The Enterprise of Healthcare
volume 6 / issue 11 / November 2011 / ` 75 / US $10 / ISSN 0973-8959
www.ehealthonline.org
Redefining Hospital Infrastructure on the back of Technology
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volume
06
issue
11
SSN 0973-8959
contents COVER STORY
Castle of Care
08 Tele-Health Prescribing Quality Healthcare for all
18
State of mHealth in India
22
Sustainable Models for mhealth
30
OPINION Tele-Health Taking it Beyond the Pilot Phase
A comfortable stay is what a patient demands from a hospital, while the infrastructure integrates the solutions to make it possible By Shally Makin
40
INDUSTRY UPDATE
25 29
WiMAX Empowering Healthcare in Nigeria
32
ECG on your mobile
36
Telemedicine for rural women Cancer Care
4
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37
INTERVIEW Amol Naikawadi Joint Managing Director of Indus Health Plus
Tele Diagnostics Centre Sets up in Remote Areas
perspective
38
Challenges for Telemedicine in India
interview
34
Dr Prasad Sistla
42
Girish Kumar VSM (Retd)
CASE STUDY Text to Change
46
Chief of Telemedicine, Care Foundation
Practice Head, India – Healthcare & Life Sciences, HP Enterprise Services
book review
44
Biomedical Informatics Reviewd By Gp Capt (Dr) Sanjeev Sood
expert corner
48
A Solution Whose Time has Come Dr Arjun Kalyanpur
volume
06
issue
11
The Enterprise of Healthcare
President Dr. M P Narayanan
Editor-in-Chief Dr. Ravi Gupta
gm Finance Ajit Kumar
dgm strategy Raghav Mittal
programme Dr. Rajeshree Dutta Kumar specialist partnerships & Sheena Joseph Alliances Shuchi Smita, Ankita Verma Editorial Divya Chawla, Rachita Jha, Dhirendra Pratap Singh, Sonam Gulati, Pragya Gupta, Shally Makin (editorial@elets.in) Sales & Jyoti Lekhi, Fahimul Marketing Haque, Shankar Adaviyar, Rakesh Ranjan Mobile: +91-8860651635 (sales@elets.in) Subscription & Gunjan Singh Circulation Mobile: +91-8860635832 subscription@elets.in Graphic Design Bishwajeet Kumar Singh, Om Prakash Thakur, Shyam Kishore
inbox Awesome review, I like your site. Sandeep on Healthcare Technology Resource Guide 2011 I have wanted to post something like this on my site and you have given me an idea. R Shah on Synergies for long term gains through Health Insurance Soon after all, what a terrific internet site and useful posts, I’ll upload inbound hyperlink – bookmark this net web site. Diablo on China gets the virus after a decade of declaring themselves polio free
Web Development Zia Salahuddin, Anil Kumar IT infrastructure Mukesh Sharma, Zuber Ahmed
Events Vicky Kalra
human resource Sushma Juyal
legal R P Verma
Accounts Anubhav Rana, Subhash Chandra Dimri Editorial Correspondence eHEALTH, G-4 Sector 39, NOIDA 201301, India, Tel: +91-120-2502180-85, fax: +91-120-2500060, email: info@ehealthonline.org
ehealth does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. ehealth is published by Elets Technomedia Pvt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS) Owner, Publisher, Printer - Ravi Gupta, Printed at Vinayak Print Media, D-320, Sector-10, Noida, UP, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP, Editor: Dr. Ravi Gupta © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic and mechanical, including photocopy, or any information storage or retrieval system, without publisher’s permission.
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editorial
Celebrating 60! In the era of globalisation, a massive boom in private hospitals in India has changed the nation’s health delivery landscape beyond recognition in the last decade. And, Indian hospitals with the mantra of star facilities and bleeding-edge technology are writing a new chapter in healthcare services. The vision is to create a truly unique institution that delivers world-class healthcare with a conscience of trust. eHEALTH has achieved yet another landmark of completing 60 successful issues. The journey has been extremely exciting with the Indian healthcare sector achieving greater heights in the past decade. Healthcare has emerged as one of the most progressive and largest service sectors in India with an expected GDP spend of 8 percent by 2012 from 5.5 per cent in 2009. At present the sector is estimated to be around US$ 40 billion, in size, and will grow to US$ 78.6 billion by 2012. The Indian healthcare sector is expected to become a US$ 280 billion industry by 2020 with spending on health estimated to grow 14 percent annually. Our cover story, this month, focuses on hospital infrastructure. A hospital’s prime focus lies on the connectivity of the hospital and the networks seamlessly integrating the entire healthcare applications and services with the power of information technology. A hospital requires an expert in the design and installation of medical power systems in ICU and ICCUs, operating theatres, anesthetics rooms, and premature baby rooms including the range of resilient flooring and acoustical ceilings for hospital and healthcare sector. We express our deepest gratitude for authors, contributors, advertisers, readers and subscribers of this publication who have time and again reposed their faith and belief in our purpose, by being our biggest supporters and advisors. We are also pleased to announce that eHEALTH India, the Premium Healthcare ICT Event, is taking place during 15-17 December in Gandhinagar, Gujarat. The event will once again bring together the entire community of health IT professionals, practitioners, end-users and decision makers to engage over a three-day power-packed conference and dynamic exhibition. See you there!
Dr. Ravi Gupta ravi.gupta@elets.in
november october / 2011 www.ehealthonline.org
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cover story
Castle of Care A comfortable stay is what a patient demands from a hospital, while the infrastructure integrates the solutions to make it possible
By Shally Makin, shally@elets.in “The whole is often greater than the sum of its parts. This can’t be true for healthcare.” Dr Hemant Kumar, Director-Healthcare, Dell Services, feels that a large part of the problems in hospitals stems from the fact that there are too many parts—too many stakeholders working in silos. On the other hand he believes that these parts when stitched in an infrastructure with software, and services can then provide smart, integrated solutions that enhance the delivery of care. Why do we feel homesick when we stay in hospital despite proper care? The answer lies in the environment where the
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body relax and rejuvenates. Infrastructure plays an important role in making the hospital stay comfortable for a patient and this generates a need to revamp the look, feel, processes and systems to deliver better healthcare facility to a patient for a happy stay. Hospital infrastructure in real terms is a venture that enables clinical staff to deliver care with a huge initial investment but leads to a long term gain. There are companies which take up such projects and plan with their deep applications, technology and industry knowledge to deliver largest and technologically efficient hospital. Companies like Wipro
cover story
“We need to build a future-ready infrastructure that supports tomorrow’s healthcare demands. The building blocks of this structure include intelligent infrastructure, simplified infrastructure management, streamlined application and workload management and smart data management” Dr Hemant Kumar Director-Healthcare, Dell Services
and HP have come forward with their cohesive set of technologies and services replacing single-function systems with a comprehensive solution that aligns technology with operational and patient priorities. The building systems needs to be service designed to build and maintain the information, communication and technology (ICT) systems for a digital hospital. The new technology automates clinical and facilities management workflows to improve care and efficiency and deliver better outcomes for patients. A massive boom in private hospitals is changing India’s health delivery landscape beyond recognition. New hospitals are mushrooming, even in smaller towns, and leading healthcare entrepreneurs with deep pockets are expanding their em-
pires, even overseas. The booming hospital service industry is projected to grow at 9 percent during 2010 – 2015 along with the introduction of 20 health cities which are expected to come up in the next 5 years. The need to design a flexible infrastructure lies in the demand created by the masses for effective yet affordable healthcare. Targeting an annual growth rate of 10 percent, the Prime Minister called for a need to double the country’s infrastructure spending to US$ 1 trillion by the fiscal year 2016-17. A healthcare report mentions, hospital industry will account for more than 70 percent of healthcare sector revenues by 2012. The report shares the need to increase beds per population in India and the current figure of 9 beds per 10,000 people has to escalate to equalise to the world average of 40 beds per 10,000. India needs an investment of US$ 14.4 billion by 2025 to increase the bed density to 20 beds per 10,000 people. The emphasis on the participation of PPP to develop infrastructure and create superspecialty hospitals is important. The main objective of encouraging PPP initiatives is to provide low-cost, super-specialty care to families as well as maintain and upgrade total infrastructure to meet modernisation and expansion requirements. A research shared by KPMG reported that per head spend on healthcare infrastructure during 2009-13 is projected to be over US$ 250 for Andaman and Nicobar and Manipur, while for states like Bihar, Uttar Pradesh, Chhattisgarh and Jharkhand it will be less than US$ 50.
Flexible Infrastructure Architecture is born out of operations and then there’s a lot that goes into these processes including budget, timeline, relationnovember / 2011 www.ehealthonline.org
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cover story
“The hospitals of today need a modification to reassure safety and apt treatment of patients. Hospitals need to reinvent themselves to meet the challenges in the coming years. A typical future hospital is a place where patient’s safety is assured; quality of care is paramount and is highly efficient” Dinesh Bindiganavale IEEE Member and independent healthcare consultant
Infrastructural Elements • Building engineering systems—such as building automation and security systems • Automatically Guided Vehicle (AGV) System—providing efficient and timely notifications to staff • Communications Systems—such as the IP PABX, to support devices • Real-Time Location Systems (RTLS)—used for patient and equipment tracking, providing improved medical equipment utilization • Fully integrated IT infrastructure- includes nurse call system, picture archiving and communication system, and sophisticated bedside terminals • Use of latest hardware devices with extensive network • Integration of Telemedicine • Incorporate Radiology department with hybrid and latest technologies with a digital reading room
ships with prior designers, aesthetics, compliance issues, the ’personality’ of the community – the list of considerations is almost endless while building a whole new healthcare arena. A hospital infrastructure designing requires arduous work and intelligence to drive effective implementation of solutions to build a comprehensive digital health IT. Introduction of customised solutions in creating an infrastructure for a hospital includes hospital planning, hospital project management, hospital ar-
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chitecture, market studies, feasibility studies, hospital space planning, biomedical equipment planning and other products for the furnishings of state of the art hospitals. An effective enterprise service management maintains the production application environment and strong IT infrastructure. With the up-scaling patient numbers and cost of healthcare worldwide, there is a dire need for better care delivery. Companies aim to leverage technology across markets, improve operational efficiency and enable care coordination to digitise operations. Rashi Agarwal, Director, Praxis Health Consultancy, believes, “Previous research has explored the relationships between quality of care, patient health and wellbeing, and the physical layout and environmental characteristics such as aesthetics, lighting, and thermal comfort. It’s about taking a holistic approach to managing technology, and using it imaginatively to improve processes, enhance safety, improve quality of care and enable customised healthcare.” Today companies take up a whole new approach to develop and strengthen the hospital infrastructure as it provides the foundation to the concept of delivering effective healthcare. There are certain elements which interconnect the entire system integrate and provide solutions for entire healthcare infrastructure. Healthcare planning is the foremost thing while designing an infrastructure to provide full spectrum of services from health service planning to architectural and interior design, equipment, and commissioning. A hospital needs to adapt best practices in healthcare design along with good wall protection material as a part of architectural products.
cover story
november / 2011 www.ehealthonline.org
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cover story
These products include door and wall protection, expansion joint systems, privacy curtain tracks, and way-finding signage. OT also needs new technologies along with other medical systems displaying IP nurse calling, LED lighting, and patient bedside terminals to provide better patient care. Dinesh Bindi-
better lighting and access to natural light to reduce stress and improve patient safety and create pleasant, comfortable, and informative environments to relieve stress and promote satisfaction among patients, their families, and staff.”
Integrating Technology
ganavale adds, “Hospitals can adopt some measures to ensure quality by improving indoor air quality with well-designed ventilation systems and air filters to prevent infection, provide
“The healthcare sector while on a high growth trajectory, is also trying to deal with the challenge of pressure on margins and a huge shortage of quality human resources.” Charu Sehgal Senior Director, Deloitte India
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Developing green hospital is again one of the most important elements to consider while designing the healthcare infrastructure. The hospitals should use disinfecting surface solutions covering the entire floor with a total spectrum air purification system to control climate and bacteria. A hospital’s prime focus lies on the connectivity of the hospital and the networks seamlessly integrating the entire healthcare applications and services with the power of information technology. A hospital requires an expert in the design and installation of medical power systems in ICU and ICCUs, operating theatres, anesthetics rooms, and premature baby rooms including the range of resilient flooring and acoustical ceilings for hospital and healthcare sector. The patient rooms are technologically oriented with the use of wireless technologies, temperature control and customised entertainment and educational systems along with patient lifts and bar coding of medication administration. The hospital infrastructure basically provides an overall physical design to improve patient safety and quality. Analogous to buildings, a hospital infrastructure comprises of various academic institutions, laboratories, diagnostic centers, healthcare management and administration. TV Sivakumar identifies the need to design hospital infrastructure in India with a holistic approach. He says, “The ‘design’ for a right solution (be it infrastructure, technology, resources etc) must not be overlooked and must keep all stakeholders (management, employees and patients) and scalability in mind. Adoption of technology is inevitable and care must be taken to put it to best use. Continual Medical Education (CME) and technology training at all level is necessary to achieve constant growth in medical care.” The upcoming models of designing an operation theatre (OT) create another interesting concept—hybrid operating suite. It is the collaborative effort of architects, engineers, equipment planners, and consultants specialising in acoustics, vibration and audiovisual design and integration who all have worked together to develop a hybrid OT. Since it uses a highly integrated technology, a hospital should pre-design the space required to locate such an integrated amount of technology. Healthcare infrastructure is at a booming stage in India as various companies are now investing to bring the latest technologies to the hospitals with a large scope of improvement. Diagnostics industry has contributed a lot to optimize hospi-
cover story
tals and create a balance between management and offering services to the patient at an affordable price yet effective. A medical imaging department within a hospital is a stand-alone centre which can be treated as a separate business since it reaps big profits. With upgrading technology and currentgeneration equipments requires adequate radiation shielding and clean power. An imaging department should have large space, suits magnetic requirements, rooms which can control vibration and be soundproof, digital reading room mainly for MRI, PET scan, CT and X-ray rooms. Evidence based design provides a positive return on investment and even directly impact image quality which thus improves patient, family, and staff satisfaction. While integrating a digital hospital, we need a solution which provides high availability by using virtualised, clustered and dual-redundant systems.
Patient Safety Security is one of the most important elements to be included while designing the infrastructure for a hospital keeping patient safety as the most important factor. A modern hospital stores information in the form of bits and bytes as we rely on the vast network infrastructure to keep it safe. A patient’s information needs to be secured which further calls for an efficient network design to insure day to day operations. Security solutions consists of latest contact-less RFID technology to allow smooth and detailed control over all access points and detailed tracking of all staff and employees across the property: main entrances, lockers, department doors, storage rooms and any type of door with flexible solutions including wall remote controllers. Medical furniture all together enhances the entire interiors of the hospital. The furniture ranges from fully motorised beds, ward furniture, patient transfer equipment, trolleys and other seating arrangement which accommodates even the caretakers of the patient. While planning a hospital, efficient planning and consulting, designing, manufacturing and support systems including track systems, numbering systems, curtains, nurse call systems play an important role in strengthening the network. Charu Sehgal, Senior Director, Deloitte India believes, “IT infrastructure strengthens the hospital management systems and to achieve consistently good health outcomes, it involves co ordination between all stakeholders along the healthcare continuum of preventive, diagnostic and curative care. These seemingly insurmountable challenges can be solved only through the innovative use of ICT to solve the problems of access, affordability and availability in the healthcare space.” A central database of digital dictation records eliminates loss of information, improves communication and sharing of knowledge across departments. Understanding cost estimations is a prerequisite when we start a project. While incorporating health facilities, uniqueness and accuracy is taken care of with the plan to last at least three decades before renovating or investing in creating new infrastructure. Over the years, there have been certain building equipments replaced and
“It is inevitable that in the near future holistic healthcare will have very specific implications for management of hospital operations and patient care on the whole.” Rashi Agarwal Director, Praxis Health Consultancy
upgraded including controls/automation systems, fire alarm/ protection systems and security systems.
Managing Costs An infrastructure for a hospital is designed to last for at least 30 years of its service towards providing care. There is a certain criterion to follow while we develop a building information modeling software. The most importantly is capital planning largely takes 60 percent stake and likewise project management which holds 40 percent. The infrastructure should be one which limits its focus on renovation and integration of expensive projects over the years. As we move forward towards globalisation local and national demographic changes with the changing epidemiological patterns are driven away by lifestyle changes. Unpredictable advances in the medical technology and escalating demands by the patients look forward to a good value for money hospital. It is difficult to equip the new facilities in existing building as it requires an upgraded cabling november / 2011 www.ehealthonline.org
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cover story
Common Planning Mistakes • • • • • • • •
Lack of focus and directions Poor strategic planning Ineffective statistical planning model Inadequate facility analysis Lack of a master plan Poor review of alternatives Limited financial analysis Lack of documentation
infrastructure able to support new, network-intensive systems. It also requires huge operational costs to develop new structured cabling solution and develop the Health IT infrastructure in the existing building. On the other hand, while planning a hospital the initial investment for incorporating IT into the hospital does not require a lot of amount. A flexible hospital infrastructure has an advantage to deal with the upgraded technology and systems to be incorporated in the existing systems without huge investments such as having proper shell space for medical equipments and suitable structural foundations of a building to allow additional floors to be added at a later time. Layouts for functional rooms, such as operating theatres, which would allow a change of usage in the future in response to changing technology, should also be designed in a flexible manner. It is also observed that with increasing costs of healthcare the hospitals require a cost effective model with a greener approach to lower energy costs. Building an infrastructure is a complex project to initiate especially in the rural set up that does not have enough resources to support. Even the minute details such as selecting an aesthetic color to paint on walls, creating space for toilets, lobbies with abundant daylight, efficient airflow, proper signboards and much more, forms an essential part of hospital infrastructure. An efficient master plan for designing a hospital infrastructure should have a holistic approach in adapting evidence-based design, family-centered care, point-of-care services, bedside charting and modularize myriad alternatives to suit the need of patients. A well structured hospital with new technologies streamlines patient data, improves reporting and management, assures a
“In the ever growing and demanding field of healthcare, it’s very important to design, implement, refine and scale a ‘Right Solution’ to achieve better healthcare at lower cost and efficient ways. Understanding success stories from other places, refining and putting it to best practice are the need of the hour for any healthcare organisation” T V Sivakumar CEO, AmbalSoft InfoTech Pvt Ltd
comfortable stay with effective treatment. It gropes the complex systems of hospital including operations, management, planning and design together to be termed as an infrastructure. The modern technological approach helps conceptualize healthcare facility projects to enable modularity and implementation. The major concern while constructing a hospital building should focus on planning and designing to meet proper health standards. Healthcare designs are always preferred if grounded to the real time experience of the patient and not totally on the architect’s perspective. To effectively implement the design concepts, it is to be planned and driven in the direction of research and explores opportunities to improvise at every step with upgrading technological innovations.
Catch Up With Latest News, Articles, Interviews and Case Studies at www.ehealthonline.org 14
november / 2011 www.ehealthonline.org
product watch
Carestream Health India
Unveils a New DR System
The CARESTREAM DRX-Ascend System is equipped with a wireless digital X-ray detector which offers exceptional flexibility, while its floormounted tube stand saves space and reduces installation costs
Carestream Health India has recently unveiled the new CARESTREAM DRX-Ascend System, which is designed for small to mid-size hospital radiology departments, imaging centers, clinics and specialists’ offices. The DR system offers a versatile, floor-mounted tube stand and a wide and elevating floattop table with a patient weight capacity of 295 kilograms. In India, the first CARESTREAM DRX-Ascend System has been recently installed at the state-of-the-art Siddhant Diagnostic Center, Varanasi, Uttar Pradesh. Speaking on the uniqueness of the new DR system, Mr Prabir Chatterjee, Managing Director, Carestream Health India, says, “The CARESTREAM DRX-Ascend System is well suited for smaller rooms, imaging centers and orthopedic applications. This floor-mounted DR system delivers high-end features at an affordable price.” The system’s floor-mounted design saves space and reduces
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installation costs, while the wireless, cassette-size DRX detector provides exceptional X-ray positioning flexibility. The DRX detector can be moved from the wall stand to the table and can handle tabletop exams. Higher volume facilities may want to use two detectors to enhance productivity. The DRX-Ascend features innovative TechVision™ technology that allows technologists to view digital radiography exams, change generator techniques and preview images using a touch panel screen mounted on the tube stand. Allowing a technologist to remain at the patient’s side during the exam simultaneously enhances care and productivity. The DRX detectors can be shared with room-based and mobile imaging systems to make the most of the capital investment. For example, a hospital could use the DRX detector in its mobile X-ray system for early morning portable exams and then place it in the DRX-Ascend system for daytime imaging studies.
Message
It gives me immense pleasure to write the foreword for the Special Telemedicon’11 issue of India’s leading healthcare magazine eHealth! India faces a ‘triple burden’ of a large population, high incidence of chronic and communicable diseases, and a highly fragmented healthcare system. It is the right time for the policy makers to ensure that technology is embedded in all the programs that the Government is planning to roll out for healthcare delivery. Also, mHealth and eHealth have tremendous potential to reduce cost, improve reach and access, make the healthcare system more outcome driven and more importantly, lead to an ‘empowered patient’. To create awareness and increase the use of technology, The Telemedicine Society of India (TSI), organises the International Telemedicine Congress every year. TSI is competing ten years (2001-11), and to celebrate the same, it is organising a mega healthcare event, bringing together a galaxy of global healthcare leaders, to showcase the trends and developments in the field of mHealth and eHealth. With more than 875 millions cell phones, healthcare in India will certainly converge to mHealth, and ultimately this is where all practitioners, payers and users will converge to! We have decided to come out with a special edition of Telemedicon’11 preevent report, and who better than eHealth to be our media partner! We are proud to be associated with ‘eHealth’ and I personally thank Dr Ravi Gupta and ehealth team for the painstaking efforts taken to come out with this special edition of eHealth. I am sure that you will find it informative, and I look forward to seeing you at Mumbai from 11-13 November 2011, at Telemedicon’11. Rajendra Pratap Gupta Leading Healthcare Policy expert & Chairman, OC, International Telemedicine Congress – Telemedicon’11 www.telemedicon11.com
november / 2011 www.ehealthonline.org
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industry updates
Tele-Health
Prescribing Quality Healthcare for all
Telehealth can bridge the hospital infrastructure and service gap in India and promise quality healthcare to all. As a step forward in this direction, Telemedicine Society of India (TSI) will launch the first-of-its-kind ‘Tele-Health Report’ of India at Telemedicon 2011 conference to be held from November 11-13 in Mumbai
There exists a vast disparity in the quality and availability of healthcare services in urban and rural areas in India. Inadequacies in India’s healthcare infrastructure have led to severe gaps in rural areas, despite the fact that 70 percent of Indians live in rural India. Urban India has 5 to 7 times the number of hospitals, dispensaries, hospital beds, and physicians per 100,000 people than there are in rural India. The Telemedicine Society of India (TSI) has worked arduously to encourage and popularise the use and adoption of telehealth across the country. The need for a compendium of knowledge on the history, progress and future of tele-health market in India has been felt for a long time. To fill this knowledge gap, TSI launched the first-of-its-kind ‘Tele-Health Report of India’. For the success of telemedicine in India, the pre-requisite remains to be strong collaboration between the technology providers and doctors to ensure the technology deployment, adoption and use occurs seamlessly in any part of the country. This collaborative learning platform has opened new market opportunities and business models for the private sector technology providers in healthcare. So, tele-health in India is an exciting market for the technology providers—although currently at a nascent stage – it holds immense growth potential in both rural and urban healthcare delivery systems in India.
Tele-Health: A reality According to the estimates of TSI, the current market size of Telemedicine in India is estimated to be around US$ 250-300 million and potential market could be as big as US$ 2 billion. This is only a conservative estimate, considering the nascent stage of the technology adoption by hospitals and doctors in India; however the full potential of the telemedicine market could be realised in the future with better adoption.
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In recent years, mobile health or (mHealth) with mobile as a device for healthcare delivery has emerged as an important sub segment of the field of electronic health (eHealth). Now, mHealth and eHealth are linked to improve health outcomes and their technologies. For example, many eHealth initiatives
industry updates
involve digitising patient records and creating an electronic ‘backbone’ that ideally will standardise access to patient data within a national system. mHealth programmes would serve as the access point for entering patient data into national health information systems and as remote information tools that provide information to healthcare clinics, home providers, and health workers in the field. While there are many stand-alone mHealth programmes, it is important to realise the potential of mHealth for supporting broader eHealth initiatives. The succinct summary of telehealth as per the United States Centre for Technology Leadership (CTL) (2007) is “bringing the collective wisdom of the whole medical system to any patient anywhere”. More formally, the National Health Information Management Advisory Council (NHIMAC, 2001) provided the definitions of ehealth, telehealth and tele-medicine. e-health is the combined use of electronic communication and information technology (digital data transmitted, stored and retrieved electronically) for clinical, educational and administrative purposes, both at the local site and at a distance. Tele-health is that subset of e-health that includes the application of information technology and tele-communications for diagnostic and treatment services, educational and support services and the organisation and management of health services (including health information management and decision support systems).
“mHealth applications have tremendous potential in both developed economies as well as developing countries such as India. With over 850 million mobile phone subscriptions in India, mHealth can certainly play a pivotal role in delivering healthcare services across geographically dispersed population” Vishal Gupta Vice President and GM Global Healthcare Solutions Unit, Cisco
Evolution trail
Telemedicine in developing countries
Telemedicine was invented by NASA in the 1960s as a way to monitor astronaut health on space missions. Today, it is used to electronically exchange medical information among patients, clients and health providers, creating greater access to medical evaluation and improving patient care. Electronic medical data, such as high resolution images and live video, are transferred through a variety of telecommunication technologies, from fibre optics and satellites to a simple telephone line. A growing number of medical specialties rely on telemedicine to serve patients in areas such as adult rehabilitation, dermatology, emergency services, home healthcare, nephrology, pathology, pediatrics, perinatology, primary care, psychiatry and radiology.
Telemedicine applications have successfully improved the quality and accessibility of medical care by allowing distant providers to evaluate, diagnose, treat and provide follow-up care to patients in less-economically developed countries. They can provide efficient means for accessing tertiary care advice in underserved areas. By increasing the accessibility of medical care, telemedicine can enable patients to seek treatment earlier and adhere better to their prescribed treatments, thereby improving the quality of life for patients with chronic conditions. As a leading International healthcare policy expert, Rajendra Pratap Gupta says, ”The biggest issues in healthcare today are ignorance about diseases and ignoring diseases when you have one and mHealth certainly provides a promise of being a cost effective platform to address ignorance by information dissemination and address ignoring by providing remote care and follow up care to masses anywhere, anytime. The beauty of the mHealth is that, it does not need a skilled doctor onsite and thus takes the fear away from the users”. As a leader in the technology platform for Tele-health applications, Vishal Gupta, “Vice President and GM, Global Healthcare Solutions Unit, Cisco said, “mHealth applications have tremendous potential in both developed economies as well as developing countries such as India. With over 850 million mobile phone subscriptions in India, mHealth can certainly play a piv-
Popular Applications Tele-radiology is currently the most developed telemedicine service area globally, with just over 60 percent of responding countries offering some form of service and over 30 percent of countries having an established service .While the proportion of countries with any form of services range from almost 40 percent for tele-dermatology and telepathology to approximately 25 percent for tele-psychiatry, the proportion of countries with established services in those three areas was comparable at approximately 15 percent.
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industry updates
The survey examined four fields of telemedicine• Teleradiology – use of ICT to transmit digital radiological images (e.g. X-ray images) from one location to another for the purpose of interpretation and/or consultation • Telepathology – use of ICT to transmit digitized pathological results (e.g. microscopic images of cells) for the purpose of interpretation and/or consultation • Teledermatology – use of ICT to transmit medical information concerning skin conditions (e.g. tumors of the skin) for the purpose of interpretation and/or consultation • Telepsychiatry
to rural areas, provide better quality of healthcare at a lower cost, enhance use of evidence-based medicine, stress on preventive healthcare, empower patients and consumers, and support to smooth relationships between patients and health professionals. In this divided India, the arrival of tele-health brought the best of the doctors and renowned specialist accessible to remote villagers, needy and poor patients. The Telemedicine practice was initiated in Lucknow and Chennai in 1997. In Kerala, first unit of telemedicine was formed at the Medical College Trivandrum in 2003. Recognising the common interest of health and community welfare, telemedicine was promoted for the availability of quality medical services to the needy, irrespective of socio economic and geographic disparities like rural, remote and inaccessible places. mHealth can embrace modern technology to widen health-
Table1: World Health Organization (WHO) survey for four most popular areas of telemedicine.
Established Pilot Informal No Stage Provided Total
Teleradiology
33%
20%
7%
2%
62%
Telepathology
17%
11%
9%
4%
41%
Teledermatology
16%
12%
7%
3%
38%
Telepsychiatry 13%
5% 5%
1% 24%
Source: WHO Telemedicine (Opportunities and development in member states) report, 2010
Table 2: Comparison of Healthcare Expenditures across Countries for 2009 Indicator India China SriLanka Thailand USA HealthCare Expenditure (% of GDP)
4.8%
Govt. Healthcare to Total Healthcare Expenditure Govt. Healthcare to Total Govt. Expenditure otal role in delivering healthcare services across geographically dispersed population. Improving access by bringing healthcare services to the patients’ location will result in a dramatic improvement in the quality of life and health of the people. Treating patients in their homes and communities, with access to expert care, through mobile technology could be advanced by using newer technologies like 3G. mHealth has been effectively used in variety of use case scenarios such as patient education, awareness creation, remote data collection, sms reminders and notifications, disease surveillance and Health worker training etc. Given the early field trials and success stories, mHealth is certainly well positioned to address 21st Century healthcare challenges.”
The future – Mobile healthcare mHealth can be understood as a term for collectively describing use of electronic information and communication technology in the healthcare sector. This refers to technology used across the value chain in healthcare industry from clinical trials, educational, research, and administrative purposes, both at the local site and across geographies or regions. It has the potential to improve efficiency in healthcare delivery, extend the healthcare
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5.8%
3.7%
4.4%
14.6%
21.3%
33.7%
48.7%
69.7%
44.9%
4.4%
10.0%
6.0%
17.1%
23.1%
care accessibility in rural India and can be a solution for India’s healthcare woes. A vast country like India, with a population of over 2 billion across 28 states and 6 Union Territories and governed by a federal system, needs affordable healthcare. As Rajendra Pratap Gupta says “It is a fact that has not been accepted by policy makers that it is nearly impossible under the current rural infrastructure and payment terms to get good doctors to work in rural India. In addition, building healthcare facilities and maintaining them in rural India is financially unviable. So, it will always be an ad hoc arrangement and a highly subsidised one and that is not a lasting solution. Rural India needs to extensively leverage the 3G and WIMAX technology and adopt preventive care model to avoid pain, suffering and high cost of healthcare” Potential key applications of mHealth include education and creating awareness, remote data collection, communication and training for healthcare workers, disease and epidemic outbreak tracking, diagnostic and treatment support and remote monitoring, access to technology, end user and healthcare provider acceptance, lack of regulatory issues, logistics and availability of appropriate, need-based, customised solutions are some of the other challenges.
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industry updates
State of
mHealth in India
mHealth can be understood as a term for collectively describing use of electronic information and communication technology in the healthcare sector. This refers to a technology used across the value chain in healthcare industry from clinical trials, education, research, and administrative purposes, both at the local site and across geographies or regions. It has the potential to improve efficiency in healthcare delivery, extend healthcare to rural areas, provide better quality of healthcare at a lower cost, enhance use of evidencebased medicine, stress on preventive healthcare, empower patients and consumers, and support to smooth relationships between patients and health professionals.
Paradigm shift
mHealth can embrace modern technology to widen healthcare accessibility in rural India and can be a solution for India’s healthcare woes. A vast country like India, with a population of over 2 billion across 28 states, 7 union territories and governed by a federal system, needs affordable healthcare
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In order to meet demand, healthcare will have to undergo a paradigm shift. It will witness massive convergence to tele-health and mobile health to fill the massive ‘need gap’. Whether it is large hospitals, small clinics or independent practitioners, tele-health would have to be adopted directly or indirectly in order to increase outreach, expand network and offer better services to patients. A telemedicine service provider provides advanced care in remote locations and increases the bandwidth to remote clinics with the help of WiMAX technology. In the rural areas, this service will be very beneficial. Another window to this point is remote surveillance and improving roadway safety. Understanding the needs, the Indian government has realised the importance of broadband and has made rollout of rural broadband a national priority.
India Story Currently, in India‘s three-tier government supported system for healthcare delivery, states have the primary responsibility
industry updates
of public healthcare. This results in significant disparity in quality and access to healthcare services in various regions within the states and even cities in India. The disparity is far greater between urban and rural regions in India. On the other hand, India is technologically advanced in the ICT sector and selfsufficient in meeting its needs of software, connectivity and services. Therefore, ICTs have the potential of making healthcare affordable for India, especially in rural India. This success can be further reinforced if these technologies are integrated into existing health-care delivery systems. In the last decade there has been active investment for development of mHealth in India but considering the demographic spread this investment is not sufficient for such a large country. The scale of mHealth services in India has been limited so far to medical transcription, health awareness through portals, telemedicine, and hospital management system and customer service using the internet. While globally and particularly in Africa, advanced technologies such as 3G services are used efficiently for providing healthcare solutions to remote villages, the use of communication devices such as mobile phones or conferencing solutions for mHealth in India has been limited.
Ride the Telecom growth wave Prof. K. Ganapathy, President Telemedicine Society of India, and President, Apollo Telemedicine Foundation says, “mHealth is more relevant in India than conventional eHealth, as access to PCs, laptops and broadband is far less than access to mobile phones just 12 million broadband connections, 24 million internet subscribers, 85 million PCs but 900 million mobile phones. Utilising wireless to access the internet is steadily increasing and telecom operators in India see this as a potential gold mine.” He adds, “The ubiquitous all pervading universally available mobile phone can now be used as a tool, an enabler to deliver healthcare to the haves and the have nots. There are unlimited opportunities and strategies for using the mobile in implementing mHealth in hospitals, insurance companies, pharma companies etc. With 50 mobile phones being sold every second, with an urban tele-density of 113 percent and a rural tele-density of 49 percent, we in India, should certainly be poised, to incorporate mHealth into the very fabric of our healthcare delivery system. mBanking, is taking off with 31 banks having 60 million urban customers (11 percent of the urban population use mBanking). Thirty five television channels can now be accessed on the mobile phone. This is just the beginning of m-entertainment. Today’s PC based online shopping, will soon give way to mCommerce.“
nation. The optimum utilisation of these networks, involving SHGs and training them with point of care diagnostics connected to mobile devices for diagnosis and treatment, will help deliver a cost effective and an impactful primary healthcare system for rural India. Satnam S Bains, Managing Director, Sero Solutions says, “The opportunity for mHealth has been stimulated by a number of factors, which include technological innovation relating to systems integration, improvements in wireless networks, mobile handset innovations, and the continued growth of mobile phone subscribers. There are a number of mHealth solutions that are in use in the marketplace today, application types include mobile access to medical records, adherence applications, medication compliance, chronic disease management solutions, as well as general ‘wellness’ applications including health surveys and data collection. The adoption of mHealth globally has initially been based around healthcare information and alerting using SMS as a medium, this has a proven model in India, however with the emergence of smart phones this traditional model is going through some rapid change.” Potential key applications of mHealth include education and awareness generation, remote data collection, communication and training for healthcare workers, disease and epidemic outbreak tracking, diagnostic and treatment support and remote monitoring. Access to technology, end
ICTs have the potential of making healthcare affordable for India, especially in rural India. This success can be further reinforced if these technologies are integrated into existing healthcare delivery systems user and healthcare provider acceptance, lack of regulatory issues, logistics and availability of appropriate, need-based, customised solutions are some of the major challenges in the way of widespread utilisation of mHealth. As per an estimate, there are at least 20 active mHealth pilot projects in India being carried out by some state governments and NGOs as part of mGovernance initiatives. A few sporadic projects have been carried out by others as well. They include use of mobile games to enhance HIV/AIDS awareness (10.3 million game sessions were downloaded in 15 months). Handheld devices were used to collect raw health data which were transmitted in real time to the health information system database. Disease and epidemic outbreaks have been tracked and daily health alerts have been sent to subscribers for nominal charges.
Mobile for health Today, India has the right opportunity with 875 million mobile phone users, 1.55 lakh post offices, 2.38 lakh gram panchayats, 8 lakh chemists and 2.2 million SHGs spread across the
Challenges The explosion of technologies in the last five years has witnessed an upgradation in the communication technology, november / 2011 www.ehealthonline.org
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industry updates
which has helped to position India amongst the BRIC (Brazil, Russia, India and China) globally. The adaptability of 3G, WiFi has shown a positive acceptation to WiMAX. These services are said to overcome the limitations of the rural spectrum allocation. The wireless broadband services also help the urban population to stay connected through their mobile broadband. This system of WiMAX is different from that of commonly known GPRS and 3G technology. These two services are designed specifically for the voice and data transfer whereas WiMAX is a separate forum similar to the Wi-Fi mesh. It is also a difficult task to get consumers to adapt to new technologies in urban and rural sectors. When compared to the 3G technology the condition of technical support is different for WiMAX technology. The technical support system of 3G is expensive and is available in limited handsets. These services provide varied opportunities to address enterprise mobility in sectors like transportation, aviation, and manufacturing. It is also a difficult task to get consumers to adapt new technologies in urban and rural sectors. When compared to the 3G technology the condition of technical support is different for WiMAX technology. These services thus offered provide varied opportunities to address enterprise mobility in sectors like transportation, aviation, and manufacturing.
Future outlook It is nearly impossible under the current rural infrastructure and payment terms to get good doctors to work in rural India. In addition, building healthcare facilities and maintaining them in rural India is financially unviable. So, it will always be an ad hoc and a highly subsidised arrangement, which is not sustainable. Rural India needs to extensively leverage the 3G and WIMAX technology and adopt preventive care model to avoid pain, suffering and high cost of healthcare. As Dr P S Ramkumar, Director, Applied Cognition Systems says, “Practically mHealth will take time, although the concept is easy to sell due to large scale user friendly nature of mobile phones. Although mobile communication has equipped the country with more than 800 million phones, a recent survey has found that out of 30 Tele-Health projects only two had intersected with mobile phones while 60 percent used free satellite connections provided by government initiatives.” Speaking from a global perspective, Michael Setton, CEO, Sensaris says, “With the arrival of low cost smart phones in the market, we believe that the market is poised for takeoff in emerging countries. In the western world, the majority of medical professionals seem to change averse and additional regulations regarding software will be a major obstacle for fast diffusion of mHealth.”
INSIGHT INTO THE BUSINESS OF HEALTHCARE
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10/14/2011 3:36:41 PM
opinion
Tele-Health
Taking it Beyond the Pilot Phase There are more than 540 million mobile phones in India, which can be used for pushing as well pulling information about preventive healthcare, as well as other healthcare services
Mobile interface is changing the generation, our society, our habits, the way we handle our daily lives and thus impacting every business. It is estimated that 92 percent of the US adults are on cell phones, one out of eight marriages in the US happen via internet, 80 percent of the world is under cell phone coverage and 80 percent of twitter is used on mobile. Word of mouth is transforming into the word of mobile. Anyone who ignores the role of mobile in his business is committing a great strategic mistake. Usefulness of mHealth is never debated;
usability is, and that is a big challenge for both the providers and users. If we are to overcome this hurdle, we must make the right start, and focus upon the areas of rural, geriatric and mental health. If we cannot do this, mHealth would never move beyond the pilot stage.
Ignorance is not bliss Most individual doctors are blissfully oblivious of what is happening in the field of mHealth and of the tremendous untapped potential this technology holds in bridging the urban rural health divide. Unless awareness is created and success stories highlighted, there will be no significant change. We will have more pilots in the mHealth arena than there are in the Indian Air Force!! We have a long way to go before a mobile phone becomes a hand held hospital, before refractive errors can be checked with it, before it is used as a microscope or before DICOM images can be manipulated, ECGs seen, heart sounds heard and the mobile from a patient used to connect bluetooth enabled sensors and a Body Area Network to a physician remotely. Storing mPHR and enabling access to drug interactions appears child’s play compared to this. Considering that worldwide, even in 2007, only 20 of the 50 documented mHealth projects were actually operational, serving less than 100,000 people, progress is certainly being made. Who could have predicted even two years ago that a mHealth summit in Nov 2010 in Washington would attract 2300 attendees, 200 speakers and 125 exhibitors from all over the world. However, less than 10 november / 2011 www.ehealthonline.org
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15-17 December, 2011 |
Mahatma Mandir, Gandhinagar, Gujarat
Chief Guest Narendra Modi Hon’ble Chief Minister Government of Gujarat
organisers
exhibitors
Co-organisers
Key Speakers Jay Narayan Vyas Minister of Health Government of Gujarat
Keshav Desiraju Additional Secretary Ministry of Health & Family Welfare, Government of India
Dr Ajay Singla Additional Secretary, Department of Health & Family Welfare, Government of NCT of Delhi
Anju Sharma Mission Director, NRHM, Gujarat
Dr S Vijayakumar Special Secretary (H & FW) & Project Director, TNHSP
Dr Ashok Kumar Former DDG and Director, Central Bureau of Health Investigation Government of India
Vijayalaxmi Joshi Former Principal Secretary & Commissioner, Department of Health & Family Welfare, Government of Gujarat
Sangita Reddy Executive Director Apollo Hospitals Group
Dr Girdhar Gyani Secretary General, QCI
Maurice Mars Prof of Telehealth Dept of Telehealth, Nelson R Mandela School of Medicine, South Africa
Dr Shakti Gupta Professor & Head, Dept of Hospital Administration, AIIMS
Dr Dharminder Nagar Managing Director, Paras Hospitals
Dr Sanjeev Sood CEO, Batra Hospital & Research Centre
Amod Kumar MNH Project Director, IntraHealth
Babu A CEO, Aarogyasri Healthcare Trust, Government of Andhra Pradesh
Dr B S Bedi Advisor-Health Informatics, C-DAC, Government of India
Dr Balaji Utla CEO, Health Management & Research Institute, Hyderabad
UK Ananthapadmanabhan Past President, Kovai Medical Centre & Hospital, Coimbatore
And many more...
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opinion
The immediate benefits of mHealth are enjoyed by patients who receive the service instantly and closer to home, but the institutions and organisations building the mHealth infrastructure and connecting all the other stakeholders benefit only at a later stage. These institutions need to be compensated in their early stages so that return on investment can be justified
percent of participants were medical practitioners. It appears that health is too serious a matter to be left to only doctors! Mobile network operators, IT specialists, software programmers, technologists and businessmen are playing a major role in mHealth compared to doctors. At least one mHealth conference takes place somewhere in the world every week. There is an imperative need to educate all the stakeholders of the potential of mHealth which could indeed be the answer we are all looking for.
Incentives for beneficiaries The three key players involved in the mHealth include the patient who is also the main beneficiary, the practitioner, and the service provider. To ensure that the three stakeholders work together to develop, promote and deliver healthcare service, mHealth applications must perform the following functions: delivery of health information services, facilitation of interaction between providers and patients, facilitation of the integration of healthcare industry-related business processes, local and remote access to healthcare information and support for employers and employees, payers and providers. Today there are many applications in the market that enable healthcare service delivery, impart education, and enable preventive healthcare. However, medical practitioners, patients, normal people and other stakeholders need incentives to use these mHealth applications. The immediate benefits of mHealth are enjoyed by patients who receive the service instantly and closer to home, but the institutions and organisations building the mHealth infrastructure and connecting all the other stakeholders benefit only at a later stage. These institutions need to be compensated in their early stages so that return on investment can be justified. A proper incentive system which benefits all involved parties would need to address the following issues healthcare service providers use different technologies and many times custom user interfaces. In order to motivate these service providers to come together on a single platform and share information with each other in order to create a unified healthcare system, it is highly important that these entities are properly incentivised to share the information. Critical drugs are rarely available in rural areas and some remote parts of the country. In order to create a robust supply chain that ensures continuous supply of medical drugs, an interconnected system needs to be put in place.
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This system will include hospitals, patients, as well as pharma companies. The entities in this system need to be incentivised in order to have an interconnected flow of information that will enable them to share information among themselves. There are more than 540 million mobile phones in India, which can be used for pushing as well pulling information about preventive healthcare, as well as other healthcare services. However, an incentive system must be put in place so that people on the ground are encouraged to use these services and provide or access health related information. Medical practitioners are often reluctant to use technology for providing healthcare services. This is so because it requires extra efforts to familiarise themselves with these technologies. The United States has been experimenting with a scheme which provides doctors an extra compensation that uses technology for providing healthcare services. The same model can be experimented with in India. People in rural areas are often not able to afford any kind of medical insurance or enrol themselves for any kind of healthcare services. But these people can provide information regarding their immediate surroundings (using simple tools such as mobile messaging, etc.) which can be useful for mapping diseases on a national level, and enhancing preventive healthcare. These people need to be encouraged to participate and in return be compensated for their valuable service.
Tele-health as point-of-care Massive spending by itself does not guarantee proper and universal healthcare. Take the US for example: it spends over US$ 7000 per capita on healthcare, but still faces a number of problems. In order to ensure quality and universal healthcare, we need not only innovation, but also pro-activeness in healthcare delivery to address the issue. We will have to reduce healthcare costs, reduce the burden of chronic diseases and increase positive outcomes. Telehealth should be used as the de facto POC (point of care) tool for preventive care and follow up care in chronic disease management. The channels of delivery must not just be confined to doctors and hospitals but must also reach pharmacies and other channels nearer to the POC. Given the situation in developing countries, telehealth is the only economically viable way to address the elderly population, rural areas, preventive care, chronic diseases, and increasing healthcare costs within current limitations.
case study
Text
to Change
Country: Country: Uganda Sponsoring Organisation and Partners: Celtel, AIDs Information Centre (AIC), Merck, and the Dutch Ministry of Foreign Affairs
A mobile phone is one of the latest Information, Education and Communication (IEC) tools that are effectively being used to solve information sharing gaps within the health sector in rural Uganda. Text to Change has a flexible platform which can adapt to participants’ communication needs. For example, messages can be sent in English or Luganda, the local language. To overcome any illiteracy issues, Text to Change is going to use voice SMS, so that recipients receive a pre- recorded message, instead of having to rely solely on a text SMS. Text to Change (TTC) provided HIV/AIDS awareness via a SMS-based quiz to 15,000 mobile phone subscribers during three months in Uganda. TTC was founded with the goal of improving health education through the use of text messaging, which holds the advantages of anonymity and strong uptake among the population. Partnering with the mobile carrier Celtel and the local NGO AIDS Information Centre (AIC), TTC conducted a pilot program from February till April 2008 in the Mbarra region of Uganda, with the objective of increasing pub-
lic knowledge of and changing behaviour regarding AIDS. The program aimed to encourage citizens to seek voluntary testing and counselling for HIV/AIDS. Free airtime was offered to users to encourage participation in the program; this was determined to be a powerful incentive since users can exchange the airtime with other subscribers as a type of currency. The quiz was interactive when participants gave a wrong answer they received an SMS with the correct answer from the cell phone provider. The uptake rate of the survey was 17.4 percent. The quiz focused on two specific public health areas such as general knowledge about HIV transmission and benefits of voluntary testing and counselling etc At the end of the quiz, a final SMS was sent to motivate participants to go for voluntary testing and counselling at the local health centre. Those who went to the centre were asked a final question: “Was this was the first time they had an HIV test?” After testing, participants were requested to leave their mobile phone number so that post-test counselling could be arranged. For the people who came to the health centres through TTC, HIV testing and counselling was free of charge. Initial grants from Merck, the US pharmaceutical company and the Dutch Ministry of Foreign Affairs supported the program launch. In September 2010, Text to Change (TTC) and Health Child began a two year project in Jinja, to “accelerate the uptake of postpartum care and promote the promotion of child health including early infant HIV diagnosis”, using SMS text and voice technology. The program targets 450 pregnant women, to improve their awareness of maternal health and to attend at least four antenatal care visits at their local health clinics during their pregnancy. The program also aims to encourage them to take up post-natal care services, which include family planning, full immunisation, as well as Prevention to Mother to Child Transmission (PMTCT) and early infant HIV services. november / 2011 www.ehealthonline.org
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industry updates
SustainableModelsformHealth The Indian government and private players need to work together using the “Public Private Partnership” (PPP) model in order to provide healthcare services to India’s geographically and culturally diverse masses.
The implementation and delivery of mHealth requires multidisciplinary collaboration, establishing joint ventures involving government and local or foreign partners to participate with each other and to take equity stakes in the delivery of mHealth services. Any mHealth PPP strategy must identify appropriate partners, specify appropriate technology and find viable financing solutions. Partnerships among governments, businesses and non-governmental organisations will require the creation of national associations, committees and task forces, with a multidisciplinary composition. Information technology experts, health professionals, consultants, industry and other key players must be brought in to assist in developing effective and sustainable mHealth programmes.
Need for PPP in mHealth The public sector encourages the private sector financing and provision in delivery of healthcare services especially in rural areas. There are many leverage points that a PPP model offers which is crucial for providing efficient and cost effective healthcare services to all sections of society. Initial capital expenditure (CAPEX) required for the healthcare facilities and operational expenditure (OPEX) required to run them is very high. Private players alone cannot invest so much of money into the system, so it is important that the government provides them with the initial funds. However, private players can provide the management skills and operational efficiency required to make the most of invested funds. Further, expertise of private players in running healthcare institutions is very important for providing healthcare services to India’s huge population. Over 80 per cent of the health expenditure in India is from the private sector while government’s contribu-
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tion is only around 20 percent. Looking at the average of 73 percent in OECD countries, the government needs to spend more, and PPPs could be the way to achieve it. It has been seen that usually, healthcare projects have a long gestation period and low rate of return in comparison to other industries. To compensate for the extra risk these projects have, private players need a partner to lower the cost of financing and provide long term security by underwriting the project risks. And, private players alone do not have the bandwidth to cover length and breadth of the country (especially rural areas), so the government needs to tie up with private players and provide healthcare services to people living in remote areas.
Existing PPPs in India The Indian government is working along with non-governmental organisations, private players and others to make healthcare services available using mHealth and other mediums. Some of the examples of existing PPPs in India are given below: An initiative of an NGO6 –OTTET and State Orissa Government in India The Orissa Trust of Technical Education and Training (OTTET) is rolling out telemedicine centres in villages across the state—the ninth largest in India. The project is being executed through a public-private partnership involving the Orissa state government and Sanjay Gandhi Post-Graduate Institute of Medical Sciences (SGPGI), Lucknow. It aims to establish telemedicine centres
industry updates
Advantages and Disadvantages of Public Private Partnership (PPP) PPPs provide several benefits but at the same time they also have some inherent risk involved in the structure. Advantages • PPPs provide a solution for shortages of initial capital and non-recurring finances • Integrates multiple stakeholders for a single cause • PPPs introduce private sector disciplines to mHealth investment • Build and maintains mHealth for higher quality and longer life • Non-core, highly skilled services handled by those most capable, usually excluding clinical and medical skills • Risks transferred to the party best capable of mitigating it
Disadvantages • Cost of capital to a PPP operator can be higher for governments and non-government organisations (NGOs) • HPOs can take on a significant, fixed commitment for PPP fees, increasing annual revenue expenditure over the longer-term • Potential oligopoly of operators that needs direct management by the HPO, especially complex sub-contracting relationships • Some operators may not find PPP appealing and therefore they withdraw from the PPP model • Operational transaction costs are reduced through-life flexibility • Lack of integration between mHealth and new clinical and healthcare models • Risks not measured realistically, transferred or shared as envisaged
in 51,000 villages covering the whole of Orissa. As partner to the project, the government is providing broadband connectivity, services of doctors, and also providing subsidies for Capex. Private players on the other hand are bringing in Capex for medical kits, and communication equipment and also managing the Opex. Telemedicine initiative by Narayana Hrudayalaya in Karnataka Stakeholders are Government of Karnataka, Narayana Hrudayalaya hospital in Bangalore and Indian Space Research Organization (ISRO). It is an experimental tele-medicine project called ‘Karnataka Integrated Tele-medicine and Telehealth Project’ (KITTH). With connections by satellite, this project functions in the Coronary Care Units of selected district hospitals that are linked with Narayana Hrudayalaya hospital. Satellite linking is provided by ISRO using its GRAMSAT (rural satellite) programme, and space technology that it has developed for healthcare and education. Apart from ISRO’s telemedicine network association, Asia Heart Foundation and Narayana Hrudayalaya have initiated telemedicine activities with the help of high speed telephone connectivity or Integrated Services Digital Network (ISDN) connectivity to connect remote intensive care units to provide critical care to cardiac patients admitted in government district level or subdivisional hospitals in the remote areas of West Bengal, Assam, Bihar, Jharkhand and tribal belts of Karnataka.
Factors for successful PPP A Public Private Partnership model has two major stakeholders--government and private players. For the government, it is important that accountability and proper audit systems are implemented from the initial stage as public funds are deployed for the project; hence the government is accountable to the public to use the capital efficiently. On the other hand, the private player is accountable to its shareholders so profitability is important, they need to have some kind of material or other tangible benefit coming out of the partnership otherwise they would not be enticed to maintain the relationship for a longer period. Hence for a PPP model to be successful it is required that the government should adopt a liberal policy which identifies and respects the profitability requirement of the private partner. In a similar vein, the private partner should also remain accountable and follow full auditing process in order to justify the use of public funds. For a PPP model to be successful there is a need to provide mHealth services to the lower strata of the society and at the same time have a structure that it can be brought out of the pilot phase and rolled out on a large scale. There are certain things which should be highlighted while implementing a PPP model such as getting alignment on deliverables, provide clarity on scope and services, modifying mechanisms as per need, develop trust on projects, maintain cash flow and financial drivers during the project, clearly define Capex and Opex for the project and target realistic timeframes.
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case study
WiMAX Empowering
Healthcare in Nigeria The introduction of telemedicine technology in Nigeria has the potential to change the course of healthcare delivery, especially in rural areas.
The step towards introduction of tele-health began in 2007, when Intel announced a comprehensive set of digital inclusion projects aimed at improving education, healthcare and economic development for country’s 140 million populations. With the support of the Federal Ministry of Health, Intel launched a pilot project on telemedicine that brings critical pediatric care to a rural hospital serving a region of 4.5 million people. Nigeria’s first Telemedicine Center, linking a rural clinic in Bida of the central Niger State and the National Hospital Abuja, was inaugurated in Abuja. The center is an interactive healthcare platform, utilising telecommunications technology, to fast track consultations, diagnosis and prescription on real time basis. With Intel’s support, doctors in Bida are now able to consult in real time with pediatric and surgical specialists in Abuja through the new telemedicine system, which features video conferencing and high-speed broadband connections through Wimax, a long-range wireless technology. The pilot makes it possible for physicians to shorten both time and distance in getting to patients to treat them. The system connects one of Nigeria’s flagship medical institutions, the National Hospital in Abuja with the Federal Medical Centre in Bida, a rural 200-bed medical facility. So far, patients who needed referrals from Bida were forced to travel at least 250 kilometers to reach specialists – a trip which most cannot afford. Developments in the telemedicine field are vital to help provide improved medical care for those living in rural areas and to ensure doctors who are able to perform more complex medical procedures. Africa is a highly populated landmass with many people unable to access basic medical care. By improving Africa’s healthcare system through remote access vehicles and technology, governments will be able to provide essential medical advice to those in need. Bida has an acute need for care from pediatric medical specialists. In the project’s first phase, a fetal monitoring capability will permit baby doctors to remotely – and more quickly – consult with medical staff and examine expectant mothers to monitor the progress of their pregnancies. Intel is also training medical practition-
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ers and technical specialists at both hospitals to use the new technology tools. In early 2009, the Nigerian Federal Capital Territory Millennium Development Goals Unit (FCTMDGU), health officials, and Intel Corporation began discussing ways that Information and Communication Technology (ICT), could be used to improve health and healthcare delivery in rural areas. Intel decided to take healthcare to the communities through mobile health (mHealth) and telemedicine, which eventually, gave birth to the Mai Lafiya Health Programme. Recognised for its leadership in telemedicine technology, Intel Corporation was also presented the ‘Nigerian Telemedicine Entrepreneurial Company Award’ by Frost & Sullivan in 2009 - one of Africa’s leading Excellence Awards platforms.
interview
Care Hospitals has been in the practice of tele-medicine in India since 2001 and a witness to the changing technology landscape in tele-health over the years. In the backdrop of the Telemedicon 2011, Dr Prasad Sistla, Chief of Telemedicine, Care Foundation shares his views on the effective strategies that a hospital can undertake to reach out to a larger set of patients in need of care
Telemedicine Needs More Practioners than Technology! Tell us about the most exciting aspect of telemedicine in India. Nothing is static in tele-medicine and it is ever-evolving with technology advancements. There are two sectors of excitement speaking from the extensive work done at Care Hospitals. From a practioner’s point of view tele-medicine has opened up a new channel of communication for the doctor to connect with his patients. Today, this technology not only allows reaching out to people but also assists doctors in their practice of medicine. It has given them the ability to reach out to a larger number of patients in rural and remote areas without physically visiting the hospital or clinic. The second excitement is surely from the technology perspective, as many new platforms such as the iPhone, iPads and portable mobile devices have arrived in the tele-health market, thus making it easier for the doctors to view and review patients details anytime anywhere. How can hospitals leverage on tele-medicine for patient care? For any doctor, there is no replacement for a physical examina-
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tion of the patient. However, in case of emergencies and reaching out to rural and remote villages, technology is definitely an enabler. There is still a limitation on the use of telemedicine in the rural areas due to bandwidth and connectivity challenges. The practice of telemedicine is still in its nascent stage and has yet to find its presence in the tertiary care segment hospitals across India. Currently it is the technology that is driving the telemedicine growth in India, more than the demand from doctors. We need to strengthen the practice of tele-medicine first and then ride on the various technology platforms depending on the most-suited solution. I feel it is good that patient-related data is now available on the mobile, however we observe a skills gap in adoption of telemedicine as a practice. This limits not only to the urban areas but also touches the lives and health of villagers. Therefore, hospitals especially operating in the tertiary care segment should come at the forefront and take leadership in using tele-health to connect with district hospitals and remote clinics. They can function in regularised systems that are operational 24X7. Tele-medicine will achieve its goal of healthcare for all only when appropriate technology and equipments is coupled with
interview
We need to integrate the second tier of healthcare institutions that include our district hospitals with our tertiary care expertise using telemedicine technology. This will make quality healthcare not only accessible but also affordable high end medicine and care. A city hospital can easily cater 100150 kms area away from the city front. How can the rural patients benefit? It is not just access to information and technology that defines quality healthcare, in the realm of changing platforms of technology we need to have a minimum benchmark for telemedicine in India. This is based on the many realities and challenges of the rural India. We can build on the available technology such as the availability of fiber optic lines laid down making communications easier than before. However, the challenges of broadband and operating in limited constraints benchmark for tele-medicine with minimum requirements for practice. Also, telemedicine can go beyond connecting to patients and become a medium for capacity building and training for general practioners in small clinics and primary healthcare centers in remote areas. We need to integrate the second tier of healthcare institutions that include our district hospitals with our tertiary care expertise using telemedicine technology. This is achievable as we have
been involved in this model of hand-holding for over a decade in Andhra Pradesh and plan to reach out to more than 100 villages in the state in the coming years. There is also a need to include tele-medicine as a medium for medical education and training using high quality video conferencing solutions; this will create more capacity of trained medical professionals in their daily practice. This will make quality healthcare not only accessible but also affordable. Another advantage of this would be getting back to the state of ‘prevention is better than cure’ as continuous monitoring and surveys of ailments can indicate the type of diseases prevalent in a particular locality. This can be then followed by a specialised line of treatment from the tertiary hospital along with focused programmes as complimentary activities as a part of prevention strategy. What is the future outlook for the growth of telemedicine in India? Technology is a catalyst to healthcare delivery, and if we depend too much, it might appear as a deterrent in adoption and practicing telemedicine can also work for the hospitals and doctors just as trendy gadgets can. The growth of telehealth has just begun in India and while technology will always be there, there is a need to popularise the practice of telemedicine by doctors, medical staff and nurses to ensure all are included in the ecosystem. Undoubtedly, ICT platform will come in the next decade and will have highest impact in the healthcare industry and we must be geared to reap the maximum benefits both for the rural and urban India. november / 2011 www.ehealthonline.org
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case study
ECG
on your mobile
Country: India and the United Kingdom Application Area: Remote Monitoring Sponsoring Organisation and Partners: The UK – India Education and Research Initiative (UKIERI), Loughborough University, Indian Institute of Technology, All India Institute of Medical Sciences, Aligarh Muslim University and London’s Kingston University Probably the first prototype of a mobile phone that can transmit ECG images was made as early as 2005. In a university lab, engineers used a mobile phone that can easily receive, collate and send a person’s ECG and other vital signs to clinicians, eliminating the need for large, fixed home-based tele-health systems. This application could be used for a number of medical purposes, such as remote routine check-ups, as well as in emergency and rescue situations. Long considered a ‘rich country disease,’ diabetes is spreading rapidly in the developing world as affluence changes traditional dietary habits. Engineers from the UK-based Loughborough University entered into a partnership with experts from India to develop a unique mobile phone health monitoring system. The system, 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
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anywhere in the world. Presently the system can transfer the signals pertaining to the ECG, blood pressure, oxygen saturation and blood glucose level. Created by Professor Bryan Woodward and Dr Fadlee Rasid from the Department of Electronic and Electrical Engineering, the system allows doctors to use mobile phone networks to monitor up to four key medical signals (electrocardiogram heart signal, blood pressure, levels of blood glucose, and oxygen saturation levels) from patients who are on the move. Engineers and technicians from the Indian Institute of Technology Delhi (IIT Delhi), the All India Institute of Medical Sciences, Aligarh Muslim University and London’s Kingston University are working to miniaturise the system so that sensors are small enough to be carried by patients while procuring the necessary biomedical data. The network of sensors would be linked through a modem to mobile networks and the Internet, and to a hospital computer. Doctors could then use this device to remotely monitor patients suffering from chronic diseases such as heart disease and diabetes, which plague millions across the world. In the United Kingdom, the solution will be used to improve healthcare delivery, while in India it will connect Centers of Excellence to hospitals and clinics in more remote areas. Over the coming years, clinical trials will be conducted in both the United Kingdom and India. The idea behind using mobile phone technology for healthcare is that a doctor can monitor a patient who can be anytime anywhere. The most important aspect of the system is the integrity of the signal. The only limitations appear to be the temporary loss of mobile phone signal when going through a tunnel or other areas not covered by a mobile network. The next step for the researchers will be to develop a credit-card sized device that can do the same thing, which will be easier to carry for everyone.
case study
Telemedicine for rural women Cancer Care The OBCSDP project aims to reduce the breast cancer mortality rate in Mexican women in the age group of fifty to sixty-nine with the effective use of ICT
In 2006, breast cancer became the leading cause of death in Mexican women in the age group of fifty to sixty-nine. The Opportune Breast Cancer Screening and Diagnosis Program (OBCSDP) is meant to transcend economic and personnel barriers through the innovative deployment of ICTs. The project aims to reduce the breast cancer mortality rate in women between the age group of fifty to sixty-nine; the programme will increase the national screening rates from 7.2 percent in 2007 to 21.6 percent by 2012. The telemedicine network had the goal to screen 1.3 million women in the 30-months period between May 2010 and December 2012. With over 34 million Mexican pesos (approximately US$ 2.8 million) of seed funding from the federal and state governments and not-for-profit groups, 30 screening sites in 11 states were linked by Internet to two interpretation centres, where results of the screenings could be viewed by radiologists. In 2012, eight more interpretation sites will be opened, and the programme would become self-sustaining in terms of operational costs. Due to challenges with Internet
connectivity in rural areas of Mexico, many communities lack the necessary bandwidth for Internet protocol-based image transmission which is necessary to transmit mammograms. To overcome this challenge, CDs were used for patient data transfer and long-term data storage. Each carried four patient images and up to four patient mammograms. CDs are privately or commercially couriered to the closest interpretation centre. It took approximately three weeks to produce results and deliver it to individuals. Communities with Internet access will be evaluating individual partnership agreements with TelMex—a private telecom company— for one calendar year after Phase 1 is initiated. If feasible, these should allow for instant data transfer between the screening and interpretation sites. This arrangement would cut half the picture-to-result in time of 7–21 days required with the use of the CDs. Quality control of hardware and its interoperability was also a challenge along with standardising the skill levels of radiology technicians. Initially, the programme faced challenges while scaling it up across Mexico. The decentralisation of partner institutions was also less than ideal, due to independent organisational structures, jurisdictional logistics, and funding schemes – all of which required extensive coordination and time to successfully overcome. This collaboration led to the programme overcoming shortage of radiologists to improve equity of access in preventative breast cancer screening and diagnosis for rural and remote residents in over five states in Mexico. Source: Telemedicine - Opportunities and developments in Member States; Report on the second global survey on eHealth; 2011 november / 2011 www.ehealthonline.org
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Perspective
Challenges for
Telemedicine in India It has always been heard that doctors are the biggest impediments for use of technology; on the contrary it is the doctors’ community that is fast becoming tech savvy and forward looking when it comes to technology. Perhaps what is worrying them is the transmission of reports securely and without error or loss. Once the industry is able to give clinical evidence, eHealth and mHealth market will explode!
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november / 2011 www.ehealthonline.org
Perspective
For healthcare to reach masses and to support the growing demand of healthcare services in India, India’s mHealth infrastructure needs to undergo drastic changes. Government has taken up some initiatives aimed at providing affordable and quality healthcare services through setting up of primary health centres (PHC) all over the country. However, the communications at these PHCs are not reliable and the internet speed, 33.6 kbps, at which these PHCs get connected to the district or state level hospitals, is inadequate. Thus, PHCs are unable to provide instant healthcare solutions to patients in remote villages through basic online information exchange or more advanced video transmission for telemedicine. There is a need to build sustainable, cost effective infrastructure and ecosystem for implementing mHealth throughout the country. mHealth will transform the lives of common people if there are adequate initiatives from both the private and the public sector for development of ICT technologies in healthcare. The cost of this infrastructure is a big concern as there are not enough funds available for providing healthcare services to the masses. One solution is to pool resources from different government schemes and to create a fast and robust technology infrastructure fund that serves multiple verticals such as healthcare, education, finance, etc. This will not only help in overcoming high infrastructure costs but also create a synergy between different verticals while ensuring maximum utilization of existing infrastructure. More than 44 percent of rural India faces power cuts of 12 to 15 hours a day, where even a battery backup system does not work-out. Thus, while most modern technologies designed for developed countries assume continuous availability of power and telecom connectivity, it takes time and cost to customise them to address such gaps. Another barrier to rapid delivery of equitable care is linguistic diversity. For example in India with over 22 officially recognised languages and over 1600 ‘mother tongues’, linguistic diversity seems a major barrier in the way of a patient in one region being able to talk to a doctor in another region. Incentivising all the stakeholders involved is a major challenge and raises the question of who will pay the bill, as the cost of infrastructure, medical drugs, fees of doctors, and other operating cost could go very high. Hence there is a need to divide these costs among different entities which include third party financing solution. There is a chance that people may deceive system by duplicity of the same procedure over and over again, which would lead to unnecessary cost overrun. A physician must be motivated and incentivised in order to share medical records of his/her patient with other practitioners, as they might jeopardise bond of faith between a patient and a doctor. Initial investment which usually is fairly large must be borne by government, and this may raise return required by those parties who are going to get there returns on a longer time horizon. Cost Containment: Cost of providing healthcare to population of India is a huge task and introducing ICT would require extra upfront investment. Hence, there is a need to manage the cost in such a way that overall cost of healthcare goes down.
If a bigger share is given to ICT spending in overall healthcare budget, this could be achieved. It is also required to look at generating volume beneficiaries for costs to be justified. Information Exchange: Health information exchange needs to be demanded and driven with proper access and control mechanism in place. Challenge is to motivate and encourage key stakeholders like patient, medical service provider, insurance companies and government to pull as well as push right kind of information from the system. Adoption and Resistance: In India and across the globe there is a problem of reluctance on the part of patient as well as doctors in adopting mHealth. There is a need to bring in the right kind of technology in the right way so patients as well doctors feel comfortable in using them. This could work as an ultimate test of technology, as companies not only have to prepare best technological systems but also make sure that they are easy to understand and use. It is also required to run multiple awareness programmes for benefits of mHealth. Staffing at different levels: mHealth is not just about having technology in place, it should also have an identifiable, approachable and well qualified human interface to interact with. Getting the right kind of people to use these technologies in order to provide proper healthcare services is very important. Hence, there is a need to hire right kind of people and train them properly so that they are well equipped to carry out the task of providing healthcare in remote areas. Evaluation: Evaluation of the processes needs to be fair and done by an independent third party observer. There is a need to have benchmark so as to compare against them. These could be taken from best practices from local projects or from global examples such as Sweden, Singapore, etc. An independent body could be created for this purpose which provides rating as well as guidance on how to lay down dependable framework for mHealth. Power Sharing: The entire system of healthcare should be such that it can be driven from both central and state government. Power, responsibility, accountability, rewards and risks must be well defined in advance so as to avoid any conflict of interest. Managing Information: All the information that has been collected should be media rich (containing video, image, text, etc.). This information should be properly archived, accessible, retrievable, secure and readable from remote location using different technology platforms. One patient-one record needs to be implemented, so as to avoid duplication of information. Innovative and cost effective health informatics solutions need to be created for the purpose. Education: mHealth is not just about providing healthcare service when someone is unwell, but it should also be used to promote preventive healthcare to improve the standard of living and reduce the cost in the medium to long term. This will also help in improving and enabling higher productivity. But achieving this requires bringing people into the system and educating them about the different preventive measures to avoid disease outbreaks like Swine-flu or other seasonal diseases. november / 2011 www.ehealthonline.org
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case study
Tele
Diagnostics
Centre Sets up in Remote Areas
Pioneering work of providing tele-diagnostic facility has been implemented in remote areas
Located about 120 kilometers from Pune, Baramati is a Tehsil or administration centre, for a group of villages primarily possessing agricultural economy. Baramati has a wellbuilt infrastructure, with roads, water, and utilities. The small town also boasts India’s largest dairy, capable of processing one million liters of milk per day and also pioneering work of tele-diagnostic facility that has been implemented at Rui Hospital. A new Community Service Centre features kiosks that provide internet access and services. Wimax enables broadband speeds in a wireless environment, while Intel-powered PCs provide computing power and access, even in areas with erratic power supplies. One beneficiary of the town’s new PC access is the network of more than 100 women’s vocational self-help groups. A digital community health center was implemented with remote diagnostics in ophthalmology and cardiology. The center delivers specialised care in areas like cardiology and eye care at dramatically lower costs than in urban areas – sometimes as much as 25 times less expensive. The initiative involved health-
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care partners SN Informatics and Schiller Healthcare, along with tertiary care providers Narayana Hrudyalaya and Aravind Eye Hospital, and supported by the leading local institute at Baramati, Vidya Prathisthan’s Institute of Information Technology (VIIT). The ECG test of a patient in Baramati is transmitted to the cardio-care room of Narayana Hrudayalaya and a slit lamp captures the inner image of the eye and the data is transferred to Aravind Eye Clinic. The existing tele-medicine set-up of the hospital was utilised for this purpose. A cardiologist examines the test results and reports the abnormalities, if any, round the clock through this procedure. The average response time is less than 10 minutes. The community health center is making a striking difference, with 11,000 outpatients served in just first four months of its operation. The project was under the World Ahead Programme, an initiative launched by Intel to provide education and healthcare service in India and encouraged by the working of the Baramati project. Intel has expanded the tele-health scheme to a 100-bed hospital in Tindivanam as well.
interview
“mHealth
is Poised to Revolutionise” mHealt hh opportu as got a wind ow of nit will ope ies that techn n ology the rura especially for l India. W devices , intellig ith smart e and aff ordable nt features p industr y will su rices, mobile r ely dem their du an e from th share of atten d eh tio provide ealthcare tec n hnolog rs. Com y Kumar m VSM (R ander Girish etd), P Head, I rac nd Life Sc ia – Healthcar tice ien e& Service ces, HP Enter st pr optimis ells us more o ise m arou nd mHe n the India alth in
What is teleme the most ex c d Curren icine marke iting aspect tly t of the teleme , there are tw in India? dicine, o wave s o tric ap proach ne is based of excitemen on the t aroun the en to tele tec d dm and pra user perspe edicine and hnology-cen ctive w the oth ctioners hich in e and th It is ev cludes r from e id im e n pact o t that te patien ICT de f tec lem ts pe techno ndent servic edicine is a hnology. techno logies e and there is logy an that ha industr d ve y a is und – but as far a arrived into lot of excitin oubted g s telem th e h ealthca ly the m edicine ryone’s re ob is a in India ttention and ile sector th concerned it at has . This h has su got ev health as also ccessfu eca b and in re technolog ecome a m lly penetrate d edium clude y prov m ider’s for us medic ri a ine se obile as a rvices device de on the w s tives th ave inclu to at the mo otherwise w ding the he transact tele althcare ould h bile de ave be vic ity into en an o operathe he es have defi rdea nite alt wider re ach th hcare spectr ly brought-in l. So, an eve u m a n r before d a pro mobil. mise o f
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november / 2011 www.ehealthonline.org
interview
Earlier there were fixed lines housed in special centers that use to transact for the purpose of patients reference. Today, with the convergence of many technologies and capabilities that are easily achievable on the mobile platform, mHealth is poised to revolutionise the way we look at tele-medicine use and penetration in India. The penetration of mobiles has also blurred the rural-urban divide and the on-going research is exploring how a landline telephone will be able to transact i.e. send and receive significant volume of tele-medicine related information. If one were to have a patient’s standpoint and also the providers of care using tele-medicine, the excitement is because of the user friendly features and affordability of mobile phones. Doctors now have a faster platform for cross consultations for peer reviews of case history and diagnostic procedures and treatment. Thus, these three trends that are conjuring-up a mood of optimism with regards to tele-health includes affordability, penetration and convergence of technologies on the mobile platform for anytime anywhere communications between the doctor and the patient. Role of innovation in telemedicine and how farther can this work? The role of innovation is more on the medical technology, equipment and gadgets side. Earlier, in a telemedicine centre, most of the patient data ECG, blood reports, etc were recorded on analog machines and then carried out on a manual data entry report in the software provided to them. Today, with the advent of mobility devices in the healthcare segment, most of these data sets can easily be shared and transferred on devices designed to be used in the rugged conditions of the rural India. One such device is the digital stethoscope that has become popular among tele-medicine practioners. A lot of innovation is thus needed in building medical gadgets that are capable of working across many device inter-faces within the tele-medicine network so that the usability of the platform of tele-medicine becomes much easier and data is shared much faster. Also the time constraint in terms of volume of patients that each doctor examines is addressed, as he uses a lot of intelligent and automated gadgets to connect and communicate with patients. What are your key recommendations to the government for faster growth of the tele-medicine in India? If one were to map the growth of tele-medicine in India, one would observe that it has developed in patches. There has been an absence of a central agency – that can act as an umbrella body for telemedicine in India. Thus we first need a central body in the government that undertakes the mandate of tele-health in the country. We also need a dedicated policy on the telemedicine in India that provides guidelines and framework to weave the various activities that has been undertaken by different stakeholders in healthcare so far and also take the programme ahead to the next phase.
g uildin b n i d g neede e of workin s u h t l is ab he vation hat are cap es within t lity o n n i t bi of ac A lot al gadgets ice inter-f hat the usa mes v medic many de twork so t icine beco s e s n acro edicine f tele-med m tele- platform o of the easier much
In my opinion, another strategy that needs to be focused by government of India to have a well-planned framework that outlines the facility of a tele-medicine centre in each PHC in India. And there has to be a network created between the center and the district level hospital to support a better quality of expertise and specialty advice to reach patients. Usually the specialist level opinion and expertise are not available at the PHC level and they are not able to deliver quality of healthcare delivery at par with the tertiary care hospitals to the rural India. However, connecting them through tele-health network can solve that. There should be a nationwide network of telemedicine, where all stakeholders can share the resource pool, especially for the rural India wherein the specialist cover is many kilometers away. And my third suggestion would be of fund allocation as there is a need for a dedicated fund from the government for the support and scaling-up of telemedicine network. The government should encourage more PPP models for the growth of the telemedicine network, and there should be more involvement of the private player so as to ensure that the momentum of telehealth remains faster and wider in rural India. Your future prediction on the growth of the tele-medicine market in India and what are the key investments made by your company in this regard? HP has taken the first step towards supporting telemedicine by joining the mHealth bandwagon. We have already pledged that as part of our social innovation commitment, we will contribute funds for research and propagation of mobile health which is going to be the platform for telemedicine. Secondly, we are poised to two projects under our funding scheme that operates in Trivandrum and Madurai involving cancer-related care and psychiatric-care respectively. We have also invested into HP Labs, and it aims to develop solutions which can cut across the communication channels and promote telemedicine to strengthen the rural India to get a better access and quality of healthcare. So we have a strong inclination towards telemedicine not only in terms of the technology but also affordability for the end users. november / 2011 www.ehealthonline.org
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book review
Biomedical Informatics
Title: Biomedical Informatics Author: Jules J Berman Publisher: Jones and Bartlett India Pvt Ltd Edition: 2010 Pages: 459 Price: Rs 395/- paperback ISBN: 978-93-80-108-17-9
“We are drowning in data but starved for knowledge.” – John Naisbitt
Reviewd By Gp Capt (Dr) Sanjeev Sood Gp Capt (Dr) Sanjeev Sood, is a Hospital Administrator at AF Hospital, Chandigarh. He is an NABH empanelled assessor and prolific writer on healthcare matters. Email:doc_ssood@yahoo.com
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Healthcare organisations hold vast amounts of data related to clinical encounters. How can this unstructured data be contextualised and translated to meaningful research? How to acquire, merge and share confidential medical data from incompatible and diverse sources and translate them into actionable clinical results? How to reliably identify data and bind observations to unique patients? Who owns medical data – patients, physicians or hospitals? What is data warehousing and data mining? And what critical role HIS plays in organising this data? Biomedical informatics by Jules J Berman answers these and many more such tricky questions which are fundamental to advancement of medical knowledge and research. Biomedical informatics draws heavily from other fields like health care, software programming, computer scientist, statistician, metadata analyst and so on so forth. The purpose of this book is to provide the reader with tools and strategies for obtaining, organising, and analyzing biomedical data. The book aims to achieve following learning objectives for any reader how to acquire and organise biomedical data even when the data are received in the form of unstructured text, how to merge and share biomedical data even when the data are confidential or come from seemingly incompatible sources, how to write your own programs in Perl that will allow you to perform common informatics tasks with just a few lines of code, how to automatically index biomedical text and code text using freely available biological and medical nomenclatures.
Contents and key features Written for healthcare workers, students, and biomedical researchers who wish to equip themselves with basic skills of informatics technologies in their own clinics and laboratories, biomedical informatics discusses and reviews many types of biomedical data. The book provides in-depth discussions of data representation including XML metadata, RDF, and ontologies, an extensive appendix describes free, open source tools that will facilitate software interoperability and greatly reduce the cost of information technology, contains over 240 lists that can be downloaded and used in power-point presentations, includes Perl source code to be used in your Perl applications and provides guidance in employing data organizations and data sharing technologies in research grant applications. No book on biomedical informatics would be complete without some instruction in computer programming. So as not to discourage nonprogrammers, the book is organised so that all of the programming instruction is found in ‘Just enough Programming’ (Chapter 5) and ‘Programming Common Biomedical Informatics Tasks’ (Chapter 6). A glossary is included, and new terms introduced in the text are set in boldface type. There is an extensive reference section with 180 references; each appended with an explanatory note (Chapter 18).Chapter 19 provides the summary of open source programming languages.
About the author The author, Jules Berman, PhD MD is a pathologist with an eclectic technical background that includes a bachelor’s degree in mathematics from MIT. He was Program Director for Pathology Informatics in the Cancer Diagnosis Programme in the U.S.
interview
e v i t n e e r v a e c r P lth ur o eH h t of lly d e dua e a r N is g dian e e r h a in In is t lthc
a e H
ing a s g r a t a e n n y h a ive he m try, sa int Ma hile t n t ve g Jo lus w ngh us , i Pre omin e ind ad ealth P tap Si r w bec lthca a ik s H Pra hea l Na Indu ndra care and o f s e th Amector o to Dhir e heal ologie Dir king entiv techn a , ev spe the pr rends t on ustry ind re mo
cal establishments across the country is reaching out to many. Please tell us about Indus Health Plus operations in India. Headquartered in Pune, Indus Health Plus has presence in a number of regions including Maharashtra, Delhi, Bhilai and Goa. Indus has offices in Mumbai, Delhi, Nagpur, Nasik and Goa and it has tie-ups with reputed delivery partners that are spread all over Maharashtra. We have reached out to more than 2,70,000 clients across the country during the operation period of almost 11 years and currently we are present in 14 cities with 36 delivery partners. As more and more people are waking up to the concept of preventive healthcare with us, our association with reputed medi-
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What are the services that you are currently offering? Our services are our products — preventive healthcare packages and Healthfriend card. Preventive healthcare packages include Essential Care Health Checkup Package (EsCP); Early Care Health Checkup Package (ECP); Exclusive Health Checkup Package (EHC); Exclusive and Comprehensive Health Checkup Package (ECHC). A part of our drive is to make quality healthcare ‘accessible, available and affordable’ to all. Our Healthfriend cards enable ‘Indusites’ (those associated with Indus Plus) and their families to access quality medical treatment at highly discounted rates.
interview
What are your views on advances in the field of preventive healthcare over the last few decades? Which technologies have mostly benefited this sector? The Indian healthcare industry, unlike other industries, stands untouched by recession. There has been a steady growth in this sector, revenues from the healthcare sector account for 5.2 percent of the GDP, making it the third fastest growing sector in India. Additionally, the preventive healthcare market is growing at the rate of 25 percent per annum. According to the WHO, India is increasingly becoming the capital for various diseases like cancer, heart and various other lifestyle diseases. A CII report indicates that 8 percent of households are pushed below the poverty line each year due to health expenditure. Technopak reports indicate that 40 percent of the low and middle income population borrow money or sell assets to pay for hospitalisation. Most of these unexpected expenses are medical expenses, due to which many people bankrupt. Hence, it is time for one and all to wake up to the concept of preventive healthcare. Technologies such as CT Angiogram and other non invasive forms of testing such as 2D Echo Cardiogram have been great use in the field of preventive healthcare. We incorporate the latest available technology, such as CT Angiogram, as soon as they are launched in
How do you foresee the transformation in healthcare delivery through preventive health checks? A recent ICRA report emphasises the role of prevention, especially in battling chronic diseases rampant in India, and so there is an immense scope of work. There is a need for an awakening in the thought process of Indians. As prevention becomes a culture in India, the impact will be phenomenal. Planned surgeries can be undertaken instead of last minute critical operations. The mortality rate due to lifestyle diseases can also be minimised. Overall, the losses can be reduced and it would help in the effective use of India’s GDP. Hence preventive healthcare is the need of the hour and there is tremendous scope of the same in India as well as at the global level. What is your perspective on the preventive healthcare check-ups market in India? The Indian healthcare industry, unlike other industries, stands untouched by recession. The preventive healthcare market is growing at a rate of 25 percent annually. As awareness about the need and importance of preventive healthcare grows amongst the middle class segment, our sector is bound to grow further.
What has been your marketing and business strategy? The preventive healthcare industry, on the whole, relies strongly on word of mouth publicity. As a brand, we want to expose as much Technopak reports indicate that 40 percent of the of the society to preventive health solutions and their benefits as possible. Our strategy low and middle income population borrow money involves initially exposing the society to this or sell assets to pay for hospitalisation. Most of type of solution and then increasing the share these unexpected expenses are medical expenses, of voice within the societies we are present, due to which many people bankrupt. Hence, it is within the discussions on health and within the time for one and all to wake up to the concept of media. preventive healthcare Our marketing plan involves a 360 degree approach which involves public relations, advertising, online, as well as non media events the market to ensure higher customer satisfaction through unto reach the society directly. We have been concentrating on paralleled quality. making sure all this communication is properly integrated to make sure our entire target market understands the same What are the key equipments and technologies installed message regardless of the media they consumed the mesat your centres? sage from. We use different marketing channels like exhibiIndus delivers quality healthcare through trusted delivery parttions, seminars etc to reach out to the audience. ners across 36 centres. According to Time magazine, cardiac CT scan is the most comprehensive scan available for the What do you predict will happen within preventive heart. We have evolved from the basic preventive health packhealthcare in the next 5-10 years in India? What are your ages to the high-end packages. This scan involves a huge sum future plans? of money but Indus offers this service along with a bouquet of The Indian preventive healthcare market is growing at a treother services at a very nominal rate. Indus believes in adding mendous rate, though it is still a relatively new concept for value for consumers, as we know that in India almost 80 percent most Indians. We foresee strong demand for hospital serhealthcare expenses are paid out of pocket. We have invested vices in tier-II and tier-III cities and thus have a targeted efand developed ERP software, in order to give a better experifort to reach out to these customers. Indus Health Plus is the ence to our clients. At Indus, in a bid to provide our clients with only company in India to have such an extensive network of the packages, we work in close conjunction with our delivery preventive healthcare delivery partners across most tier-II and partners. tier-III cities across Maharashtra as well as pan India. november / 2011 www.ehealthonline.org
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expert corner
A Solution Whose Time has Come
e-Teaching can be applied, not just to paediatric cardiology and radiology as has been successfully done in India, but to all branches of medical specialists in India
By Dr Arjun Kalyanpur, editorial@elets.in
Although the number of medical colleges in the country has been increasing steadily and currently stands at 260, unfortunately there is an acute shortage of teaching manpower in the existing medical colleges. This shortage is in the region of 20–25 percent in most departments and as high as 33 percent in some departments, based on data published in the National Medical Journal of India. The shortages are particularly acute at the postgraduate level. Hence, while medical school training in India is phenomenal and world renowned in quality, speciality and super speciality training in India has been the purview of a limited number of institutions in India. hwari, The problems in the field of super specialMahes Sunita ants. r D y b ity training in India are several. The number ip tform, d the partic co pla n of trainers i.e. specialists interested in teachg a Cis tent, video a in s u , y n rdiolog n shows co ing is limited in number. Even if the trainers e tric Ca Paedia ist. The scre in g achin iolog would like to focus on training, the amount 1. e-Te ic Card Figure ltant Pediatr u of energy and time needed for clinical work a cons makes content creation/class delivery a challenge. The quality is variable and differAn ideal e-learning platform would allow student teacher inent institutions have different protocols/approaches to patient teraction. Such a platform should be easy to use since many care so there is no standard content necessarily taught across doctors are limited in their technologic capabilities. It should the country. work on inexpensive bandwidth which is easily available. It Solutions should be web based so that the teacher and student can log The use of technology in speciality training is an innovative soluin from anywhere anytime. tion. The use of ‘e’ in training for specialists has been attempted Such a platform should have the ability to demonstrate a via teaching websites and distribution of DVD’s/CD’s. However power point presentation as well as a drawing board. It should these are non-interactive i.e. there is no direct interaction bebe recordable so classes can be replayed. It should be intertween the student and teacher and thus, although available, active such as a question and answer (Q and A) session can they do not have a desired impact. complete the class.
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november / 2011 www.ehealthonline.org
expert corner
enables highly interactive, online classroom learning with live audio, video, white board and presentations. Instructors need only a computer with Internet, webcam and an optional digital notepad. Remote class rooms need a computer with internet, webcam, microphone, speakers and an optional projector. Instructors can easily create content, manage and schedule courses. The advantages of virtual live e-teaching in medicine are several. One trainer can Figure 2: Cisco Learning Environment (CLE) teach multiple students in multiple geographic locations at the same time, obviating the issue of teacher shortage. The best teachers from around the world can participate in teaching increasing the quality of education for each individual student. The same content can be disseminated to all the students undergoing specialist training so that there is a national consensus Figure 3. e-Teaching in Radiology, using Cisco platform, lecture on imaging of Oncologic Emergencies by Dr Carl Aschkenazi from Israel, Consultant Radiologist, Teleradiology Solutions. on diagnostic and management approach among all Virtual medical training trainees/centers.The e-classes can be recorded and replayed Since May 2010, a not for profit trust ‘Heart strings, a Peoso they can be viewed repeatedly by the same group or new ple4people initiative’ run by Dr Sunita Maheshwari, a pediatric trainees through the internet. The question and answer sescardiologist in Bangalore, partnered with Cisco Systems to pisions are fully interactive and similar to a normal classroom. lot live interactive e-teaching in Pediatric Cardiology. From May Additionally, no significant up-front cost is involved as the sys2010 to September 2011, 125 simultaneous e-classes have tem is fully Internet based. There is no hardware or servers or been conducted by faculty across India and abroad, using this software to install and maintain. technology, in Pediatric Cardiology for postgraduates in BangaWe believe that e-teaching is an innovative solution that can lore, Kolkata, Chennai, Delhi and Nigeria. be applied, not just to Pediatric Cardiology and Radiology as Similarly in radiology, Teleradiology Solutions has used the has been successfully done in India, but to all branches of e-teaching method to disseminate teaching in radiology to specialist and superspecialist medical training in India and this postgraduates in India as well as to practicising radiologists. Dr part of the world. Dharmaprakash and Dr Sridhar have been coordinating daily training sessions which are beamed to radiologists in Delhi, Hyderabad and Mumbai using the Cisco e-teaching platform. Additionally, a series of e-lectures by distinguished international faculty in radiology have been delivered from locations such as Phoenix, AZ, Birmingham, AL, Ann Arbor, MI, Philadelphia, PA and Jerusalem, Israel, which have been viewed in real time by radiologists and postgraduates at locations throughout India. About the Author The Cisco Remote Education Center platform is completely Dr Arjun Kalyanpur is Chief Radiologist and CEO of Teleradiology Solutions, Bangalore Board advisor to Telerad Tech internet based with no special equipment or software required. It november / 2011 www.ehealthonline.org
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15-17 December, 2011 |
Mahatma Mandir, Gandhinagar, Gujarat
“e-Governance to me is easy, effective and efficient governance”
Chief Guest Narendra Modi Hon’ble Chief Minister Government of Gujarat
Key Speakers at eINDIA 2011
R Chandrashekhar Secretary, Department of IT Ministry of Communications & IT Government of India
Shankar Aggarwal Additional Secretary Department of IT, Ministry of Communication & IT Government of India
R S Sharma Director General, UIDAI
Maheshwar Sahu Principal Secretary, Industries Government of Gujarat
Hansmukh Adhia Secretary, Education Executive Chairman, Gujarat Knowledge Society Government of Gujarat
Raj Kumar Secretary, Food, Civil Supplies & Consumer Affairs Department, Government of Gujarat
Prof V N Rajasekharan Pillai Vice Chancellor Indira Gandhi National Open University (IGNOU)
Prof Sudhir K Jain, Director, IIT Gandhinagar
Jay Narayan Vyas Minister of Health Government of Gujarat
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www.eINDIA.net.in