on the local infrastructure. This is a big challenge faced by most well designed solutions. Lastly, it is not just transferring the DICOM files that will address teleradiology need. Many tech savvy radiologists, even today are using emails and FTP solutions to access the imaging data and report. Not knowing what exactly constitutes teleradiology workflow is the biggest hurdle. The aspects that are completely ignored in the process are:  Security and privacy of the data: Without this the service seekers will always be hesitant to outsource the services.  Accountability and process quality ensured through the systems: Adherence to turn around time (TAT), ensuring patient history and prior investigation data availability and continuous evaluation of people involved in the process will make the system reliable and safe.  System for all stakeholders: Teleradiology process has multiple stakeholders apart from the radiologist and the technician. Referring consultants, Teleradiology Company, administrative staff and transcriptionist to the radiologists, KPO operation staff, and management/owners of the Hospitals/Centers etc. All have some input to the process and output from the process. The portal should rope in all of them to make a meaningful solution.

Schematic overview of how a Teleradiology portal works

Q. How do you gauge the future of teleradiology in

general and the teleradiology portal solution? A. Aniruddha: Let’s split the answer in two - a) for the populous and emerging economies like India, China, Brazil, etc. and b) for developed economies. For countries like India, it will be a mission-critical, lifesaving service. The fact is that the number of radiologists in June 2008

Doctor Speak A peripheral hospital without a regular radiologist, uses 21st Century Health’s teleradiology portal solution ‘Nidaan’ for CT reporting routinely. Sometimes cases get uploaded on Nidaan for trauma cases in the middle of the night and get reported within 15 minutes and save a life! Dr. M. D. Mhaskar, consulting physician and Cardiologist says, “I tried a few teleradiology solutions before registering for Nidaan. I had very little confidence in it initially, because of my experience with other teleradiology solutions. 21st Century Nidaan changed my perspective completely. The ease of use and consistency of the product is remarkable. 21st Century Helpdesk was instrumental in overcoming my reservations about the IT solutions and now I regularly use Nidaan. Pay-by-use scheme of Nidaan is ideally suited for the need of peripheral hospitals.” Cities have a high concentration of teleradiology expertise and in fact, can report for Peripheral Centres. Nidaan workflow suits an organised pool of radiologists such as Dr. Deepak Patkar, Chief Radiologist, CT scan and MRI, Nanavati Hospital Mumbai and his team who have been reporting as a teleradiologist group for Centres in India and abroad for the past 3 years. Dr. Patkar says, “We have used Nidaan satisfactorily. The solution is very simple to use and affordable because of very low upfront investment.”

cities is not going to grow suddenly, let alone the interiors of the country. I believe that increasing the throughput of the existing skilled radiologists through technology like teleradiology is the only way to move forward. Pay for use commercial models are most suited for any teleradiology operation and it should be affordable for Indian operations. In India we have a large number of independent Diagnostic Centers, unlike the western culture of prominently hospital bound diagnostic centres. Few of the Centres in the country are owned by radiologists; thus, teleradiology solution can provide the owners access to the radiologists anywhere and ease out their dependence on local skills. We are sure to see a marked rise of corporate chains of such Centers. So consolidating the radiology skills to optimise the throughput is an obvious choice. Teleradiology KPO (Knowledge Process Outsourcing) is now an established feature and some of the Indian radiologists have demonstrated the success of this business model. As many as 60000 examinations go unreported every day because of spill over in the US alone. There exists a huge opportunity to be tapped. A quality pre-read by an Indian radiologist can always help the board certified radiologist to read the examination in a fraction of the time taken otherwise. In addition, the cost differential in the US and Indian services leads to a sound business model. If the teleradiology KPO offers sub-specialty based skill set, it becomes a more promising solution. In short, I see Indian radiologists will look at the portal as a great convenience and at times as a life saving tool. Domestic application of teleradiology will mould them for digital culture for huge patient load to handle and they would look at overseas teleradiology as a good revenue model. A Portal will project the combined strength of Indian Radiologists to the outside world for years to come. 55

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