Medical Education Aiming For Excellence

asia’s first monthly magazine on The Enterprise of Healthcare

volume 7 / issue 6 / June 2012 / ` 75 / US $10 / ISSN 0973-8959

Medical Education

Aiming For

Excellence ICT-enabled medical education can drive socio-economic inclusion in ways that are faster, cheaper and more effective

Dr Damodar Bachani Director, Lady Hardinge Medical College p-16

Aditya Mani

his - empowering growth p-27

MRI - Envisioning hidden ailments p-42

William Hammink Mission Director, USAID p-25

www.ehealthonline.org

Director (Technology), Acuis p-30

The first-ever digital broadband MR is changing expectations, and lives. Even in routine imaging.

Thanks to Philips Imaging 2.0, a revolutionary new imaging approach, the Philips Ingenia 1.5T and 3.0T MR systems set a new standard in clarity, speed and expandability. Ingenia captures and digitizes the signal closest to the patient to improve SNR by up to 40%. Easier coil handling and improved patient comfort help increase productivity by up to 30%. And, Ingenia is designed to meet your demands in fast routine imaging. Discover the revolution in MR technology at www.philips.com/Ingenia30T.

volume

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contents

ISSN 0973-8959

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cover story En-route to Success in Healthcare India needs the political will to make medical education affordable and accessible to all sections of society

Medical Education: Aiming for more Equitable Distribution

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Prof Ashok K Agarwal, IGNOU School of Health Sciences

Applications Gateway to Quality Medical Education

Rohit Kumar, Managing Director, Elsevier Health Sciences, South Asia

Dr Damodar Bachani

Director, Professor & Head, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi

Santanu Mishra Co-founder and Executive Trustee, Smile Foundation

M Vennimalai

CEO, Aavanor Systems

16 24 38

zoom in

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Technology on the Go

54

in focus Need for Adoption of ICT in Medical Education

Experts Group, Healthcare Practice, Frost & Sullivan

Birth of Hope

special feature HIS “HMIS is Adaptive and Modular” Suchet Singh, CEO, Srishti Software

“We need to Educate People about HIS”

Rakesh Kumar Singh, Director (Healthcare-IT), Aarogya Infotech & Management Systems Pvt Ltd

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“Future of HIS is Patient-centric Systems”

40 43

28 32

leader speak Aditya Mani

Director (Technology), Acuity Information Systems Private Limited

The Inside Story Getting Managed

tech trends Som Panicker Vice President , Sanrad Medical Systems

45

S Jaisankar

48

MRI has a Great Future

46 50

25

Sanjay Jain, Managing Director, Akhil Systems

Muralidhar Koduri, Vice President, Napier Global Development Centre

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special focus Dhirendra Pratap Singh, Elets News Network (ENN)

“HIS is a Good Managerial Tool”

30

Prof Suptendra Nath Sarbadhikari

Founder and Director of Supten Institute

36

15

expert corner

Dr Sudhir Srivastava Chairman & M D, International Centre for Robotic Surgery

By Dhirendra Pratap Singh

medical research

30

Service Manager CT/MRI- Customer Support, Trivitron Healthcare Pvt Ltd Dr Harsh Mahajan, Director, Mahajan Imaging Centre

expert speak Dr H Satishchandra

Medical Superintendent, Bowring & Lady Curzon Hospital and Professor & Head, Department of Radiodiagnosis & Imaging,Bangalore Medical College & Research Institute

spotlight Ventilators: The Support System

speciality

56 58

Nextravagance in Heart Care “Technology is Constantly Advancing in Cardiology” Kaustav Banerjee, Country Manager, St Jude Medical

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

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President: Dr M P Narayanan

Partner publications

Editor-in-Chief: Dr Ravi Gupta consulting editor: Ashis Sanyal

Editorial Team

Web Development & Information Management Team

Group Editor: Anoop Verma

Sr. Executive Officer - Web: Ishvinder Singh

Health Product Manager: Divya Chawla, Mobile: +91-8860651643 Principal Correspondent: Dhirendra Pratap Singh Research Assistant: Shally Makin

Sr. Executive Officer – Information Management: Gaurav Srivastava

governance Manager – Partnerships & Alliances: Manjushree Reddy Senior Correspondent: Rachita Jha Research Assistant: Sunil Kumar

Associate Developer: Anil Kumar Information Technology Team Dy. General Manager – IT: Mukesh Sharma Executive-IT Infrastructure: Zuber Ahmed Finance & Operations Team General Manager – Finance: Ajit Kumar

education Research Analyst: Sheena Joseph Senior Correspondent: Pragya Gupta Research Assistant: Mansi Bansal

Legal Officer: Ramesh Prasad Verma

Sales & Marketing Team Manager – Marketing: Ragini Shrivastav National Sales Manager – digitalLEARNING: Fahimul Haque Associate Manager - Business Development: Jyoti Lekhi, Amit Kumar Pundhir Assistant Manager-Business Development: Rakesh Ranjan, Shankar Adaviyar, Puneet Kathait

Executive Officer – Accounts: Subhash Chandra Dimri

Sr. Manager – Events: Vicky Kalra Associate Manager – HR: Sushma Juyal Associate Manager – Accounts: Anubhav Rana

Subscription & Circulation Team Sr.Manager – Circulation: Jagwant Kumar, Mobile: +91-8130296484 Sr Executive - Subscription: Gunjan Singh, Mobile: +91-8860635832 Executive - Circulation: Ashok Kumar Design Team Team Lead - Graphic Design: Bishwajeet Kumar Singh Graphic Designers: Om Prakash Thakur, Shyam Kishore Trainee Graphics: Meenakshi Rajput Editorial & Marketing Correspondence eHEALTH - Elets Technomedia Pvt Ltd Stellar IT Park, Office No: 7A/7B, 5th Floor, Annexe Tower, C-25 , Sector 62, Noida, Uttar Pradesh 201309, email: info@ehealthonline.org Phone: +91-120-4812600 Fax: +91-120-4812660 ehealth does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors.

The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. ehealth is published by Elets Technomedia Pvt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS) Owner, Publisher, Printer - Ravi Gupta, Printed at Vinayak Print Media, D-320, Sector-10, Noida, UP, INDIA & published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP, Editor: Dr. Ravi Gupta © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic and mechanical, including photocopy, or any information storage or retrieval system, without publisher’s permission.

www.ehealthonline.org | www.egovonline.net | www.digitalLEARNING.in Write in your reactions to Health news, interviews, features and articles. You can either comment on the individual webpage of a story, or drop us a mail: editorial@elets.in

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editorial

Lots in Space If India‘s GDP continues to grow at 7 percent a year, in 2020 the number of citizens in the high-income segment will rise to 52 million and in the middleincome segment to 372 million. The number of households in the low-income group will drop to 933 million. As a result, India has the potential to add around 4 million citizens every year to the high-income segment and 26 million citizens every year to the middle-income segment.

These new entrants into the middle class and the upper classes will need quality healthcare and that can only come through well trained healthcare professionals. New avenues for creating the doctors of tomorrow have to be found.

ICT has proved itself in almost every avenue of education. In medical education also it is being widely used. Through a range of interviews and write-ups from leading stakeholders, we have endeavoured to present a perspective on the medical education issues in the country.

Going further, we have special focus on HIS and MRI in this issue. The HIS cuts manpower costs, reduces the possibility of potentially fatal errors, allows faster delivery of medicines to the patient and helps prevent/ avoid stock outs.

Also, the growing clinical applications of MRI have been a result of continuous advancements in technology and increasing Tesla strengths. The enormous market growth in this segment has also been a result of the increased clinical applications.

The era of intensive care medicine began with positive-pressure ventilation.

Positive pressure ventilation is one of the most effective methods of ventilation. Positive-pressure ventilation means that airway pressure is applied at the patient’s airway through an endotracheal or tracheostomy tube.

In Uttar Pradesh, the Innovations in Family Planning Services (IFPS) project began in 1992, as a joint effort between the Government of India and USAIDIndia. The project is intended to serve as the proverbial catalyst that will enable the Government of India to reorient and revitalise the country’s family planning services. It gives me great pleasure to tell you that we are also featuring a comprehensive write-up on this project in the current issue.

Happy reading!

Dr. Ravi Gupta ravi.gupta@elets.in

june / 2012 www.ehealthonline.org

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asia’s first monthly magazine on The Enterprise of Healthcare

Tweeting eHealth Kiran Mazumdar Shaw@kiranshaw Consequences of sedentary living range from obesity to even cancer. Hyperthyroidism is also one of them.

inbox Indian govt is taking the right steps. The ratio of doctors to population is awful in this country.

Edwin on “Gujarat govt to invest `300 cr for healthcare”

Kiran Bedi@thekiranbedi In an event I was asked,’how does one sustain personal energy? I said ‘respect your body as a place of worship. Keep it ‘holistically’ clean.

Everyday Health@diabetesfacts By 2030, 42% of Americans will be obese and 11% will be severely obese.

Michael Martineau@eHealthMusings I think that distinction between eHealth and mHealth is an artificial one.

SmartPlanet@SmartPlanet Mobile health technology will save lives, help overpopulation.

Doctor at large@doctoratlarge Medical research has merely become a euphemism for medical experiments in the form of drug trials.

BBC Health@bbchealth Arthritis cases ‘set to double’.

If total available medical knowledge software are brought in daily use ; both for clinical and as an educative tool the professional performances shall be heavenly bliss for people, professionals and especially patients. ICT has a pivotal role to play.

Dr S C Garg on Apollo and IBM’s endeavour to facilitate online medical knowledge A very nice medical technology, especially for the ones who suffer from aortic heart valve diseases.

Kudos to Dr. Pavan Kumar who successfully performed this surgery on an old lady.

Rajesh Kumar on “Fourth generation bioprosthetic heart valve” Technology must become nothing more than a tool.

Where all are able to obtain access to hardware and applications if needed. Notebooks, iPads, and netbook computers — paid for with the help of state dollars — are becoming an increasingly popular sight in classrooms.

Narendra Mohan on “Texas Instruments”

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Cover Story

En-route

to Success in Healthcare

India needs the political will to make medical education affordable and accessible to all sections of society

By Dhirendra Pratap Singh, Elets News Network (ENN)

T

he health crisis in India has been exacerbated by the shortage of doctors and also by the fact that majority of specialists are based in urban areas. An abysmally low government spending on health is also the reason behind poor state of healthcare in India.

Seventy four percent of the Indian population lives in the villages, thus the delivery of health services to rural masses

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holds the key and forms an integral part of their socio-economic development.

Reforms in Medical Education Reform in medical education is urgently needed. The field of medical education in India is not sufficiently advanced. Government as well as private sector should provide further impetus to medical education. There is no dearth of students

who want to be doctors and at times they are unable to fulfil the ambition as there is lack of quality institutes for medicines. There is also the need to review the current fee structure in government medical colleges. A monthly fee of around `200 seems too less, particularly when many students come from better off families and are clearly in a position to pay a realistic fees.

Cover Story

There is acute shortage of doctors in India. India needs more than one lakh doctors per year. And we only produce 35,000. We must scale up our medical infrastructure five times. Shortage of doctors affects the poor, who do not have easy access to healthcare services. Policy pronouncements and intentions to provide universal healthcare can be just wishful thinking unless backed by a political will to make education affordable and accessible to all.

Medical Education in the Digital Era What happened in the USA a decade ago in terms of creating robust medical education technology systems and services to manage the same, is just about beginning in India. While many are keen to adopt scalable technology, the lack of quality service providers is rare and there is no precedent in the market. The second issue is not just getting the right technology in place, but supporting it with the right content that is pedagogically sound for a fulfilling distance learning experience.

In diverse medical education contexts, e-Learning appears to be at least as effective as traditional instructor-led methods such as lectures.

Prof TK Jena, Director, School of Health Sciences, IGNOU is of the view that “the doctor of future is going to be an engineer.

Fifty years ago, it was Doctor who mattered. Today it’s the radiologist or other

ICT in support of caregivers Working conditions health & wellbeing (peer suport) Help lines, phone, skype email, online social network

Web stes Online cources Multimedia training ICT supported accreditation Phone help lines

ICT can help

Quality of Care Communication Coordination Collaboration Telecare, phones, email, online information

Private life social integration Phone, skype, email, online network Language Learning Cultural knowledge Online information and Training, Multilingual info

Learning / employment / social inclusion / integration

specialists, who matter.” He further says, “Already people are working towards developing virtual classrooms in the field of medical education. ICT can play an important role in health education.”

If India‘s GDP continues to grow at 7 percent a year, in 2020 the number of citizens in the high-income segment will rise to 52 million and in the middle-income segment to 372 million.

The number of households in the lowincome group will drop to 933 million. As a result, India has the potential to add around 4 million citizens every year to the high-income segment and 26 million citizens ever year to the middle-income

Prof TK Jena

Director, School of Health Sciences, IGNOU

“The doctor of future is going to be an engineer.

Fifty years ago, it was doctor who mattered. Today it’s the radiologist or other specialists who matter”

segment up to 2020. ICT-enabled solutions in healthcare, education, financial services and public services can drive socio-economic inclusion of 30 million citizens each year, faster, cheaper and more effectively than traditional models.

Says Dr Dheeraj Mehrotra, Deputy General Manager, Schand Harcourt, “The tilt from Web 1.0 to 2.0 and now to 3.0 offers new opportunities to our students. It is up to the teachers to guide their students through the maze of the digital world.

Teachers need to develop a balanced approach in developing new policies and practices that can guide the students in regards to usage of the Internet.”

A large part of the ICT agenda in medical education is being driven by the technology companies rather than education companies. Mostly the conversations are about hardware or software without any focus on adequate quality of content or providing support to the teachers. Experts believe that it is all about the teachers.

Says Kartikay Saini, Chairman, Scottish High International School, “Until teachers become the facilitators of digital education, all the interactive whiteboards, smart tools, cloud computing and educational software will not be of much use. The best practise in education is one that leads to inquiry based learning, research based learning. As june / 2012 www.ehealthonline.org

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Cover Story

we can see around us, the learner’s profile is changing.”

The integration of e-Learning into medical education can catalyse the shift toward applying adult learning theory, where educators will no longer serve mainly as the distributors of content, but will become more involved as facilitators of learning and assessors of competency.

Kartikay Saini

Chairman, Scottish High International School

Rural-urban Healthcare Divide Sending doctors to remote villages where there are no basic facilities is a challenge. There should be basic facilities for the doctors, who are being sent to rural areas. The Government is really serious about improving rural health.

Government has already allocated huge funds to improve rural healthcare sector.

National Rural Health Mission is a very good step in this direction. There is a ray of hope and things will improve. Government alone can’t do everything. It also needs public support.

Health system can be generator of jobs, but the need of healthcare personnel is so huge in the country and abroad that our output is much less than the desired numbers. Moreover it is not as rewarding as other branches are and it calls for long hours of struggle and perseverance which is not found in this generation. However, things can improve if we improve the working conditions and facilities for healthcare personnel.

Management skills and communication

Key areas that require attention • • • • • • • • • •

Establishing the NCHRH Instituting a nation-wide examination to determine college admissions Earmarking medical and nursing education for public investment Making private capital an exception Increasing the remuneration of teaching faculty and expanding their gross availability by inviting foreign faculty alongside increased use of technology; Working out a fair fee structure for private medical education Creating new cadres of health professionals who are trained to address the needs of the rural population Health Ministry announced the target to achieve 80,000 MBBS seats and 45,000 PG (MD/MS/Diploma) seats by 2021 GoI is targeting additional 38,431 seats in the MBBS and 22,806 seats in the PG streams by 2021 This ambitious plan will need about 20 medical colleges to open each year with an intake of 200 students

should be augmented with resources for improved quality. IT skills and e-labs can

Dr Dheeraj Mehrotra

Deputy General Manager, Schand Harcourt

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“The best practise in medical education is one that leads to inquiry based learning, research based learning. As we can see around us, the learner’s profile is changing”

“Teachers need to develop a balanced approach in developing new policies and practices that can guide the students in regards to usage of the Internet”

be launched to reach out far and wide.

Vision sharing by experts and orientation to nation’s health system and policy is the need of the hour. Professional skills, Ethics and human values should be preached and stress management be incorporated at all levels.

Public hospitals are spurred on by the growing need to really understand the cost of health consum-ables and avoid waste. Private hospitals, in order to stay in business and function effectively, need to find ways of saving money and re-establishing a profit margin in an environment where revenue is stagnant and costs are increasing. The health funds are also searching for ways to reduce operating costs and look to ecommerce, using industry standards, as a better way of dealing with claims.

CHAOS

Medical Research

Medical Education

Aiming for more Equitable Distribution

Prof Ashok K Agarwal IGNOU School of Health Sciences

H

ealth Survey and Development Committee (Sir Joseph Bhore), 1946, paved the way for developing the healthcare delivery system in India. In its short term and long term recommendations, it prescribed 2 and 5 hospital beds per 1000 population by 1951 and 1972, respectively. In stark contrast, India is still groping with 1 bed per 1000 population. This is further diluted to less than 0.5:1000 population in the rural, tribal, hilly, desert and coastal regions. Poor financial allocations to medical education and health sector, is further compounding the problem. The country needs 100,000 doctors per annum while we produce not more than 35000. To meet this shortage, medical education should enlarge infrastructure for training of dental, nursing and paramedical students as well.

Medical, Dental, Nursing and Paramedical education and training institutions and hospitals should be evenly distributed in the rural and other neglected areas. The Union Minister for Health and Family Welfare has recently commented that the medical education institutions are concentrated in only a few states of the country and that Govt. of India shall rectify it. While rectifying this mal distribution, GoI

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and the State Governments need to bridge the urban-rural divide, and establish good number of these institutions in under developed- rural parts of the country. This is not going to be easy. Why? Because unless the GoI and state governments have political will and commitment to all round rural development programmes, including infrastructure communication, income generation, nutrition, education, women and child development, maternal and child health, water and sanitation; we shall not be able to promote and sustain the medical education and health training activities in the under developed States or rural areas. The under development of the rural and similar areas is the main reason for gross under utilisation of vastpublic health care delivery system in the country. The more equitable distribution of medical and other education institutes in rural areas will not only bridge the acute shortage of doctors, dentists, nurses and paramedics but will also make the rural HCDS more vibrant. It is going to be a win-win for one and all.

Public private partnership, quality and accreditation, user charges, RandD, increasing availability of essential drugs, vaccines and contraceptives, HMIS, equipment management, training and capacity building of the various health functionaries are the other simple mantras.

Quality in medical education The increase in the number of medical and other colleges will only partly address the complex problems of health sector.

Many do not know that barring a small percentage of private medical, dental and nursing colleges, a large majority of them in private sector have little clinical teaching material, in terms of patients and other support services in the attached hospitals.

How can a medical student learn without observing and working on adequate num-

ber of patients under the guidance of good quality teachers (becoming a rare commodity). One small example: the author of this article and his fellow medical students were required to perform 20 deliveries independently during the fourth year of the MBBS course with detailed documentation and subsequent presentations. Similarly, all medical students were required to go through similar hands-on-skill development in other disciplines.

A qualified doctor should also exhibit good leadership and managerial skills and qualities. Because it’s the doctor only, who is the leader, whether it’s a primary health centre, CMO/DHMO, district hospital, medical college, the Directorate of Health Services or the MCI/ DCI. But these doctors, more often than not, make repeated mistakes as they have not received any administrative/managerial training during the medical education. MCI and the government recruiting agencies need to consider to inbuilt these inputs.

Medical and health institutions, in general, have little or no research or RandD activities. Research and RandD activities in health sector will also promote medical students and PGs to have an analytical and research oriented approach and thinking. Unfortunately, adequate budgets are not allocated to conduct and promote research activities and publications.

As of March 2010, delays in recruitments resulted in high vacancies even in available posts at health centres – over 34 percent for male health workers are not in position, while 38 percent of radiographer posts, 16 percent of laboratory technician posts, and 10 percent of doctor posts are vacant. Further, only 17 percent of all allopathic doctors and 6 percent of allopathic doctors in rural areas are women i.e. less than one female doctor per 10,000 population. Now we can understand the reason for high MMR and IMR.

Applications

Gateway to Quality Medical Education Elsevier’s web based, e-learning tool will help bridge the gap between demand for quality medical education and lack of faculty, skills and teaching aids

By Rohit Kumar

T

oday medical schools are facing several challenges in producing larger number of well skilled doctors due to the changing demographics and the political environment of the country.

There are over 35,000 students joining the medical profession each year in 335 medical colleges, 23,000 students joining each year in 290 dental colleges, and another 72,000 students enrolling in 1500 nursing colleges. At a time, there are around 1,65,000 students pursuing medicine, 92,000 students pursuing dentistry and another 2,16,000 students pursuing nursing. Medical institutions are growing at a rate of 5 percent YoY, whereas dental and nursing institutions are growing at four percent and eight percent YoY respectively.

To assess the need of the healthcare professional education market we conducted extensive research. It was observed that growth of this market has shown a weak link in the system-availability trained faculty and support staffs (which has a long gestation period i.e. 11 years for faculty and up to 5 years for the support staff) and unavailability of

adequate cadavers/animals/ patients for practical exposure. Since these are structural problems, government and regulatory body of healthcare professional education is pushing alternate solution for increasing efficiency of the existing human resources by use of digital products for enhancing the process of teaching/learning of theoretical and practical skills.

Medical students say that while attending the lectures and practical classes, they get so overwhelmed by the same topic taught in different subjects at different time, that it becomes very difficult to understand and visualise the important concepts, and then acquire the practical skills.

Faculty also finds it painful to integrate the clinical and non clinical subject areas/ topics, and make lectures interesting and interactive. The greatest need to address the above issues lies in important and difficult practical concepts/ skills as per the curriculum prescribed by the regulatory bodies. The Medical Council of India has now directed all medical colleges to use Information Technology for teach-

ing medicine by establishing e-classrooms, e-libraries, and providing access to e-content.

There is a growing mandate for e-learning and many college libraries now have computer terminals with e-journals.

Currently, there is no prominent provider in the market which provides one-stop solution aligned with curriculum.

Some local publishers provide DVDs (with limited content) along with books which are not comprehensive enough.

Elsevier has rolled out a product, which is a Web-based, e-learning tool for medical/ dental/nursing colleges to supplement teaching/learning process. It will provide modules that will help bridge the gap between demand for quality education and severe lack of availability of faculty, skills and teaching aids.

We aim to serve the student by clearing important and difficult concepts along with giving enough exposure towards practical skills. This product will thus enhance our local publishing programme through brand building and faculty/ student relationship.

It is envisaged that in the early years of the product,

many medical colleges will not have their own learning management systems, and will prefer the convenience of a full-managed and well-supported option for content delivery. The LX LMS supports the content delivery, access and entitlements, learner tracking, class management and assessment functionalities required to support the needs of our product.

Some larger seats of learning in India are starting to rollout e-learning tools for their staff and students, including Learning Management Systems like Moodle and Blackboard. This trend is anticipated to continue over the coming years, and institutions providing such systems for elearning delivery are likely to want to utilise a single virtual learning environment across all staff and students. This may also be the case in institutions where there are challenges around internet access, and where an intranet-based solution may offer improved performance for multimedia content, including animations and videos. For these institutions, we will ensure that we can supply content in IMS Common Cartridge and SCORM-compliant formats suitable for loading into most major learning management systems used by Indian educational institutions.

About the Author The author is Managing Director, at Elsevier Health Sciences, South Asia june / 2012 www.ehealthonline.org

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Expert Corner

Redefining Medical

Education Through Technology In context of medical education, technology based learning appears to be more effective than traditional methods

T

he central mission of medical education is to improve the quality of healthcare delivered by doctors.

As doctors, we must never fail to remember that our ultimate responsibility is to serve the patients. What doctors do, and how and when they do it, depends on the quality of medical education.

The need to ensure greater integration in the diverse streams of medical curriculum is now well recognised as a priority. Curriculum reforms are being implemented in medical schools worldwide.

In diverse medical education contexts, technology based learning appears to be more effective than traditional instructor-led methods such as lectures. A developing infrastructure to support such learning within medical education includes repositories, or digital libraries, to manage e-learning materials, consensus on technical standardisation, and methods for peer review of these resources.

The integration of digital learning into medical education can catalyse the shift toward applying adult learning theory, where educators will no longer serve mainly as the distributors of content, rather they will become involved as facilitators of learning and assessors of competency.

Through open and distance learning systems, short term certificate or diploma courses in integrated medicine and surgical needs can be developed. This

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will help in reaching out to more and more aspirants to meet the needs of our society. Continuing Medical Education and capacity building through blended learning system is the need of the hour.

In India, we haven’t really reached out to the grassroots levels through conventional courses.

In the face of increasing demand for satellite-based connectivity, role of a dedicated HealthSAT and EduSAT to spearhead telemedicine, tele-education and remote disaster management activities in the country is beginning to be deeply felt.

Education & training in telemedicine Physicians have acknowledged information technology (IT) efficiency and now utilise it in their professional practice and patient management. The benefits of incorporating IT in the healthcare space has now come to the notice of the academic community; however, existing literature currently pertains to limited areas.

Growing awareness of the potential benefits of advanced medicine, emerging democracies, growing middle classes and an ageing population world-wide are significant forces shaping future demand for world-class healthcare. Coupled with an increased awareness of the potential benefits of advanced modern medical technologies, these factors will have a dramatic impact on medical education systems.

Dr Damodar Bachani

Director, Professor & Head, Department of Community Medicine, Lady Hardinge Medical College & Associated Hospitals, New Delhi

Zoom In

“Medical Education

has to be Aligned to the Needs of Healthcare�

Regarded as a pioneer in spreading awareness on health informatics in India, Prof Suptendra Nath Sarbadhikari is the founder and Director of Supten Institute. In this freewheeling interview with Dhirendra Pratap Singh, he shares his perspectives on issues in medical education in India What is the present medical education scenario in India?

The Medical Council of India has recently made public the guidelines and regulations for Graduate Medical Education in India. The commendable revised curriculum for graduate medical education suggests many innovative and relevant changes.

However, unless the assessment of skills and competencies are well defined operationally, simply a change in curriculum will not bring about required changes in the way faculty members are likely to implement the GMR 2012. A good plan does not automatically translate into effective implementation.

Like the other competency based training models, the GMR 2012 appro-

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priately emphasises the importance of training not only the science of medicine but also the art like providing holistic care, compassionate care, adequate communication, life long learning, professionalism and ethics. However, how are we going to ensure that the students have developed these competencies?

Barring the knowledge and skills part, none of the competencies listed in the document will be assessed at end-term examinations. All of them need to be followed for a long time through a robust system of internal assessment (IA).

The bottom line is that unless we change assessments, no curriculum change is going to be effectively implemented and the said document will serve only a cosmetic purpose.

What are the loopholes in the medical education system? How can they be removed?

It must be recognised that medical education has to be closely aligned to the needs of the healthcare system. The country needs to be provided with essential healthcare services, and it is the duty of the government to ensure this.

The MCI did not permit the creation of new cadres such as nurse practitioners and nurse obstetricians. Also, the content of our undergraduate medical education courses must become more closely aligned to primary health-care needs rather than being attuned to tertiary care practice.

On the other hand, Physiotherapy profession is not regulated by a statutory

Zoom In

body, so each and every other institution offering health courses has started physiotherapy in the recent years. As a result the quality is very much compromised.

Physiotherapy courses were also run by technical and agricultural universities.

After much outrage, such courses were stopped, thanks to UGC for their intervention. Adding to the adversity the opportunities for career progression, as well as post graduation training, are also very less and as a result there is much brain-drain.

What is your opinion about medical training in India? Why are we not able to retain talent?

The quality of medical or rather healthcare professional education is not uniform throughout India. While there are quite a few good colleges, both in the public and private sectors, the average product may not be considered as competent by all standards. Student teacher ratio is often dismal in many of the colleges. The answers to some of the following questions point as to why it is difficult to retain talent under such circumstances.

Rural India, today, faces a serious lack of doctors and healthcare facilities. What needs to be done with medical education to bridge the rural-urban healthcare divide?

A meeting of Parliamentary Consultative Committee on Health chaired by Health Minister, Ghulam Nabi Azad, was called on May 14, 2012 in New Delhi to discuss the scenario of medical infrastructure in the country. There it was announced that the target is to achieve 80,000 MBBS seats and 45,000 PG (MD/MS/Diploma) seats by 2021. However, unless the current imbalance among the regions is corrected, the problem of poor doctor/ patient ratio, the magnitude of which is debatable, will remain.

Increasing the numbers of physician extenders (Physician Assistants, Nurse Practitioners, Advanced Nurse practitioners) might be an integral part of the overall solution. The basic infrastructure in the rural health centre should be commensurate with the demands of today for standard of primary care with facili-

ties to transport patients to secondary and tertiary level institutions if needed.

The set-up should be a reasonably large campus with the Health centre (water, electricity, telecommunications) manned by a team of at least four doctors (one CMO and a Physician, Surgeon/ Orthopedician and Obstetrician/Gynaecologist), 6 to 8 nurses and 10-12 support staff reporting to the CMO there.

We should raise a new ‘army’ of rural healthcare delivery personnel and merge similar existing efforts like Aanganwadi workers, ANMs (Auxiliary Nurse Midwives), rural education and adult education schemes into this endeavour.

What is the role of ICT in improving medical education?

The efforts to introduce ICT in medical education will pay in long run, if we harness its potentials to fit to our needs. Of course, there is a definite need to continue research to find out the usefulness of any system designed (including cost effectiveness and cost benefit). While I’d be personally very happy to go on elaborating on this particular question, let me be very brief. Web 2.0 tools like wikis, blogs, podcasts and webinars are now becoming regular modes of instruction. Further, the explosion of online social networks activities is giving us the opportunity to reach the students and patients (User-driven healthcare) at the place where they may be spending a considerable amount of their wakeful time. Virtual Learning Environments

“

There is a definite need to continue research in medical education to find out the usefulness of any system designed including cost effectiveness and cost benefit”

(VLEs) are now becoming part of mainstream learning activities.

What do we need to scale up our medical infrastructure?

In the meeting of Parliamentary Consultative Committee on Health chaired

by Health Minister Ghulam Nabi Azad called on May 14, 2012 in New Delhi it was announced that the target is to achieve 80,000 MBBS seats and 45,000 PG (MD/MS/Diploma) seats by 2021. The objective is also to improve the availability of doctors by ensuring a doctor-patient ratio of 1:1000 as against the current 1:2000 ratio. The Ministry of Health and Family Welfare is targeting additional 38,431 seats in the MBBS and 22,806 seats in the PG streams by 2021, representing a whopping rise of 92.45 per cent and 102.75 per cent respectively over the current availability.

This ambitious plan will need about 20 medical colleges to open each year with an intake of 200 students.

Health system can be such a huge generator of jobs, besides improving the quality of life of our people. And hence such undersupply is incomprehensible.

So, how can we improve the situation?

By opening more private medical colleges, all are winners. The Government wins – more private colleges means the responsibility and cost of the government towards providing healthcare to the poor or salaries to the employees is drastically reduced. Economy wins: the government earns a lot of money as fees/ taxes for various things. Even different government sectors like telecom, electricity, municipality, registrars too earn a lot of money. Land around a college develops fast, increasing real estate costs, increasing small businesses around and movement of labour class from unorganised to organised sector. Parents win: as they are able to make their children doctors without much competition and to channelise their black money as well, their social standing goes up. Lastly, for the want of quality, patients die, population decreases and hence India wins. june / 2012 www.ehealthonline.org

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In Focus

Need for Adoption of ICT in Medical Education Indian medical education should imbibe updated technology in clinical as well as non-clinical areas

By Experts Group, Healthcare Practice, Frost & Sullivan

T

he Medical Council of India (MCI) is a statutory body with the responsibility of establishing and maintaining high standards of medical education and recognition of medical qualifications in India. According to World Health Organisation “Health Statistics Report of 2012 – India” has 10 nurses and 6.5 physicians per 10,000 people. On an average 1,000 doctors migrate abroad every year, this trend is seen in the last 3 years. Also, there are 335 allopathic medical colleges for approximately 35,000 students every year. Growth in number of medical colleges in India during 2009-12 has been at 1.1 percent with an addition of 46 new medical colleges.

As per 2012 population, India requires an additional 4.3 lakh doctors to reach at the mark of 1 doctor per 1,000 people.

According to WHO estimates of 2012 India requires additional 5 lakh nurses to achieve the mark of 2 nurses (including ANM, GNM, LHV) per 1,000 people.

Loopholes in Medical Education The major problem in the education system is the gap in infrastructure. There is prominent divide seen between urban and rural education infrastructure. Other issues which need to be addressed are: skewed ratio of doctors to ever increasing population base leading to excessive work pressures in the public

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facilities; training on latest technology for diagnostics, tests and other clinical areas; adoption of modern education tools like ICT tools; very few world recognised education institutes for specialised courses; lack of sponsored student exchange programme on wider level for training abroad; changes needed in course curriculum level like inclusion of health informatics, quality, health management.

Some of the measures which are discussed across major forums includes imbibing updated technology in clinical as well as non-clinical areas and required level of training to be imparted. The indigenous systems of medicine should be promoted and brought in the medical system. More centre of excellences to be developed at state levels. ICT should be used to bridge the gap like online/offline conferences, case studies.

Medical Training in India Continuous training is an important part of medical education; the issue that India faces is two dimensional with additional requirement of manpower and standardisation, requirement of education system across country. ICT tools will be important in imparting the training, education and capacity building programs and can play a key role in practical education. Continuous training of paramedical and nursing staff should be mandatory for all the institutions.

Rural-urban Healthcare Divide The entire process of tutor, student and their environment has to be analysed with provision for their basic comfort, clean surroundings and safety. There must be basic facility for doctors in rural areas to treat the patients. Incentives and acknowledgement programmes should be implemented for doctors working in rural areas. Also, fixed term and duty rotation of doctors should be managed at the district college levels. Prioritising the regions where there is acute need to upgrade the education scenario is required at both national and state level for greater focus.

The 12th and 13th annual national health plan has identified 7 high focus states for medical education development.

Medical Infrastructure Since there is a huge gap of current and desired number of doctors, the numbers would not be achieved radically in a year or so. We need a composite structure of support from government and doctors to fill the ever expanding gap. A 360 degree approach is needed to overcome the situation, few of them could be addition of more colleges not only for doctors, but also for nurses and paramedics, increasing the MBBS and PG seats as the pilferage can be controlled by a certain level only, equitable distribution of funds in infrastructure and capacity building; encouraging private participation into education.

Expert Corner

Crack the Code of

Poor Healthcare

India has a scope of looking beyond the formal public healthcare focused medical education, says Santanu Mishra

I

ndia is the country with the highest number of medical colleges in the world. All 315 odd medical colleges in India produce some 30,000 doctors and 18,000 specialists. Yet we are almost at the bottom in terms of the number of doctors per people at one doctor per 2000 people.

There is a huge difference between private and government healthcare systems and a majority of the population remains always outside the healthcare coverage owing to various reasons and challenges. This holds true for a huge section of the rural general population and the urban poor. The challenge is for all of us – government, development sector and the medical fraternity alike – to build a healthy nation.

The journey begins from medical education. India already boasts of a stringent and very respectful medical education system in the world. There are many countries including China which produce over 1000 doctors per medical college an average. On the other side, India has been focusing on training some 100 doctors per college.

The Medical Council of India (MCI) has an estimated 6.12 lakhs allopathic doctors registered with it as on 2011.The high-level expert group (HLEG) on universal health coverage (UHC) under the Planning Commission has recommended setting up of 187 more medical colleges across India. Once implemented, this makes one doctor available for 1000 people on an average. Nevertheless, we will still face the challenge of making healthcare available and accessible to a large section of the population.

The alternative and complementary medicines hold potential to reach the unreached. More work should be done in terms of standardisation of educational

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Smile On Wheels Smile on Wheels is an innovative mobile hospital programme of Smile Foundation. This is a unique mobile healthcare unit that seeks to address problems of mobility, accessibility and availability of primary healthcare with a special focus on children and women, in urban slums and remote rural areas.

The Smile on Wheels programme at present has 15 operational projects targeting a population of 11,72,099. Since inception in 2006 this programme has directly benefitted 4,75,131 beneficiaries

curriculum and of drugs, research and development and finding possibilities of integration in the medical education in allopathic and the alternative & complementary medicine systems. Such possibilities would make doctors from other approved medical education such as Ayurvedic, Homeopathic and Unani methods complement the efforts bringing more unreached population into the primary healthcare and beyond.

Secondly, we have a scope of looking beyond the formal public healthcare focused medical education and consider upgrading complementary solutions such as community medical practitioners. Half of our rural population is extremely poor and also healthcare is major concern in urban slums. The solution lies

in developing a medical education system which can produce community medical practitioners who can solve the issue of affordability and geographical accessibility of vital healthcare for the poor.

This will on the other hand help curb the quack menace prevailing amongst the low income group communities.

Innovation and integration of relevant information communication technology (ICT), affordable diagnostic techniques, more intense ethical education and orientation towards serving the unreached masses are the few the things which should be imparted to the future doctors.

About the Author The author is Co-founder and executive trustee of Smile Foundation.

Special Focus

Birth of Hope

The positive response to Sambhav voucher scheme augurs well for pro-poor health policies and programmes in developing countries

By Dhirendra Pratap Singh, Elets News Network (ENN)

A

ccording to the National Family Health Survey, India has the highest number of cases of anaemia in the world. Almost 79.1 percent of India’s children between the ages of three and six, and 56.2 percent of married women in the age-group 15-49 have been found to be anaemic in 2006. Almost 20 percent of maternal deaths are caused directly because of iron deficiency, or anaemia, which is a contributory factor in 20 percent more deaths.

India’s maternal and infant mortality levels are very high and repeated childbirths are seen as an insurance against multiple infant and child deaths. Vast

numbers of people cannot avail services even when they are available, due to lack of knowledge and access.

The progress in the last two years has been remarkable, which gives the hope that the importance of population stabilisation has been recognised by people themselves. This has now to be sustained and accelerated particularly in the Hindi belt states where fertility levels are very high. Many of the factors that have an impact on the population momentum are cultural in nature. Attitudes to early marriages, expectations about early childbearing, and disregard for the need for spacing between children need to be altered. Low female literacy impacts

adversely on safe motherhood and the maternal care that their children receive.

Institutional Deliveries Among BPL In December 2005, Gujarat launched a pilot voucher scheme, Chiranjeevi Yojana, to facilitate institutional deliveries among BPL women. As per UNICEF records, by October 2009, more than 800 providers participated in the programme and more than 384,920 deliveries had been supported through the scheme.

USAID-India’s Support in UP The total fertility rate of Uttar Pradesh is 3.8. The infant mortality rate is 67 and june / 2012 www.ehealthonline.org

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Special Focus

maternal mortality ratio is 440 (SRS 2004 - 2006), which are higher than the national average. In Uttar Pradesh, the Innovations in Family Planning Services (IFPS) project began in 1992 as a joint effort of the Government of India and USAID-India. It is intended to serve as a catalyst for the Government of India in reorienting and revitalising the country’s family planning services. In Uttar Pradesh, the project has been implemented in three phases (1992–2004; 2004–2009; 2009–2012). The objective of the scheme is to increase the Contraceptive Prevalence Rate (CPR) among the BPL families and address their family planning requirements.

Voucher schemes, generally operated as public-private partnerships (PPPs), or collaborative efforts between the public and private sectors, have had positive effects on health service utilisation in many developing countries. Four voucher programmes, called Sambhav, were implemented from 2006-2012 as part of the IFPS Project, a bilateral project of the Govt. of India and the United States Agency for International Development (USAID), to expand access to FP/ RH services to below poverty line (BPL) beneficiaries in selected districts of Uttar Pradesh, Uttarakhand, and Jharkhand.

Essentially, a voucher is a token that can be used in exchange for a restricted range of goods or services. Health vouchers are used in exchange for medical consultations, laboratory tests, drugs and vitamins for the pregnant women.

Speaking in Lucknow, William Hammink, Mission Director USAID said, “The innovations in family plan-ning that resulted from the partnership between USAID, the Government of India, the Government of Uttar Pradesh, civil society, and the community, demonstrate that challenges can be addressed using local resources and solutions. India has become synonymous with innovation and the IFPS innovations demonstrate India’s commitment to improving the health and lives of millions of people.”

Encouraging Results The results have been encouraging, as the Sambhav voucher pilot programmes

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William Hammink

“India has become synonymous with innovation and the IFPS innovations demonstrate India’s commitment to improving the health and lives of millions of people”

Mission Director, USAID

Maternal Mortality Ratio in Selected States All India 254* State MMR State Uttar Pradesh 440 Karnataka Assam 480 Andhra Pradesh Rajasthan 388 West Bengal Madhya Pradesh 335 Punjab Bihar 312 Gujarat Orissa 303 Haryana Maharashtra 130 Tamil Nadu Kerala 95

MMR 213 154 141 192 160 186 111

*In the industralised countries the average MMR is 8.

MMR: Maternal deaths per 1,00,000 live births Source: Registrar General of India, Survey Report 2006

facilitated delivery in private health facilities of nearly 12,500 infants, supported approximately 44,000 antenatal care visits and 10,300 postnatal care visits.

Women and men also used approximately 9,500 vouchers to avail a range of FP methods. This positive response augurs well for pro-poor health policies and programmes in developing countries.

For the government, the voucher schemes help to meet public health goals and reduce strain on public sector human resources and facilities. Private nursing homes and hospitals are willing to offer services at reduced rates in return for increased client volumes—which provides a more stable flow of resources.

Regular monitoring and corrective action

was essential throughout the voucher system implementation process.

The voucher programmes, and the quality of services in the private sector, played a key role in increasing service uptake, especially for maternal health services, such as institutional delivery.

From the baseline to end line in Haridwar, even with the public sector Janani Suraksha Yojna, delivery in government institutions by BPL women decreased slightly, from 12.1 percent to 9.5 percent.

In contrast, delivery in the private sector among BPL women more than doubled, from 15.0 percent to 37.5 percent, during the same time period, suggesting that the poor valued the quality of services offered by private providers.

Special special feature-his feature

HIS Empowering Growth

By Shally Makin, Elets News Network (ENN) A reduction in operating costs, especially savings attributed to staff efficiency, is a key driver of the market for HIS. Approximately 40 percent of the estimated financial benefits can be attributed to the gains that can be accrued from full system deployment and maturity. HIS will eventually replace many of the manual processes that hospitalists have traditionally performed. Most notably the handwritten orders in patient charts will get automated through HIS. HIS will promote seamless and complete clinical data capture and improve billable charges, including medical supplies, drugs, procedures, and ancillaries.

The system will produce more granular information

for all inpatient encounters, more accurately reflecting care intensity; and its automated charge capture will also enable earlier identification of encounters that are potentially billable. HIS provides a host of benefits some of which are less tangible.

Though non-financial, they are no less important to an overall investment decision. The HIS will also be a driving force behind the adoption of care management protocols and best practices known to improve health outcomes.

Today HIS is being looked at as a routine tool, which manages nearly all hospital operations with the objective of enabling hospitals to deliver better care to the patient.

june / 2012 www.ehealthonline.org

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Special feature

“HMIS is Adaptive and Modular” C

“In recent years, HMIS has evolved both in terms of features, and extensibility.

From technology perspective the shift is from client server architecture to web based solutions,” says Suchet Singh, CEO, Srishti Software

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urrent HMIS allows complete integration with handheld devices, such as PDAs and smart phones, so that it can be carried anywhere anytime helping consultants/ doctors to review and send their suggestions on the fly. HMIS has also matured to handle multiple data source such as bedside monitors, GPS systems, bar code readers, RFIDs and iris scanners. Finally, HMIS of today conforms to most robust healthcare standards ensuring better patient care.

The healthcare solution suite, PARAS is an integrative platform that has helped hospitals manage their costs at activity level and substantially improve their revenues. It allows high interoperability of entire spectrum of healthcare technologies enabling client hospitals to deliver best-in class service. Most unique feature of PARAS is the activity based costing approach which has allowed client hospitals to price their services right. PARAS conforms to all global and industry standards including HL7, HIPAA, NABH, JCI, ITIH, etc.

India is said to have about 100-120 super specialty healthcare providers.

Analysts predict the number to reach 200 in the next five years. Typically a super specialty hospital has an IT budget of anywhere between INR 50,00,000 to INR 1,50,00,000. If we consider INR 80,00,000 as an average IT budget for

these hospitals, 100 hospitals would make the market worth INR 8,00,00,0000 currently. The cost of installation depends upon the modules chosen.

Post PARAS HMIS implementation, client hospitals noticed increased efficiency in the following areas- improved customer service, improved employee productivity, cost savings, stationary cost and revenue leakage.

Majority of work force is not IT trained and hence IT adoption may be slow.

We have overcome this barrier by training hospital staff to ensure faster adoption and high usage. Most branded IT products, fail to deliver in a typical Indian scenario on the grounds of relevance.

Srishti, being an Indian company has known market more closely and hence, PARAS is built to deliver in an Indian hospital ecosystem. With IT sector developing fast, hospitals fear technology obsolescence. We have offered a solution to this problem by making PARAS adaptive and modular, which allows hospitals to choose a customised solution, based on their requirement to enhance clinical care without the fear of technology obsolescence and functional outgrowth.

Conforming to healthcare standard will enable hospitals to provide better quality of patient care. Medication error can be greatly reduced with the usage of various scenarios of drug interaction alerts. The usage of proper appointment scheduling feature of an HMIS results in significant reduction in patient waiting time. This results in greater satisfaction amongst the patients. An HMIS with an integrated EMR ensures continuity of care record, which can be made available at the time of clinical encounter enabling consultants and physicians to provide right treatment to the patient.

Average length of patient can be greatly reduced by having a robust ADT feature of HMIS helping patient to discharge without having to wait unnecessarily. Drug interaction alerts can be very useful, as while administering drug to the patient the caregivers can avoid all kinds of human-error related mistakes. HMIS compliant with diseases and procedures code can help doctors avoid entering wrong diagnosis in the EMR.

leaders speak

Cloud Computing for Health Ecosystem “The year ahead will herald an increased adoption of the cloud within our customers.

The real question is: How many of us as service providers are ready for this paradigm shift?” says Aditya Mani, Director (Technology) at Acuis, in conversation with Shally Makin Give us an overview about Acuis.

The word acuis is coined from two parts where ‘acu’ is derived from the word ‘acuity’ which means sharpness of vision and ‘i.s.’ is short for ‘Information Systems’. While the name of the brand is “acuis”, the company is called “Acuity Information Systems Private Limited”. We founded the firm in 2004, almost eight years ago with a vision of a ‘converging health ecosystem’. Though this was conceived in the past when the cloud did not in its current form, we had envisioned a multi-tenant, single instance application talking to multiple stakeholders via multiple devices.

Today, we are able to leverage the power of the cloud and will soon roll out cloud-based services to many of the stakeholders of the Indian healthcare ecosystem. Our focus areas include software products for blood banks and

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leaders speak

hospitals. For the blood bank industry, we have integrated enterprise solutions that range from hospital-based blood banks (a department in a hospital) to comprehensive solutions for a national or state-wide transfusion service. For the hospital industry, we have solutions from clinical practice management to Management Decision Support Systems (MDSS). Our design principles revolve around ease-of-use and we’ve often been termed as the ‘best kept secret’ in the health IT industry since we choose to style our approach and operations in a boutique nature. I believe this is our strength today.

Why did acuis decide to focus on the blood bank industry?

After looking at the hospitals and laboratory services in India, we felt that the blood bank industry was a niche that lacked a focussed effort. We decided to work with various leading lights in the blood bank industry and this has helped us evolve and became a thought leader in the blood bank software segment.

Can you tell us something about the achievements of acuis?

Instead of focussing on ‘computerisation of all processes’ as our objective, we decided to align with the customers’ objectives and in turn computerise their processes. This slight tweak in our approach has helped us achieve increased adherence in our journey of digitisation together. This has also helped us understand that every customer has a different pain point that needs to be addressed. It has also made us realise that though the processes in general are similar in function, workflows differ radically based on usage patterns and workload.

To be more specific, one of our clients, AIIMS (All India Institute of Medical Sciences) wanted us to identify all blood donors using biometric identification (fingerprint capture) since they had to deal with professional donors who often donate blood before they are next eligible. Many trust-based blood banks who are licensed to conduct blood camps or blood drives have a different approach.

They want that the concept of loyalty be

built not just with the blood donors but also with organisers of camps. Since these organisers are often corporates, they want interactive features like email notifications and web-based logins etc.

We have been working with the Rotary Blood Bank in New Delhi in helping them streamline their workflows for camp management and we have helped design loyalty management tools to manage data of the camp organizers as well. In the Pushpanjali Crosslay Hospital, we have integrated our blood bank software, acuVena, with a third party HIS. We can integrate our blood bank software with other HIS products both by connecting to common web services or by exchanging standard messages like HL7. When we talk about big enterprise customers like the Max Healthcare group, we have managed to connect the blood banks in the various locations in the country over a single instance of the web application.

There is a fundamental difference in the approach of how traditional enterprise solutions and cloud based services are

lood b r u te o ther HIS a r g o te n in re with necting a c We ftwa by con s o s e k ban cts both servic rd a u eb prod mon w g stand in om to c exchang L7 H y or b ges like sa mes marketed. Enter-

How is acuis different from other health IT companies?

While we bring forth years of domain expertise within our teams of consultants and technologists, we are well aware that our knowledge in these domains is finite and our customers know more than us in their respective domains.

Every suggestion or modification from their side is always viewed as a learning opportunity that helps us evolve at every step. Not only do we adopt these changes, we share them across our product builds updated within our customer-base which often triggers the next level of thought process from another customer and we believe this is a perpetual learning engine that we are proud to be a part of.

Tell us about your marketing strategy?

We wish to position ourselves as a leading provider of cloud based solutions for the Indian healthcare industry.

prise solutions are ‘sold’ while cloud services are ‘bought’ by simple sign-up processes. This summarises the shift in the consumerization of our industry as the cloud becomes a more visible enabler. There will be three clear deliverables that a customer will want to choose how much he or she wants. These are: application rent, application support (remote) and on-site training and support services. Traditional methods of bundling all of the above in a pre-paid model will slowly fade away with time.

How is acuis looking at the year ahead?

We will be soon announcing a few key partnerships later this year. Though most HIS systems have focused on administrative processes, most members of the senior management take their decisions based on what their managers advise them or via excel sheets. We believe this is a great opportunity to introduce a new concept that we like to call MDSS that will be like the administrative equivalent to Clinical Decision Support System (CDSS). Mobile app development is also on our product horizon later this year.

The year ahead will herald an increased adoption of the cloud within our customers. The real question is: How many of us as service providers are ready for this paradigm shift? june / 2012 www.ehealthonline.org

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special feature

“We need to Educate

People about

HIS” T

he advncements in HIS can yet not be termed as stisfactory. Most of the implementations of HIS are still about billing, inventory, diagnostic reporting etc. The number of hospitals using systems like BI (Business Intelligence), EMR (Electronic Medical Record), CDSS (Computerised Decision Support System) or mobility are still very less. Today technology or techno-financial feasibility is no more an issue but hospitals need to look beyond vanilla solutions and demand more. It is happening in metros and at corporate hospitals, but the real advancement will be seen only when mid size hospitals in tier II/III cities decide to move up the ladder.

Hospital is a place where we find huge support for introduction and adoption of new technology. Every good doctor or hospital is willing to spend premium on new equipment or technology if they see their patient benefiting from it. HealthcareIT needs should be judged by its value and not by its cost. I think the change in mindset of top management towards health IT is the biggest challenge.

The improvements in front office, inventory management, bill processing etc are visible at many hospitals. So efficiency has improved but for outcome (clinical) to improve EMR needs to be implemented. Today we have cost effective solutions for bed side comput-

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Rakesh Kumar Singh, Director (Healthcare-IT), Aarogya Infotech & Management Systems Pvt Ltd believes that a good HIS implementation creates a big impact, irrespective of hospital or HIS provider ing which was a major factor preventing EMR adoption. Remote access, mobility, real time information sharing, all these are available and affordable. Hospital management and particularly doctors will show more faith in clinical usage of healthcare-IT. Cooperation of nursing staff will be a major contributor in ensuring success of outcomes through HIS. The first challenge comes from the way healthcare provider industry works in India. There is no nationwide body, which guides or set rules for hospitals. There are no universal standards.

There is no universal nomenclature to be used for services or disease. ICD-10 is there but it is optional. So for every implementation we spend lot of time and resources creating schedule of charges, inventory master list etc. Nowadays several discussions are taking place on inter-op (sharing of data between two different HIS).

The next challenge is the approach of hospital management towards HIS. The challenge is that it is still being looked as a computerisation issue. He believes,

HIS is not about technology alone. It affects the complete work culture of the hospital. It affects the interaction between different departments. It changes the job profile and non-clinical staff’s outlook towards work. Hospitals must take a holistic view in planning for HIS. Modular approach helps only during implementation.

The real value of HIS can never be realised if it is implemented partially.

We need to educate people about its importance. HIS can continue to innovate and contribute towards improvement in patient care. These need not be big, revolutionary changes. There are plenty of good ideas floating around which can be implemented easily with the help of HIS. Patients who are cured and discharged from the hospital tend to skip their follow up visit if they feel fine. The HIS solution by us started sending an automated but personalised SMS two days prior to stipulated visit date. This was very successful and certainly helped in several cases. So HIS will continue to contribute towards better patient care, all it needs is some ingenuity and efforts from HIS solutions providers.

case Study

“HealthFore’s Suite of Solutions @ Aditya Birla Memorial Hospital”

Aditya Birla Memorial Hospital (ABMH) is a 500-bed, multi-specialty medical center located at Pimpri-Chinchwad, Maharashtra. Today, the hospital has completely streamlined its IT services, giving it a competitive edge over other hospitals

A

BMH is equipped with the latest technology infrastructure and has some of the world’s best doctors, making it a benchmark hospital in healthcare standards.

The healthcare center is known to provide high-quality, cost-effective medical services with state-of-the-art resources and infrastructure. Due to its size and complexity of business, ABMH wanted an IT solution modeled on ERP concept to efficiently handle the hospital operations. The apparent increase in demand for healthcare services today, necessitated the integration of such solutions into the business management of ABMH hospital. In the year 2005, the hospital management floated a tender for IT services and solution providers to which

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five major industry players participated.

After a detailed and stringent analysis of the participant’s Request for Proposals (RFPs), HealthFore’ HIS and PACS were short-listed among the other HIS vendors, including Siemens, Wipro etc.

Amongst the many differentiators, robustness and stability of HealthFore’ HIS & PACS products scored over its peers.

Business Challenges A majority of these officials did not have prior healthcare experience. This was one of the biggest challenges that HealthFore had to contend with. Commissioning of the hospital was also delayed due to an extension in the hospital planning, design and construction phase.

Many processes and policies had to be

articulated and put in place to enable a smooth transitioning of the hospital operations from a manual form to an electronic form. The hospital premises being huge, transfer of information from one processing unit to another and the chances of information being tampered or missed, posed as a critical issue in a healthcare setup like this. Towards this, the hospital decided to completely digitise and automate all departments in the facility. With its vision to be a world-class Medicity and a completely paper-less, film-less organisation, the interfacing of IT solutions with the hospitals latest equipment also posed as a huge challenge.

Due to its world-class infrastructure, competitive pricing and brand, the hospital received a very good response

case Study

from the community. To address this increasing demand and deliver efficient, effective medical care, the hospital has employed 1200 people to cater to an outpatient load of 200 on an average, and 65 percent occupancy for its Inpatient services, apart from external and healthcare package patients.

“After an exhaustive review, we realized that HealthFore was one of the more competent companies to offer an exhaustive range of solutions that can integrate and automate workflow across various points

(HIS) for managing the automation needs of every segment of the healthcare environment. To achieve complete automation, Magnum is tightly integrated with HealthFore’ other Healthcare products like Medical Imaging – Picture Archival and Communication System (PACS), Patient Relationship Management, Knowledge Management and Business Intelligence applications.

HealthFore has adopted, proven and tested project management programs to streamline both, internal and external fac-

of medical care whilst fulfilling the specific needs of individual departments, whether that be at the patient’s bedside, or in the emergency department or in the revenue department. The staff and physicians that were privy to the selection procedure chose HealthFore’s Magnum suite of solutions based on the quality of the products, the expertise of its people and the ability to support the product suite over a long term. Over the years we have also adopted HealthFore’s financial management systems to increase operational efficiencies as well as upgraded HealthFore’s older version of medical imaging solutions that eliminated film costs while improving turnaround time and diagnostic quality. Our strong relationship with HealthFore gives us confidence that we can meet industry challenges and provide the best care possible to our patients” mentions Ashwin Kothari, Director and Trustee, ABMH.

tors affecting the project, its timelines and implementation. HealthFore solutions’ HIS and web based PACS and Telemedicine systems helped ABMH cross boundaries to reach the community and vice a versa.

Magnum facilitates the consistency of information and shares required information with outside consultants, satellite clinics and patients. PACS enables radiologists to view the scanned images of patient and report from outside the ABMH network.

Robustness and flexibility has made the system self-reliant and more efficient in performing tasks and allotting more time with the patient for addressing their issues. CPOE makes billing real-time, eliminating the waiting time for patients.

Discharge process, which is always a challenge to any multi-specialty hospital, requires tight coordination amongst clinical, administrative, support and billing teams for accurate, timely and efficient discharge of a patient. Insurance module enables one-time definition of the schemes and automatically calculates breakups in the bill, reducing human intervention and chances of wrong billing.

Solution HealthFore’ Magnum is a comprehensive Healthcare Information System

Success Today, the hospital is completely streamlined with IT services, giving it a competitive edge over other hospitals. It is now, the most preferred hospital by the masses, as per one of the daily newspapers survey in the city. The patients / customers are delighted with prompt, accurate, satisfying response and output given by the hospital. It is one of the largest automated hospitals in the country with IT usage in almost all departments of the facility.

It has drastically brought down the patient waiting time for consultation, increased transparency in terms of empowering patients by providing interactive systems, achieved a below national average time of discharge process and kept a check on mortality with frequent quality reports generated through the IT solution.

“Magnum has been adopted broadly across most of the departments within ABMH. Magnum has been running successfully for the last four years and with Magnum at the core of our systems, our doctors are able to spend more time rendering quality care and ensuring that the most appropriate decisions about the patients care have been made. This has resulted in outstanding patient satisfaction” says Rekha Dubey, Sr GM – Operations, ABMH. The hospital’s satellite clinic was started with only three specialties and has now spread across 11 specialties to address the increasing demands of customers in the city and the customer groups who avail only preventive treatment. Thus, Magnum has broken barriers and maintains the uniformity in data.

Process automation using HealthFore’s Magnum HIS was one of the key factors for ABMH to achieve the standardization of its processes which helped ABMH in winning the Indian Merchant’s Chamber’s (IMC) Ramkrishna Bajaj National Quality Awards (RBNQA) which was instituted in 1996 to give special recognition to excellence in organisations.

RBNQA has chosen ABMH for its Performance Excellence award in Healthcare segment for the year 2011.

HealthFore assisted ABMH comply with industry best practices which effectively helped them plug uncoordinated and non-accountable process leaks. june / 2012 www.ehealthonline.org

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special feature feature-HIS

“HIS is a Good Managerial Tool” Sanjay Jain, Managing Director, Akhil Systems, says, “Health information, which is currently being stored in our hospitals, should be used for creating better awareness about health related issues in the country”

A

ccording to a new report from Springboard Research, healthcare IT spending in India is expected to grow from USD 274.2 million in 2009 to USD 609.5 in 2013. This represents a Compounded Annual Growth Rate (CAGR) of 22 percent from 20092013. Indian healthcare is experiencing a transformation, with the advent of newer, better IT systems and applications.

Adoption of IT has become one of the top priorities for Indian healthcare companies. But most big healthcare organisations allocate only two to three percent of their annual budget to IT expenditure. The cost of an HIS installation can vary from ` 1 lakh to ` 1 crore, or even more. There are several factors, such as size of the organisation, number of locations and users, and number of HIS modules implemented, on which the price of such solutions depends.

As new technologies keep entering the fray, it has now become possible for hospitals to pay a very affordable subscription fee per month or even on a per usage basis.

Now we are proceeding towards a system with isolated health networks which

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Expectations from the Government Currently Healthcare IT does not figure on central government’s strategic map for Indian healthcare. This needs to change. The industry’s expectations from the government include the following: .

• Formulation of data and system standards for a cohesive, nationally-led IT architecture that enables healthcare information to flow seamlessly • Provide essential infrastructure and security • Coordination of resources • Sensitising the health workforce • Funding or Tax rebates to enable adoption across all quarters are becoming silos of precious public health information. This information can easily be utilised for the benefit of the populace and healthy functioning of the healthcare system. The state should act

as binding factor in the current fragmented situation by coming up with some market friendly guidelines and regulations.

The last decade has witnessed a tremendous increase in adoption of newer technologies by the healthcare sector in various countries, including India. In countries like USA, where IT adoption in healthcare accounted for only 12 percent by 2009, there has now been an exponential increase. This adoption rate of healthcare IT in USA is expected to reach up to 95 percent by 2015.

Hospital Management Information System (HMIS) help in improving healthcare delivery by providing medical personnel with better data access, faster data retrieval, higher quality data and more versatility in data display. There is improvement from the point of view of efficiency and also from the cost angle. The cost gets reduced, as there is avoidance of duplications, delays, missing records and confusions.

The bottom line is that the HMIS can be a good managerial tool to provide total, costeffective access to complete and more accurate patient care data for improved performance and enhanced functions.

special feature

“Future of HIS is

Patient-centric Systems” Muralidhar Koduri, Vice President of Napier Global Development Centre, talks about the layered architecture of hospital information system, which leads to efficiency while ensuring adherence to all the healthcare standards

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he Hospital Information System (HIS) is one such comprehensive, integrated information system designed to manage the administrative, financial and clinical aspects of a hospital. Its implementation in hospitals has led to improvements in efficiency, It has also led to reduction in the hospital’s operating costs. This clearly makes it one of the best tools to be implemented in the hospitals.

Much of the human efforts have been reduced which also saves money for the hospitals. This scenario brought ease to the task of integrating and seamlessly managing patient’s record across hospitals, clinics and between states or countries.

In addition to providing access to the office staff and the physician, HIS also offers

controlled access to patients, pharmacists, and other users, who can use the platform for various tasks that would otherwise have to be performed at a physician’s office.

Napier HIS is a workflow driven holistic solution to cover the end-to-end processes of a hospital and it can be deployed in hospitals having beds ranging from 50 to 1500. Napier HIS enables the administrators/stakeholders/ management in enhancing the efficiency of operations through optimised workflows and accurate/real-time information. The service-oriented architecture with built-in business rules engine, workflow engine and business intelligence enable service provider to adapt to changing dynamics of the business.

According to this source there are a total of 17,87,800

beds in India in 2005. The healthcare industry is growing at 14 percent per year and has doubled to reach approximately 357.56 beds per lakh population. Assuming an average cost of installation per bed for HIS is at `1000, the total HIS industry could be worth around USD 70 million.

There are various challenges in the adoption of new technologies in hospitals such as healthcare infrastructure, low spending on healthcare, lack of proper vendor support, high cost of implementing and managing multiple diverse infrastructural components.

HIS and HMIS has increased efficiency and output in the hospitals as it integrates all the functions including clinical, administrative, financial, inventory, resources and services within the healthcare organisation

to bring a host of benefits.

There is scope for faster decisions with critical information at your fingertips. There is acceleration in patient care with reliable information at point of care. There is elimination of revenue leakage by streamlining of processes.

The adoption of HIS/HMIS is a big challenge in Indian hospitals primarily due to lack of standards, lack of in-house IT domain knowledge, reluctance of medical, nursing and other staff to adjust to change, apprehensions around technology failures (paper systems appear more reliable), lack of standardisation and confidentiality concerns.

The future of HIS is patient-centric systems, which are now evolving to next levels of perfection and are more patient-centric. Patientcentric does not imply a fixed set of guidelines; rather it is a fluid and still-evolving definition characterised by practices that benefit patients.

The system ensures that the patients receive the best treatment, at a reasonable cost, while putting into place strategies that will help individuals avoid becoming sick in the first place. Three key patient centric management systems, which will be the future of HIS/HMIS are EMR, CPOE, and CDSS. june / 2012 www.ehealthonline.org

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In Conversation expert corner

“HIS Can Resolve the Myriad Trouble Spots in

Healthcare Facilities” How do you see the advancement in the field of Hospital Management Information Systems in the recent years?

IT usage by hospitals has rapidly matured over the recent years, Hospital Information Systems (HIS) is being used in far deeper ways and we seem to have moved on from the ‘uni-faceted - billing is key’ approach. With this upgradation of user requirements, we see an increase in demand for systems that help improve ‘effectiveness of operations.’

Surprisingly NABH has helped hospitals focus on effective management – addressing all key aspects of running a hospital, and this is motivating healthcare providers into seeking holistic solutions.

Please provide us with a brief about your products.

Over the last 12 years, our product has evolved into a complete suite, which automates almost every department in the hospital. Starting from ‘Q...less Money,’ which enables remote registration using mobile phones to ‘No Entry Store,’ a completely automated store and pharmacy department, where almost no data entry is required. From using ‘eBook EMR’ to practically eliminating training for doctors and nurses, to providing a ‘Fully Loaded’ HIS that comes with all possible clinical templates, lab tests, medicines, charge heads and packages. The Hospaa3 suite of healthcare solutions automates all the departments of large to medium healthcare organisations. Our multi-tenanted cloud based offering is a robust Java based product that has been refined over the years and can get a hospital automated in less than 30 days.

“A good HIS can positively impact almost every trouble spot in the healthcare facility – from medication errors, to wait time management, M Vennimalai

CEO, Aavanor Systems

inaccurate billing and waste reduction,” says M Vennimalai in an

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interaction with eHealth june / 2012 www.ehealthonline.org

Inexpert Conversation corner

The biggest challenges for hospitals is to come up with a clear long term roadmap in terms of technology and scope of IT usage, without falling into the temptation of doing something in this ‘budget year’ What is the market size of the HIS industry in India? Can you tell us the cost of installation?

The market is highly stratified. We see it being split into very large governmental market where multiple hospitals are networked and projects are in the range of a few hundred crore of rupees each.

Chain hospitals with each facility having 100 plus beds are being automated through use of multi-tenanted web applications or cloud applications, at the cost of around ` 50,00,000 to ` 1 crore.

Smaller hospitals with less than 100 beds are being automated at around ` 25 lakh.

The cost is entirely dependent on the scope of automation. Many small organisations are investing heavily in IT systems as they see them as being a vital tool for achieving success in the high growth market.

How can IT create its space in hospitals? What are the challenges faced by the solution providers?

There are still a number of offerings which push outdated concepts and technologies without a clear roadmap for future upgradation. The number of client server offerings and independent department solutions that are still being adopted is alarming.

I think the biggest challenge for hospitals is to come up with a clear long term roadmap in terms of technology

and scope of IT usage, without falling into the temptation of doing something in this ‘budget year’. The challenge for solution providers is the same, we need to engage healthcare providers and establish a clear vision for IT deployment. The obsession about ‘closing the deal’ must end.

I must also state that hospitals must look beyond their preference for ‘established’ technologies and providers, and seriously evaluate the possibilities of new offerings. We are in the stage where a simple but critical advancement in the IT offering can bring RoI to the entire project within a 2 year span.

How far do you think HIS and HMIS has increased efficiency and output in the hospitals?

Sometimes an external push is required to get us out of our comfort zones. This is the role of HIS and HMIS. It provides the impetus to bring further advancements in the healthcare sector. It must be said that we owe a great deal to the Obama government in the US, which bit the bullet and firmly moved healthcare into the digital age. This decision was made with the objective of providing patients with better care, which surprisingly enough was long overlooked as a key concern. There has not been a single physician who would go back to paper after using an effective EMR nor a hospital that would go back to paper after using an integrated IT system. This is because the benefits are clear and visible at every layer.

What are the key challenges in the adoption of HIS/HMIS? The biggest challenge is to envision the ranges of services that a good HIS can provide. There are many instances of industry dismissing the latest developments as ‘fads’. This leads to loss of time and we are left playing ‘catch up’. A good HIS can positively impact almost every trouble spot in the healthcare facility – from medication errors, to wait time

management, to inaccurate billing and to waste reduction. I remember meeting a paper industry professional who was in shock after a visit to a paper manufacturing facility in Finland that employed four engineers to run a plant of the same size that his organisation used to run with a staff of 377 staff. Proper and effective automation had achieved such high level of efficiency that only four people could do the job of 377.

IT can definitely make huge contributions in addressing uncharted territory such as traffic congestion. By connecting doctors and patients to the facility in a remote yet satisfactory manner, we can bring resolution to many health realated issues. Anyone who has purchased HD TV recently will be amazed by the fantastic quality of beamed digital images and this will soon become a part of everyday commerce and indeed healthcare.

So in my view the biggest challenge facing the adoption of HIS in India today is our penchant to ‘Think Small’ rather than ‘Think Big’. But this is rapidly changing and just last week I was visiting Sanjiban, a facility in a rather remote village in West Bengal, which has the most amazing plans to setup a modern, scientific and comprehensive healthcare delivery system. Their growth has been explosive and they plan to fully utilise IT to serve their patients- be it communicating directly and extensively with the patient’s mobile phone or providing a paperless setup in the hospital that can be accessed from anywhere in India.

What kind of HIS/HMIS solutions can be expect in future?

Lot of innovations are expected. Many companies and healthcare entities are working to make all kinds of advancements possible in the HIS/HMIS space.

We believe that successful HIS offerings in the future will bring about an ‘Apple’ type of revolution. There can be disruption of the existing setup as new kind of products come into being. All the key stakeholders in the medical space including doctors, nurses, allied services staff, administrators and also the patients - are going to benefit from the revolution. june / 2012 www.ehealthonline.org

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Case Study

The Inside Story

Getting Managed NextGen e-Solutions was founded in 2005 with a view of tapping the nascent healthcare IT market. With a committed team of software developers, and two years of dedicated product development, NGES went to market in India with a user-friendly HIS

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ew realities are placing pressures on the healthcare industry, and how patient care is delivered. Legacy systems, lengthy administration processes, rising hospital management costs, and inconsistent quality, are coupled with an influx of international patients, the rise of health insurance, the corporatisation of hospitals, and the emergence of the informed, middle-class patient. The industry has reached a point, where hospitals need to decide how services can be delivered more effectively to reduce costs, improve quality, and extend reach.

Healthcare Information Technology, which enables immediate, informationrich communications and provides easy-to-use collaborative tools, is increasingly becoming a vital part of today’s healthcare.

NGES (previously known as NextGen), a Healthcare IT Solution Provider, is committed to preparing hospitals to meet future challenges - and to secure their attractiveness to patients, referral sources, and staff by means of longterm concepts. Leveraging a dedicated healthcare practice group, NGES has developed a next-generation HMIS that is powerful, flexible and easy-to-use and has been designed to deliver real benefits to hospitals.

Primus Super Specialty Hospital is a state of the art multi specialty hospital, with a capacity of 150 beds, prominent surgeons from across the globe, excellent infrastructure and state-of-art advanced technology. The hospital has set new benchmarks in Medical care.

The hospital complies with international

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Technology PHP 4x, My-SQL 5.0 Apache Server 2.0, Java Script Architecture LAMP, Client Server

Solution Components

Major Modules Implemented • Front Desk, Billing & Cashier • Clinical, Investigation • OT, MIS Report, Pharmacy & MM • Scheduler & Roaster

Services Post Implementation Support - onsite, email, telephone Upgradation

Feature Highlights • Role wise Permission • Registration • Admission • Billing & Refunds • Patient Information • Ward Assignment • MIS Report • PO & Indent • Scheduler

Solution Components of HIS module

guidelines and strives to bring worldwide best practices to India.

NGES proposed a complete solution to meet their requirements and expectations by providing the HospiLogix TM, which was cost-effective and easily configurable to their day-to-day workflows in the hospital.

NGES’s solution is particularly known for reducing waiting times and generating error free reports – a critical feature for Primus Hospital, with their ever-increasing numbers of international and embassy patients.

The Challenge The hospital wanted to manage scientific information as well as the treatment modalities offered by their departments. The need was to create an aesthetically pleasing yet practical system. In spite of the large volume of information, the structure and navigation needed to be simple and targeted to the audience perspective.

With multiple departments having multiple functionalities and information running into hundreds of pages, the

hospital felt it was critical for the information to be organised systematically in an uncomplicated way.

The system needed to support audio as well as video files and integrate the Picture Archiving System seamlessly.

The system also needed to support their pharmacy and material management system, which was running into losses because of pilferage. Since, the hospital was a very busy one, especially the OPD, they needed a system, which could handle a very heavy workload of the patients during the morning hours.

The hospital mentions, “Being seven years in the field of Information Technology, several talented professionals and companies have been providing solution, with NextGen being one of them.

But what sets NextGen and its people apart is a highly focused and efficient methodology that never fails to deliver, in-time and within-budget.”

The breakthrough came in the form of an innovative project proposal that created a consolidated solution for the hospital’s requirements and expectations.

(As contributed by NextGen e- Solutions)

June / 2012 www.ehealthonline.org

Special tech trends feature-his

Predicting future developments in any major technology is always a challenge, and the field of MRI is no exception

MRI

Envisioning

Hidden Ailments

By Shally Makin, Elets News Network (ENN)

Magnetic Resonance Imaging (MRI) is the most flexible diagnostic imaging modality; it allows us to characterise many aspects of the living patient from metabolism and physiology to tissue microstructure. MRI has continued to rapidly develop since its introduction as a clinical tool in the early 1980s. Widespread use of 3T scanners is already becoming a reality and future developments in coil technology and new image contrasts will continue to provide new tools for clinical diagnosis. MRI could become the most widely used medical imaging modality if several market variables, such as reducing the actual cost of an exam and designing smaller MRI systems, come to fruition. With its unique ability to image both anatomically and functionally, MRI has found its way into surgical planning and navigation as well as diffusion and perfusion imaging. It is being combined with other modalities to achieve image clarity not previously attainable. The researchers believe that such “smart tag” technology could one day improve diagnostic sensitivity and specificity of magnetic resonance imaging. Combined modalities and targeted contrast media are also on the clinical horizon, and it will take a few years for this to become a reality for specialist referral centres.

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Tech trends

MRI Customers

Expect Quality C

urrently, the Indian MRI market is growing at the rate of 22-24 percent and this is an interesting development. In 2011 alone, more than 230 MRI systems were sold in India. Out of this, more than 75 percent are superconducting, mainly 1.5T and 3T. In 2011 there was a steep increase in the sale of 3T MRI making at least 25 percent of the total sale.

On the other hand, permanent magnet sales have declined considerably. This makes for less than six percent of the total sales.

A fast emerging application of MRI is its therapy use like HIFU (High Intensity Focused Ultrasound) presently used for treatment of Fibroids and prostate cancer. This will open up therapy and interventional MRI applications.

The key factors for driving this growth are the rising focus on healthcare and increased demand from rural India. The awareness on MRI is increasing and there is a greater demand for 3T MRI in metros and 1.5T MRI in small cities and this will further increase the number of MRI units in 2012-2013.

There has been a reduction in average selling price (ASP) for the 1.5T MRI as well as 3T MRI in recent times making the units more affordable. Introduction of helium less technology by some MRI equipment vendors makes the cost

difference between a superconducting and a permanent MRI much lower compared to previous years.

Indian MRI market is dominated by MNCs like GE, Philips and Siemens. The market share is divided equally among them and Sanrad is poised to become the fourth player in this space dealing in both 1.5T as well as permanent MRI models.

Few other players like Blue Star, Trivitron and maesters are also in the league.

Sanrad has an ambitious plan to assemble the 1.5T MRI units in India in next few years with a technical collaboration with ISOL corporation, South Korea. Sanrad recently introduced their helium less 1.5T MRI with Helium life of 10 years making it the longest helium refill frequency.

Today almost every customer is looking for multi channel MRI system and many of the present MR systems are equipped with 16 Channel as standard.

Most of the MR systems are offering important specification high gradient strength and fast slew rate to handle high end applications like whole body diffusion.

Many MRI systems are now equipped with multiple voxel spectroscopy compared with the earlier single voxel spectroscopy and also some new scan techniques like DTS and SWI .

Innovative technology started from noiseless gradient switching, whole

Som Panicker Vice President , Sanrad Medical Systems body imaging, MRI integrated with PET, HIFU, embedded body coil in the patient table, pre amp and other signal processing in the table, ambience, noise reduction techniques, MR Elastography etc.

Apart from this MRI is used for various interventional techniques like RF ablation, HIFU and even integrated MR surgical theatres are being planned in the country today.

Sanrad was the first company to introduce a high definition OPEN MRI system with world’s highest 0.45T few years

“

The awareness on MRI is increasing and there is a greater demand for 3T MRI in metros and 1.5T MRI in small cities and this will further increase the number of MRI units in 2012-2013

“

Som Panicker, Vice President, Sanrad Medical Systems, believes that the Indian healthcare sector is poised for a massive investment from local investors as well as MNCs and this opens great opportunity for introducing new innovations in MR product range

june / 2012 www.ehealthonline.org

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Tech trends

back and till date no other system surpassing this field strength is available in India. After a successful track record with permanent MRI in India, we have recently launched our 1.5T MRI, CHORUS EX in technical collaboration with ISOL Corporation, South Korea. This unit is based on Mitsubishi Magnet with helium less technology making the original Helium last for 10 years.

This MRI is a 16 channel system with high power gradient and slew rate at the same time making a power consumption just 80 KVA.

One of the big challenges is to keep the prices lower while providing quality service. However, the regulations and tax structure are creating a conducive climate for vendors to start manufacturing these high value equipments in India.

In rural side, a reliable power is still a major issue. It makes the projects expensive to run and many customers want vendors to offer CMC with Helium included. But with unstable power the helium consumption can become very high and this entails frequent filling by the supplier.

Insurance Coverage for Imaging will Drive this Industry KN Umesh Kumar, Business Head, MR Division, Siemens Heatlhcare, believes the future of MRI is bright with increasing new applications and zero radiation effects

T

he market size of MRI equipment in India is approx ` 7 Billion with 10 to 12 percent CAGR. All the latest MRI equipment will have one of the following key specifications Tim (Total Imaging Matrix), Trueform in 3T, 45 mT with SR of 200 gradient strength, 70 cm wide bore, Dot (Day Optimising Throughput) Engines. The latest innovations in MR are Tim CT Angiography and Tim CT Oncology (CT like table movement in MRI), Dot Engines, Tim 4G (4th generation coil technology), Direct RF (Digital RF technology). Siemens’ new MAGNETOM systems have one or

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more of the latest technologies and even the old systems can be upgraded with the latest technologies.

One of the major challenges faced today is USD appreciation followed by Helium cost increase along with increase in logistics costs. The advancements also bring an opportunity to increase clinical applications and awareness of MRI, affordability and commercial viability. The increase in regular health checkups and insurance coverage for imaging will drive this industry much ahead. Scanning result should logically end in curing, which can be achieved through minimally invasive procedures. So the imaging and minimally invasive procedures will be complimentary to each other.

Future of Imaging is in non-invasive Diagnosis Dr Rajeev Sikund, Director, Sikund Diagnostics says, “Diagnosis is quite affordable today as the resolution and quality of images has improved and cost to patient remains the same”

I

mprovement in technology should be aimed at bringing down the cost, making it more affordable. Future technology needs to combine the real time applicability and portability of ultrasound and the resolution of MRI. For choosing a MRI equipment we would opt for a 1.5 Tesla machine of a company who has an engineer based locally in the city as after sales service is most important. The equipment should be cost effective.

MRI has revolutionised the world of diagnostics by its excellent soft tissue resolution and also because of multi-planar image availability and no risk of radiation exposure.

Future developers should think of how to amalgate the real time applicability and portability of USG with high resolution of MRI. Future of imaging is in non-invasive diagnosis. It will bring functional and molecular imaging, as well as continued expansion of electronic imaging, computer applications, and interventional radiology.

tech trends

“Image Quality

Remains a Major Factor in

Equipment Selection” T

S Jaisankar, Service Manager CT/ MRI- Customer Support, Trivitron Healthcare, says, innovations in MRI technology have focused principally on improved image quality and enhanced speed

he MRI market, which is approximately worth ` 550 crore, is large, dynamic and is predicted to be on growth path over the coming years.

Growth in this highly sophisticated industry is driven by innovation, with emphasis on improved image quality and reduced acquisition ttimes. In a trend that is predicted to continue into the future, growth has also been supported by the increasing range of potential applications for this technology.

With its ability to image both anatomically and functionally, MRI is now used in surgical planning and navigation as well as in diffusion and perfusion imaging.

Significantly, MRI is also now routinely combined with other technologies to further improve image quality. With recent advances in the scope of MRI, the technology can now be used for imaging cartilages as an alternative to arthroscopy, and is able to measure myocardial contractility and cardiac volumes with impressive accuracy. As the technology improves, the potential for MRI to investigate new tissue types with greater accuracy will continue to get better.

Hitachi’s Echelon 1.5T provides outstanding imaging performance and is the basis for high performance far into the future. A wide range of multi-channel receiver coils provide unmatched value as a data acquisition platform. Hitachi Medical Systems has its eye on patient comfort, with two developments that take into consideration space, orientation, and image clarity.

Trivitron’s Hitachi’s Echelon XL clinical and vascular imaging suites provide sequences, tools and features such as RADAR radial acquisition and Fluoro triggered bolus MRA. Tools include MIP,

MPR, vascular volume rendering, dynamic analysis and ADC, and isotropic DWI analysis. ORIGIN MR operating software incorporates a graphical user interface, and the layout intuitively guides the operator from patient registration through image archiving. An integrated image quality calculator informs the technologist of impact that the parameter changes will have upon the image. Intelligent parameter guidance displays options to begin scanning. Echelon’s magnet delivers high homogeneity, and the standard per patient higher order active shim enables optimised general image quality and uniform RF fat saturation.

Image quality remains the major factor in equipment selection. Indeed, increase in MRI sales has been propelled by the improved image quality made possible by higher field strength magnets. Increased field strength also extends the application range, improves signal- to-noise ratio, and reduces examination times. The search for faster examination times has also been the impetus for the development of new sequences, improved coil design and significant hardware advances.

Despite the considerable successes achieved to date and the potential for future growth, a principal barrier in the adoption of MRI technology remains: concerns over capital costs and limited working life. However, installation of the MRI imaging systems in health care facilities has been shown to deliver increased return on investment for health care providers. The rapid patient turnaround offered by modern MRI scanners, and the accuracy of medical diagnosis now possible, has been shown to deliver high cost effectiveness in the long run. june / 2012 www.ehealthonline.org

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expert speak

“Hybrid Imaging Systems will be the Future�

How do you perceive the growh of MRI equipment market in India?

Primary and integral component of most health care needs today is radiological diagnosis. With increasing healthcare burden, the market for MRI in India is huge and bound to grow as MRI scanner is quintessential in any diagnostic setup.

The demand for high field MRI systems has gone up considerably as 3 Tesla systems have become the norm in most tertiary centres.

Do you think the technology still needs to be improved? If yes, what is the scope of improvement?

There has been considerable improvement in MR technology in the domain of imaging. However, now with the advent of MRgFUS and MR guided laser surgery, there is definitely scope for improvement of MR technology in the direction of early MR guided treatment for various pathologies.

With the advent of various models in MRI equipment, how do you plan to choose the best out of the pool?

There is a wide variety of MRI scanners available today from a number of leading healthcare imaging companies. An ideal choice would be a high field scanner with a short bore, priced competitively and with reliable after sales service.

In a price sensitive market like India, is MRI diagnosis an affordable technology?

MRI has provided a never before perspective to accurate diagnosis but it

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Dr H Satishchandra, Medical Superintendent, Bowring & Lady

Curzon Hospital and Professor & Head, Department of Radiodiagnosis & Imaging,Bangalore Medical College & Research Institute, shares his views on the current market status in India and growth prospects comes at a price. Affordability is still an issue for the majority seeking healthcare in government run units but cost shouldn’t deprive any individual from getting the best possible treatment. An effective public -private partnership will be able to provide the latest in MR technology to the common man.

To what extent, MRI has revolutionised radiodiagnosis?

What more do you expect from the developers?

There is no doubt that MRI has revolutionised diagnosis to a great extent and has made inroads in treating various pathologies with its guidance. Early diagnosis is the key to effective treatment and with minimal risk and diagnosis, MRI has become indispensable in the management of a good number of pathologies. PET-MRI with unmatched anatomical details of MRI combined with functional imaging of PET can provide exciting new applications, which can truly revolutionise the world of diagnosis.

What is the future of imaging? Do you think interventional radiology can rule the treatment procedures?

Imaging at the functional and molecular level with the use of hybrid imaging systems will be the future. As radiology is an ever growing and complex medical speciality, it is practically impossible for a radiologist to maintain adequate expertise in the entire field. This warrants the need for subspecialties to be developed in radiology paralleling the clinical counterparts. Interventional radiology is one such subspecialty which has taken radiology into the forefront of therapeutics with minimal risk. Although IR procedures are expensive with short hospital stay and less complications, the cost benefit analysis is in favour of IR procedures. There are and will be turf issues with IR procedures and if the radiologists are given sufficient clinical training, then IR can eventually rule the treatment procedures as rapid advances are being made in neuro intervention and interventional oncology.

featured product

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More services and faster delivery are the name of the game.

Powered by the breakthrough dStream architecture, the Ingenia is the first MR system that brings MR signal digitisation where it has never been before – in the RF coil, as close to the patient as possible. dStream unleashes the power of digitisation by delivering a high purity MR signal for increased SNR, combined with largest FOV, enhanced workflow and ease of use for greater efficiency in a radiologist’s daily operations.

The demand for MRI services continues to grow worldwide, mainly as a result of an increasing need for neurological studies and the early detection and treatment of malignant tumors, as well as the continued need to perform orthopedic examinations. In addition, there is an emerging requirement for MRI equipment to have a larger bore, due to increasing rates of obesity throughout the world, while maintaining homogeneity.

Philips Ingenia MR is the first available digital broadband MR system. It provides high-quality MR images, enhancing the physician’s ability to arrive at a rapid and accurate diagnosis, and it improves the overall patient experience, using shorter scan/setup times and a comfortable environment, consisting of a wider bore and lighter coils. set up time, bringing about a throughput increase as much as 30 percent.

Contrast uniformity, speed and consistency The revolutionary Patient adaptive MultiTransmit system from Philips has reached new levels of to benefit cardiac MRI@3.0T in a big way by in its 4D MultiTransmit avatar. It adapts RF signals to each patient, addressing dielectric shading to provide superb image uniformity, contrast and consistency, as well as faster imaging.

Channel-free coil system Unlike conventional MRI systems, Ingenia is channel-independent, which gives excellent scalability: for example, simply by adding a multichannel receiver coil having more elements and capturing high-quality images. This plug-and-play capability means it’s easy to keep up with advances in coil technology, without requiring major upgrades. Apart from convenience, it also directly translates into economical benefits for the users.

Maximizing Patient Comfort Increase SNR by up to 40 percent Philips-exclusive DirectDigital RF samples the MR signal directly in the coil on the patient, and sends it to the reconstructor via fiber-optic cable. The result is up to 40 percent higher SNR and a dynamic range that exceeds 185dB.

Largest homogeneous FOV for a 70cm bore Combining patient comfort with extended coverage and high image quality, Xtend provides the largest homogeneous field-ofview in a commercial 70cm wide bore system and an excellent combination of magnet homogeneity and gradient performance.

Thirty percent improvement in throughput Designed to streamline workflow and reduce exam time, FlexStream enables imaging with fewer coils and reduce patient

The benefit of Ingenia goes beyond technological advances.

Ingenia’s 70cm wide magnet bore with largest FOV and Patient Adaptive MultiTransmit creates the excellence in scanning patients of all sizes and shapes. Notably, despite the larger bore the homogeneity of the magnetic field is enhanced, considerably reducing the image distortion found with conventional scanners.

The patient also benefits from the speed at which the exams can be performed, and the system’s ability to scan more body parts. The high SNR, Digital Broadband technology, and largest homogeneous FOV can be leveraged to perform most of the time consuming examinations in less than 8 mins for routine imaging. Also, the Multi station screening for oncology with Ingenia is one of the hall mark of the power of imaging at 3.0T. June / 2012 www.ehealthonline.org

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tech trends

MRI

has a Great

Future

Various state governments are looking at outsourcing MRI services in their district hospitals to private players which is enabling high-quality low cost scanning for patients visiting government hospitals, without any investment whatsoever from the government

By Dr Harsh Mahajan, Director, Mahajan Imaging Centre

T

he growth of MRI as a diagnostic modality in India was limited initially by two factors. First, the inherent high cost of setting up a new system, ranging anywhere from ` 3-10 crores, which in turn ends up as higher cost for the patient. And secondly, there was tremendous lack of knowledge about the clinical applications of this new technology amongst doctors at large.

The staggering growth in this modality is evidence of the fact that both patient and clinician acceptance of this modality has increased many fold, to the extent that it is readily recognised that MRI actually improves clinical outcome for patients.

The percolation of the modality to tier two and three cities has also driven this growth and having to travel many miles for an MRI scan, for routine applications, has become a thing of the past.

There are three main equipment vendors as far as high-field superconducting MRI systems are concerned, General Electric (GE), Philips and Siemens, and all three have almost equal market share. There is always a debate about the significance of the “field-strength” of the magnet, there is almost no significant and clinically relevant difference

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between a 1.5 Tesla MRI scanner and a 3 Tesla MRI scanner except in limited areas of application. This debate is also being laid to rest by companies, such as Esaote from Italy, which are developing ‘dedicated’ MRI systems which, although having low field strength (0.25 and 0.3 Tesla), have image quality comparable to conventional 1.5 and 3 Tesla MRI systems. Their latest introduction in India, the O-Scan, a very small MRI system dedicated for scanning of the wrist, elbow, knee and ankle, makes it possible to have an MRI scan done while literally sipping a cup of coffee and reading the newspaper. In the high-field MRI segment, all three companies have recently In the year 1989 a panel of senior radiologists discussed the requirement of MRI in India. It was postulated that India requires only permanent magnet low field MRI systems, and that a total of 12 MRI scanners would be adequate for the entire country. Today, 23 years later, India has a total MRI installedbase of about 1200 scanners, out of which 600-700 are high-field super conducting MRI systems

come out with products that finally harness the capability of 3 Tesla magnets and provide significant advantages over the existing 1.5 and 3 Tesla scanners.

MRI guided therapy using focused ultrasound (HIFU) is another new introduction in India that enables clinicians to treat disease without any cutting, scarring, pain or hospitalisation for fibroids in women. There are also significant advancements in the fields of kinematic imaging, dynamic imaging, perfusion imaging and non-contrast angiography imaging by MRI. Weight bearing imaging using an MRI scanner that can scan the patient in the standing position is opening new dimensions in spinal disease imaging and treatment.

The future of MR Imaging lies in highfield MR systems but equally in low field systems which are patient friendly and targeted to specific body parts and diseases.

Public-Private-Partnership may also play a huge role in providing accessibility to patients residing in remote parts of the country. There is a constant increase in the number of hospitals, day centres and private clinics all over India and to cater to this growing need there will be immense demand for diagnostics in the country.

applications

Biograph mMR A milestone in diagnostic imaging - With Biograph mMR, Siemens turns the dream of molecular MR imaging into reality for the first time

S

ince the mid-80s, physicians and medical physicists have been dreaming of the tremendous possibilities offered simultaneously by magnetic resonance imaging (MRI) and positron emission tomography (PET) in an integrated whole-body system. This technological milestone was made possible through the vast experience of two Siemens business units - Magnetic Resonance and Molecular Imaging in close cooperation with its clinical partners for the pre-development and clinical application (University Hospital of Tuebingen, University Hospital “Klinikum rechts der Isar” of the Technical University of Munich, Massachusetts General Hospital in Boston, Section for MR Imaging (Prof. Dr. Harald H. Quick, PhD) at the “Institut für Medizinische Physik” (Institute of Medical Physics, IMP) of Friedrich-Alexander-University of Erlangen-Nuremberg).

“With simultaneous MR-PET hybrid imaging, we open the door to entirely new diagnostic and technical possibilities in medical imaging,” says Prof Dr Harald H Quick, Head of the Section for MR Imaging at the IMP Erlangen.

The Biograph mMR is a very sophisticated and elegant integration of the two imaging modalities (MR and PET). This realises for the first time the vision of simultaneous acquisition of MR and PET data across the whole body, leading to better diagnosis and management of the patient.

Clinical utility of hybrid systems is seen in the combination of functional information (e.g. PET) and anatomic structures (e.g. CT, MRI) into a single image. MRI provides superior soft-tissue contrast along with functional information as in MR spectroscopy, diffusion imaging, perfusion imaging, and functional MRI (fMRI). Further, no radiation exposure helps in preventing long term cell damage in young children and patients with repeat follow-ups.

Innovative Concept There were numerous physical and technical preconditions and challenges, which hampered the development of hybrid MR/ PET scanners for a long time. Siemens with its innovative concept of utilising new generation assembly consisting of APDs (Avalanche Photodiodes) over the conventional PMT (Photomultiplier Tube) could overcome the hurdle of a simultaneous MR/ PET. These are not only insensitive to magnetic field but also have a small footprint to

addition to its low space requirement, an integrated system also offers considerable advantages in clinical operation. Acquiring a single exam with an integrated system, controlled by one technologist via one control unit, dispenses with the necessity of coordinating two examination dates for two systems in different departments. This saves the hospital unnecessary work and leads to faster examination results for patients.

Simultaneous MR and PET imaging also

Specifications The PET unit of Biograph mMR has the largest axial PET field of view in the industry of 25.8 cm. This offers an advantage of fewer bed positions need to be acquired during whole-body examinations. Again with industry best crystal dimension of 4 mm x 4 mm x 20 mm [NEMA 2007] and sensitivity of 13.2 cps/kBqz it sets entirely new standards for PET imaging. In addition, the large solid angle covered allows for a very high volume sensitivity which translates directly into low-noise images. be cased within the MR gantry. Siemens MR systems with 70 cm bore are hence a pre-requisite for the above integration.

Biograph mMR also houses the stateof-the-art 3T MRI system with the same gradient specification as all other premium 3T MR scanners from Siemens (45 mT/m, 200 T/m/s). Together with the Biograph mMR specific coils (Siemens Tim (Total imaging matrix) coil technology) especially optimised for simultaneous MR and PET imaging, it is possible to perform not only the standard imaging sequences, but also all the advanced functional MR sequences that you want to combine with PET imaging, all this across the whole body and, thanks to Tim coil technology, without changing coils or repositioning the patient.

One advantage of an integrated system as compared to two separate systems is that it requires about 50 percent less space.

With a total of 33 m2, the footprint is similar to that of a conventional 3T MR scanner. In

opens up entirely new possibilities with regard to image quality and thus diagnosis is precise. Its uniqueness lies in precise spatial and temporal registration of anatomical, functional and metabolic image data, simultaneous acquisition of PET and MR data for attenuation correction, MR gating for motion correction in the PET data.

New Era Physicians expect to make inroads in several important areas using simultaneous PET/ MR. Overall, PET/MR may be the modality that ushers in a new era for personalised medicine. According to Bruce R. Rosen, MD, PhD, Massachusetts General Hospital, Boston, as individualised medicine is on rise the PET/MR is the first stepping stone towards a long term goal for better patient care. Thus, the dream of molecular MR imaging also becomes reality for those who are to profit from it - mostly patients.

(As contributed by Siemens Healthcare) june / 2012 www.ehealthonline.org

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spotlight

Modern ventilators allow exact adaptation of pressure and flow characteristics to suit any patient’s medical needs

A

Ventilators The Support System

By Dhirendra Pratap Singh, Elets News Network (ENN)

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ventilator is often used for short periods, like during a surgery when the patient is under general anaesthesia. A ventilator can help bring ease to the exercise of breathing. People who can’t breathe on their own also use ventilators. Respiratory failure is a failure to maintain adequate gas exchange and is characterised by abnormalities of arterial blood gas tensions.

In the mandatory controlled mechanical ventilation (CMV) mode, full ventilatory support is provided and no patient effort is required. Ventilation is becoming established as an important modality in the management of acute respiratory failure. The skills required are easily learnt and the equipment required is relatively inexpensive. If an acute ventilation service is not provided, the shortage of ICU beds means that some patients will die because facilities to ventilate them invasively are not available.

Even if they are incubated, some patients will die unnecessarily from complications such as pneumonia which they would not have developed if they had been ventilated non-invasively. These factors must be weighed against the potential disadvantages of an acute ventilation service, the most important of which is that severely ill patients might receive ventilation when intubation and invasive ventilation would be more appropriate.

spotlight

Positive-pressure ventilation The era of intensive care medicine began with positive-pressure ventilation. Positive pressure ventilation is one of the most effective methods of ventilation. Positivepressure ventilation means that airway pressure is applied at the patient’s airway through an endotracheal or tracheostomy tube. Noninvasive positive pressure ventilation (NPPV) refers to positive pressure ventilation delivered through a noninvasive interface (nasal mask, facemask, or nasal plugs), rather than an invasive interface (endotracheal tube, tracheostomy).

Its use has become more common as its benefits are increasingly recognised.

Need for Tracheostomy Prolonged intubation may injure airway and cause airway edema

Advantages • Issue of airway stability can be

• • • •

Intubation and extubation Continuous capnography from intubation to extubation offers several benefits, including confirming tracheal intubation, monitoring the integrity of the endotracheal tube (ETT) and ventilatory circuit, assisting with the titration of mechanical ventilatory support, assessing pulmonary capillary blood flow, and monitoring for extubation readiness. The technology required to perform capnography on expired gas is not new, although recent advances have greatly improved the reliability and clinical applicability. From the start it must be noted that capnography has been considered a basic standard of care in anesthetic monitoring by the American Society for Anesthesiologist.

Pressure Control Ventilation Ventilator determines inspiratory time – no patient participation

Parameters • Triggered by time • Limited by pressure • Affects inspiration only

Disadvantages • Requires frequent adjustments

to maintain adequate VE • Pt with noncompliant lungs

may require alterations in inspiratory times to achieve adequate TV

•

separated from issue of readiness for extubation May quicken decision to extubate Decreased work of breathing Avoid continued vocal cord injury Improved bronchopulmonary hygiene Improved pt communication

breathing is higher than through a normal airway (although this simulates laryngeal edema or airway narrowing). If tolerated, the chances of successful extubation are high. If not reattachment to a ventilator is simple. An alternative variant to this is the use of a CPAP circuit, which overcomes some of the work of breathing through the ett and prevents airway collapse.

Many physicians extubate the patient directly from PS and PEEP (the PS overcomes the tube resistance). The conventional wisdom is that 7cmH2O of pressure support is required to overcome the resistance through a size 7.5mm (internal diameter) endotracheal tube, and 3cmH2O through a tracheostomy. If a smaller tube is in place, pressure support of 10cmH2O is required.

Disadvantages

Need for tracheostomy

• Long term risk of tracheal steno-

The surgical procedure of inserting a tracheostomy tube into a patient’s windpipe is called a tracheotomy. A tracheostomy tube may be needed for ICU patients requiring long-term mechanical ventilation, patients unable to cough effectively to clear secretions, and patients with an obstructed or blocked airway. The decision to perform a tracheostomy on a particular patient depends upon the circumstances surrounding that patient and often follows use of breathing (endotracheal) tube. The tracheostomy can be performed in the operating room or at the patient’s bedside. Typically light anaesthesia is required during the tracheostomy procedure. The tracheostomy tube can be inserted either of two ways - the open technique or the percutaneous technique.

The open technique involves a small incision made in the lower part of the neck just above the windpipe (trachea). Subsequently, an incision is made in the windpipe (trachea) and the tracheostomy tube is inserted. A common clinical observation is that patients wean more rapidly from mechanical ventilation following tracheotomy. Expected changes in tube resistance and dead space are not adequate to explain this observation in adult patients.

Theoretical considerations are too complicated to allow evaluation of expected changes in work of breathing following tracheotomy.

sis • Procedure-related complication rate (4 percent - 36 percent)

Mechanical ventilation is associated with numerous life-threatening complications, and should be discontinued at the earliest possible time in the course of a patient’s illness. Weaning patients from a ventilator is one of the most challenging problems faced by physicians working in an intensive care unit (ICU), and accounts for a huge portion of the clinical workload in this setting. Management of the weaning process has fallen within the realm of clinical judgement, but studies now indicate that an empirical approach can prolong the duration of mechanical ventilation

Spontaneous breathing trials The best way to determine suitability for discontinuation of mechanical ventilation is to perform a spontaneous breathing trial. There are three ways to do this: putting the patient on a minimum pressure support and PEEP (for example 5-7cmH2O PS/5cmH2O PEEP performing mechanics and extubating), using a T-piece.

A T-piece trial involves the patient breathing through a T-piece plus a flow of oxygen-air and no ventilatory assistance) for a set period of time. The work of

june / 2012 www.ehealthonline.org

51

applications

New Insights into the Lung Nikil Rao General Manager Draeger Medical India Pvt. Limited

T

he University Hospital Leipzig is the first hospital in the world to implement the PulmoVista 500. Mechanical ventilation uses pressures that are much higher than normal breathing which creates a risk of overstretching areas of the lung. On the other hand, if the pressure at the end of the breath is set too low, some lung areas may collapse. Both of these situations can impede the healing process of an intensive care patient. Up to now, Computed Tomography (CT) has given the physician a clear picture of the status of the lung, albeit only as a snapshot in time. PulmoVista 500 now delivers complementary information in the form of dynamic images – comparable to a film sequence. The physician can continuously track how the breathing gas volume generated by the ventilator is distributed in the lungs. “With EIT, we can now see how ventilation of the lung changes and subsequently functionally evaluate the changes. This is the first time this type of assessment has been made available,” said Prof Dr Hermann Wrigge, Deputy Director of the Clinic and Polyclinic for Anaesthesiology and Intensive Care at the University Hospital Leipzig, the first hospital in the world to use EIT device from Dräger. Measurements are performed using a flexible belt, with 16 integrated elec-

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The new PulmoVista 500 is the first EIT device (Electrical Impedance Tomography) intended for everyday clinical use by intensivists to view regional distribution of lung ventilation directly at the bedside. With up to 50 images per second, physicians can track the effects of intensive care ventilation in real time

trodes, placed around the patient’s chest.

The electrodes apply a small current to the patient’s body; the resulting voltages change according to the amount of air in the lungs. PulmoVista 500 uses the measured voltages to create tomographic images of the lung function.

An important step in lung protective ventilation PulmoVista 500 supports therapy management by continuously updating images of regional distribution of ventilation.

For example, if the physician changes the PEEP (positive end-expiratory pressure) on the ventilator, the EIT device immediately shows the effects on the distribution of the ventilation and end-expiratory

lung volume. The PEEP, the airway pressure at the end of a breath, must not be set too low in order to prevent the alveoli from collapsing. On the other hand, if the PEEP is set too high this may result in areas of the lung being overstretched which may damage the lung. Studies show that EIT can continuously provide information about the recruitability of the lungs and

optimal PEEP settings. This feature can help users optimise distribution of ventilation in the lung. Prof Dr Christian Putensen, Head of Surgical Intensive Care at University Hospital Bonn, has conducted research about clinical applications of EIT since 2003. Further underscoring the use of EIT to guide mechanical ventilation, he stated: “EIT support for setting ventilation parameters clearly has the potential to improve gas exchange for patients with respiratory complications.”

Clinical processes in focus One of the primary goals in developing PulmoVista 500 was to make sure that the device was easy to use in the demanding intensive care environment: Thanks

to the easy to attach flexible electrode belt the device is ready for use in just a few minutes. Measured values as well as previously recorded EIT data can both be accessed at the bedside. Furthermore, because the noninvasive EIT procedure can be completed without radiation PulmoVista 500 supports ventilation monitoring without side effects.

At your side in intensive care: Dr채ger.

The intensive care area is one of the most complex and cost-intensive areas in any hospital. Spiralling costs, rising morbidity and a trend towards individualised therapies are increasing the demand for higher levels of efficiency. At Dr채ger, we have a long history of developing solutions that address not only therapeutic, but also work flow improvement. Our innovative technology can turn an intensive care unit into a healing environment, where your patients feel more comfortable and your staff are naturally motivated.

expert zoom inspeak

Technology on the Go

Philips lightens the life of women with their initiative called ‘Asha Jyoti’, outreaching a large number of masses along with PGIMER and RAD-AID International, a non-profit organisation from United States

T

he ‘Asha Jyoti’ Women’s Healthcare Outreach Mobile Programme was inaugurated on 22nd April 2012

by Shri Pawan Kumar Bansal, Hon’ble Minister of Parliamentary Affairs, Science and Technology and Earth Sciences in the presence of Prof YK Chawla, Director, PGIMER and Prof N Khandelwal, Head, Department of Radiodiagnosis, PGIMER. Shri Pawan Bansal also flagged off a mobile van equipped with a microdose digital mammography unit for breast evaluation, a DEXA scan for evaluation of bone density and a digital video colposcope for evaluation of the cervix. This project is a collaboration between PGIMER and RADAID International, a non-profit organisation from United States founded by a team of radiologists from Johns Hopkins Hospital, USA and Philips Healthcare, US. ‘Asha Jyoti’ is a population based screening programme of healthy women in the age group 45-60 years for detection of breast cancer, cervical cancer and osteoporosis. The aim of this programme is to detect any of these three diseases before the individual has any signs or symptoms. The target population will include urban and semi-urban women and

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will be extended to the rural women in due course of time. In the pilot phase of this project 500 women will be screened in six months while in the regular operational phase 2000-3000 women will be screened in one year.

This mobile van ‘Asha Jyoti’ will be able to define need-based screening standards for the cases of breast, cervical cancer and osteoporosis in the northern part of India, which may aid in the formation of national policies for screening of such diseases. PGIMER Director YK Chawla said that the ‘Asha Jyoti’ Women’s Healthcare Outreach Mobile Programme was proposed as model for promoting preventive healthcare for women and providing doorstep screening for three diseases in a single visit. This is a population based screening programme of healthy women in the age group 45-60 years for detection of breast cancer, cervical cancer and osteoporosis. The project cost of this mobile clinic is `4.5 crore and it is first of its own kind in India. Philips has equipped the mobile van with a micro-dose digital mammography unit for breast evaluation, a DEXA scan for evaluation of bone

“We are excited to be part of the “Asha Jyoti” initiative in collaboration with a leading government institution like PGIMER. It’s a first of a kind mobile outreach program which brings breast, cervical cancer screening and treatment to women in underpenetrated rural areas. We are committed to this program as it is in line with our vision to improve patient’s lives through innovative solutions that increase healthcare access and solve key challenges in healthcare, cancer in India.”

Rekha Ranganathan Sr. Director, Marketing Strategy and Business Development, Philips density and a digital video colposcope for evaluation of the cervix.

Need based screening standards for breast and cervical cancer as well as osteoporosis in the northern part of India will be defined which may aid in the formation of national policies for screening of these diseases. This project is likely to be extended to other urban-rural areas as a part of community based radiology services. The various departments involved in this collaborative effort include the department of Radiodiagnosis as project manager and departments of Community Medicine, Orthopedics, General Surgery, Obstetrics and Gynecology, Cytology, Histopathology and Radiotherapy.

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speciality

Nextravagance in Heart Care New technological innovations have contributed to decline in cardiovascular mortality rates globally, but unfortunately similar decline is not being witnessed in India

By Dhirendra Pratap Singh, Elets News Network (ENN)

A

research shows that by the year 2010 and beyond, around one million deaths per year in India will be attributable to smoking, and the majority of these will occur in middleaged adults. This will represent 10 percent of all deaths in the country—one in five deaths in men and one in 20 in women. This was the first such national study in India, which covered over one million homes and 78,000 deaths.

In 1960, only four percent of people in India died of cardiovascular disease.

This figure has increased to 13.5 percent in 2009 and is expected to reach 25 percent by 2025. An ageing population and increased focus on cardiovascular diseases have led to an increase in popularity of cardiovascular devices. There are immense economic consequences of such diseases, leading to productivity reduction and causing a detrimental impact on the workforce.

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The World Health Organisation (WHO) estimates that between 2005 and 2015, income loss could rise to as much as USD 237 billion in India. There has been an increase in device implanting centres, some of which have come up outside the metros. There is also an increase in number of implanting physicians with a number of interventional cardiologists doing implants.

Programmes of third party payment for the underprivileged have been taken up in Andhra Pradesh, Karnataka and possibly some other states, where there is increase in number of pacemaker implants.

Cardiac Surgeries Percutaneous coronary intervention (PCI) is a major method of revascularisation for coronary artery disease. Over two million coronary interventions are being performed annually. The majority of interventions (more than 90 percent) are coronary dilatations, which are performed using

stents. The catheterisation laboratory personnel so far have been operating in an unfriendly environment, which is often subject to continuous x-ray radiation. This has been the case since the beginning of the field of interventional cardiology more than 25 years ago. “Interventionalists disc disease” is a well confirmed entity with cardiologists reporting more neck and back pain, more subsequent time lost from work, and a higher incidence of cervical disc herniations, as well as multiple level disc disease owing to the tiresome standing procedure of angioplasty and the heavy weight of the anti-radiation gear that takes a toll on the operator.

Interventional physicians are among the most highly trained operators in the field of non-invasive surgery; robotic intervention utilises the physician’s existing techniques while incorporating an additional level of control through the use of robotic technology. This combination

speciality

Setting renaissance in cardiology

Dr Upendra Kaul Executive Director - Academics & Research (Cardiology), Department of Invasive Cardiology, Cardiology, Fortis Escorts Heart Institute

World Health Organisation (WHO) estimates that 60 percent of the world’s cardiac patients are Indians. India has the highest number of patients with diabetes. India is the diabetes capital of the world. Deaths due to cardiovascular diseases are decreasing globally. India has the largest number of people dying due to coronary artery disease in the world. Forty percent of heart disease sufferers are below 40 years of age. Pace of by-pass surgery is not picking up with that of Angioplasty. In many patients, coronary anatomy alone does not adequately reflect the functional severity of a coronary stenosis. Therefore, for decades, cardiologists have searched

introduces the exactitude of robotic precision to interventional procedures and is expected to produce better clinical outcomes in the drug eluting stent era.

Further, a high level of x-ray exposure to medical professionals is of fundamental concern. Remote controlled technology significantly reduces x-ray exposure to operators. The advantages of using the interventional cardiology approach include the avoidance of the scars and pain, and long post-operative recovery.

companies in the world that is engaged in developing such healthcare solutions. The Enrhythm MRI compatible pacemaker has changed the lives of a large number of patients, who need to undergo an MRI scan for diagnosing other ailments. Currently the patients need to get the pacemakers explanted for getting the MRI done, this by itself is a major procedure, as it entails that besides the pacemeaker, the leads that are implanted in the heart of patient have to be removed.

Pacemakers

Market

Patient care and treatment has reached new dimensions. Medtronic is one of the

Global market for Cardiac Defibrillators is forecast to exceed USD 16 billion by

INDIA – Alarming CAD Epidemic • India has the largest number of people dying due to Coronary Artery Disease (CAD) in the world • World Health Organisation (WHO) estimates that 60 percent of the world’s cardiac patients are Indians • India has the highest number of patients with Diabetes • CAD is responsible for 32 percent of all deaths in India • 10 fold higher rate of MI and death <40yrs • Greater Severity

• 3 vessel disease more common, even in premenopausal women • Higher Rates of CAD at any given level of Conventional Risk Factors • 2 fold higher than in Americans, Europeans • 4 fold higher than in Chinese • Higher prevalence of Emerging Risk Factors • Metabolic Syndrome • Lower HDL, High levels of Lipoprotein(a), Homocysteine, ApoB, Fibrinogen, Small Dense LDL

for additional methods to assess physiological stenosis severity and its impact on myocardial perfusion more reliably. The angiographic severity of a coronary stenosis correlates poorly with ischemia severity. Performing PCI based on the anatomic appearance of a lesion may not be the most effective ischemia management. In the study, 101 patients (111 lesions) were identified between 50 percent-90 percent Occlusion, if PCI would have been considered for all the lesions, then 111 stents would have been used. By doing FFR, only 30 lesions were found ischemic out of 111 Lesions. It means 81 lesions were not considered for PCI. FFR is better and less expensive.

2015. The market is primarily driven by the increasing incidence of cardiovascular diseases due to aging population and the increasing availability of emergency medical services world-over for the revival of sudden cardiac death victims.

A report by Global Industry Analysts says that the global market for ECG telemetry devices is estimated to reach USD 1.1 billion by 2015.The market will be driven by increasing cases of cardiovascular diseases and an ageing population.

The US represents the largest regional market for ECG telemetry devices in the world and, according to the report, the market will be driven by the increasing number of US citizens receiving home care. Asia-Pacific represents the fastest growing market for ECG telemetry devices.

It is estimated to grow at a CAGR of more than 5 percent over the study period. Central display, control and recording stations is the largest product segment of ECG telemetry devices, while electrical leads will be the fastest growing, the report added.

Minimally invasive cardiac surgeries have transformed medicine completely and generated great amount of excitement among surgeons. It is one of the latest attempts of converting open heart surgical procedures to minimally-invasive procedures, causing least trauma to the patient. june / 2012 www.ehealthonline.org

57

Leader Speak speciality

“Technology is Constantly Advancing in Cardiology” The cardiology space has witnessed significant positive change in terms of new technology introduction says Kaustav Banerjee How have you seen the advancement in the field of Cardiology in the recent years?

The field of cardiology has grown significantly in India over the past few decades and continues to do so at a fast pace. This growth is mainly due to the increasing awareness of the importance of this field at every societal level. The gradual increase in the reimbursement schemes from various state governments is helping to reduce the affordability related access barrier for many patients. This, along with the positive changes being made in the regulatory environment can only help improve quality of healthcare and patient outcomes.

Also, over the past few decades, the cardiology space has witnessed significant positive change in terms of new technology introduction.

Technology is consistently advancing – this is something that is true both in India and throughout the world. At St. Jude Medical, we are doing our part, and in the past year have introduced important tools that will help cardiologists improve care, including launching the latest generation of Optical Coherence Tomography (OCT) to aid physicians in visualising inside vessels.

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Kaustav Banerjee Country Manager, St. Jude Medical Please give a brief about your company. What are its offering in the field of Cardiology?

St. Jude Medical products first became available in India in 1994, with heart valves offered to physicians through various distributors. The company’s first office in India was established in 2000 to assist with the distribution of the company’s products. Some specific products for cardiologists are the Amplazter Cardiac Plug, Angio-Seal, PressureWire™ Certus and PressureWire™ Aeris Wireless FFR Measurement Systems and C7-XR™ Optical Coherence Tomography (OCT) Intravascular Imaging

System with the C7 Dragonfly™ Imaging Catheter.

What are the current technology and market trends in the cardiology equipments?

Cardiovascular disease presents an expensive and burdensome global challenge, impacting millions of people.

It is the number one cause of death globally, and the World Health Organisation (WHO) estimates that in 2008 more than 2.3 million people died from the disease in India.

While cardiovascular disease presents a challenge, medical management and medical devices in many in-

stances are viable treatment options for patients. As more people are diagnosed with the disease and healthcare costs escalate, it has become increasingly important to find treatment options that can improve patient care in a cost effective manner.

An example of a technology that helps physician to better understand the severity and nature of a patient’s cardiovascular disease is Fractional Flow Reserve (FFR) measurement technology. It helps in the diagnosis and treatment by indicating the severity of blood flow blockages in the coronary arteries. A landmark study called FAME demonstrated that instances of major adverse cardiovascular events (MACE), including death, myocardial infarction or repeat revascularisation, were reduced by 28 percent for patients whose treatment was guided by FFR rather than by standard angiography alone.

What are the challenges in the adoption of new technologies in Cardiology?

At present, a vast majority of patients with various heart ailments remain undiagnosed and untreated. The barriers to treatment in India are the affordability of care, lack of awareness and geographic barriers.

The affordability related access barrier is gradually changing with government taking active initiative in improving the reimbursement for the underprivileged and also with the growing awareness on private health insurances.

(In Conversation with Dhirendra Pratap Singh)

expert corner

Setting a New Pulse in Cardiology Robotic Surgery allows surgeons to perform complex surgical procedures that may not be feasible through Laparoscopic or Endoscopic procedures

T

oday’s successes would not be possible without the foundation of yesterday’s developments.

From a very long time, doctors have been performing open heart surgery which requires the heart to be exposed in order to perform the procedure. In these cases, the sternum (breast bone) is cut in half vertically so the chest can be opened, making the heart visible. The pericardium is open and pulled away from the heart, giving the surgeon direct access.

After the operation, one needs to spend 7 to 10 days in the hospital with overnight stay in ICU. Two to three tubes will be in your chest to drain fluid from around your heart.

They are usually removed 1 to 3 days after surgery. It may take 4-6 weeks for recovey.

There is significant blood loss and pain.

Then further to the developments, laparoscopic/ endoscopic surgery was introduced which is also called minimally invasive surgery.

It is a modern surgical technique in which operations are performed through small incisions (usually 0.5–1.5 cm)

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as opposed to the larger incisions needed in open surgery.

In modern day Robotic Surgery has come up as a revolution where in doctors perform surgery in a manner that has never been experienced before through a system called Da Vinci which enables surgeons to be a more precise, advancing their technique and enhancing their capabilities in performing complex minimally invasive surgery.

This surgery is typically performed through small incisions. Complex surgical procedures that would normally require large incisions can now be done through fingertip sized incisions. The surgeon sits at a console a few feet from the patient; the system translates the surgeon’s hand movements into corresponding micro-movements of instruments inside the patient’s body. The Da Vinci System also provides better visualisation, dexterity, precision and control than open surgery, while enabling the surgeon to perform procedures through tiny, 1-2 cm incisions.

This superior system provides unparalleled vision inside the patient’s body with

Dr Sudhir Srivastava Chairman and Managing Director, International Centre for Robotic Surgery natural depth perception and magnification for more accurate tissue identification like, revolutionary 3D, high definition vision with up to 10x magnification, bright, crisp, high-resolution image, and immersive view of the surgical field. Hence, improved visualisation allows surgeons to handle and dissect delicate tissue with added precision – even in confined spaces like the chest.

In a nutshell, the robot serves as an instrument for the surgeon. The Da Vinci Sys-

tem replicates the surgeon’s movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way or perform type of surgical manoeuvre without the surgeon’s control.

Robotic Surgery is different from Laparoscopic/Endoscopic procedures because Robotic Surgery utilises the most advanced technology allowing surgeons to perform complex surgical procedures that may not be feasible through Laparoscopic/Endoscopic procedures.

In Conversation

Ensuring Safe

Future in Cardiology

Dr Pavan Kumar (Consultant Cardiovascular Surgeon), Head-Department of Cardiovascular Surgery, Dr Balabhai Nanavati Hospital

Tremendous advancements have occurred in field of cardiology, especially technological development. Invasive procedures have become safer smoother smaller.

Department of telemedicine, Nanavati Hospital has developed the tele ECG concept and ECG on smartphone, a first in India, which has contributed in technological advancements in the field of cardiology. Dr Balabai Nanavati Hospital – Heart Institute (NHHI) has facilities for emergency ventilator care, bedside pacing, sophisticated bedside and central monitoring system and intra aortic

balloon pump.

E-ICU, Cathlab on ipad, more and more cardiology applications on iphone like smartphones are being developed and will be part of technological growth story in cardiology. The introduction of Tele-Cardiology services can improve patient care and save costs. Every health care professional knows the time is extremely critical, and mobile monitoring – whether it is on an iPhone, or at a remote center – could truly revolutionise the delivery of urgent care.

The healthcare IT market is now catching steam in India.

With the markets in the west

heading towards maturity, Indian providers are slowly waking up to global trends.

The Market size of the healthcare IT industry in India is around Rs 1000crores. The cost of installation of solutions in cardiology range from one lakh to 25 lakhs.

The biggest challenges in the adoption of new technologies in cardiology are investment problems by management and lack of understanding by professionals. New cardiology equipments have great future towards achieving improvements in patient care applications, but it will take time.

june / 2012 www.ehealthonline.org

61

Index of People and Organisations People

Organisations

Aditya Mani, Director, Acuity Information Systems

Aarogya Infotech & Management Systems

32

Aavanor Systems

38

Acuity Information Systems

30

Akhil Systems

36

Bangalore Medical College & Research Institute

46

Dr Balabhai Nanavati Hospital

61

Dr Harsh Mahajan, Managing Director, Mahajan Imaging 48

Draeger Medical India Pvt Limited

52

Dr Pavan Kumar, Head-Department of Cardiovascular Surgery, Dr Balabhai Nanavati Hospital

Elsevier 15

Dr Damodar Bachani, Director Professor & Head, Department of Community Medicine, Lady Hardinge Medical College Dr H Satishchandra, Professor & Head, Department of Radiodiagnosis & Imaging, Bangalore Medical College & Research Institute

30

16

46

61

Frost & Sullivan

20

Dr Rajeev Sikund, Director, Sikund Diagnostics,

44

IGNOU School of Health Sciences

14

Dr Sudhir Srivastava, CEO & MD, International Care for Robotic Surgery

Intel Healthcare

21

60

International Care for Robotic Surgery

60

Kaustav Banerjee, Country Director, St Jude Medical

58

Lady Hardinge Medical College

16

Mahajan Imaging

48

Napier Global Development Center

37

NextGen e-Solutions

40

Palash Healthcare Solutions

33

KN UmeshKumar, Business Head, MR, Siemens Healthcare 44 M Vennimalai, CEO, Aavanor Systems

38

Nikil Rao,General Manager, Draeger Medical India Pvt. Limited

52

Muralidhar Koduri, Vice President, Napier Global Development Center

37

Philips Healthcare

47,54

Religare Technologies Limited

Professor AK Agarwal, IGNOU School of Health Sciences 14

Sanrad Systems

Rakesh Kumar Singh, Director (Healthcare-IT), Aarogya Infotech & Management Systems

Siemens Healthcare

34 43 44,49

Sikund Diagnostics

44

Rohit Kumar, Managing Director, Elsevier Health Sciences, South Asia 50

Smile Foundation

24

Srishti Software

28

S Jaisankar, Service Manager CT/MRI- Customer Support, Trivitron Healthcare

St Jude Medical

58

45

Supten Institute

18

Sanjay Jain, Managing Director, Akhil Systems

36

Trivitron Healthcare

45

Santanu Mishra, Co-Founder, Smile Foundation

24

32

Som Panicker, Vice President, MRI Div, Sanrad Systems 43 Suchet Singh, CEO, Srishti Software

28

Suptendra Nath Sarbadhikari, Founder and Director, Supten Institute 18

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