Health in the Times of Disasters: March 2007 Issue

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A monthly magazine on ICT and Health

Vol. 2 No.3

March 2007

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Health in the Times of Disasters

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Contents Cover Story

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Telemental Health Support After Disasters Dr. S.B. Gogia

“Many e-Health experts have emphasized that IT will and can help disaster management, but much preparatory work is required. However, whenever IT in healthcare, and specifically for disasters is being talked about, the discussion has concentrated on the technology rather than how it should be used to help the people.�

Global Event

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eHealth ASiA 2007 Saswati Paik

Profile: Allscripts Inc.

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Scripting an aggressive growth strategy in e-Health

Book Review

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Knowledge Management in Healthcare Demystified

Focus: CSR Conclave Commitments Reaffirmed 32 Social G. Kalyan Kumar

Case Study

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A GIS Based Referral Planning System Dr. Jibanananda Roy, Dr. Chandreyee Das

In Conversation: Dr. K. Ganapathy but Steady; Telemedicine Making 34 Slow a Big Headway in India Swarnendu Biswas

News

26 World News

Health Informatics

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29 Business News 30 India Update March 2007 | www.eHealthonline.org

e-Learning in Reproductive Health Dr. Naira Roland Matevosyan

Project Showcase

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CLINICIP Project Draws Great Interest in Europe 3

Editorial Guidelines Contributions to eHealth magazine could be in the form of articles, case studies, book reviews, event report and news related to e-Health projects and initiatives, which are of immense value for practitioners, professionals, corporate and academicians.

We would like the contributors to follow these guidelines, while submitting their material for publication: • Articles/ case studies should not exceed 2500 words. For book reviews and event reports, the word limit is 800.

• An abstract of the article/case study not exceeding 200 words should be submitted along with the article/case study.

• All articles/ case studies should provide proper references. Authors should give in writing stating that the work is new and has not been published in any form so far.

• Book reviews should include details of the book like the title, name of the author(s), publisher, year of publication, price and number of pages and also have the cover photograph of the book in JPEG/TIFF (resolution 300 dpi).

• Book reviews of books on e-Health related themes, published from year 2002 onwards, are preferable.

In case of website, provide the URL. • The manuscripts should be typed in a standard printable font (Times New Roman 12 font size, titles in bold) and submitted either through mail or post.

• Relevant figures of adequate quality (300 dpi) should be submitted in JPEG/ TIFF format.

• A brief bio-data and passport size photograph(s) of the author(s) must be enclosed.

• All contributions are subject to approval by the publisher.

Log on to www.ehealthonline.org for goings-on in the world of eHealth 4

eHealth | March 2007

Editorial Vol. 2, Issue 3

March 2007

An e-Healthy State of Being I am starting with a happy news. The much talked about eHealth Asia 2007 conference, held during 6-8 February 2007 at Putrajaya International Convention Centre (PICC), Putrajaya, Malaysia, has been an out and out success story. The three-day conference attracted a galaxy of high profile participants ranging from academics, industry and ministry, and created a platform for generating awareness and disseminating useful information about the burgeoning domain of e-Health; a nascent field with immense possibilities.

Going by the response from the conference, it would not be an overstatement to imply that e-Health is destined to make its presence felt in public healthcare, in the very near future. However, today e-Health is not only emerging as an effective tool in catering to the day-to-day healthcare needs of the underprivileged and underserved sections of the society in times of normalcy, but also a technological panacea of sorts in the aftermath of any natural disaster. In fact, the crucial role of ICT in providing relief to the hapless victims of disasters and catastrophes, through telehealth, has been recognized in a very big way. The telemental health support of the recent tsunami survivors in Tamil Nadu, India is a pertinent case in point, which we have covered in our cover story.

Here it deserves a mention that after the tsunami, relief operations were carried out by the Indian government machinery and relief agencies on a war-footing, but those operations mostly concentrated on providing immediate relief, such as caring for the injured, disposal of the dead bodies, providing for sanitation, shelter and disease prevention, etc. The long-term rehabilitation phase, which also involves treating the mental trauma of the survivors (which generally emerges as a disorder only after a few weeks after the disaster), was largely inadequate. That is where SATHI (Society for Administration of Telemedicine and Healthcare Informatics) stepped in with lots of humanity, and ICT sulutions to address the issue of mental and psychological health among the survivors, despite several odds. Read more about it in the interesting feature.

I would like to add that the stupendous success of eHealth Asia 2007 has entrusted greater responsibility on us. We are going to organize eIndia 2007 in Pragati Maidan, New Delhi, during 31 July- 02 August 2007, and the event is slated to attract the best of the best in the world of ICT and development. eHealth India 2007 is positioned as an integral part of this eIndia 2007 conference. eHealth India 2007 will deliberate and parley on major e-Health initiatives and endeavours happening across the globe, with a special focus on India. I am sure the entire exercise is going to raise awareness and interest about myriad eHealth developments spearheading our times and their usability in the Indian context.

Let me end this on a happy note. A 21.9 percent hike in the allocation on health and family welfare in the 2007-08 budget, does have the latent potential of infusing greater health in the e-healthcare scenario of the future.We look forward with anticipation to the developments ahead ...

Ravi Gupta Ravi.Gupta@csdms.in President Dr. M.P. Narayanan Editor-in-Chief Ravi Gupta Sr. Editor G. Kalyan Kumar Assistant Editor Swarnendu Biswas Web Zia Salahuddin

Designed by Bishwajeet Kumar Singh Om Prakash Thakur

Printed by Vinayak Print Media, Noida, G.B. Nagar (U.P) India

Alliance & Advertisement Dipanjan Banerjee dipanjan@csdms.in

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eHealth does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. eHealth is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. eHealth is a publication of Centre for Science, Development and Media Studies (CSDMS, www.csdms.in). eHealth is marketed by elets Technomedia Pvt. Ltd. (www.elets.in). Š Centre for Science, Development and Media Studies (CSDMS) knowledge for change

IT is a State of Health

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eHealth | March 2007

Global Event

eHEALTH ASiA 2007

Giving Health an ICT e-dge I

n the last few years, e-Health has emerged as a tool for substantial productivity gains and restructured, citizen-centric health care. Thus it was no wonder that e-Health Asia 2007, which was one of the five main tracks of the eAsia 2007 event, organised by Centre for Science, Development and Media Studies (CSDMS), at Putrajaya International Convention Centre (PICC), Putrajaya, Malaysia during 6-8 February 2007, garnered considerable attraction among a cross-section of e-Health experts, medical professionals and academics. The conference sought to provide a platform to discuss the recent trends and emerging issues in the development of information and communication science and technology and its integration in the healthcare systems.

Following the grand inaugural session of 6 February 2007, the sessions with interesting presentations and discussions commenced on February 7. The first session of e-Health track was on ‘ICT Integration in National Health Policy.’ The session was chaired by Prof. Yun Sik Kwak from ISO T/C 215 Health Informatics Standard, Korea. In this session, Gabe Rijpma, Director of Government Solutions, Microsoft Corporation, Asia Pacific, highlighted three main themes: paradigm shift in healthcare, improving productivity March 2007 | www.eHealthonline.org

in healthcare and scaling health to overcome biggest challenges. He described ICT as ‘enabler’, not as the ‘only answer’. He emphasized on innovative ways of scaling health service delivery, which can be supported by technology. He also stressed that ICT integration in national health policy needs to be supported in the budgetary process so as to deliver results.

Frank Lievens, Board Member, International Society for Telemedicine and e-Health, Belgium, shared his views on international initiatives, structure and trends in the e-Health policy aspect. He narrated the challenges associated with health and suggested probable means to meet those challenges. In this context, he explained the significance of the concept of ‘e-Health’. During the question-answer session, the following recommendations were made: (i) It is essential to consider the people’s concern while implementing ICT for health services, (ii) key challenges and issues need to be focussed with crosscultural perspectives.

The second session was on ‘Health Informatics Standards’, which was chaired by Dr. Basheerhamad Shadrach, IDRC, telecentre.org programme, India.

In this session, Dr. S. Selvaraju from Ministry of Health, Government of Malaysia, discussed about the health

eHEALTH Asia 2007 conference was aimed to provide a platform to discuss the recent trends and emerging issues in the development of information and communication technology and its integration in the healthcare systems

infrastructure in Malaysia and emphasized on the standardisation of medical terminologies. Prof. Yun Sik Kwak pointed out the importance of global standards as a key to interoperable e-Health systems for continuity of care and disease surveillance.

He also highlighted the activities of eHealth Standardisation Coordination Group (eHSCG), that targets to promote stronger co-operation amongst the key players in the e-Health standardisation area. Bruno von Niman, TC Human Factors, European Telecommunication Standards Institute (ETSI), Sweden, discussed about user experience design

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guidelines for telecare services and narrated the activities of European Telecommunication Standards Institute.

Qurat-ul-Ain Salim Khan from National University of Science and Technology, Pakistan, described a step towards interoperability in ECG equipment. In her presentation, she focussed on the present ECG standard and the proposed ECG standard, emphasizing on implementation of a single standard, seamless integration with existing systems, recognised medical body and discouragement of proprietary standards. The recommendations in this session, based on the question-answer session at the end of the presentations, included developing a regional coordination sector for regional standardisation of health database.

Building up standards for medical terminology and introducing telecare services in all the nations were also recommended.

The third session of the day was on ‘ICT Capacity Building for eHealth Implementation.’ The session was chaired

by Frank Lievens, Board Member, International Society for Telemedicine and e-Health, Belgium. Dr. H.M.Goh, WG2, Asia Pacific Association of Medical Informatics (APAMI), Malaysia, discussed on ICT capacity building for e-Health implementation with reference to Malaysian e-Health journey. Dr. Dhrupad Mathur, Fellow and Alumni, Diplo Foundation, Geneva, presented a paper jointly written by Eva Tanner, Diplo Foundation, Switzerland and him. He explained the pilot project of Diplo

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Foundation, titled Health Diplomacy Research Course. The recommendations in this session, based on the questionanswer session, were as follows: (i) As a major step for capacity building, ICT must be introduced in medical schools, (ii) list of courses linked to e-Health must be available to the citizens online, (iii) effectiveness of any training related to capacity building must be measured in a proper way.

The fourth and the last session of the day was on ‘e-Health Applications in Asia’, chaired by Dr. H.M.Goh. This session showcased the efforts in the Asia region in e-Health application. Dr. Azrin Zubir, CEO/Health Informatics Consultant, Meridian Project Management Sdn Bhd, focussed on ‘Electronic Health Record: Pre-requisite and Challenges,’ with special reference to Malaysia. Dr. Shashi Gogia from Indian Association for Medical Informatics (IAMI), India, highlighted on telemental health support after disasters, based on the post tsunami experience from India. He also narrated the activities of Society for Administration of Telemedicine and Healthcare Informatics (SATHI). The title of the paper, presented

by Jay M. Bernhardt, Director, National Centre for Health Marketing, US Centres for Disease Control and Prevention, USA, was ‘The Potential of E-PublicHealth: CDC’s Focus on the Future’. Santulan Chaubey, Manager-Information Technology, Institute of Liver and Biliary Sciences, Government of Delhi, described ‘Common EHCR Architecture for eHealth Applications in Asia’. The major

recommendations in this session include the following: (i) Legal issues related to ICT use in the health sector need to be taken care of; (ii) Electronic health record needs to be maintained for the community care; (iii) Blog might be a useful way for communicating among people of e-Health community.

The first session of 8th February was entitled ‘Health IT Initiatives: Country Case Studies’. It was chaired by Dato’ Prof.

Jai Mohan, FAMM Professor of Health Informatics & Pediatrics, International Medical University, who also presented his paper on the need of total health informatics system, with special mention on Malaysia’s health vision. Case studies on health IT initiatives were discussed by Dr. Molly Cheah, Open Source Health Care Alliance (OSHCA), Malaysia where she also described the mission, vision and initiatives of OSCHA. Jagjit Singh Bhatia, Director, Centre for Development of Advanced Computing (C-DAC) Mohali, India, narrated the initiatives in implementing telemedicine technologies

by C-DAC, Mohali and Dr. J.A.Davis from GP Assist, Australia, explained the role played by GP Assist in Australian healthcare sector. GP Assist provides after hours workforce relief to rural general practioners (GPs) throughout down under.

The title of the paper by Dr. Penny O’Hara, Clinical Director, BT Health, UK was ‘e-Health in the UK – A Supplier Perspective’, where she explained the activities of the National Health Service (NHS) of the UK and UK NHS National Programme for IT. Dr. Marie Carmela M. eHealth | March 2007

Lapitan from National Telehealth Centre, Philippines, also presented a paper, jointly written by Dr. Alvin B. Marcelo and herself. The title of the paper was ‘The Philippine eHealth Initiatives’. At the end of the presentations, questions were raised regarding the limitations of open source use for health information and also regarding the maintenance of privacy of information, while using ICT. A major recommendation of this session was exploring the possibility of using health IT at local levels.

The second session of the day was on ‘Technology Innovations in Health Service Delivery’, which was chaired by Dr. J.A.Davis from GP Assist, Australia. In this session, Dr. Anis Fuad, Sr. Lecturer, Health Management Information Systems Department, Graduate Programme of Public Health, Faculty of Medicine, Gadjah Mada University, discussed the innovations in district health information system in his paper with special reference to cases in Indonesia. Gabe Rijpma described the technology innovations with the help of some audio-visual presentations and emphasized the next generation clinical user interfaces. The paper entitled as ‘A Proposition for Low Cost Preventive Cardiology for Rural Health Care System’ was presented by Sujay Deb from G. S. Sanyal School of Telecommunications, India and Dr. D. Goswami from B. C. Roy Technology Hospital, India. During the questionanswer session, questions were raised on the cost indicators for telemedicine

March 2007 | www.eHealthonline.org

centres and standardised equipments. A major recommendation was made for setting up of data collection and analysis centres, especially for the developing countries like India.

‘Service Delivery Mechanisms for e-Health’ was the theme of the third session of the day, and this session was chaired by Dr. Anis Fuad.

Dr.Jibanananda Roy from Institute for Planning Innovative Research, Kolkata, India, presented his paper on ‘A GIS Based Referral Planning System’ where he described the referral system in the context of health system development, providing examples from Sunderban in India. Dr. Ahmad Taufik, Head of IT, Hospital UKM shared the experience of developing and deploying hospital information system, in a major teaching hospital in Malaysia. Sapiah Binti Sulaiman, Faculty of Computer Science & Information Systems, Universiti Teknologi Mara, Malaysia, discussed about information ethics in paperless hospitals.

Dr. Zaitun Abu Bakar from University of Malaya, Malaysia described the Malaysian Immunisation Registry and Tracking System (MIRTS). Toms K. Thomas, Senior Manager, Evangelical Social Action Forum (ESAF), India, presented his paper entitled ‘E-Solution in National Rural Health Mission’ where he described the national rural health mission of India and the main issues of health in India. There was a recommendation for emphasizing the requirement of infrastructure development, for basic healthcare system.

The theme of the final session of the last day of the conference was ‘Opportunities and Challenges of e-Health Adoption’, which was chaired

by Dr. Penny O’Hara. The title of the paper presented

by Melinda G. Frost, Lead, Global Communication & Marketing, US Centres for

Disease Control and Prevention, USA was ‘eHealth on the Frontline of Disease Control and Prevention: Ensuring 2-way Communi- cation to Affected Populations’ where special mention was made on the pilot projects for 2006-2008. Ramin Moghaddam, MD, Medical Informatics Department, Tehran, Iran shared his views on Transcontinental Electronic Health Record (HER); he discussed about the issues related to health in Asian countries and raised the question whether HER is a ‘myth’ or a ‘reality’ in Asia.

Dr. Rakesh Biswas, Associate Professor, Department of Medicine, Melaka-Manipal Medical College, Melaka, Malaysia, discussed his paper titled ‘Meaningful Health Information for All, Utilising a User Driven Health Care Model’. Jayanthy Maniam, Head, ICT R&D Centre, School of Computer Technology, Sunway University College, shared her experiencebased views on ‘Mobile Phone Based Pregnancy Support System’. She explained how the system would assist the pregnant mother and her spouse to be aware of the changes during pregnancy and take necessary actions to prevent the unforeseen problems. A major recommendation of this session was the creation of web-based info platform to share knowledge and information.

At the end of all sessions, the recommendations of the e-Health track were discussed in the valedictory session, which made a sum up of all the five tracks of the eAsia 2007 event.

Read conference papers and presentations at www.e-ASiA.org -Saswati Paik

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Case Study

A GIS Based Referral Planning System Optimization model for arduous terrains proposed

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eferral system is one of the important aspects of efficient public healthcare delivery mechanism. It defines processes for effective use of multi-tier system of health centres and hospitals for treatment of patients, according to the severity of illness. Complicated cases beyond the scope of treatment in a particular facility is stabilized first with appropriate medical care and then promptly referred and transferred to a technically equipped higher-tier hospital by following a definite referral chain. Such a system has been introduced in most of the states of India within various administrative units.

The basic concept of a referral system is to emanate from lowest level and to end in the tertiary care facility. The referral system planning involves two decisions, which are: (i) deciding on the referral protocol, (ii) deciding on the referral chain. While referral protocols contain administrative guidelines, facility, equipment and service norms, referral chains, at present, are designed based on primarily two criteria. They are distance and availability of required service facility at the nearest point, following the hierarchical pattern of healthcare delivery.

The referral mechanism has been introduced and made functional in most of the districts but are providing mixed

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results in terms of compliance and noncompliance to the defined hierarchical pattern of referral. The characteristic of referred cases reveal various lacunae.

Patients often do not reach the appropriate health facilities, patients most often do not reach health facilities in time, and patients often do not follow the referral advice.

Moreover, patients bypass lower level health facilities, unnecessarily overcrowding the higher level hospitals.

The outcome of this system is mixed in terms of compliance and non-compliance to the defined hierarchical pattern of referral, due to a number of factors ranging from awareness, spatial and supportive logistics and socio-economic conditions of the beneficiaries. This is particularly relevant in areas with a difficult terrain, where spatial factors and socio-economic conditions play a decisive role in complying with the suggested referral chains, to the pre-defined hierarchical health units. Thus planning for an adequate health system with an efficient referral mechanism, requires a combination of facility and spatial analysis to derive an optimal service delivery system and GIS could serve as a useful mechanism for decision support planning, considering the incorporation of spatial and non-spatial data in a single reference frame.

The use of GIS in health has been

The referral mechanism has been introduced and made functional in most of the districts but are providing mixed results in terms of compliance and noncompliance to the defined hierarchical pattern of referral. The characteristic of referred cases reveal various lacunae

Dr. Jibanananda Roy Institute for Planning Innovative Research, Appropriate Training and Extension jibroy@eth.net

Dr. Chandreyee Das Institute for Planning Innovative Research, Appropriate Training and Extension chandreyee@inspirationindia.org

eHealth | March 2007

attempted by different agencies in India.

Danida-assisted National Leprosy Eradication Programme is one of the foremost in introducing GIS in health, in the country [1]. Apart from DANLEP, many development agencies [3,4,5] and government institutions are exploring health GIS in India. Malaria Research Centre, New Delhi [2], Vector Control Research Center, Pondicherry, UNICEF, WHO for leprosy, TB, Malaria and Pulse Polio programmes, HIV/AIDS programmes in TN, Orissa and MP are few of the recommended studies.

However, all these studies aim at developing health / disease maps to aid in facility and preventive planning. An interesting work has been carried out by LN Balaji [4] of NATMO Kolkata, using GIS to study the influence of locational attributes on health conditions and also to determine the nature of disease diffusion across geographic regions. Some research has been attempted on creating health database, and using it as a support for health facility planning. The study by Mili Ghosh. Shantanu Lal and Dr. MS Nathawat of BIT Meshra[6] is on these lines and it provides a facility upgradation plan. So far no attempt has however been made for referral system design in India, as institutionalization of the referral mechanism is a relatively new management concept in public healthcare delivery system. A somewhat similar study in identifying referral regions based on the service population and catchment area features has been attempted by Dartmouth Atlas of Health Care in the United States.

There is no spatial component in the state health referral system. However, in the arduous terrains like Sundarbans, West Bengal, the spatial component has a major role to play while deciding for a referred health center. The major factors, in addition to distance and disease type/ condition, are type of road, availability of river route, seasonal dependency, time of the day (day or night for river route), available conveyance type, etc.

Here we show how GIS can be used as a useful tool for decision support planning, March 2007 | www.eHealthonline.org

considering the incorporation of spatial and non-spatial data in a single reference frame. Sunderban region of India, located in the state of West Bengal, has been chosen as a case study area. The present state of health referral system is devoid of specific spatial considerations, except for crude nearness estimate between the source and the destination health centers.

While this absence of detailed spatial considerations may be acceptable for urban, semi-urban or even mainland rural areas that enjoy a good connectivity by rail & road; it is a cause of grave concern for arduous terrains like the Sunderbans where free movement between a source point to a destination health center often gets heavily impaired due to spatial limitations.

We have proposed a network optimization model, based on several spatial as well as non-spatial factors, to minimize an integrated cost function. An optimization model, incorporating spatial and non-spatial data, has been proposed for designing an effective referral system model, specific to arduous terrains. The model has been developed considering the geographical spread and terrain characteristics, natural and climatic conditions, seasonal deviation, land use, infrastrutural and service facilities, connectivity and communication network, etc. and to identify the natural and physical conditions and factors limiting mobility.

The optimization model analyzes several routes from one health center to another center, using road, river or a combination of road and river, depending on several factors like disease condition, severity of disease, season, time, socioeconomic condition, etc. Whenever there are changes in health center availability, new roads and river routes, the spatial database could easily be updated and new routes will be derived.

Insight into the Optimization Model The study thus attempts to formulate a health-system-aware and terrain-sensitive referral strategy that would take the

spatially dominant factors into due consideration. The overall strategy is formulated as an optimization problem where, initially, every health center is considered an equally potential referral candidate for any patient, originating from any village in the region and having any possible complaint or condition. A set of feasibility constraints is overlaid on the whole set to prune out a smaller subset that qualifies as one of the viable referral points.

Finally, a composite cost function that computes the economic, temporal, qualitative and other variant costs, makes a choice of the ‘ideal’ referral point that minimizes the cost and therefore, maximizes benefits. In order keep the option open for subjective judgments that may not be captured in the model (due to lack of data and / or timely update), we generate two or more ranked referralpoint candidates and allow for a final human selection.

The Cost Function The objective of the referral system design activity is to create a networked optimization model based on several relevant spatial as well as non-spatial factors that would minimize the cost functions, which hinder the effective use of the referral chain. Amongst various parameters, the cost function would attempt to optimize the following:

Commutation Cost This model describes the distance between any two points, the different modes of transport used and the total cost to reach the destination. For Sundarbans, in order to reach a particular point from a given point, one has to go by the land or by the river or both. Thus the distance information is broken up as land distance and river distance respectively. The sum of the above two distances gives the total distance to travel. Likewise the total cost to travel is the sum of the costs to travel on land and the costs to travel by river.

Based on the total time (TT) and total cost (TC), commutation details defines a priority index called Accessibility Index.

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Comparing the accessibility indices for the different routes from one point to other, one can identify the best possible route in terms of time and cost.

Service Availability Constraint The service model describes the services rendered by the different health centers.

It identifies the name of the health center, its type (i.e., PHC, BPHC, RH, SDH, etc.), diseases/ ailments that are treated and the criticality level of the disease that can be handled. For a given patient, with a certain level of criticality and originating from a particular location, one can determine the possible destination health service centers from the service model.

Distress Factor Distress factor is a quantitative measure of the amount of distress or discomfort that

Accessibility Index.

Disease Constraint The Disease Constraint model defines all the factors (both clinical and spatial) that must be met for treating the diseases with different level of criticality. This includes the allowable time (maximum) necessary to get a particular treatment, the condition of the road required to transfer the patient to the health center, and the maximum number of transport changes or relocations that can be allowed.

The Referral (Computation) Model The model is thematically multi-sliced with a combination of spatial and nonspatial slices intertwined on hierarchical information architecture. These slices are mostly conceptual. In terms of an implementation under a GIS system,

We have proposed a network optimization model, based on several spatial as well as non-spatial factors, to minimize an integrated cost function.

An optimization model, incorporating spatial and non-spatial data, has been proposed for designing an effective referral system model, specific to arduous terrains. one has to bear in order to travel from one point to other. The distress factor for any two points is defined by the condition of the roads, the time in waiting for the availability of transport (worst case consideration) and the number of transport changes that one has to undergo.

In case of Sundarbans all of these three factors are again dependent on the season (navigable waterways) and the time of the day (occurrence of tides).

Thus the Accessibility Index between any two points computed in the commutation model varies inversely with the distress factor between them, and combining this distress factor with the commutation details, one can redefine Accessibility Index as Qualitative

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multiple slices are flattened into a few GIS layers for efficiency of storage, visualization and computation.

At the base slice there is a spatial layer.

This is where the whole story starts and this is where the story should end as well.

This layer has a set of node points – nodes representing the villages (origins for patient) as entry points and also the nodes representing the health centers (destinations for referrals) as exit points.

Besides the entry and exit points, this layer also marks the village clusters as GPs and represents the distinguishability or indistinguishability of every village, in terms of resolution for the referral.

The next slice is again a spatial layer that represents the routing information. It

comprises node points (called Intermediate Points or IP) that are used for transiting from one mode of conveyance to another or from one route to the next. A typical IP comprises of bus stops, ferry ghat, villages and health centers. Besides IPs, this layer also has the road and river network for easy computation of connectivity and routing information. This connectivity information is annotated with day/night and seasonal information that affects the routes.

Overlaid on the same slice and registered with the connectivity is the information on various routes based on different modes of transport – bus, van, boat. etc. This also provides the necessary commutation data (including fare and time of travel) required in the cost function. Next couple of slices mostly maintains various non-spatial data that primarily act as constraints for feasibility of using a HC as a referral point for a patientdisease-condition point. The non-spatial information includes: 1. Available facility at HC – the manmachine-medicine trio; 2. facility required to handle a disease / and or condition; 3. list of high occurrence diseases and conditions; 4. treatment conditions required for handling a disease or condition.

Process of Optimization / Constraint Satisfaction We use iterative constraint satisfaction to refine from a global set of HCs, with the repeated application of one or more sets of constraints. The idea is to first ensure that a HC under consideration must satisfy the basic requirements for service delivery for any case under consideration. Once the constraint satisfaction is achieved, we can have one of several situations: 1. No HC is left out in the viable satisfied set. We then have no solution. This should be rare. But as and when it happens, it would be a grave warning to the health system because it indicates that the system is unable to provide any treatment path of the village/ disease combine. eHealth | March 2007

2. Only one HC is left in the viable set.

We know the unique referral and we are done.

3. More than one HC is retained. We then identify the cost components for optimization and compute the overall referral cost for each of the HCs. The one with the lowest cost is marked as the referral in this case.

For the case 3, we may optionally accept more than one best (least cost) solution. The final referral can then be selected based on human judgment using criteria that may not have been captured / modeled above.

Conclusion It is indeed difficult to address the problems of public healthcare utilisation in the Sunderbans in totality, as it is extremely dependent on geophysical and natural conditions. Serious attempts are being taken to tackle some of the problems by

providing supportive logistic facilities, but a planning process in-building the conditioning factors is bound to strike the problem at the root and thus create a situation for improved utilisation through appropriately designed referral chains.

Study of the referral and referred cases would reveal the degree of compliance with and utilisation of the referral mechanism and resulting improvement in morbidity status. The realistic referral chains may also give indications for facility allocation among different units, depending on the service load.

Acknowledgements The authors duly acknowledge the financial assistance provided by the Department of Science and Technology, Government of India for carrying out the present work.

References [1] http://www.danlep.org/gismis.html.

[2] Srivastava, Aruna and B.N. Nagpal.

Mapping malaria. GIS Dev., 4(6):28-31.

[3] Dhiman, R.C., R. Sudarshana, V.P. Sharma, M.K. Das and S.K. Bhan.

Targetting mosquitogenic conditions with emphasis on Anopheles sundaicus on Car Nicobar using remote sensing and Geographic Information System techniques: A pilot study. Asian-Pacific Remote Sensing and GIS J., 13: 23-28.

[4] http://www.gisdevelopment.net/ application/health/overview/index.htm [5] http://www.gisdevelopment.net/ application/health/overview/ healtho0003.htm [6] Spatial Decision Support System Using GIS based Infrastructure: Planning in Health Education for Ranchi District, Mili Ghosh,Shantanu Lal,Dr. M. S. Nathawat, Map India 2002.

[7] Referral System Planning using GIS, Chandreyee Das and Jibanananda Roy, ICMIT 2005, Kharagpur, India.

The Area of Study The Sundarbans, located in the eastern part of India and in southern West Bengal, with a population of more than 3.5 million, spreading over 19 blocks of both the districts of 24 Parganas, is one of the underdeveloped regions in the state with predominance of small and marginal farmers.

The 54 islands, interspersed with bodies of water, are covered with forests and swarms. Wide tidal rivers and estuaries and narrow tidal creeks intersect them. Transport and communication networks are inadequate in this hostile geographical and topographical location and people have to travel in an assortment of improvised country boats, cycle-rickshaws and buses to reach their destination, which is extremely time and cost inefficient.

There are no major hospitals in the region and travel time varies between 6 to 8 hours for reaching sub-divisional or

March 2007 | www.eHealthonline.org

district hospitals from the core of Sunderbans. 11 RHs, 8 BPHCs and 45 PHCs are located in the region with 659 SCs. Most of the BPHCs, PHCs and SCs are situated in the riverine area whereas SUNDERBANS

Source: Inland Waterways Authority of India

The map of Sunderbans

RHs are located at the entry/exit point of the mainland area of Sundarbans.

A study on a representative sample of gynecological and obstetric cases in three selected blocks of South 24 Parganas in Sunderbans revealed that in case of patients originating from hospitals, 45 percent of the cases have complied with the designated

referral chain while 55 percent did not comply. Any pre-defined norm based system of health delivery like the referral system, which may be applicable to different districts of West Bengal, may not be applicable in the case of Sunderbans, particularly because of its geographical features.

Thus planning for an adequate health system with an efficient referral mechanism calls for the design of an interactive and dynamic system for optimal design of referral chains, considering the spatial and non-spatial attributes.

It requires a combination of facility analysis along with spatial analysis to arrive at an optimal service delivery system, and GIS is the most useful tool for decision support planning considering the incorporation of spatial and non-spatial data in a single reference frame.

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18-20 April 2007 THE INTERNATIONAL EDUCATIONAL AND NETWORKING FORUM FOR eHEALTH, TELEMEDICINE AND HEALTH ICT eHealth and Telemedicine applications worldwide are at a critical growth phase.

Med-e-Tel offers unmatched opportunities to meet and network with qualified buyers, specialists, users, researchers, policy makers, and payers/insurers from 50 countries around the world.

Med-e-Tel provides visitors with hands-on experience and an opportunity to discover and evaluate new products, systems and technologies and to hear about the latest eHealth/Telemedicine news and trends.

Med-e-Tel features an extensive educational and conference program with more than 120 presentations and workshops on topics that matter to your daily business, research and care activities.

Topics will include a.o.: - personal and in-home monitoring - use of ICTs in independent living for the ageing and disabled - disease management and medication compliance - maximizing the potential of ehealth in developing countries - funding opportunities for ehealth programs and projects - interoperability and standardization - wireless and broadband applications - satellite communication - and more …

Additional events being planned in conjunction with Med-e-Tel 2007, include meetings and workshops by some of the following organizations: - International Society for Telemedicine & eHealth - International Association of Homes and Services for the Ageing / Center for Aging Services Technologies - European Commission & European eHealth Projects - World Health Organization - European Telecommunications Standards Institute - Telemedicine and Advanced Technology Research Center - World Academy of Biomedical Technologies - United Nations Office for Outer Space Affairs - Centre de Recherche Public – Santé

For registration, exhibition and sponsorship applications, conference program, hotel and travel information, newsletter subscription and more, go to: www.medetel.lu Supported by

Venue

www.medetel.lu

COVER STORY

Telemental Health Support After Disasters SATHI sets record with its work among tsunami affected

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Dr. S. B. Gogia

Many e-Health experts have emphasized that IT will and can help disaster management, but much preparatory work is required. However, whenever IT in healthcare, and specifically for disasters is being talked about, the discussion has concentrated on the technology rather than how it should be used to help the people

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elemedicine –literally meaning medicine from a distance – is a means of improving access to healthcare for far flung and remote communities, by providing a virtual doctor at their doorstep. It is expected to be the next big leap in Indian healthcare, for telemedicine has a force multiplier effect in widening the reach and access of medical specialists.

This would be the single most factor to allow India to reach the status of ‘Healthcare for All’ by 2020.

After any natural or man made disaster, supplies, food, etc. can be moved to the affected area, but disease and healthcare needs require specialized care, which in most cases mean a reverse transfer. In disaster situations, health problems and their management can broadly be classified into three phases.

These are: 1. Immediate phase - first 2-3 days, requiring evacuation and care for the injured, disposal of dead bodies, etc.

2. Intermediate phase where the emphasis is on sanitation, shelter and disease prevention.

3. Late or rehabilitation phase where the shattered lives and livelihoods have to be rebuilt. eHealth | March 2007

Use of IT can improve the outcome in all three. While the beneficial use of IT in the first and second phases are better known, they require a huge infrastructure to be in place even before the disaster has occurred. Since most funds are released after the disaster, we believe that IT and telemedicine technology can and should be used to improve the outcomes.

Telemedicine has been found to be an effective method of helping the healthcare aspects of disasters, by providing healthcare specialists virtually to the affected area, thereby overcoming geographical barriers. The process can be sustained over a long time - a critical and often overlooked aspect especially for the rehabilitation phase- as most relief agencies tend to pack up and leave after the acute phase is over.

Many e-Health experts have emphasized that IT will and can help disaster management, but much preparatory work is required. However, whenever IT in healthcare, and specifically for disasters is being talked about, the discussion has concentrated on the technology rather than how it should be used to help the people. Most of the budgets – literally crores – have been spent entirely on the technology along with grandiose inaugurations. Most have seen little turnover after the initial hype was over, with an average turnover of less than one patient a day.

However, despite the odds, telemedicine remains the panacea for addressing healthcare issues during disaster, and there are some organizations in India who are doing commendable work in the field of telemedicine to alleviate the sufferings of disaster affected people. One such name is SATHI. SATHI, an acronym for Society for Administration of Telemedicine and Healthcare Informatics, is a resource organization for Healthcare information technology (HIT), consisting of IT savvy doctors, community health specialists, IT personnel, telecommunications experts and sociologists.

SATHI has been involved in implementing the Healing Touch

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Project, which was sponsored by OXFAM Trust India. As project consultants our role was to pilot a sustainable telemedicine system which could also provide a roadmap for the future.

This project was started after the Tsunami disaster in Tamil Nadu, to benefit the surviving victims. Telemedicine being a new and yet untested field, many problems were faced. However, despite a delayed start, the project has managed to provide mental health support to the victims, while they were at home, virtually, through specialists working in their hospitals in Chennai.

The project was based directly on the needs at the grassroots level. We had a limited budget in hand and to maximize returns, we followed the approach of proper planning and implementation, based on the actual needs at the grassroots level. Search for proper

locations, appropriate partners, capacity building, orientation, social marketing, etc. were part of the elaborate planning process.

Arul, a tsunami victim who suffered post-tsunami psychiatric problems, with sister

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Our first step was to initiate a visit to the affected area and to do a needs assessment of the various health problems which were to be tackled in the affected areas in Nagapattinam district.

When we visited the area in late January 2005, we found that the immediate and intermediate phases were over and were well managed, thanks to the prompt action by the state government and supporting NGOs. However there was a need for mental health support due to high incidence of a sense of loss and bewilderment and alcoholism, with the survivors still in grip of fear and shock due to the loss of family members and loved ones. They were anxious, depressed, still displaced and unemployed with an unwillingness to venture back into the sea for fishing and other means of livelihood. Most were largely ignorant about tsunami and were unable to cope with the after effects and didn’t know how to be prepared for another similar eventuality. We ourselves experienced mass panic reactions wherein a high tide was thought to be another tsunami wave.

The occurrence of this problem was articulated by WHO at around the same time. We felt that the steps taken by the government for upgradation of mental health of the victims were inadequate, as well as wrongly directed. There also were eHealth | March 2007

no proper guidelines for its management, in the existing protocol available with the government offices. Though social workers as well as psychiatrists from NIMHANS Bangalore had visited the area, the visits were too early (PTSD takes a few

organize such searches better on a continual basis and identify the 4-5 percent of the population who require help. This would ensure access to specialists’ services for the victims and would also ensure quality. However, it was

Though social workers as well as psychiatrists from NIMHANS Bangalore had visited the area, the visits were too early (PTSD takes a few weeks to be established as a clinical disorder), too short and sparse, and could not leave a lasting benefit

weeks to be established as a clinical disorder), too short and sparse, and could not leave a lasting benefit. There was also a mismatch between the needs and available services around the affected areas, with a severe dearth of mental health specialists.

We could also see the increasing trend of psychosocial effects – depression and alcoholism with stress and fatigue among relief workers. There was no community participation in the rehabilitation efforts.

Information available from the experts in WHO told us that 80 – 90 percent of the population would be expected to have a lowered mental health status after such disasters. Though that situation of lowered mental health would improve in most but would sink to the level of requiring a specialist help in around 4 – 5 percent. Here it deserves a mention that PTSD and other serious mental problems manifest a few weeks after the disaster and the effects can last for up to 1 –2 years in some cases.

The problem was in identifying the exact persons, who would require specialized medical help. This meant a virtual door-to-door search on a repeated basis. Telemedicine was felt as the right solution to the problems as it would allow the specialist to train the health workers, who being in the community could eHealth | March 2007

important to look for problems among the health workers themselves too who might themselves be affected.

A continual dialogue was possible through video conferencing, allowing people to articulate their needs and participate in interactive sessions with experts. This enabled the service provider to be need specific and strengthen the healthcare delivery system. It increased

the efficiency of the service provider who could cover more areas.

A teleconsultation time-table was made and a tele-conference based training module was developed, which was based on assessed needs and considered human rights perspective. It provided on the job and continual training, using an innovative, interactive and participatory training methodology, supported by audiovisuals.

The Project Cycle The project was conceptualized in January 2006. All initial processes such as identification of stakeholders, operators, locations, etc. were ready by mid February. 6 -7 units were planned in the periphery and one in the center.

SCARF (Schizophrenia Research Foundation) was identified as the central unit, which would provide mental health support. This selection was based on willingness to do voluntary work and familiarity with language, as well as proximity to the affected areas, so that in case of need, actual transfer and care should be possible.

Units in the periphery were to be

Maivizhi, the social worker who cared for Arul and helped him back to normalcy

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located in various places, depending on how much affected the population was and the willingness of local NGOs to run the system and to pay for the running costs. Proximity to the exchange (to allow ISDN connectivity) and access to government channels were two other important factors influencing location of periphery units.

The units were to be located in the PHCs or government hospitals and run by the health workers, with the supervision and support of local NGOs. OXFAM had promised funding support for the machines as well as for maintenance and connectivity, for the first six months. Currently there are three systems, two in the periphery managed

by ISED (Dharmakulam in North Nagapattinam district) and PEDA (Karaikal) and one in the center (SCARF – short for Schizophrenia Research Foundation) in Chennai.

The project however could not start till the middle of May due to various reasons. First of all the funding was slow and it was never fully released; so the scope of the project had to be shortened.

Lack of connectivity proved to be another impediment. Satellite connectivity was promised (from the French Govt) in three locations but the antenna did not work and ISRO connectivity was beyond the budget.

Furthermore, ISDN lines, which were promised within two days of application, took a minimum of two months.

Moreover, in some areas the exchanges are too old so the project had to be shelved after extensive preparation.

ISDN connectivity was a problem, leading us to drop the initial choice of location from the Taluk Hospital in Tharangammbaddi, which incidentaly housed a large rehabilitation colony in the premises of the hospital. In fact this hospital had been flooded by the tsunami.

Delayed release of connectivity elsewhere also delayed implementation. After this experience, we decided to look for locations only if the connectivity could be easily established. Besides, this being

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a new type of technology, there were doubts about the project and delays meant that continuous retraining of volunteers was required.

However, once the connectivity was established and the system was up and running, the results have been gratifying.

There have been thrice weekly sessions where in patients were asked to come to the local telemedicine center. They were seen online by doctors from SCARF, and counseling was done. The medicines which were prescribed by the doctors at Chennai, were provided to the patients by the attending volunteers – a separate stock of medicines used was kept locally as no chemists were available in the periphery where the patients were undergoing treatment. This solution was

There was a need for mental health support due to high incidence of a sense of loss and bewilderment and alcoholism, with the survivors still in grip of fear and shock due to the loss of family members and loved ones provided by SCARF and the local agencies.

Currently, the patients in these and surrounding areas requiring mental health support have been largely treated.

OXFAM has been happy to hand over the project along with the installed equipment to SATHI to manage and use further as they please, now that the basic functions of the project are over. The volunteers from Dharmakulam are now asking for online treatment for other specialties like general medicine, cardiology, etc.

In retrospect, much more would have been possible if we had a freer hand and

got more support. Mobile units and easy satellite connectivity would have allowed us to provide help for a large segment of the affected population. Early release of all the funds was another constraint, which induced us to cut down from ten planned units to three. Thus the psychiatrist sitting on his computer screen in Chennai would have seen and managed many more persons online if there were enough centres in the periphery.

This project has been different form other telemedicine projects in the sense that it was: (i) Sponsored and managed by NGOs; (ii) the local community NGOs were directly trained to manage their own health problems after the natural disaster; (iii) intensive pre and post execution work was done.

An independent evaluation was conducted in May 2006 and this report has pointed the project in a highly positive light. Overall the conclusion of the report was ‘Telemental health is economically viable.’ We as a nation and society should wake up to this possibility.

Ultimately, technology should be used to solve the problems of the people.

Unfortunately most telemedicine projects have not succeeded because they focus too much on the technology and less about the needs of the people who have to utilize those technologies.

A paradigm shift in the management of such new technologies in healthcare is the need of the hour. Much ground work and a road map for future disaster management needs to be created in this regard.

Note : I acknowledge the contribution of my SATHI members and partners: Dr. M. R. Surwade, Project Co-ordinator and Ms. Gurinder Kaur, the then Director of OXFAM. Dr. S. B. Gogia President, SATHI President, Indian Association for Medical Informatics gogia7@gmail.com

eHealth | March 2007

India's Premier ICT4D event 30 July - 03 August, 2007 Pragati Maidan, New Delhi, India www.eINDIA.net.in

eINDIA2007 unites seven specialised conferences and exhibitions

ommun ty Rad o

The National eGovernance Plan (NeGP) launched by the Ministry of Communications and Information Technology is a comprehensive programme designed to leverage the capabilities of ICT to promote good governance across the country. The Indian economy is growing at a steady rate of 8-9%. For this growth to be sustainable there is a need to increase efficacy of business processes especially those directly controlled by the government. The eGov track of the eIndia2007 aims to bring together key stakeholders to forge the path to good governance for citizens and businesses in India, ensuring cross-pollination of information & knowledge across socio-economic and geographic boundaries.

INDIA

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While India has made huge strides and has been a key player in the Information technology revolution, vast digital divide still exists that inhibits a sustained all-inclusive growth for the society. India is bracing itself to catalyse the potential of ICTs in all spheres of development and creating opportunities for private investment and initiatives to supplement its development. In this immense growth environment, there is also a need for strategic planning, knowledge sharing and collaborative vision building between the government and the private sector to leverage the country’s growth potential and steer the country to lead the knowledge revolution. eINDIA 2007 is an inclusive, consultative and constructive ICT for Development forum – the largest and only one of its kind in India – promoting and propagating the use of ICT4D through its seven seminal conferences. Through its seven different but interrelated conferences namely, ● egovIndia2007, ● Digital Learning India 2007, ● Indian Telecentre Forum 2007, ● eHealth India 2007, ● mServe India 2007, ● Community Radio India 2007 and ● eAgriculture India 2007 the conference will address the issues of digital divide and identify and explore opportunities for Digital India.

India is trying to achieve the 'Education for All' goal in one hand and investing in building infrastructure and initiating programmes to build a world class human resource capacity on the other. The National Knowledge Commission has emphasised the need for extensive use of ICTs for 2007 research, collaboration and university networking for building ICT skills, sharing education resources and reaching the un-reached in higher education though distance learning. Digital Learning India 2007 will take on the existing debates and provide a platform for all stakeholders to deliberate on the issues of enabling and strengthening capacities to achieve the national goals of education.

INDIA

INDIA

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INDIA

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With the launch of a national programme, 100,000 Community Service Centres, the Indian telecentre movement is at a vibrant stage of development, with the key stakeholders representing government, private sector and civil society besides donors being engaged in fulfilling the aspirations of the grassroots community to join the knowledge economy. Second year in the series of annual consultations, the Indian Telecentre Forum 2007 will provide the platform to take stock of what has happened. The Forum will shape the way forward for the telecentre movement within India, and for creating an example for the world to learn from.

Telemedicine has been a technological takeaway for the developed countries. Defined as the use of communication networks for the exchange healthcare information to enable clinical care, it is increasingly being viewed as a tool for improving care and enhancing access to healthcare. Telemedicine helps to connect remote rural hospitals/health centres to super specialty hospitals located in the cities and helps patients in remote and rural areas to avail timely consultations from specialist doctors without the ordeal of travelling. eHealth India 2007 will deliberate on such initiatives and many other excellent though scattered efforts in this field and bring it together to form a conduit of critical information.

INDIA

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ommun ty Rad o

INDIA

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The Indian telecom sector after liberalisation has shown tremendous growth with its growth rate being one of the highest in the world. The mobile phones apart from bringing in the aspect of mobility in connectivity have an inherent ease in terms of usage unlike computer-based connectivity, which requires people to be literate and e-Literate at the same time. In a nation plagued by connectivity lapses, mobile technology may well emerge as the key to bridging the digital divide. mServe India 2007 will showcase the immense potential of mobile technology in the implementation of existing and future m-Government, m-education, m-agriculture and other applications.

Amongst all the broadcasting media in India radio has the highest penetration and thus makes it the media which can reach the rural and remote areas servicing even the unlettered and illiterates. Realising its potential in November 2006, after seven long years INDIA of lobbying by groups like the Community Radio Forum, that the government finally 2007 accepted to make changes in the Community Radio Policy, to allow community based groups to set up their own radio stations. Community Radio India 2007 will bring together key stakeholders on a common platform to take the community radio movement in India to the next level.

e-Agriculture India 2007 will explore the opportunities of how ICTs can be used to improve the lives of the rural communities. Timely information on weather, disasters, improved agricultural practices, commodity prices and market information would greatly benefit farmers directly to minimize the risks and provide opportunities for enhanced incomes while cutting out high debt servicing costs, and taking informed decisions. The impact is felt directly with improved incomes and savings, access to services and valuable connections with stakeholders. The Universities, policy makers, development specialists and NGOs working for the farmers’ interests would explore the current developments and scalability of experiments.

www.eINDiA.net.in

i4d Film Festival “A picture speaks a thousand words”… The audio-visual medium is obviously an extremely powerful tool that can change the way global dialogues take place.

The first attempt of its kind in this arena, CSDMS will bring together over 50 films at the upcoming eIndia2007 forum. The features, long and short, will be gathered from around the world through the well-established networks that we already foster.

Grassroots representation from not only India but around the world in the various cinematic forms will constitute the world's first ICT4D film festival. The film festival will cater to all sections of the ICT4D domain.

Interested persons are requested to visit our website at http://www.eINDIA.net.in/films to download the application form and guidelines. All submissions will be reviewed by the festival committee. Please be advised that we do not return VHS tapes or DVDs. We will contact those film-makers whose films/videos are accepted to participate in the festival.

For any further enquires, please contact Sulakshana Bhattacharya at sulakshana@eINDIA.net.in or call at +91 98119 25253.

Call for Proposals for Special Sessions/ Workshops@eINDIA2007 CSDMS would like to invite you to co-host a session/workshop under the umbrella of eINDiA2007 Criteria for Participation ● The activities of the co-hosted sessions/workshops should have direct links with one of the six tracks under the eINDiA2007 banner (i.e e-Governance, digital Learning, eHealth, Telecentres, m-services, Community Radio and e-Agriculture) ● The responsibility of the content and conduct of the session will remain with the organisers of the session ● The submitting organisation must have a proven track record in delivering major impact on ICT4D issues.

The following entities can submit proposals for co-hosted sessions/workshops: ● Government Agencies ● International Inter-governmental Organisations ● Bilateral & Multilateral Development Agencies ● NGOs/Civil Society Organisations

How to submit a request Any organization interested in co-hosting an event must submit a request at sulakshana@eINDIA.net.in attaching a detailed description of the proposed event, including its thematic focus and the planned speakers/presenters.

Past Sponsors and Exhibitors

empowering education... enabling careers

®

Sida

Centre for Science, Development and Media Studies (CSDMS), G-4, Sector - 39, Noida, Uttar Pradesh - 201301 Phones: +91-120-2502180-85 Fax: 91-120-2500060

For any information/enquiry contact Sulakshana Bhattacharya Tel: +91-9811925253 email: sulakshana@eINDIA.net.in

www.eINDIA.net.in

Profile: Allscripts Healthcare Solutions

Scripting an aggressive growth strategy in e-Health The US company is a pioneer in ICT-driven healthcare

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he advent of electronic health records (EHR) heralded the automation of healthcare delivery and became a significant landmark as the discovery of penicillin in the medical world. Technological advances are helping the healthcare sector towards better gathering, processing, management and distribution of medical data.

However, EHR is just a beginning in the rapidly expanding technology solutions market in healthcare.

Policy shifts by various governments favouring cost-effective, high quality healthcare delivery are driving the healthcare technology market at an exponential rate.

This growth is set to increase in the coming years as wider penetration of ICT in healthcare will become unstoppable. A study by the Rand Corporation suggests the savings in costs; it sees a saving of $80 billion in the annual $1.6 trillion healthcare budget of the U.S, if IT tools are to be used very judiciously.

What is more, e-prescribing has significantly reduced the estimated 7000 deaths per year due to medication errors, March 2007 | www.eHealthonline.org

reports eHealth Initiative (eHI), a Washington D.C based non-profit organization, and suggests electronic prescribing having the potential to save $30 billion in health care.

Allscripts Healthcare Solutions, headquartered in Chicago, is a leading player in the technology market in healthcare. Allscripts portfolio comprises clinical software, connectivity and information solutions, along with practice management solutions.

The Clinical Solutions arm of the company provides clinical software solutions, including electronic health record (EHR), electronic prescribing (e-prescribing) and document imaging solutions. The clinical solutions include TouchWorks, TouchScript, and TouchChart. The Practice Management Solutions comprise HealthMatics HER, HealthMatics Ntierprise, HealthMatics ED and EmSTAT and Canopy.

In the U.S, TouchScript is a widely used e-prescribing solution. This software enables physicians to quickly generate and

In the U.S, TouchScript is a widely used e-prescribing solution. This software enables physicians to quickly generate and send prescriptions from the exam room to the pharmacy, using a wireless pocket PC device. With a touch of the screen, TouchScript physicians get instant access to dosing information and insurance status and a feedback on possible drug interactions, prior adverse reactions and allergies; thereby giving a measure of patient safety to each prescription send prescriptions from the exam room to the pharmacy, using a wireless pocket PC device. With a touch of the screen, TouchScript physicians get instant access

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Main competitors of Allscripts in the EHR and practice management are Cerner, eClinicalWorks, Emdeon, Epic Systems, GE, iMedica, McKesson, Misys Healthcare and Quality Inc. In the hospital segment, they are MedHost, Picis and Wellsoft Corporation.

Allscripts’ Physicians Interactive Group faces competition from Aptilon Inc, Dendrite International Inc, Emdeon Corporation, Lathian Systems Inc, Medsite Inc, Quintiles Transnational Corp and Ventiv Health Inc.The Medication Services Group of Allscripts has competitors in Cardinal Health Inc., DRx, McKesson Corporation, PD-Rx Pharmaceuticals, Pharmapac, Physicians Total Care and Southwood Pharmaceuticals.

Inorganic Growth to dosing information and insurance status and a feedback on possible drug interactions, prior adverse reactions and allergies, thereby giving a measure of patient safety to each prescription.

The TouchScript e-prescribing solution is used by physicians, on Dell Axim X3i Windows mobile-based pocket PC devices, and connects to the Internet via Cisco

handheld devices, desktop workstations and the Internet.

Physicians Interactive Group of Allscripts covers clinical education and information solutions for physicians and patients with physician-patient connectivity solutions. Allscripts’ Medication Services Group offers prepackaged medication fulfillment

The US healthcare IT market is to the tune of $20 billion. By 2011 it is expected to reach $35 billion in sales; a 14 percent annual compounded growth rate. The hospital segment, now contributing a larger portion of the market with 53 percent of sales, will see it diminishing by 5 percent in another four years ...

Aironet Wireless Access Points.

TouchWorks software is a modular electronic medical record (EMR) that enhances physician’s productivity by automating the common activities like prescribing, dictating, capturing charges, ordering labs and viewing results, providing for patient education and documenting clinical interactions. TouchWorks is available on the latest tablet PCs, wireless

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solutions, including medications and software for dispensing and inventory control. Hospital emergency department information systems automate emergency room processes, including patient registration, triage, tracking and reporting.

It enables emergency department information systems in hospitals to manage patient flow and the emergency department activity.

Allscripts’ take over of ChannelHealth from IDX Systems last year has signaled the rapid expansion of e-Health industry.

Expanding its market presence further, it added thousands of physicians to its client list. IDX is a wholly owned subsidiary of General Electric Company (GE). Allscripts provides ambulatory, point-of-care clinical EHR solutions to IDX’s physician customers, numbering about 1.5 lakh.

Incidentally, Allscripts Healthcare Solutions is a Microsoft health care go-tomarket partner and charter member of Microsoft’s Mobility Partner Advisory Council (MPAC).

The US healthcare IT market is to the tune of $20 billion. By 2011 it is expected to reach $35 billion in sales; a 14 percent annual compounded growth rate.

The hospital segment, now contributing a larger portion of the market with 53 percent of sales, will see it diminishing by five percent in another four years, touching 48 percent.

The homecare and nursing sector will overtake the hospital sector with about 51 percent share by 2011. The former, having a market size of $10 billion, is growing at 15 percent, and may touch $18 billion by 2011. With a rapidly growing market behind it, Allscripts can expect more growth ahead. eHealth | March 2007

Book Review

Knowledge Management in Healthcare Demystified Dealing with KM applications in healthcare is a challenge

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nowledge management is the key to modern healthcare environment.The book, Healthcare Knowledge Management, Issues, Advances and Successes, targets practising professionals and students in medical informatics, hospital administration and knowledge management.

The editors of this book have put together some good pieces from international contributors, reflecting the diversity of KM applications in healthcare sector. Unlike other KM texts, which suffer from pitching theoretical issues at a technical level, this one adopts the twin approach- academic as well as commercial. Dovetailing the two, the book doubles up as a practical guide, managing and developing KM, underpinned by theory and research.

The book explores the challenges in knowledge management within contemporary healthcare and related organizations. The readers gain an insight into the various approaches to critical nature and use of knowledge, through investigation of healthcare-based KM systems.

Healthcare practitioners and managers face clinical situations where they have to think fast and process a large number of diagnostic test results, medications and post-treatment responses to arrive at good decisions.

Effective problem solving in a clinical environment or classroom simulated lab March 2007 | www.eHealthonline.org

The Evolution ...

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nowledge management is a business activity now. Management theorists like Peter Drucker, Paul Strassmann and Peter Senge have stressed the growing importance of information and explicit knowledge as organizational resources. Recognition of the growing importance of organizational knowledge was accompanied by concern over how to deal with exponential increases in the amount of available knowledge and increasingly complex products and processes. Knowledge managementrelated articles began appearing in journals like Sloan Management Review, Organizational Science, Harvard Business Review, etc. In the nineties, knowledge management became popular in the media following Tom Stewart’s ‘Brainpower’ in the Fortune magazine. By the mid-1990s, thanks to Internet, knowledge management thrived. The International Knowledge Management Network (IKMN), in Europe went online in 1994, followed by Knowledge Management Forum of the U.S. The funding for KM-related projects came through the ESPRIT programme of the European Community in 1995. depends on access to fresh information.

The challenge for healthcare practitioner is to manage knowledge, even when options like consulting a library stands closed.

The book has succeeded in demystifying the KM process and in demonstrating its applicability in healthcare, at the same time offering contemporary and clinically relevant lessons for future organizational implementations.

The editors are Bali, Rajeev K. Dwivedi and Ashish N. The table of contents include: New Healthcare Management Paradigms: A Case for Healthcare KM

Clinical Knowledge Management - A Model for Primary Care Role of Information Professionals as Intermediaries for Knowledge Management in Evidence Based Health Care Healthcare Knowledge Management and Information Technology: A Systems Understanding Medical Technology Management in Hospital Certification in Mexico Healthcare Knowledge Sharing: Purpose, Practices and Prospects Healthcare Knowledge Management: Incorporating the Tools, Technologies, Strategies and Process of KM to Effect Superior Health Care Delivery.

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An e-healthy gift to USA’s ageing population Getting a head-start on assessment and intervention for age-related conditions such as Alzheimer’s disease and injuries from falls is the goal of the collaboration between Intel Corporation and Oregon Health & Science University (OHSU).

Intel, a global leader in silicon innovation, has given a research grant of $1 million, renewable up to three years, which will enable researchers to focus on improving the quality of life of the USA’s ageing population by developing behavioural marker technologies that help to sense changes in behaviour and, in doing so, provide earlier detection and more effective and personalized treatment.

Over the years, Intel has provided OHSU with grants to support the development of this unique research.

However, with the rapidly growing challenge of ageing, Intel has decided to increase the attention and investment through research partnership with OHSU. From the development of hardware, such as gait and speech sensors, to that of software designed to aggregate data and create coaching tools, this funding may lead to research results that may translate into new products and services, supporting healthy and independent ageing.

Intel has created the Behavioral Assessment and Intervention Commons (BAIC), a unique US-based

academic-industrial collaboration that constructs a research commons — a shared pool of tools, technology and thinking — around behavioural markers and health outcomes. This collaboration promises to bring resources and attention to the development of healthcare technologies that will create sensors and other behavioural assessment tools to provide early detection and intervention. This research grant will foster the BAIC collaboration.

Behavioural markers are an exciting, emerging area of research, focusing on measurable changes in behaviour that might help us discover a medical problem earlier, notice an important trend in dealing with a chronic disease, or help us personalize treatment for a particular person’s needs. “Alarmingly, it is a worldwide problem that healthcare focuses on crisis, not prevention or early detection, and Intel is committed to supporting research initiatives that will create new technologies for early disease intervention,” observed Eric Dishman, General Manager of Intel’s Health Research and Innovation Group. “Most healthcare solutions are established on large population-based studies, underscoring the need for personalized treatment. Intel is launching the BAIC program to bring resources and attention to this promising technology area. We hope to grow the field of behavioural assessment and intervention technologies,” he added.

Arizona takes a step ahead in health informatics The state of Arizona, US is making significant inroads into e-Health, more specifically into health informatics.

The state will develop a computerized medical record-keeping system for those patients, who are enrolled in the state’s publicly funded healthcare system- Arizona Health Care Cost Containment System- and for this a federal grant of $12 million has already been allocated. The funding will be done by the US Department of Health and Human Services and the pilot testing of the system will commence from January 2008.

This innovative step would not only reduce the number of medical errors, but would also improve patient care and make the cost of medical record keeping significantly cheaper. The availability of patient medical records on a computerized database will enable doctors to be more informed and educated about their patients’ medical history and ailments, thereby improving the healthcare system.

However, confidentiality of the patients will not be compromised for medical efficiency. Records would be password protected and some could be backed up with paper files or electronically. The project is likely to be completed by the end of 2011.

Futuristic robotics to retrieve quality patient-medico time Europe is an ageing society, where patients-to-medics ratio is continually on the rise, leading to adverse effects on the quality of healthcare, and increase in recovery time. Intelligent robot swarm for attendance, record, cleaning and delivery (IWARD) project is the answer to this nagging problem.

IWARD focuses on hospitals and healthcare centers to overcome the paucity of healthcare staff, a major problem of European healthcare

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industry. This project proposes a robot swarm to deliver support to oversee activities in healthcare environments; providing a multipurpose, costeffective and scalable solution to enhance the quality of healthcare.

The project has a gestation period of 36 months, and it commenced on January 2007.

With a budget of 2.79 million euro, the project is scheduled to be executed

by Dec 2009. In the project, four major tasks of the healthcare robots are being envisioned as attendance, recognition, communication and support. In technical terms, attendance means to monitor hospital wards by robots acting as a dynamic swarm.

Recog-nition points out that the swarm is able to recognize patients or objects needing attention, providing imme-diate information about the location and needs of the concerned eHealth | March 2007

patients. The robots would be equipped with different adaptable hardware components for floor cleaning and delivery of food, linen, medicine, etc. and all mobile healthcare robots would be capable of providing patients and visitors to the hospital with guidance and information.

with an array of sensors to enable it to move around the hospital. The proximity sensors will enable them to avoid collusion. They would also have inbuilt cameras, which will enable them to explore their environment.

Moreover, one robot will be able to warn another robot, if its cameras detect a collusion.

Each robot will consist of a basic platform, mounted with a module of sensors and equipment, in order to perform varied tasks. The healthcare robots would also be programmed to guide visitors around the hospital.

Each of the robots would be equipped

Robots could coordinate or communicate with each other either through a wireless Local Area Network (LAN) or Bluetooth technology or even infrared lasers. The possibilities are open regarding this.

The project also envisages that the

e-Records go wireless Toronto-based Sherbourne Health Centre, which primarily works with homeless people and recent immigrants, is using wireless technology to ensure that its electronic medical records can be accessed during any point of treatment and care. This will ensure that electronic records are connected by the wireless technology.

The wireless network will be connecting the clinic, the buses of the Sherbourne Health Centre and the new infirmary of the center. According to Sherbourne Health Centre’s Senior Networks and Systems Administrator, George Pinto, the infirmary will be equipped with a host of IT options to enable better healthcare, including VOIP and WiFi. Presently there are two laptops per bus and wireless technology allows the nurses to connect back to the EMRs at the centre via Microsoft Terminal Server.

The networks between the clinic, buses, and infirmary, and the infirmary itself should be operational by the fall.

This technology will pave the way for continuity of care, savings in medical costs and reduce duplications of efforts, and will also address the problem of severe paucity of healthcare practitioners, which plagues Canada’s health scenario in a big way.

This initiative will be funded by an investment of $900,000

by Canada Health Infoway, an e-Health non-profit advocacy group. Besides establishing the network between the clinic, mobile health buses and the infirmary, the funding will also improve the existing connections and IT outfit of the infirmary.

The wireless network between these healthcare infrastructure units of the Sherbourne Health Centre will also facilitate the medical professionals to remotely keep track of the elements and symptoms of many diseases, which needs regular monitoring. This will help the patients

March 2007 | www.eHealthonline.org

mobile robots would communicate with patients and pass messages on to the staff, and could also coordinate with each other regarding the assigned tasks. This futuristic robotics would give the doctors and nurses more time with their patients, and thereby strengthen the good oldfashioned philosophy of patient care.

The success and fruition of this innovative technology will lead to fast identification and location of patients needing immediate care and relief, drastic reduction of human errors, much more cleanliness in hospitals, and wider reach of specialist medics.

suffering from chronic diseases like diabetes, respiratory problems, etc. without putting a great load on the hospital’s health infrastructure.

Here comes Dr. Robot Now the stroke victims in the Livingston County, USA can have a stroke of luck. A new diagnostic robot can ensure them better healthcare than the average stroke victims in other parts of the USA. The robot, named as RP7, will enable teleconferencing between St. Joseph Mercy Livingston Hospital in Howell and endovascular surgeons at St. Joseph Mercy Oakland Hospital in Pontiac, which is a major stroke intervention center.

The robot uses telemedicine to enable physicians discuss and consult online, which can save precious time. This will enable the specialists from Pontiac to ascertain if the cardiac patients need to be immediately transferred to the St. Joseph Mercy Oakland Hospital in Pontiac, without any unnecessary delay. Now specialists in Pontiac can listen to the heartbeats and lung sounds of the affected patient and also discern if there is a blockage in the carotid artery by using a stethoscope transmitted by the robot.

That’s not all. Now the doctors in Pontiac can also ask patients at the Livingston County hospital to respond to them, by doing such physical tests as holding their hands in the air and opening and closing them.

Through this robot the patients and their families can also communicate with the physicians at mutually convenient times, which endows the innovative technology with great interactivity. The Pontiac doctors can also communicate from the comfort of their homes, through this robot. The in-built camera of the robot links the family to the doctor.

The robot, which incurred a cost of $220,000, was financed by the Michigan Stroke Network. It is a network to which St. Joseph Mercy Livingston Hospital in Howell recently joined.

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New York Mayor takes a proactive stand on health informatics US, it seems is taking the lead and showing the way in e-Healthcare.

Recently Michael Bloomberg, the mayor of the New York City, has urged for universal electronic health records by 2012 at the National Health Policy Conference.

He said that five years from now every clinic, hospital and doctor’s office in the US which comes under the ambit of Medicaid and Medicare, should use prevention oriented e-Health records. According to Bloomberg, the total estimated cost of the transition to electronic records is pegged at $20 billion.

However, this is not all empty talk as New York has become one of the first cities in the globe to introduce electronic health records in public hospitals and community health centers. The city health department is even introspecting on building a national model for electronic health records. But, according to Bloomberg, local governments cannot achieve this transition single-handedly.

According to him, the federal government can facilitate to achieve this five-year goal by giving doctors and hospitals necessary funds to procure computers, and restructuring Medicare and Medicaid reimbursement packages through rewarding providers, who can show that they are using the electronic health records to focus on prevention, and on emphasizing primary care. However, though many bills to execute electronic health records have been proposed in the Congress, but none graduated to become a legislation.

According to Bloomberg, this hesitation is impeding the progress in adopting electronic health records.

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India to get mobile phone based health monitoring system UK-based Loughborough University’s engineers have entered upon a partnership with experts of India to develop a unique mobile phone health monitoring system. The device, which was first unveiled in 2005, uses a mobile phone to transmit a person’s vital signs, including the complex electrocardiogram (ECG) heart signal, to a hospital or clinic anywhere in the world. Professor Bryan Wood ward and Dr Fadlee Rasid from the Department of Electronic and Electrical Engineering at the Loughborough University have developed this mobile phone monitoring system.

Presently the system can transmit the signals pertaining to the ECG, blood pressure, oxygen saturation and blood glucose level.

Delhi will form a new mobile- health partnership ‘hub’. The research team is aiming to miniaturise the system, through designing sensors and miniprocessors that are small enough to be carried by patients, and at the same time procure biomedical data. The network of sensors would be linked through a modem to mobile networks and the Internet, and to a hospital computer. Then, doctors can use this device to remotely monitor patients suffering from chronic diseases, like heart disease and diabetes, which plagues millions across the world. “I am delighted to have gained the support of the UKIERI to take this lifeenhancing research to the next level – and tap in to the knowledge of experts in India,” asserted Prof. Woodword.

Now the UK-India Education and Research Initiative (UKIERI) has awarded Professor Woodward a grant to further develop this mobile phone monitoring system. They have tied up with the Indian Institute of Technology, Delhi (IIT Delhi), the All India Institute of Medical Sciences and Aligarh Muslim University and London’s Kingston University, to further develop the system. The project will be managed by Loughborough University, which with IIT

The UK government will promote the device to improve the efficiency of healthcare delivery. In India, the project will link clinics and regional hospitals in remote areas to centres of excellence. The clinical trials of the system will take place in the UK and India in the next three years. This technology will be a great help to the people of India, who are direly needing expert diagnosis. It is also expected to be a boon for patients undergoing post-operative care.

Incorporating mobility with quality in patient care Royal Philips Electronics has announced its plan to manufacture a Mobile Clinical Assistant (MCA), which has the potential to facilitate healthcare in a big way in the near future. The MCA would enable nurses and physicians to improve bedside patient care by using an integrated, wireless device to connect to patient information stored in electronic medical records. The MCA is a new category of mobile point-of-care devices that was designed with input from clinicians and through clinical workflow studies, interviews and ethnography research, conducted by Intel Corporation. The overall concept of the MCA has been defined by studying different usage models, with direct input from clinical staff. In fact, the Philips MCA brings a number of technology features together into a single platform. The portable, always connected device is designed to require minimal training and provides significant benefits to the clinical users, helping to reduce medication errors, positively identify staff and patients, fill out charts, capture vital signs, write up reports and validate blood transfusions as well as the ability to closely monitor the healing of wounds. eHealth | March 2007

NEWS

Business A partnership to enhance virtual medical care

WebVMC, the developer of the RemoteNurse™ telehealth system that enables 24 hour virtual medical care for remote disease management, has entered into an exclusive partnership with Home Telehealth Ltd. (HTL); one of the United Kingdom’s leading providers of telehealth products and managed care services. WebVMC provides virtual healthcare technology, using the Internet to manage care for the person with a chronic illness, thereby connecting the patient, caregiver and clinician for 24-hour disease management from any location, in multiple healthcare delivery systems, such as home care, hospitals and assisted living facilities.

Under this partnership, HTL will distribute WebVMC’s softwarebased telehealth monitoring product

in the United Kingdom and 25 other EU countries.

The announcement was made by Scott Sheppard, President and Chief Technology Officer of WebVMC, and Peter Range, Chief Executive Officer of HTL. Furthermore, US-based WebVMC’s expansion into international markets will assist HTL in its efforts to provide telehealth solutions with a strong emphasis on patient education and empowerment, so that people are fully informed about their condition and are better able to manage it.

“We selected WebVMC as we feel it is clearly the ‘best of breed’ technology available in home healthcare monitoring, empowering those with longterm conditions to do more to care for

themselves,” said Range.

WebVMC’s Sheppard said the main distinction between other telehealth options and his company’s product is its unique features, which include multi-patient, multi-language, multiplatform and customizable disease management capability. “Most telehealth products simply provide disease monitoring through existing systems,” Sheppard stated. “But our software-based technology offers increased connectivity and the ability to access healthcare data via the Internet, which allows patients at home to obtain a speedy intervention if their health deteriorates. This timely response could prevent an unnecessary hospitalization and allows the person to stay at home and remain independent, added Sheppard.”

Siemens to manage information technology operations of Touro Infirmary Siemens Medical Solutions, one of the world’s leading suppliers to the healthcare industry, known for bringing together innovative medical technologies, healthcare information systems, management consulting, and support services, to help customers achieve tangible, sustainable, clinical and financial outcomes, has signed a strategic agreement with Touro Infirmary of New Orleans, USA. Under this agreement, Siemens will provide Touro Infirmary with a long-term information technology (IT) managed services solution. The solution includes the management of Touro’s complete IT operations and the implementation of Siemens’ Med Administration Check™ solution. Here it deserves a mention that Touro Infirmary, founded in 1852, is a not-for-profit, community-based hospital, which for more than 150 years has been a vanguard of medical excellence.

By looking to Siemens for management of its IT operations, Touro benefits from Siemens’ expertise in complex healthcare and IT infrastructures. Siemens will work with Touro to create operational and financial efficiencies, maximizing its investment in IT resources, and achieving its strategic business objectives. As a result of the expanded relationship, Touro and Siemens employees will work collaboratively to deliver advanced

March 2007 | www.eHealthonline.org

IT solutions, designed to meet the organization’s needs.

According to Janet Dillione, President, Health Services, Healthcare IT Division of Siemens Medical Solutions, “We see tremendous potential to transform the entire healthcare industry through innovative solutions and strategic customer partnerships that enable healthcare providers to focus on the business of patient care. We look forward to expanding our long-standing partnership with Touro in support of their goals for enhanced patient safety and measurable operational improvements.”

Touro has implemented a wide range of Siemens INVISION® applications throughout its healthcare enterprise, using INVISION to streamline information across clinical, financial, and administrative functions to help improve patient care and outcomes. Touro will also adopt Siemens’ Med Administration Check, designed by nurses and pharmacists to support and improve nursing medication administration workflow, with online, point-of-care information technology that helps reduce errors. Additionally, Siemens provides Touro with leading-edge diagnostic imaging technologies including integrated solutions for interventional cardiology, nuclear medicine and echocardiography.

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INDIA UPD ATE UPDA

NEWS

Alwar gets the joy of good health Thanks to the new telemedicine center at Neemrana- a non descript village in the Alwar district of Rajasthan, known for its Neemrana Fort - the healthcare scenario of Alwar district in Rajasthan is all set for a positive change. The new telemedicine centre at Neemrana village has been set up by a NGO named Khushii, in technical collaboration with the Fortis Charitable Trust. Khushii has started the centre as part of its ongoing Neemrana Community Development Project. The Fortis Charitable Trust that runs more than 20 telemedicine centres in north India, has joined hands with Khushii as part of its endeavour to generate increasing awareness and providing adequate medical care to the underserved community of India.

The telemedicine center, named as Khushii Telemedicares, has telemedicine networks with Fortis hospitals across India, which now enables the residents of Alwar district, and more particularly the underprivileged villagers from Neemrana and other villages in its vicinity, to access world class medical care within their geographical and financial reach.

Except the registration charge of Rs 50, the patients coming to this telemedicine centre do not have to pay any other fees.

Already the centre is registering 25 patients per day, on an average. The numbers are expected to go higher as the word of mouth catches on.

The centre is well-equipped with an X-ray machine, an ECG, and a fully equipped pathology lab for testing.

Of course, the telemedicine room has a huge television screen, a camera, mike and speaker, and a special computer with broadband facility. About seventy percent of the patients coming to the telemedicine centre to consult with the Fortis specialists, are afflicted with osteo-arthritis.

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A digital wave sweeps through Orissa’s rural healthcare From now on Orissa will not only be known for its rich cultural heritage and turbulent beauty of Bay of Bengal. The state is enhancing its perennial appeal by embracing tomorrow’s technology. The state of Orissa in India is all set to spearhead a digital revolution in the rural healthcare system. Already three government medical college hospitals of the state are linked through telemedicine service, and very soon all the 30 district headquarter hospitals of this state would be linked with the state’s referral hospitals. The telemedicine facilities of the state will be monitored by an exclusive telemedicine centre with state-of-the-art techniques, installed at SCB Medical College and Hospital, located in Cuttack. In the first phase, district headquarter hospitals in Kalahandi, Koraput, Sundargarh and Mayurbhanj would be linked with the three medical college hospitals, which will enable the rural patients from remote corners of these tribal dominated districts to access specialists in the city, merely with the click of a mouse. The state government has approached the Indian Space Research Organisation (ISRO) to provide equipments to facilitate the progress of telemedicine in Orissa. According to Dr. B.N. Mohanty of SCB Medical College and Hospital, equipments worth about Rs. 8 lakhs would be required for each telemedicine center. Telemedicine facility would be extended to other districts in the state in a phased manner as soon as the diagnostic centres at their district headquarter hospitals are ready.

Health outlay hiked in the Union Budget The Union Government has proposed to enhance the allocation for the National Rural Health Mission (NRHM) from Rs.8207 crore in 2006-07 to Rs.9947 crore in 200708. Presenting the Union Budget for 2007-08 in Lok Sabha on 28 th February 2007, the Finance Minister, P. Chidambaram said that the major emphasis would be on mother and childcare and on prevention and treatment of communicable diseases like TB and malaria.

Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) systems were also being mainstreamed into the health delivery system at all levels. Polio eradication programme has been integrated with NRHM and Rs.1290 crore has been allocated to this segment, with the aim of eradicating the menace of polio from India.

Chidambaram further stated that the government has brought HIV/AIDS out of the closet and promised bold, determined initiatives to achieve zero-level growth of the disease.

The epidemic will be deemed ‘stabilised’ if the prevalence rate is less than one per cent of the population. The Finance Minister announced that the National AIDS Control Programme (NACP)-III, starting in 2007-08, would target the high-risk groups in all the states. Furthermore, Chidambaram proposed to step up the provision for the AIDS Control Programme to Rs.969 crore, for the fiscal year 2007-08. Overall, the finance minister enhanced the expenditure on health and family welfare by 21.9 percent as compared to that of the current fiscal.

Now the challenge lies in sprucing up this healthy element in the Union Budget, through innovative applications of ICT in healthcare, which in turn will facilitate the percolation of these budget measures and proposals to the underprivileged and underserved sections of the Indian society, who do not have access to even basic healthcare.

eHealth | March 2007

Funding

Euro-India ICT Cooperation Initiative Workshops To enhance India’s participation in FP7

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he Euro-India ICT Cooperation Initiative, a project funded by the European Union, aims to identify the research excellence and expertise in India across academia, research and enterprise segments, in order to bring them at par with their European counterparts with the aim of developing collaborative projects; which could benefit from the substantial funds that the European Union spends on R&D in ICT. This initiative enjoys the full support of the Ministry of Information Technology of the Government of India. Many of the IITs, frontline universities and CDAC centres support this innovative initiative actively.

The two workshops, organised in Pune and Hyderabad during January 2007 by the Euro–India ICT Co-operation Initiative (www.euroindia-it.org), focussed on the growing opportunities for Indians to participate in European research funding and strengthen India’s participation in Framework Programme 7

(FP7). FP7 is Europe’s main tool for funding research projects, running from 2007-2013.

The objective of these workshops was to facilitate Indian organisations, particularly from academia and research, to find partners in Europe with whom they can plan proposal writing for the EU's current funding stream (2007-2013). These two workshops leveraged the success of other three Euro-India ICT workshops, held earlier in Bangalore, Mumbai and Kharagpur.

Over 15 speakers from leading IT enterprises, research organisations, and experts from European funded projects provided a first-hand look at European projects, challenges, solutions and new ideas. European experts explained the inner workings of EU-funded research projects with a practical guide on how Indians can get involved in successfully funded international research projects.

Ravi Jain, Vice-President, Tech Mahindra Limited, India said, "The EuroIndia ICT Cooperation Initiative provides Indian enterprises with the opportunity to interact and network with experts from industry and academia, to innovate and develop solutions with the help of information and communication technologies (ICT); addressing challenges that we all face.”

Upcoming Workshops

Looking beyond the perceived potential March 2007 | www.eHealthonline.org

Two more workshops are planned during March 2007 – one in Kanpur and another in Chennai. The Euro-India ICT

A united initiative in progress

Cooperation Initiative is organising the third of a series of workshops on 27 March 2007 in Kanpur, with the objective of unveiling the potential of collaborative research between the European Union (EU) and India in the domain of information & communication technologies (ICT).The day-long workshop will be held at the Indian Institute of Technology (IIT) Kanpur campus. It is significant that ICT is the most prominent domain in FP7 with ambitious research objectives and ample funding.

The Kanpur workshop will be followed by another similar workshop on 29 March 2007, in Chennai, to be organised by the Euro-India ICT Cooperation Initiative.

The day-long workshop will be held at the Indian Institute of Technology (IIT) Madras campus, and it is geared around the same objective as that of the Kanpur workshop.

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Focus

Social Commitments Reaffirmed NASSCOM’s conclave identifies healthcare as key area of action

T

hat India’s social problems are high on the agenda of technology companies was in evidence at The Global CSR Conclave, organized by NASSCOM Foundation in Mumbai, on 9th February. The event was significant for its exemplary focus on social issues pertaining to livelihood, healthcare, and education, with the CSR track having a theme, “Community Development: A Social Investment and Economic Exercise.”

If initiatives by NASSCOM Foundation are any indication, the technology companies, mainly those in software, are keen to shed the elitist sheen and seen tackling complex social issues that perturb the underprivileged sections of the society.

The conference brought lot many perspectives in focus and touched a plethora of issues where corporate social responsibility has a stake. This holistic objective reverberated all through the conference, with the desire to enlarge the role in social space and gain an edge in global markets.

Nobel laureate Amartya Sen, who delivered the keynote address, lauded the new effervescence in the IT industry and called it a “step in the right direction”.

Laced in humour, Amartya Sen noted that when he received the invite, he had “wondered why NASSCOM was inviting an economist like me and I doubted whether it could have been a case of mistaken identity.”

On a serious note, Sen reminded that

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Amartya Sen releasing the souveneir at the CSR Conclave, organised by NASSCOM Foundation

the IT industry was obligated to the Indian society because, if not for the focus on technical education after Independence and the liberalization that happened in 1991, the IT industry would not have been in a position where it was now.

IT sector has a big responsibility towards making India a more equitable country.

One of the huge obstacles to the development of the local market was the low priority and investment in literacy, schooling and healthcare.

Making a comparison between India and China, Sen observed, “One of the reasons for the larger domestic reach of IT

in China is its much wider base than India, borne out of good schooling. The same goes for a much wider base of elementary healthcare in China, though this has been going through a turmoil, after the Chinese economic reforms started in 1979 and abolished free healthcare and asked citizens to rely more on privately purchased health insurance”.

Looking at the healthcare scenario in India, Sen called for sustained action to expand its reach and quality, where technology industry can contribute substantially because of its resources and pool of quality manpower. Quoting a eHealth | March 2007

historical anecdote, Sen observed that the Chinese traveller Fahian had recorded, centuries ago, after a visit to the then Pataliputra and now Patna, that the “Indian medical care was much better than the Chinese medical systems in terms of quality and reach.” Sen quipped that now the truth is in the opposite.

Amartya Sen released ‘Catalysing Change’ – the annual publication of NASSCOM Foundation on the occasion.

The publication compiles the CSR survey, entailing Indian IT industry’s social commitment and the roadmap towards societal development with an explicit CSR-focus.

NASSCOM Foundation is already working on healthcare as a key CSR area.

It may be racalled that the U.S. Agency for International Development (USAID) is already working with NASSCOM Foundation in the realm of HIV/AIDS eradication. Last year, they held a conference of CEOs of leading IT companies in Mumbai, and deliberated on HIV/AIDS issue and the roles that corporates can play. The conclave has resolved to galvanize the domestic IT industry towards HIV/AIDS policies into workplaces, which are to play an active role. The joint statement on HIV/AIDS

NASSCOM Foundation is already working on healthcare as a key CSR area. It may be racalled that the U.S Agency for International Development (USAID) is already working with NASSCOM Foundation in the realm of HIV/AIDS eradication. Last year, they held a conference of CEOs of leading IT companies in Mumbai, and deliberated on HIV/ AIDS issue and the roles that corporates can play. The conclave has resolved to galvanize the domestic IT industry towards HIV/AIDS policies into workplaces, which are to play an active role.

by U.S. President George Bush and Prime Minister Manmohan Singh in 2005 mandates private sector and corporate partnership on healthcare related actions, under the ‘Indo-U.S. Corporate Fund for HIV/AIDS’.

Other stalwarts who spoke on the track included Dr.Paul Ackerman, Advisor, Accessibility Practice – Iridium Interactive Limited; Nandan Nilekani, CEO & Managing Director, Infosys; Kiran Karnik, President, NASSCOM; Saurabh

Srivastava, Chairman NASSCOM Foundation; Dr. Lavanian, Former CoConvener, Sub-committee on Standards, Govt. Task Force for Telemedicine; Dr. Ganapathy, Head, Apollo Telemedicine Foundation, Chennai; Dr. Kim, Arvind Eye Hospital, Madurai.

Saurabh Srivastava, Chairman, NASSCOM Foundation, explicated the commitment of NASSCOM members towards social sector goals through application of ICT, to transform and empower the lives of the underserved.

Working in the twin areas of ICT for development and corporate social responsibility, the organization, according to Srivastava, “is playing the role of a facilitator, connecting the IT industry with the underserved population, in helping them access information, services and opportunities to build their capacities and realize the potential.”

NASSCOM Foundation and its CEO Rufina Fernandez can be proud in having done a good job, that of communicating the CSR cause forcefully.

The grand finale of the summit had Prime Minister Manmohan Singh attending it, winding up the two-day leadership summit.

-G. Kalyan Kumar

March 2007 | www.eHealthonline.org

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In Conversation

Slow but Steady; Telemedicine Making a Big Headway in India Dr. K. Ganapathy exudes optimism despite many barriers

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he NASSCOM India Leadership Forum, held in Mumbai from February 7-9, provided eHealth the opportunity to interact with many experts, who are working in the field of ICT applications in healthcare. Dr. K. Ganapathy is a luminary known for his pioneering work in telemedicine. In an exclusive interview, he shared his experience and wisdom with us.

Taking a hard look at the telemedicine scenario, Ganapathy prefaced his remarks saying, “The most important advance about telemedicine is that it has come to be recognized as the key to healthcare delivery in suburban and rural areas.

The realization has dawned that telemedicine, in the near future, can provide a level playing field and act as a great equalizer too.”

According to Dr. Ganapathy there are certain institutes in India whose healthcare standards and facilities are more than a match to the prevailing international standards, but the miserable fact is that their reach is limited to a few metros and elite sections of the society. “As far as healthcare in India goes, it is not a question of standard, it is a question of reach,” he stated.

A vast majority of Indians do not have

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access to that international standard of healthcare. It is here that telemedicine has a role to play, in bridging this divide in making global healthcare go local. “By definition, telemedicine transcends geographical barriers and makes distance meaningless, that way it is turning geography into history,” he quipped.

Elaborating on the barriers to the spread of telemedicine, the doctor pointed to many lacunae in the system, inhibiting its reach in rural India. Chief among them is the lack of awareness about new technologies, coupled with lots of scepticism towards accepting innovative ideas and technologies (a common feature in any country where literacy levels are relatively low and poverty is widespread), lack of adequate infrastructure in connectivity to transmit images, text, etc. and lack of funds to have access to good medical experts, coupled with the high cost of rare and life-saving medicines.

Despite the roadblocks, Dr. Ganapathy is optimistic of the growth and success of telemedicine in India if collective efforts are in place. “A consortium can achieve much more than individual players working in isolation,” conferred the physician.

Ganapthy called for a national policy on telemedicine to cover accreditation, certification and adherence to uniform

Dr. K. Ganapathy Secretary General of the Asian Australasian Society of Neurological Surgery, and Head, Apollo Telemedicine Networking Foundation drkganapathy@gmail.com

standards. He sounded very passionate on a universal health insurance as the remedy to hasten the rate of success for teleconsultation. “Only universal health insurance can ensure that investigations and treatment follow teleconsultation route,” he affirmed.

Ganapathy claims Apollo Hospital to be a pioneer in telemedicine networking in India. “Apollo Telemedicine Networking Foundation is probably the largest and oldest multi-specialty telemedicine network of South Asia. Way back in 2000, Apollo started its telemedicine network in Aragonda village of Andhra Pradesh,” recalled Dr. Ganapathy.

“It was in March 2000 that Bill Clinton, the then President of USA, formally commissioned the world’s first VSAT enabled village hospital in Aragonda, kickstarting telemedicine in South Asia”, he added. Since then there has been no looking back. What started off as a proof eHealth | March 2007

of concept validation by Apollo for the Indian Space Research Organization (ISRO), has turned out to be a big success story.

Elaborated Ganapati, “So far we have given 2,900 teleconsultations for the poorest of the poor sections in Aragonda and nearby villages. In the past 7 years, Apollo Telemedicine Networking Foundation (ATNF) has set up 95 telemedicine units in India and abroad.”

The overseas telemedicine units of ATNF are located in Colombo, Dhaka, Maldives and Lagos among others, giving ATNF an extended reach across South-Asia. “Today, more than 17,000 teleconsultations are under our belt and ATNF has emerged as the largest multi-specialty telemedicine network in South-Asia”, he disclosed.

In the coming months, Apollo is planning a big-ticket telemedicine workshop, covering all the Indian Medical Association conferences across the country to step up awareness among the general practitioners. “This will facilitate more mobilization towards telemedicine,” informed Ganapathy. The doctor also announced that Apollo group will be adding 100 more telemedicine centers.

Noticing a new paradigm shift in favour of telemedicine, at the central level, Ganapathy observed, “There are significant initiatives from the government of India at the telemedicine front. It is a matter of pride that the Indian government has embarked on a mega project to provide teleconsultation to 53 countries in the African Union, for a period of 6 years. The best part is that the project includes teleeducation also”. Apollo is an active player in this private-public initiative.

Apollo by itself is spearheading many private-public partnership initiatives in the telemedicine front. “The setting up of the National Task Force on telemedicine, constituting a working committee on telemedicine by the Planning Commission, and formation of a National Institute of Medical Informatics and Telemedicine are steps in the right direction and would boost the growth of telemedicine. Apollo is too pleased to be actively involved in all these March 2007 | www.eHealthonline.org

projects,” Ganapathy affirmed.

Talking about the recent advances in the domain of telemedicine; both at the national and global levels, the doctor informed, “Many advances are taking place in acquisition, display and transmission of images, audio and text which are the sine qua non in telemedicine. Now homecare telemedicine is a reality. And mobile telemedicine includes the use of PDA. Teleconsultations aboard a ship, aircraft, prisons or a moving ambulance are routine now. Telementoring and Telesurgery with telerobotics are catching up. Even wireless telemedicine in a Wi-Max environment is going to be achieved.”

But technical advances are nothing without sustained advances in R&D. According to this techno-savvy physician, “Serious research in telemedicine is in two areas; research in peripheral medical devices which can be linked to a PC, and research for developing costeffective transmission of images and audio files, using low bandwidth without losing data and developing of user friendly intuitive software, low cost hardware and so on.”

Dr. Ganapthy conceded, “Social, ethical and legal issues are as important as technical problems,” and added, “there is need for serious research on social issues including factors that hinder the growth and development of telemedicine; and also on issues relating to the acceptability of this technology.”

Ganapathy, who heads the Division of Stereotactic Radiosurgery in Apollo Hospitals, Chennai, ventured into telemedicine in 1999 and has risen in the hierarchy of its apex body; today he is the Joint Secretary and Treasurer of Telemedicine Society of India.

He spoke about the mission of the society, as an organization committed to the growth and development of telemedicine in India.

The society has been holding annual conferences and workshops, creating effective platforms for generating awareness and dissemination of

information on recent developments in telemedicine. According to Ganapathy, TSI is gearing up to organize training programmes and plans to bring out a journal. According to Dr. Ganapathy, “The TSI now represents India on the board of the IsfTeH (International Society for telemedicine and e Health).”

TSI held its first national conference in Bangalore, in 2005, which was organized

by ISRO. The second national conference followed in Delhi in 2006, organized by SGIPGMS Lucknow. The third national conference of Telemedicine Society of India is to be held in Chennai, during 2-4 November 2007, with ATNF as the principal organizer.

Throwing more light on the forthcoming conference, ‘TSI Chennai 2007’, Dr. Ganapathy said, “The conference in November will cater to the experts as well as to the newcomers.

The workshop will be limited to a small number of individuals and there will be hands-on exposure to hardware, software and various peripheral devices, used in telemedicine.”

Participants will also be able to see live teleconsultation from a hospital on wheels.

“The deliberations of the conference in November, if implemented, will hopefully enable us to achieve that critical mass required for a successful take off,” he presumed.

The conference is expected to attract the who’s who of telemedicine from India.

“The delegates would come from the corporate sector, academic institutions, government organizations and ISRO. The vendors of software and hardware, along with manufacturers of peripheral medical devices used in telemedicine will also attend.

Since the IsfTeH conference will take place concurrently, about 40- 50 overseas delegates are also expected. They will include professors from the US-based universities, the UK eHealth association, and representatives from SAARC countries, South- east Asia and the Middle East,” informed Dr. Ganapathy.

-Swarnendu Biswas

35

Health Informatics

e-Learning in Reproductive Health Deployment of e-learning in RH opening up new vistas

A

lthough open access to the reproductive health (RH) literature accelerates the recognition/dissemination of the research findings, its actual effects are often controversial. e-Learning creates new and emerging paradigms in RH education like self-directed learning, limitations of which can defocus the endpoint selection in clinical and experimental trials.

Nowadays, the citation of the open-foraccess (OFA) RH research papers, are gradually dominating upon the citation of fundamental not-open-for-access (NOFA) literature and solid innovative conclusions. The researchers, clinicians, and policymakers must confront the question of whether or not the OFA literature accelerates scientific advancement and knowledge translation of research into practice. Overall, the citation ethics and policy in RH research need to be enforced-catalyzing the scholarly process of bringing the evidence into the action, and helping the clinicians to act on the evidence.

Making RH Open for Access The unique characteristics of e-Learning lies in its ability to enable a truly interactive learning environment and create communities of learners like KOALA™ (Computerized Obstetrics and Gynecology Automated Learning Analysis), OMNI (Organizing Medical Networked Information), and MORE OB (Managing Obstetrical Risk Efficiently). The

36

ubiquitous use and a quick deployment of e-Learning RH materials (connectivity, accessibility, mobility, multi-media capability, dynamic feedbacks), create new and emerging paradigms in education, and self-directed learning.

Meantime, a collection of evidence that demonstrates a personal learning strategy, may result in the expansion of competencies beyond the expertise, and iatrogenic malpractice. The discipline of reproductive medicine has not been immune to these effects.

Open for access (OFA) to the RH literature assumes the removal of the barriers (financial, academic, timing) from accessing the scholarly work. OFA considers two possibilities: e-Journals (freely available articles in the journal websites, a model mostly paid by the author usually through a research grant), and selfarchiving (published papers in traditional journals, where only the subscribed members may have immediate access, but are available in their personal or institutional website repositories or archives).

Among the arguments of OFA proponents is that the ‘open’ work is more quickly recognized, cited, and utilized.

This raise some ethical, practical, and policy questions for scholars, clinicians, and RH policymakers, like whether or not the OFA literature accelerates scientific advancement and knowledge translation of research into practice. Also, an economical issue rears up a debate. That

The researchers, clinicians, and policymakers must confront the question of whether or not the OFA literature accelerates scientific advancement and knowledge translation of research into practice

Dr. Naira Roland Matevosyan Emory, Centers for Disease Control and Prevention (CDC) Atlanta, GA narage@lycos.com

is, what the return on investment is when paying for publishing an article in an OFA journal, or whether investments into institutional repositories should be made, or if self-archiving should be mandatory, as contemplated by some funding entities.

The Objective We have attempted to compare the bibliometric impact of OFA and NOFA through citation topology, in a cohort of articles in a journal (Birth: Issues in Perinatal Care). Here we locate citation eHealth | March 2007

patterns through mapping the results of a longitudinal quasi-baseline biblio-metric (citatory-metric) study of 27 (33 percent) OFA scholarly e-articles and 55 (67percent) OFA papers in RH (a total of 82).

Here it deserves a mention that Birth: Issues in Perinatal Care is a multidisciplinary, refereed journal, devoted to the issues and practices in the care of childbearing women, infants, and families. The aims of Birth are: • To publish original, well-designed, peerreviewed research on issues in pregnancy and childbirth, featuring physical, psychological, and social aspects of care; • To provide review articles on topics of major importance in perinatal care; • To present a forum for discussing current issues in maternal and new born care; •· To underline the importance of evidence-based research in changing clinical practices.

Free online access to this journal is available within institutions in the developing world through the Health InterNetwork Access to Research Initiative [HINARI], with the World Health Organization (WHO).

A longitudinal quasi-baseline citatorymetric analysis of a cohort of OFA and NOFA articles were published in the journal ‘Birth: Issues in Perinatal Care’, between March 2005 and June 2006.

Article characteristics were extracted; potentially confounding variables, including the number of authors, authors` lifetime publication count, submission track, country of corresponding author were adjusted for in logistic and linear multiple regression models. A total of 82 original research articles were analyzed, among which 27 (33 percent) were OFA articles and 55 (67 percent) were NOFA articles.

The average number of citations of OFA articles was slightly lower as compared to NOFA articles. With a logistic regression model, controlling over the submission track and potential March 2007 | www.eHealthonline.org

confounders, the NOFA articles, as compared to OFA, remained likely to be more cited (odds ratio = 1.7 [1.2-2.2] ). In the crude citation analyses, the mean number of citations, as well as the proportion of the articles cited at least once, was higher in the NOFA group (RR- 95 percent CI).

2)

3)

Study Limitations However, the study, despite being scientific and exhaustive, is characterized by some limitations. Since this was an observational and not a randomized study, it statistically enabled to control only over the known confounders.

There may be a possibility of selection bias among authors judging the importance of their work, with quality differences between the articles contributing to citation differences.

Also, this study offers mainly a shortterm (one year) glimpse at what happens in the long-term citation curve. The study used the citations as proxy for impact, and may bring an argument whether and how the scientific atmosphere in RH can benefit by increased citation rates.

But notwithstanding the limitations, the findings do lead us to important conclusions. The findings suggest that: 1) The solid reputation and scientific recognition of the journal ‘Birth: Issues in Perinatal Care’ is truly deserved, as the works published in the journal illustrate longitudinal research that is endorsed with scientific evidence.

2) Overall, in RH, research needs to be reviewed, catalyzing the scholarly process of bringing the evidence into action, and helping the clinicians to act on the evidence.

4)

5)

6)

7) 8)

9)

10)

11)

Footnote: The author has no relations to ‘Birth: Issues in Perinatal Care’ or its editorial cabinet.

References 1) Carayannis EG, Campbell D. [2006].

Knowledge Creation, Diffusion and Use in Innovation Networks and Knowledge Clusters: A Comparative Systems Approach across the United States,

12)

Europe, and Asia. GWU School of Business, Praeger, 2006; Consumer Reports Questions Cesarean Frequency, International Cesarean Awareness Network; http:// www.medicalnewstoday.com Fung MF, Walker M, Fung KF, et al [2000]. An internet-based learning portfolio in resident education — the KOALA multicentre programme. Med Educ; 34: 474–9; Fung KFM, Walker M, Fung KFK. [1999]. The KOALA continuous professional development programme: an integral part of the lifelong learning continuum. J Soc Obstet Gynaecol Can 1999; 21: 1065–75; Fung Kee Fung M, Temple L, Walker M, et al [1998]. Medical education in the new millennium. Medical informatics, evidence-based medi-cine, self-directed learning and the KOALA programme. J Soc Obstet Gynaecol Can 1998; 20:999–1006; Eysenbach G [2006]. Citation advantage of open access articles, PloS Biol 4(5): e157, Centre for Global eHealth Innovation; http://www.blackwellpublishing.com/ journal.asp; Management and Leadership of Life Sciences Research in Canada: A Snapshot and Some Questions, On Management Health Group, 2005; Roy M [2003]. Self-directed workteams and safety: a winning combination?

Safety Sci.2003;41(4): 359-376; Rubeor K [2003]. Role of risk management in maternal-child health. J Perinat Neonat Nurs. 2003;17(2):94100; Wenger E [1998]. Communities of practice, learning, meaning and identity. New York: Cambridge University Press; Wenger E [2002]. Supporting communities of practice: a survey of community- oriented technology.

Overview of technologies with a potential to support communities of practice.www.ewenger.com/tech/ index.htm

37

Project Showcase

CLINICIP Project Draws Great Interest in Europe Addressing issues of high glucose levels among ICU patients

E

very year thousands of ICU patients develop atypical physiological symptoms, which keep them ill longer than necessary. Many even succumb to death due to these physiological maladies, which may result from the inability of many ICUs to control the level of glucose in patients’ blood. As glucose affects blood toxicology, any mismanagement of glucose level can be detrimental to the patient’s health.

Similar to diabetes mellitus, the high glucose level needs to be treated with external insulin. According to a study in Belgium, the intensive insulin therapy treatment cuts the mortality rates by 42 percent, as compared to standard insulin therapy for ICU indication.

Medical science has realized the importance of glucose control for ICU patients, but couldn’t find an effective solution to the problem till now, largely due to the enormous complexity of the problem. Recording glucose levels manually is not only painstaking and time consuming, but since the impact of glucose levels and insulin dose vary from patient to patient, it is very subjective.

One EU project, funded under the 6th FWP (Sixth Framework Programme) is endeavouring to find a solution to this problem. CLINICIP (Closed Loop Insulin Infusion for Critically Ill Patients) project aims to provide a pragmatic and innovative system for improved health status

38

monitoring of critically ill patients.

The project endeavours to develop an intelligent, automated glucose monitoring and control system for ICU patients.

Monitoring glucose levels and administering of insulin is done by one selfcontained system, and therefore it is called a ‘closed loop’ system. Within a closed loop system, intensified insulin treatment will make use of calculation results, leading to the external regulation of glucose.

In addition to controlling the glucose concentration, a minimally invasive treatment would also be explored upon. A number of biosensors for the determination of most important parameters such as lactate, carbon dioxide, oxygen and pH will be used to characterize adipose tissue.

The CLINICIP partners (various institutes and universities from Austria, Germany, Sweden, Italy, UK, Belgium, Switzerland and Czech Republic) are developing a system that links glucose measurement to a control unit, which would assess a patient's needs, and then release insulin automatically. The researchers have already developed an algorithm to analyze how much insulin is needed, based on carbohydrate intake and current glucose levels. Already CLINICIP's algorithm has garnered great interest among medical scientists. The algorithm is in trials, and the partners hope to have initial results by mid 2007.

Presently, the CLINICIP project is studying both intra-vascular and extravascular automated sensor systems. If the

quest of the researchers becomes successful, automated sensor systems could improve the healthcare of ICU patients and pave the way for healthy clinical practice. Here it deserves a mention that the intra-vascular sensor system is more invasive and time consuming than extra-vascular sensor system, and moreover the former is not suited for cardiac attack victims and infants. In later stages of the project, access to the data and the derived clinical recommendations for treatment of critically ill patients will be granted to additional clinical partners who are willing to implement improved treatment.

The major impediment to the success of this much-hyped project is the body interface, that is tackling the question of how the sensor in the patient’s body would link to the rest of the closed-loop system.

However Martin Ellmerer, the Scientific Director of the CLINICIP project, is sceptical about the development of the full closed-loop system within the scheduled gestation timeframe of the project.

However, work will continue even after the expiry of the life of this project.

Existing bilateral agreements between many of the CLINICIP project partners can carry out the good work initiated by the project, even after the expiry period of the project. The 11.21 million euro project, which began in January 2004, has a duration of 48 months. The project is supposed to be completed by the end of 2007(31 Dec. 2007 to be precise). eHealth | March 2007

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