asia’s first monthly magazine on The Enterprise of Healthcare
The New Gold Rush
Investors hoping to mine wealth in healthcare Anaesthesia Market Conscious Industry
mHEALTH Climbs up the Airwaves
Pulmonary care Keep up the Breath
p-24
p-36
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eHealth Magazine
volume 7 / issue 9 / september 2012 / ` 75 / US $10 / ISSN 0973-8959
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volume
07
issue
09
ISSN 0973-8959
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contents cover story Indian Healthcare: The Takeoff Story With the growth capital arriving from diverse sources, healthcare in India is all set to takeoff By Sharmila Das
Abhilash S Pillai
zoom in Dr Sunil Sanghi
Senior Consultant Dermatology and Medical Director, HealthFore
Indrajit Bhattacharya
Professor, International Institute of Health Management Research
20
42
22 44
Anaesthesia Market: Conscious Industry
24
The Next Generation of Anaesthesia Devices
29
expert corner President (Operations&Projects), Kauvery Hospitals Group, Trichy and Member, CII National Healthcare Committee
special feature mHEALTH Climbs up the Airwaves
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september / 2012 ehealth.eletsonline.com
Global Director, MAMA Alliance
Nurse the Cause
The objective of Nursing Education has been redefined with time. Along with maintaining uniform quality education, the spectrum of the domain has included many more aspects
event report
46
Thought Provoking Healthcare Leaders Forum
“Achieving Operational Efficiencies in Healthcare Management,” was the name of the latest successful event organised by eHEALTH magazine. The event was at Le Meridien, New Delhi, on August 23, 2012
Tech trends
U K Ananthapadmanabhan
Kirsten Gagnaire
special report
in conversation Sr Project Lead – Disease Management, Apollo Hospitals Group
32
speciality
48
30
Keep up the Breath
To spread awareness about Pulmonary and Critical Care Medicine, we have contacted a number of renowned respiratory doctors. What follows is a compendium of medical insights from this eminent panel of doctors:
my journey
36
52
Rajendra Pratap Gupta
56
News
President of Disease Management Association of India
At your side in the operating room: Dräger. The operating room is not only the heart of the surgical patient process. Despite its cost- and labourintensity it represents an important source of the hospital’s income. The operating team works hand in hand through a variety of parallel processes. They rely on an increasing number of medical devices and instruments. At Dräger we have been developing and refining our technology for more than a century, with a special focus on the perioperative environment. You can look to us for custom solutions – from induction to surgery and on to recovery.
asia’s first monthly magazine on The Enterprise of Healthcare volume
07
issue
09
september 2012
President: Dr M P Narayanan
Partner publications
Editor-in-Chief: Dr Ravi Gupta consulting editor: Ashis Sanyal
Editorial Team
Web Development & Information Management Team
Group Editor: Anoop Verma
Sr. Executive Officer - Web: Ishvinder Singh
Health Product Manager: Divya Chawla Research Assistant: Shally Makin
Sr. Executive Officer – Information Management: Gaurav Srivastava
governance Manager – Partnerships & Alliances: Manjushree Reddy Assistant Editor: Rachita Jha Research Assistant: Sunil Kumar
Information Technology Team Dy. General Manager – IT: Mukesh Sharma Executive-IT Infrastructure: Zuber Ahmed Finance & Operations Team General Manager – Finance: Ajit Kumar
education Sr. Research Analyst: Sheena Joseph Senior Correspondent: Pragya Gupta Research Assistant: Mansi Bansal
Legal Officer: Ramesh Prasad Verma
Sales & Marketing Team Manager – Marketing: Ragini Shrivastav National Sales Manager – digitalLEARNING: Fahimul Haque Associate Manager - Business Development: Amit Kumar Pundhir Assistant Manager-Business Development: Shankar Adaviyar
Executive Officer – Accounts: Subhash Chandra Dimri
Sr. Manager – Events: Vicky Kalra Associate Manager – HR: Sushma Juyal Associate Manager – Accounts: Anubhav Rana
Subscription & Circulation Team Sr. Manager – Circulation: Jagwant Kumar, Mobile: +91-8130296484 Sr Executive - Subscription: Gunjan Singh, Mobile: +91-8860635832 Executive - Circulation: Ashok Kumar Design Team Team Lead - Graphic Design: Bishwajeet Kumar Singh Sr. Graphic Designer: Om Prakash Thakur Sr. Web Designer: Shyam Kishore Editorial & Marketing Correspondence eHEALTH - Elets Technomedia Pvt Ltd Stellar IT Park, Office No: 7A/7B, 5th Floor, Annexe Tower, C-25 , Sector 62, Noida, Uttar Pradesh 201309, email: info@ehealthonline.org Phone: +91-120-4812600 Fax: +91-120-4812660
ehealth does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. ehealth is published by Elets Technomedia Pvt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS) Owner, Publisher, Printer - Ravi Gupta, Printed at Vinayak Print Media, D-320, Sector-10, Noida, UP, INDIA & published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP, Editor: Dr. Ravi Gupta © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic and mechanical, including photocopy, or any information storage or retrieval system, without publisher’s permission.
ehealth.eletsonline.com | egov.eletsonline.com | education.eletsonline.com Write in your reactions to Health news, interviews, features and articles. You can either comment on the individual webpage of a story, or drop us a mail: editorial@elets.in
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editorial
Healthcare Investment is Catching Up! The time is changing and so is the market dynamics of Indian healthcare sector. With an estimated market size of USD 50 billion per year, healthcare undoubtedly is one of the fastest growing sectors of the Indian economy. As per reports, the Indian healthcare sector has been projected to more than double from its current size by 2015. High disposable incomes and greater awareness towards wellness is providing the requisite impetus for growth. An important factor, however, is capital investments with leading investment entities showing greater interest in the booming healthcare sector. Investors are now seriously eyeing the healthcare, as this sector promises a healthy growth rate and substantial returns on investment. Private equity and venture capital investments are entering hospitals, clinical research and drug manufacturing sectors. The equipment manufacturing and health information technology product and service providers are also being funded by an array of investors. The cover story of the magazine revolves around the success stories of a few notable start-ups, like Nephroplus, HealthKart.com, HealthcareMagic, that have received funding recently. Here, we can find interviews of notable investors like Asian Healthcare Fund, Barring Private Equity Partners and research firm KPMG. The story provides an in-depth insight into the investment trends in healthcare sector in India. e-Health, September 2012, talks about the diverse possibilities that innovative technology are bringing into the healthcare space. One of the areas of focus is mHealth. With the country being home to more than 900 million mobile phone users, there exists a huge possibility for providing healthcare services to the people through mobile phones. The emergence of 4G technology has further spurred the use of mHealth apps and services. In the Tech Trends section, the magazine has story on anaesthesia equipment. The write-up has dealt with the anaesthesia equipment market, which is now experiencing infusion of newer technologies and equipments. The issue also has a special report on the state of Nursing Education in India. The report places the spotlight on the changing trends of nursing education in the country. Then there are the highly informative case studies and research papers on Critical & Pulmonary Care Medicine. We hope you enjoy reading the stories, as much as we enjoyed creating them. Happy Reading!
Dr. Ravi Gupta ravi.gupta@elets.in
september / 2012 ehealth.eletsonline.com
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volume
07
issue 09
september 2012
asia’s first monthly magazine on The Enterprise of Healthcare
Social Circle
inbox Readers Speak
Everyday Health @diabetesfacts One simple dietary change a day = big weight-loss benefits at the end of the month. Get started with this 4-day plan http://trib.al/Gi5ByN
As usual, the eHealth portal has been flooded with a range of comments from our distinguished readers. Few of these reader comments have been selected by our editorial team to be published in the magazine. Read on -
NPR Health News @NPRHealth Sleepless Nights May Put The Aging Brain At Risk Of Dementia http://n.pr/SGFdPP
As the country with the largest democracy in the world, India is well positioned to put health high on the political agenda, but India’s path to full health coverage reveals that a non functional health system is perhaps India’s greatest predicament .There is an availability of treatments and doctors, and the infrastructure to bring about universal health care by 2020, but often health care providers are absent from the health facilities forcing the patients to go to private providers. But unfortunately, the so called managed care also fleeces them by getting them to do unnecessary investigations, prescribing expensive branded drugs and unnecessary referral to various specialists. Seeing the huge amount of expenditure on healthcare that the government spends for its people, it is now the need of the day to strengthen our existing health facilities by putting in mechanisms for severe monitoring to check absenteeism and mal-practices, and regular prescription audits for the doctors, provision of Jan-Aushidhis everywhere and other several regulatory mechanisms to achieve at least adequate health care in our rural areas. Anjan Saxena on Do we need managed care in India?
Indus Health Plus @indushealthplus Know Affordable Health Checkup Packages for all...Save life, Save Money, Save Tax !! http:// fb.me/1R6Espe4R Dr. Sidharth Verma @drverma Just one alcoholic drink a day may up risk of cancer: Study - Firstpost: FirstpostJust one alcoholic drink a day... http://bit.ly/QIaPy9 Religare Enterprises @Religare_REL ”When I was young I used to think that money was the most important thing in life; now that I am old, I know it... http://fb.me/1qs3NL8rn Men’s Health Mag @MensHealthMag “You can tell more about a person by what he says about others than you can by what others say about him.”—Leo Aikman Neelesh Bhandari MD @edrneelesh Love it! Why EMR are key -> @grecoa3: Typeface for Doctors http://vsb.li/OzcdE1 #hcsm: Love it! Why EMR are key ... http://vsb.li/h7lP32 CNN Health @cnnhealth RT @PreventionMag: Ever had those “feeling fat” days? Here are 10 fast fixes for when you’re feeling less than fab http://at.cnn.com/YQWT9A
Facebook Like of the Month
Dr Abdul Mutalib Khan
Dr Abdul Mutalib Khan, CEO, Pioneer Future Tech (Healthcare IT) Pvt Ltd - A visionary, entrepreneur, and Healthcare IT enthusiast that has broadened the scope of E-health through innovative conceptualisation of solutions. He holds three Patents related to Healthcare IT and has tremendous interest in integrating various mobile and e-Health technologies to a single platform.
IT applications for the healthcare sector is a rapidly emerging phenomenon in India. Though the concept was pretty limited to big hospitals until late, it’s great to know that PALASH Healthcare Sys is offering holistic and end to end solutions for small & medium hospitals too which is much required now as we have IT literate staff in majority of small and mid-sized hospitals. Yogi on IT will Revolutionise Healthcare Processes India has become the world’s largest healthcare markets and there is a helpful chance medical IT industry to cultivate. We come across the supply of infrastructure software and hardware as an important approach to help the way clinicians and nurses can perform and collaborate together. Lucinda Vardey on India is a key market for Microsoft health
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cover story
Indian Healthcare
The Takeoff Story With the growth capital arriving from diverse sources, healthcare in India is all set to takeoff By Sharmila Das, Elets News Network (ENN)
A
ccording to the rating agency, Fitch, the Indian healthcare sector will to double its size to USD 100 billion by 2015 from the present size of USD 50 billion. There are a lot of factors fuelling the growth of the sector - lifestyle related health issues, improving healthcare insurance penetration, government initiatives and increasing disposable income. Amit Chander, Head-Investment Healthcare, Baring Private Equity Partners Ltd. says, “Going by past experience of other developing economies, India is expected to
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september / 2012 ehealth.eletsonline.com
increase its healthcare spend from 4.2 percent of GDP to 5 percent of GDP by the year 2030”. T Ramoji, Chief Financial Officer and Company Secretary, Manipal Health Enterprises, feels, “Indian healthcare sector has always been one of the preferred investment destinations mostly in Pharmaceutical and medical equipment segments. Of late, investors are showing interest in healthcare delivery system like hospitals and diagnostic chains.” To tap the vast potential of the sector, continuous capital inflow is required and India’s health start-ups may not be able to tap the market completely without some kind of capital infusion. Hence, the role of investors in the form of angels, venture capitalists (VCs), private equity (PE) players is crucial. Fitch is also of the opinion that PE funding is expected to play a crucial role in the expansion of the healthcare industry. The hospital sector, especially the super- specialty services, will continue to be the main area of interest to private equity investors.
cover story
While investing in healthcare investors generally take into account the following factors: • Business plan • Revenue model • Management team • The product of the investment seeking company
To Do List
A Closer Look About ten years ago, the number of companies offering healthcare products/ services was not as large as it is today. Lately a lot of investments have been made in the healthcare sector. The healthcare companies that have received funding recently include the likes of: • Healthcare Technology/ Internet: HealthKart.com, HealthSprint • Clinics: Nephroplus, Centre for Sight, Vasan Eyecare • Diagnostics: Metropolis, Dr Lals Path Labs Although the sector has good growth potential yet it continues to lack in infrastructural development. Experts of the field say that to make the infrastructure strong, Indian healthcare sector must have constant capital infusion. Hence, the sector will continue to seek investment both from the debt market, as well as from the equity market, particularly the private equity. Vishal Gandhi, MD & CEO, BIO Rx says, “Investment in Indian healthcare is very much required as we are a country where the bed and patient ratio stands at one bed for a thousand patients. So to change the ratio, investment has to be made and the healthcare sector has huge potential in attracting investment”. Vikram Vuppala, CEO & Founder Nephroplus, says, “The lifecycle of the start-up plays deciding role in attracting investment. Also a good team, diverse skill set complements each other”.
Before approaching an investor the healthcare company should check the investor’s background. Does the investor firm have enough knowledge of the domain? Are they capable of remaining involved financially till the specified period of time (may be till IPO)? It is also necessary for the healthcare company to find out the broader financial agenda of the PE company. Prashant Tandon, Co-Founder and Joint MD, HealthKart.com, explains, “Any company going for funding needs to ensure it has a clear business model, validated unit economics and a good understanding of the space and the reasons to be successful. It is also important to have a good understanding of how the funds will be used, as per a detailed operating model, which has realistic assumptions around the revenues, costs and working capital.” Apart from capital infusion, an investor brings lot more value addition on table in the form of strategy development, finding the right talent and developing robust marketing strategy for the company.
The Exit Route An investment firm normally follows the five year term period to be on board or till the company breaks even or till it gets listed publicly. Whatever be the case, depending on the company’s business plans the investors choose their own exit policy so that it becomes a win-win situation for them. Naresh Malhotra, Director, Modern Family Doctor Pvt Ltd, says, “The investors normally prefer to stay even after the company has entered the break even phase. Healthcare is a long term play, and companies prefer to look at the long term horizon. The normal exit route for investors is an IPO.” september / 2012 ehealth.eletsonline.com
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cover story
How They Did It!
Dr B S Ajay Kumar, Chairman & CEO, Healthcare Global Enterprises
Rajiv Tewari, Director, Health & Wellness, Rockland Hospital
In the first phase of the completion of its healthcare delivery model, the Rockland Hospitals and IFC, World Bank came together due to a shared belief. IFC, World Bank had invested in the Rockland initial plans of building increased tertiary care capacities in the Delhi NCR region. This plan has already been implemented with the expansion of the current facility and launch of two new hospitals in Dwarka and Manesar. Initial investment has almost been doubled in terms of value enhancement and the beds capacity has been increased from 100 to over 800 ensuring even better evaluation on investment. The second phase, involving the creation of an Asset Lite Health Network, has begun with a successful trial in Delhi. Further trials are planned along with the launch of Rockland Manesar in Oct 2012
Vikram Vuppala, CEO & Founder,
Kunal Sinha, CEO & Founder, HealthcareMagic
Prashant Tandon, Co-Founder
Financial constrain often cause a business to fail. In our case, with capital infusion we were able to scale up our business further. We were able to explore new geographies and the size of our market increased manifold. With funding we are now more conscious about our strategies and it has made us more careful to look at the balance sheet. It is also a fact that the credibility has also increased with investment funding.
Positive changes after Bessemer Venture Partners Investment have been many. • No of employees have increased 5 fold from 25 to 125 • No of branches increased from 3 to 12 • No of clients/customers increased from 75 to 500+
Our business requires upfront investments to create a scalable business. We do need to invest upfront capital to build the foundation for the business, which will then yield returns over the long term. With funding support, we were able to attract a high quality team, set up the operations (warehouse, customer service, technology) in a much more organised way. Prior to funding, we focused our efforts on developing a product and proving the concept in a limited area for validating the model.
Nephoplus
12
The Investment funding essentially gives us an opportunity to grow fast; usually we operate by using both equity and debt. The equity gives us an opportunity to put money to use rather rapidly and also to access to more debt. With this combination whatever business plans you may have built over a period of few years, can now be executed in less number of years. The other aspect is growth; when you seen an opportunity you can capitalise on it. This can be an organic or inorganic growth opportunity. So the investment has made a big difference for a company like ours, where we have been able to grow rapidly with a lot of fiscal discipline. Before the investment we were a small group with very limited revenue, with three hospitals in 2007, after the investment there was an additional growth, we now have about 25 centres across India.
september / 2012 ehealth.eletsonline.com
and Joint MD, HealthKart.com
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cover story
To be Afloat Amit Chander, Head-Investment Healthcare, Baring PE Partners Ltd, is of the opinion that the Indian healthcare is encouraging investors more than ever before
How well is the Indian healthcare sector doing when it comes to attracting investment funding? What elements the sector has that make it investment worthy or vice-versa. Indian healthcare sector is a preferred foreign investment destination for a variety of reasons. The sector is attractively positioned to grow at twice the growth rate of India’s GDP given favourable demographics, increasing affordability and improving access to healthcare over the next several years. Take demographics for instance, it is estimated that for the next 40 years almost 500 million people in India will either be below 15 years of age or be more than 60 years of age implying nearly 40 percent of the population will be in an age that is vulnerable to medical problems and will demand healthcare interventions of some nature or the other. International studies have shown that as a nation gets wealthier, it spends more and more on the healthcare needs of its population. In your opinion what kind of investment trend the Indian healthcare is showing? Is the sector able to attract good amount of funding both from domestic and overseas investment market? There is no dearth of capital for healthcare ventures in India with investors actively allocating capital across the value chain from pharmaceuticals to hospitals and diagnostics. Most of the capital is going to medium size companies where investors take up minority equity interest and partner with the entrepreneurs in taking the business to the next level. This could mean expanding manufacturing facilities or opening up new clinics or hospitals or for market expansion purposes. The availability of capital though
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Most of the capital is going to medium size companies where investors take up minority equity interest and partner with the entrepreneurs in taking the business to the next level is fairly scarce and limited for early stage, start-up ventures which are working on innovative technologies. Limited evidence of high returns being generated by ventures in this area has resulted in only a select group of investors to operate in this part of the value chain. What are the criteria that an investor looks at in a healthcare company before investing? Apart from funding what other assistance do they offer to them? There are four parameters that investors look for – strong growth outlook for the business, high return on capital profile of the company, ability to scale
the company to get a meaningful exit through an IPO within 5-6 years and strong corporate governance being followed by the entrepreneur. The first factor is typically external and a single entity can do little to influence it. PE funds assist the entrepreneur in the remaining three aspects. Helping identify scale efficiencies, operating best practices and good managerial talent can significantly improve the chances of successful scale-up. Designing strong board processes, augmenting the audit function, recruiting independent directors are all areas in which PE funds can contribute very positively. Do the investors remain on board till the company breaks even? If not, what is the exit policy that such investment company follows in healthcare? The decision to exit is driven by two considerations – the life of the investor’s fund and the maturity of the business to support an exit event. All investors invest from funds with a finite life and have to exit their portfolio companies when the fund life comes to an end. Astute investors match the maturity profile of the business they are investing in with the life of their fund. They would prefer that the business model of the company is well established by that time in terms of scale, profitability and management depth to make it an attractive investment for either other financial investors or a strategic partner. If neither is possible then buyback of their shares by the company is an option. Given the strong interest of investors in the Healthcare sector more often than not an exit is feasible by selling to another financial investor. Interviewed by Sharmila Das, Elets News Network (ENN)
cover story
The Funding Mantra
Naresh Malhotra, Director, Modern Family Doctor Pvt Ltd, has a successful track record in launching and establishing multiple brands in various healthcare segments. He shares his insights
How well the Indian healthcare sector is doing in terms of attracting investment funding? The healthcare sector is attracting the maximum attention today from Private Equity and Venture Capital. The Investors see a huge potential, with a growing population and a highly underserved market. Add to this the higher incomes, more
disposable incomes, lack of facilities provided by the Government and you can understand why everyone wants to invest in the healthcare sector. What are the criteria that an investor looks at in a healthcare company before investing in? Apart from funding what other assistance they offer to such companies? An investor wants to see rapid growth, profitability, faster scalability and will look at entrepreneurs who are either going into niche spaces or enjoy the
advantage of being the “first entrant in any niche market�. They like to go to markets which have a huge potential. Other assistance which VCs, PEs provide is getting best practices, overseas tie ups, bench marking with best of breed and corporate governance. Can you please mention a few healthcare companies got recently funded? Nationwide, Nova, Express Clinics, Vatsalya, and Mulchand Hospital have received funding recently.
Meet The Risk Mitigator Vishal Gandhi, Managing Partner and CEO, BIORx Venture Advisors Pvt Ltd, shares his thoughts on the investment scenario for Indian healthcare sector In your opinion, what kind of investment trend is Indian healthcare showing? Healthcare as a sector started attracting private investment only about ten years ago. Before that it was regarded as a charity field wherein no profitable venture could be thought of. But thanks to healthcare enterprise chains like Fortis/Apollo, the scenario has changed. In these past few years, we have witnessed more and more private investment, merger and acquisitions in the sector. This is a need of the hour considering we are a country where the bed to patient ratio stands at one bed for a thousand patients. In order to change this scenario, Private investment is the only way forward to change this scenario. The healthcare sector has huge potential to attract investment given we are a country of more than 1.2 billion population and 75 percent rural population still has to travel few hundred kms to get decent treatment for even most common diseases. What criteria an investor looks at in a healthcare company before
investing? First and foremost , a start-up or a company should only approach the angel investors/ VC/PE once they have established a proof of concept from their own equity or money raised from family/ friends. The investors look into the robustness of business plan the company has. They also look at the following areas: b) How scalable the business in terms of entry barriers? c) How well networked the promoters are d) How is the management team of the company and also what retention policy the company has for their employees. What are the steps a healthcare company opts before finalising a VC or PE funding? Before finalising a VC make sure you have all the elements needed to make your venture attractive in the eyes of the investors. Right from a sound business plan to well planned out revenue model everything has to be in sync with the nature of the business so that the investors do not get a chance to turn down the proposal. Make sure the investors are from the same domain and they
have domain expertise that would give value addition along with funding. What is the role of BIO Rx? We play the role of risk-mitigators. Because of my professional experience I can suggest ways to companies that they may not even think of. Sitting in a cabin you would assume you are the best, but we as an experienced party who has learnt the tricks of the trade by working for similar companies across the value chain and life cycle of company, BioRx can guide them about ways to avoid risks when choosing investment partners. Because many a times, a company needs a debt and ends up taking a private equity investment. So we can tell them if they should go for a debt or equity depending upon what’s the best capital structure Interviewed by Sharmila Das, Elets News Network (ENN) september / 2012 ehealth.eletsonline.com
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cover story
The Investment Roadmap Amit Mookim, Partner, Strategy Services Group, National Industry Head – Healthcare, KPMG, feels the investment scenario for Indian healthcare is changing for good How well is the Indian healthcare sector doing in terms of attracting investment funding? Healthcare is emerging as one of the top interest areas for private equity and venture capital investors. Rapid growth prospects, lack of scale in businesses and increasing market size in India makes it an interesting avenue for funding. In your opinion what kind of investment trend the Indian healthcare is showing? The sector is attracting funding from both domestic corporate, domestic investors and overseas investors. The
preference is across various delivery models – both asset light and scalable, such as eye care, ambulatory care, IVF clinics, dialysis centres as well as multispecialty hospitals
funding, some investors play an active role in influencing strategy, getting management personnel on board, opening new market opportunities/ contacts and institutionalising processes.
What are the criteria that a PE/ VC/ Insurance company looks at in a healthcare company before investing in? Management team, depth of talent, economic soundness of the idea and ability to deliver, scalability of the model, ability to exit in a finite timeframe, are some of the criteria that an investor looks at in the healthcare company. Apart from
What is the exit policy that such investment company follows in healthcare? Growing companies need several series of funding, and this is the same in healthcare. Some investors dilute partially during ensuing exit rounds, but at the same time, in a sector like healthcare, given the size of companies, exit through IPO etc is still a distance away.
List of companies that got funded recently Date Target Investor Type of deal
Deal value (USD Mn)
EV/EBITDA
EV/Revenue
Hospitals 2012
Care Hospital
Advent
PE
105
10 – 12x
2012
Sahyadri Hospitals
IDFC
PE
40
8 x
2011
Max Healthcare
Life Health Care
2012
DM Healthcare
Olympus
PE
100
10 – 12 x
2010
Manipal Hospitals
Kotak
PE
22
9 -10 x
2009
Wockhardt
Fortis
Strategic
Strategic
105
3x
187
2.5 x
Specialty Clinics 2012
Vasan Eye Care
GIC
PE
100
13.5 x
5.5 x
2011
Eye Q
Helion and Nexus
PE
10
30 x
5.6 x
2012
Nephrolife Care
DaVita
Strategic
25
NA
NA
Diagnostics 2010
Dr Lal Pathlabs
TA Associates
PE
31
16 - 17 x
2010
Metropolis Healthcare
Warburg Pincus
PE
85
15 x
2010
Piramal
SRL (Fortis)
Strategic
120
16 x
Mount Kellet
PE
Retail Pharmacy 2011
Medplus
70
1.5 x
Source - KPMG
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Interviewed by Sharmila Das, Elets News Network (ENN) september / 2012 ehealth.eletsonline.com
cover story
Let’s Talk Funding Ajay Kumar Vij, Co-founder & CEO, Asian Healthcare Fund, dives deep into the ocean of healthcare investment and brings out the following expert opinion How well is the Indian healthcare sector doing in terms of attracting investment funding? Indian healthcare, as compared to what they have in developed countries, has a long way to go. Facilitated by growth drivers like a rapidly growing middle class with enhanced affordability, increasing urbanisation and rising prevalence of chronic diseases, the Indian healthcare sector is expected to demonstrate sustained growth over the next 10-15 years and is expected to be one of the fastest growing healthcare sectors globally. This makes the sector an attractive destination for Private Equity investors who want to invest in companies which can demonstrate sustained earnings growth over the medium term. Is the sector able to attract good amount of funding both from domestic and overseas investment market? Investments in healthcare has been showing an increasing trend from both domestic and international investors with investments across the value chain from hospitals to specialty clinics, medical devices, pharmaceuticals and diagnostic chains. Healthcare companies are getting funded both at the early stage (e.g. Wellspring Healthcare was funded by Reliance & Catamaran Ventures last year) and at a more mature stage (Funding of Vasan by GIC earlier this year) What are the criteria that an investor looks at in a healthcare company before investing? A PE / VC firm would look at a number of factors like strength of management team and it’s ability to execute, the size and attractiveness of target market, uniqueness of business model, regulatory issues, entry barriers and competitive landscape and potential exit options before investing in a healthcare company. PE funds like Asian Healthcare Fund which have significant in-house operating capabilities are able to add significant value to companies that they invest in by virtue of their in-house business building abilities. This value add is typically in areas like fine tuning business growth plans/strategies, establishing robust systems and processes to support faster expansion, business development, recruitment of senior management, M&A and fund raising etc Do the investors remain on board till the company break-even? What is the exit policy that such investment company follows in healthcare? A PE investor typically takes a long term view of the companies they invest in with typical investment horizons of 3-5
years. Once this period expires and the company has executed its growth strategy, the PE investor would endeavour to exit the company. Whether the investors remain on board till the company reaches break-even or not depends on the stage of investment, type of investor and specific company situation. The preferred option of exit for a PE firm is an IPO. Secondary sale to other financial investors, strategic sale and company buybacks are some of the other exit options pursued by PE firms Give us the names of few healthcare companies got recently funded? There is Orbimed, which reportedly acquired close to 12 per cent stake in midsize drug-maker Shasun Pharmaceuticals Ltd by investing Rs 50 crore in February 2012. Then there is Evolvence, which has reportedly invested Rs 60 Crores in Dr Agarwal Eye Centre in July 2012. GIC has invested US$ 100 into Vasan Health earlier this year. Some of the successful healthcare organisations backed by investments include Apollo Hospitals, NovaMedical, Dr Lal Path Labs, Trivitron, Metropolis Healthcare, Mankind Pharma, Intas Pharma, Dabur Pharma etc. Interviewed by Sharmila Das, Elets News Network (ENN) september / 2012 ehealth.eletsonline.com
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cover story
Meeting the Challenges through Investment By Group Captain (Dr) Sanjeev Sood, Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh
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ational Accreditation Board for Hospitals (NABH) defines small HCEs as a healthcare facility that provides allopathic services by doctors registered with MCI or SMC either as a standalone/solo or a small nursing home up to 50 beds. These are mostly run by private entrepreneurs who invest their own capital and operate in highly fragmented and unregulated environment. Being run on savings of couples or few colleagues, they don’t have deep pockets to acquire sophisticated technologies, hire legal experts or undertake massive expansion plans like corporate giants. So what are the financing options before them to realise their expansion plans?
Debt funding Debt funding is by far the commonest available option .Public sector banks as well as private banks provide succour when it comes to debt funding. The interest rate and terms of payment are the most important factors governing the feasibility of the loan. Financial institutions are aggressive and willing to disburse higher bank credit in days of recession to rapidly push growth in recession proof healthcare sector. These institutions are willing to offer range of loans for raising working capital, term loans for capex, equipment funding, securitisation of receivables, services for private banking, trade finance for medical equipment vendors / hospitals as well as merchant banking services.
under sec 80 1 B for the first 5 years. Entrepreneurs can also build public private partnership with state governments for management of primary and secondary health care units by is another great option. Diagnostic Imaging Centers can provide their services in teaching hospitals by forging PPP- as a win- win situation for all the stakeholders.
Funding the expensive equipment Expensive medical equipment like MRI, cyber knife can also be funded by specialised companies/investors on a referral/ commission basis in the hospital premises there by reducing capex cost. Cost of expensive equipment such as blood gas analyser and vacuum assisted closure can be further saved by convincing the vendors to simply park their machines in the hospital instead of outright purchase and buy consumables from them, thus benefitting both. Asset utilisation can be further enhanced by sharing expensive imaging equipment and other facilities such as laser equipment, cyber knife and blood bank with other hospitals and using them round the clock instead of 7-8 hours daily.
Leveraging PPP model Land and building cost are up to 45 percent to 65 percent of capex cost of hospitals. Medical entrepreneurs can look at investors to fund the same so as to reduce capital cost per bed and reduce break even period to less than 18 months. They can obtain land at concessional rates from government in the outskirts or forge a public private partnership with land owners so as to mitigate the cost of these assets. Going for green and efficient building design for optimal land use and energy conservation in the long run is an imperative these days. Alternatively, small HCEs can consider setting up hospitals (with 100 beds or more) in rural areas to avail tax exemption
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Gp Capt (Dr) Sanjeev Sood, is a Hospital and Healthcare Administrator and NABH Assessor based in Chandigarh. He is also a prolific writer on healthcare matters.
in conversation
Sugar24x7
Mobile Solution for Monitoring Diabetes “Healthcare business in India is on the fast track of evolution. As it evolves, it will continue to accommodate new solutions and systems that enable us to meet the increasing demand for healthcare services in the country,” says Abhilash S Pillai, Sr Project Lead – Disease Management, Apollo Hospitals Group, in conversation with Shally Makin. What is your view on the “role of a manager” in today’s demanding healthcare work space. The Hospital business is complex – considering that the business depends on a uniquely extensive and varied range of stakeholders for its ultimate success. Its customer (patient) is not always a customer by choice. The hospitals trade in services, which fall beyond the pale of normal business, as we deal in matters that can involve life and death conditions. This reality makes the lives of a hospital manager challenging. He has to be always on his toes to ensure that his institution provides high-quality healthcare in a manner that is safe and efficient. He has to manage and work with a team of individuals with very different capabilities and skills to deliver optimum outcomes with excellent patient experience while complying with regulatory requirements. Industry trends indicate that major healthcare providers in India and world over are increasing their investment in IT. Can you throw some light on the various IT applications and particularly the role of clinical health IT applications for improving quality of care? In general, IT in healthcare can be broadly grouped into two categories- financial, administrative and clinical systems. Clinical Health IT capabilities are playing an important role in improving treatment outcomes and the quality of care. Quality results from using right information at the right time to make the right decision. Knowledge to make these decisions keeps evolving, guidelines and the clinical evidences get frequently updated, IT can play a key role in storing, updating and evolving options brought in through this changes. The clinical solution employed as a part of our chronic disease management offering enhances decision
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inconversation
support capability, which plays an important role in guiding our care team. Tell us something about the Chronic Disease Management (CDM) programme at Apollo Hospitals. Disease Management Solutions world over are driven by payers who employ these capabilities to improve their care treatment outcomes and reduce costs. Apollo Hospitals is one of the few provider organisations in the world to have employed facets’ of this approach primarily with the aim of improving treatment outcomes amongst patients. The philosophy of our CDM approach is to use evidence based structured care and multi-disciplinary approach to improve clinical outcomes. We currently have offerings in these three major disease area diabetes, cardiovascular and chest disease. Tell us about your recently launched diabetes mobile application. Our mobile solution for diabetes management is called Sugar 24x7; its creation has been made possible only because of Apollo Hospitals’ vast clinical expertise. The solution uses mobile and web as a platform to help patients manage their diabetic condition. In the diabetes management space, our sugar programme is a structured care management approach supported by an on-going remote monitoring enabled through the contact centre which demonstrates a clinically
and statistically-significant 1.5 point HbA1c reduction (base line “over” follow-up) corresponding to a vast reductions in the risk of heart attacks, kidney failure, stroke and other complications of diabetes. The Sugar24x7 mobile solution aims to strengthen our capability to proactively help manage the condition of our patients. Sugar 24x7 once loaded turns the patients’ phone into a powerful tool through a host of features which aid compliance, real-time tracking and feedback, coaching, education etc which we believe eventually will assist us to provide total Diabetes Management. How do you see mobile based health delivery taking shape in India? One in eight adults in India, either have or is at high-risk of diabetes. Close to 80 percent of all diabetics in India do not achieve their treatment goals and Indians’ collectively own over 900 Million mobile phone connections. Moreover, mobile is a clear enabler, it is with the owner all the time, and it can facilitate immediate action and support. Next generation smartphones do a lot more in terms of text, audio, video and multimedia. Further, there is enough evidence to confirm that remote monitoring, integrated mobile application based support goes a long way in aiding compliance and improving treatment outcomes. It is only a question of time when mobile based health applications become as ubiquitous as mobile phones.
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zoom in
Dr Sunil Sanghi, Senior Consultant Dermatology and Medical Director, HealthFore
mHealth: A Visionary System for Transforming Healthcare As India aspires to deliver effective, safe and affordable healthcare to its citizens, new innovations are getting pursued with enthusiasm, one of these innovations is mHealth 22
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obile Health, or mHealth, can be broadly defined as the “delivery of healthcare services via mobile telecommunication, including cell phone, PDAs, tablets and wireless infrastructure in general”. With limited resources and huge healthcare gap in India, most of the population living in remote rural areas along with explosive growth of mobile communication with 900 million Indian having access to some form of mobile connection, mHealth has a potential to overcome healthcare challenges around access, cost and quality. From text messages disseminating information on health lifestyle to use of smart phones as medical devices capable of diagnosis and remote monitoring, mobile technologies in the future will permeate every aspect of health system.
Applications The healthcare market is making significant investments in mHealth, the mobile technology is helping patients with chronic disease management. It is leading to improvement in quality of life for aging population, reminding patients to take medicine on time, extending services to remote areas and improving medical system efficiency. There are more than 500 mHealth projects operating globally, more than 50 in India. WHO carried out a global survey in 2009 in 114 member states and majority of member states (83 percent) reported offering at least one type of mHealth service. Another interesting fact to emerge from the survey is that while emerging markets perceive mHealth as a way of increasing access to healthcare, in developed markets it is a way to improving convenience and cost factor. India is ranked second among of developing countries in its maturity for mHealth adoption according to June 2012 report by PWC. Some of the key mHealth applications in India include health call centres, emergency helpline, remote monitoring and reproductive healthcare. Health hot lines (Medical call centre) - Technology such as mobile communication and call centre adopted for healthcare services delivery, allows providers to overcome the imbalance of resources and provide quality access to people in remote area. Mobile network operators provide the face for the health hot line and rely on third party provider. This system is good for triage and preventative services. Remote monitoring (Tele home care) - The disease pattern across the globe is changing from communicable diseases to non-communicable or lifestyle disorders like diabetes, hypertension and COPD. India faces burden from both. Remote monitoring is ideally suited in these conditions and numbers of parameters which can be monitored are growing daily. There are devices that monitor vital signs associated with the diabetes, heart condition and COPD. Significant benefits have been reported globally in chronic heart failure, COPD and diabetes leading to significant reduction in hospital admission and improving quality of life. mHealth can help with improving quality of life for aging population while reducing the cost. The mobile enabled care giver systems can provide independence for the elderly and empowering them with their own care. Elder care
The four most frequently reported health applications are: • Health call centres (59 percent) • Emergency toll free telephone services (55 percent) • Managing emergency and disasters (54 percent) • Mobile telemedicine (49 percent)
Mobile technologies in the future will permeate every aspect of health system devices to detect fall, track behavioural changes and locate Alzheimer’s patients are available in market. Emergency helpline - Quick access to trained healthcare workers to provide first aid and directions in emergencies, such as road traffic accidents, are saving lives. Some of the innovative concepts are coming in this field such as stroke helpline where saving time is saving brain and proving to be as successful as a standalone model. Reproductive healthcare - mHealth is filling the gap of skilled personnel by guiding and training, increasing flow of information via SMS campaigns in various stages of pregnancy, guiding patients towards institutional delivery leading to significant reduction in maternal mortality.
Barrier Apart from health call centre, emergency helpline, most mHealth applications are in pilot stages. Despite showing promising results during pilot, many projects are abandoned after pilot stages, largely because they lack sustainable business model. Despite demand and obvious potential benefits, rapid adoption is not occurring; the key to success lies in the interoperability between key stakeholders of mHealth, technology, finance, healthcare workers and government. Careful thought needs to be put about how to create incentives that encourage range of stakeholders to engage. For example, with current payment structure where remuneration is based on number of nights, the patients spend in hospital, there is little incentive for remote monitoring and treatment. mHealth will be effective if it is easy to use, cost effective and tightly integrated with existing healthcare professional work flow.
Conclusion In India taking healthcare to the underserved is a particular challenge. As government looks to lay a foundation for more equitable society, healthcare delivery is a critical challenge, one that mHealth is well suited to address. Mobile health is no more an optional choice, a fantastic challenge and a must for a vast country like India. One of the undesirable consequences of modern healthcare has been loss of communication and growing distance between doctors and patients. mHealth can be one of the tools to bridge this gap. september/ 2012 ehealth.eletsonline.com
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tech trends
Anaesthesia Market
Conscious Industry The primary role of using Anaesthesia machine is to help the surgeons perform a painless surgery on patients undergoing surgical procedures By Shally Makin, Elets News Network (ENN)
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he aim of anaesthesia is to ensure a safe and convenient healthcare experience for the patient. Tremendous advances have been made in modern anaesthesia equipment, which now feature intricate designs, safety aspects, and monitoring systems. Modern anaesthesia systems are capable of detecting high-risk situations, which can lead to hypoxemia, bradycardia and eventually cardiac arrest. Anaesthesiologists have a mechanical eye to watch and evaluate their patients. With the unblinking mechanical eye, on the anaesthesia equipment, keeping watch on the operation can pro-
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ceed in a much safer manner. A good quality monitor which is accurate and offers clear visibility is a must. Currently most anaesthesiologists do not have access to a monitor. The market is now coming up with various integrated stations with monitors to ensure right observations and measurements. There are certain things an anaesthesiologist needs to keep in mind, such as the pressure of oxygen and nitrous oxide in the pipelines, the amount of oxygen flowing to you from the machine, the number of times each minute that the breathing machine (or ventilator) delivers a breath to you and the amount or con-
centration of anaesthesia agents in the gas you breathe in and out. There has to be a clear connection when the medications stop, but not the oxygen as it can lead to the death of a person. Some new anaesthesia machines do incorporate automated record-keeping systems, which help to document and integrate some of this information. The latest anaesthesia machines have self-checking and monitoring capabilities, so that problems can be easily identified. There is also always a back-up system, so that if the system fails, or there is a power blackout, the anaesthesiologist can still ensure that the patient’s life is safe.
tech trends
Inroads into Emergency Airway Management Innovations in Anaesthesia are leading to better way of pain management By Dr Anutam Rai, Consultant, Anaesthesia, Moolchand Medcity
Use of ultrasound Anaesthetists have started using ultrasound machines to make procedures like placement of central venous and pulmonary artery catheters, safer. But the most significant advantage of the ultrasound machine is in the field of regional anaesthesia. Nerve blocks can be used to provide anaesthesia during and prolonged pain relief after surgeries. They are a safe alternative to general anaesthesia, especially for surgeries involving the extremities. Newer ultrasound machines for use in anaesthesia are very compact, portable, and easy to use. Patient controlled analgesia pumps Patient-Controlled Analgesia (PCA), an attractive short-term option for manag-
ing acute post-operative pain, puts the patient in the driver’s seat. At the push of a button, he can give himself a dose of pain medication without having to call a nurse for it. Patient-controlled analgesia pumps are computerised systems programmed for individual patient use. The anaesthetist fills the pump with analgesic medication in the required concentration and sets the pump to deliver the desired amount of medication when the patient presses the button, instead of having to call for the nurse and wait for the medication to be administered every time he feels pain. PCA pumps have safety settings to prevent overdosing patients with analgesics: a dose interval during which, no matter how many times the button is pushed, only one dose is delivered; a lockout dose that allows only a predetermined amount of medication to be delivered in any four hour period. Supra-Glottic Airway device The past decade definitely belongs to supra-glottic airway devices in general anaesthesia. These are devices used to maintain and control the airway of an anesthetised patient. They are much less invasive than endotracheal intubation where a PVC tube is inserted through the vocal cords into the trachea. In
comparison, supra-glottic devices form a seal in the lower part of the pharynx by way of an inflatable cuff or a moldable gel filled seal. These devices have nearly replaced endotracheal intubation for most elective surgeries. They have even made inroads into emergency airway management, since they can be used by unskilled personnel. Supraglottic devices are extremely versatile and a wide range of modifications have been incorporated in them for specialized purposes, for example, the proseal laryngeal mask has a gastric channel to drain stomach secretions; the Fastrack LMA can be used in difficult intubations; even short laparoscopic surgeries can be carried out with these devices. Scope of research Anaesthesia machines have always been the subject of a lot of research and development. New anaesthesia ‘work-stations’, as they are now called, are just as comfortable ventilating day old neonates, as they are with full grown adults. They also incorporate exhaled carbon dioxide monitoring, oxygen analysers, and anaesthetic gas monitoring systems. They are computers in their own right, and can carry out full self diagnostics. To protect theatre personnel from chronic exposure to anaesthetic gases and their side effects, anaesthetic gas scavenging systems are built into anaesthesia machines; these whisk anaesthetic gases from the anaesthesia machine and release them outdoors through channels built into the operating room pendant which supports the anaesthesia machine. september / 2012 ehealth.eletsonline.com
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tech trends
Role of Anaesthesia By Linlith Hermon Pinto, DGM – Healthcare Marketing, Avasarala Technologies Limited
Features of Anaesthesia Equipment The primary role of using Anaesthesia machine is to help the surgeons perform a painless surgery on patients undergoing..surgical procedures. It allows better Anaesthesia management. The secondary role will be to provide gas for the patients to breathe, to allow us to control what gases go into the breathing circuit, to chemically remove carbon dioxide from exhaled gases so that the remaining gas mixture can be re-circulated, allow us to control ventilation by either a bag that we can squeeze or through a mechanical ventilator, to monitor various ventilator parameters and to prevent the administration of hypoxic gas mixtures. Anaesthesia machines have several carrier gases (oxygen, nitrous oxide and medical air) and vaporisers with potent inhalation agents (sevoflurane and desflurane, maybe isoflurane). The carrier gases are controlled with flow meters, and often have centralised tank supplies. The latest innovations in anaesthetic equipment space has been syringe infusion pumps, infusion controllers, video larygoscopes and BIS monitoring in anaesthesia gas management.
Latest trends Major enhancements in anaesthesia technology has been the equipment with integrated anaesthesia functionalities and enhanced ventilation capabilities. Pressure support ventilation (PSV), a process in which the ventilator automatically completes the breath in a spontaneously breathing patient, is particularly noteworthy advancement in some modern-day anaesthesia systems. Advanced anaesthesia equipment provides the caregiver with direct visual feedback information if fresh gas flow is higher than required by leakage losses and patient uptake. The current product portfolio enables fresh gas application, volatile agent availability, and manual ventilation, even in total power failure. Sensor integration has lent itself to further equipment enhancements and has made it possible to log and track financial calculations. Flow-measurement data, and other ventilation and monitoring data, are available in anaesthesia record-keeping system. Another revolutionary technology which has provided clinical benefits is Total intravenous anaesthesia (TIVA). However, this technology has to be complimented with dedicated TIVAsupporting equipment in their Ors.
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Graduating from Basic to Integrated Workstations By K Y Ashok Murthy, Mg Partner, Erkadi Systems
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he safe administration of anaesthesia remains an art, and anaesthesia equipment is the tool that supports the patient. Their primary requirements therefore are reliability, precision and accuracy. Some innovations are spectacular, but have a limited application. There are innovations that have contributed immensely to show better quality healthcare on a daily basis. The latter have allowed the anaesthesiologist to pursue greater sophistication without requiring greater attention to the management of the machine. Effective anaesthesia depends on drawing upon the experience of the anaesthesiologist. Several trends have contributed
tech trends
Managing Anesthesia Information By Siddharth, Executive – Biomedical Engineering, Fortis Hospital, Faridabad
to this, for e.g., larger displays and user-friendly, intuitive interfaces. This allows a quicker evaluation of the patient’s condition and easier response to them. The use of ventilator modes that promote fewer interventions, including those that can be used in cardio-pulmonary bypass situations are innovations that have assisted in the easier management of routine situations, while at the same time enabled effective interventions in more critical situations. The graduation to electronic flow meter based anaesthesia machines has just started to take hold in India. They offer greater precision and a greater range of ventilator modes than the mechanical flow meter based machines. The use of integrated mainstream agent monitoring has promoted the use of lower flows and enhanced patient safety. Indian hospitals have always been good at shifting through the available technologies and adopting those that promote good outcomes and allow economy of operations. Their experience, realised the importance of good flow meter tubes in the machines, after being fed a diet of feature-rich machines that, unfortunately, rely on sub-standard flow meter tubes and controls. There has been significant up gradation of existing facilities by either adding selected items like anaesthesia ventilators, or circle absorbers. New projects have directly converted to an integrated workstation.
New technology available in the field is the anesthesia information management systems (AIMS). At present only 3 to 4 percent anesthetists use AIMS in the operating room, but we are seeing a growing interest, and improvement in AIMS technology is encouraging more anesthesiologists to move away from paper recordkeeping. It contains special software which removes error and in the meantime will alert the user also. Recently, technologies have been developed of a second-generation safety device designed to improve operating room (OR) anesthesia delivery. It is designed to reduce the frequency of perioperative and intra-operative errors. It is also useful in avoiding errors and creation of electronic records for billing and utilisation management. It also automates documentation of drug utilisation through creation of an electronic medical record, including professional fee capture, drug supply tracking, and electronic billing. The system’s modular design allows integration with existing hospital information systems, as well as electronic drug dispensing cabinets, infusion pumps, physiologic monitors, and other systems in settings where IV drug delivery occurs. The latest innovations are machines, which draw in room air through a filter. Its two-cylinder design ensures a constant supply of oxygen; while one side is being used, the other side is being replenished. Inside the cylinder, a molecular sieve removes the nitrogen from the room air, yet lets oxygen pass through into the cylinder. The enriched oxygen is directed to a pressure-reducing value with adjustable flow, through a final filter, and finally to the oxygen outlet for use during surgery. In the last few years advances in anesthesia are focused on drug safety, shorter durations of action, reversibility, and ease of administration. This has changed the settings and available risk management systems that support the investigation of these new drugs. This attests to the rapid growth and development of improved patient monitoring systems. Anesthesia in the last decade has witnessed the release of new drugs and novel uses for old ones. New equipment and devices in the past decade for regional anesthesia have been incorporated. Regional anesthesia equipment, small-gauge pencil-point needles, has spurred practice changes; spinal anesthesia has thus been improved much. Other developments include improved continuous catheters, nerve stimulators and needles, and implantable devices for the management of chronic pain. Surgical patient management with an emphasis on outpatient surgery and short hospital stays. The uses of modern imaging techniques to show the exact anatomical location of needles and injected solutions have also developed. september / 2012 ehealth.eletsonline.com
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tech trends
Innovations and Technology Revolution in Anaesthesia A simplified real time online incident reporting system can enable the medical fraternity to further ensure the safety of needy patients By Dr SS Harsoor, Professor of Anaesthesiology, BMC & RI, Bangalore
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he art and science of anaesthesiology depends on “Induction” of anaesthesia on any patient who is scheduled to undergo surgery for a specific disease. Any innovation in the field of anaesthesiology must be focused at the level of accuracy in administering required anaesthetics, though simultaneous monitoring of other vital systems of body cannot be ignored. Out of total 2211 anaesthesia related deaths reported in USA between 1999 and 2005, the overdose of anaesthetics accounted for 1030 (46.6 percent) and other 42.5 percent or 940 patients died of adverse effects to anaesthetics. A small but definite contribution of mortality resulted from difficult airway 2.3 percent. Beecher and Told found that in 1948-1952 period, the anaesthesia related depth rate was 64 per 1, 00,000 procedures. Because of various safety methods used today including new-
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er techniques, drugs and better anaesthesia training, the mortality has declined from 1 in 1000 anaesthetics (1948) to 1:1, 00,000 in 1970. There is 97 percent reduction in anaesthesia related mortality in 2005 which is estimated to be 1.1 per 10, 00,000 surgeries. With the use of fiberoptic technology into airway management, various devices are developed, which have helped in establishing a safe airway even in emergency situations. But the difficult airway management is a skill which needs to be acquired and mastered. Regular training programmes with latest innovations and gadgets are definitely beneficial. The perioperative safety has improved many folds following routine use of pulse oximeter and rightfully it is now recommended as a mandatory monitor for all types of surgeries by W.H.O. Another technological innovation which has further improved the patient safety is the development of Capnogram. But it is interesting to note that a vast majority of equipments available with anaesthesiologists attempt to monitor the complications or the safety of vital organs of body. But the awareness following inadequate or incompletely administered anaesthesia, which is not always measured, is posing major challenge in present day anaesthesia practice. Anaesthesia monitor that can measure the amount the anaesthetic administered and taken up by the body are available today and the BIS/Entropy monitors can measure the adequate depth of anaesthesia fairly accurately. Bispectral Index is a monitor (BIS) which measures brain activity, can determine the depth of anaesthesia to monitor the overdose of anaesthetics administered. Also an under dosing of anaesthetic, results long term morbidity which can be effectively managed with monitors like BIS and Entropy. Dr Ngai Liu of Hospital Foch, France resulted in development of “closed loop controlled system” and anaesthesia administration which uses BIS levels precisely to maintain adequate depth of anaesthesia. Hence any technological innovations appears meaningful, if the equipment are designed and developed for administration of only necessary amount of anaesthetics and monitor the same. With the regular usage of such devices can certainly bring down the morbidity and mortality, even in Indian subcontinent
tech trends
The Next
Generation
Anaesthesia Devices A completely integrated system which guides through anaesthesia, in both fully automated and manually ways. With the new Dräger Zeus Infinity Empowered (IE), the company has endeavoured to meet a variety of customer requirements
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he new Zeus IE provides optimised IT integration; it is easy to operate and supports clinicians in making therapeutic decisions. In future, it will be possible to integrate the device into the Infinity Acute Care System (IACS). This new anaesthesia system will replace the Zeus, which has been around in the market since 2003. Dräger Zeus IE is geared to facilitate all kinds of anaesthetic techniques: From inhalation to (total) intravenous anaesthesia. All these applications can be utilised in the closed circuit system of the Dräger Zeus IE. Thanks to its closed circuit system, the device consumes even less gas than in the low flow or minimal flow mode that is fully automated. In addition to the manually controlled fresh gas dosing, oxygen, carrier gas and volatile anaesthetics can be controlled automatically and targeted accurately (TCA = target controlled anaesthesia). The device also compensates potential leakages automatically. The haemodynamic monitoring, which can be integrated as an option, is operated via the high-definition 17” screen of the medical cockpit, the Infinity C500. Via this cockpit, the clinician can also control the ventilation parameters. By this, all OR information is fed to the integrated patient data management system, thus simplifying the work procedures.
Support for the user Even in the operating room, adult patients, children and neonates benefit from the differentiated ventilation in intensive care quality. The turbine allows for spontaneous breathing at any time; this can vastly shorten the recovery time for the patient. Up to four syringe pumps (Fresenius Module DPS), which can be controlled via the system, and the integrated medication database, which includes pre-configured default values and dosing limits for numerous pharmaceuticals, ensure an optimal intravenous anaesthesia. This supports the clinicians in their therapeutic decisions.
Safety and efficiency In the operating room and the intensive care unit, nomenclatures and principles of use should be identical. The concept of the IACS, into which the Dräger Zeus IE can be integrated, provides exactly this. The user interface, nomenclature and parts of the hardware employed correspond to those of other IACS components, such as the Dräger Evita Infinity V500 ventilator. USB ports for storing and loading device and profile settings enable the clinician to transmit settings within a very short period of time to any number of Zeus IE systems. The uniform, intuitive user interface and a more efficient service concept are intended to support the operator. september/ 2012 ehealth.eletsonline.com
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expert corner
Do Accredited Hospitals Deliver Better Quality Care?
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“Accreditation cannot be made mandatory and it should happen through voluntary compliance to make it more acceptable and sustainable,” says U K Ananthapadmanabhan, President (Operations & Projects), Kauvery Hospitals Group, Trichy and Member, CII National Healthcare Committee
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ndian healthcare industry has done considerably well after independence despite several inadequacies. Maternal and infant mortality rates have gone down and average life expectancy has gone up from 40 to 65 years. Waiting time and cost for even complicated heart surgeries and neurosurgeries is much less than in United States of America or many western countries. On the demand side, 75 percent of outpatient care and 60 percent of inpatient care are availed in the private sector. Both these observations point to the presence of a thriving private sector in the state as well as the increasing preference of the public towards private providers. Hence there is a need for the private sector to perform well and provide quality and affordable services to achieve universal healthcare. Our healthcare system has come of age and it is time that we start critically evaluating the quality of care provided in the private hospitals and government hospitals. Does accreditation ensure quality healthcare? It does. Accreditation by definition is a self-assessment and external peer assessment process used by healthcare organisations to accurately assess their level of performance in relation to established standards.” In developed countries the clinical outcomes did not significantly improve because of accreditation indicating that accreditation is ‘a’ means and not the ‘only’ means for quality improvement (QI). In America a recent survey showed that 70 percent of the people felt that accreditation improves the quality of care in hospitals. Thus accreditation is a wonderful tool in the overall armoury required to ensure patient safety and quality care. It is not the only tool required to attain excellence in quality. It is unfair to compare the Indian healthcare scenario to the American healthcare system which is a very well organised and self-regulated system. Therefore accreditation cannot be made mandatory and it should happen through voluntary compliance to make it more acceptable and sustainable.
Accreditation National Accreditation Board for Hospital & Healthcare Providers, under Quality Council of India (NABH), which comes with 102 standards in 10 chapters, is the only set of guidelines. These standards have not been deliberately made prescriptive to provide enough opportunities for the healthcare
expert corner
organisations to excel in their quality standards, comply with the laws of the land and meet standards provided by professional bodies in clinical and non-clinical areas. Sharing of knowledge and expertise among the healthcare organisations which have been accredited and which are awaiting accreditation is acceptable practice in all developed countries, but hospitals should follow all ethical principles and norms and should not resort to‘cut and paste culture’particularly while developing standard operating procedures which will curb the innovative sprit in the Indian health care system. Hospitals seeking accreditation should adhere to the NABH standards in letter and spirit and use them for bench marking their performance and misusing certificate of accreditation just as a marketing edge. NABH on it part, has been constantly reviewing the standards and in November 2011 has released
According to NABH sources there are 138 hospitals accredited for a three-year cycle and there are 478 hospitals waiting in the wings at different stages for approval. This is a clear sign that accreditation of hospitals is catching up faster than expected
latest and the 3rd Edition. This standard has been recognised by International Society for Quality in Healthcare (ISQua). All the ten chapters in the standard reflect two major aspects of healthcare delivery i.e. patient centered functions and healthcare organisation centred functions. Senior hospital administrators participating in the TN Health Summit 2012 held on 14th July on the theme ‘New Frontiers in Healthcare: Opportunities and Challenges’ at Chennai ,organised by CII –Tamil Nadu Healthcare panel felt that in practice hospital accreditation in India has definitely contributed to the
improvement of quality of care in the hospitals, especially in the Indian healthcare sector. The process of accreditation is as relevant and appropriate for healthcare institutions in India as in the hotel industry and higher education. However, the existing hospitals which are attempting for accreditation are finding it quite difficult because the NABH requirements require some structural and cultural changes which needs total top management commitment, financial resources and complete involvement of all the members in the organisation from housekeeping boy to the top medical consultant. Many existing hospitals which require considerable amount of funding to effect changes in the system are obviously not attempting to seek accreditation. It is heartening to note that all new hospitals and in hospital expansion projects, hospital authorities seem to be working for accreditation at the planning and design stage itself. In the new hospital projects, architects are developing their plans based on the SOPs given by the clients at the design stage itself. The process of accreditation seems to have got its required momentum, thanks to the constant awareness campaigns organised by the NABH and emerging trend of large corporate organisations, MNCs and insurance companies looking for NABH accredited hospitals for corporate tie ups and insurance payments. There is general agreement that in course of time market forces will drive the accreditation process.
Focus on patient safety and patient rights During the last five years accreditation process focused on various aspects of patient safety and patient rights which the patients rightly deserve. Medical errors and negligence reporting, incident and sentinel event reporting and action taken reports, medical audits seem to have greatly improved leading to better quality care in accredited hospitals. Qualified and trained NABH auditors, during their pre and final audit do a meticulous and a fair evaluation which has won the appreciation of the hospital management professionals around the country. Hospitals working towards NABH accreditation perceive that the inspection by NABH authorities is a learning and course correction exercise to improve quality of care instead of doubting it as fault finding mission. According to NABH sources there are 138 hospitals accredited for a three-year cycle and there are 478 hospitals waiting in the wings at different stages for approval. This is a clear sign that accreditation of hospitals is catching up faster than expected. Accreditation may not be a panacea for all ills in the Indian healthcare industry but as stated by Wendy Nicklin, President and CEO, Accreditation Canada ‘Accreditation is a risk mitigation strategy, a performance measurement tool, a management tool for diagnosing strengths and areas for improvement and provides key stakeholders with an unbiased third-party review.’ About Author U K Ananthapadmanabhan President (Operations&Projects), Kauvery Hospitals Group,Trichy and Member, CII National Healthcare Committee september/ 2012 ehealth.eletsonline.com
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global leader
Focusing on the End User and Patient Education More than one billion women in low- and middle-income countries own mobile phones. Mobile Alliance for Maternal Action (MAMA) delivers health information that empowers mothers living in the poorest, most remote communities. Kirsten Gagnaire, Global Director, MAMA Alliance, talks about MAMA and its programmes in Bangladesh, India and South Africa, in a conversation with Shally Makin
Brief us about the various programmes MAMA is currently working on. We have implemented a national programme in Bangladesh called ‘apanchang’ which in Bangla means trusted friends. We educate poor mothers about pregnancy and childbirth. The intention of the education is to provide the healthiest start for newborns which should be a safe and positive experience for all women. Mobile phones can help by putting the power of
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health right in the palms of mothers. Mobile health messages are easily accessible. They can inform, dispel myths, highlight warning signs and connect pregnant women and new moms with local health services. It focuses on getting the information disseminated to Bangladesh women in localised language. We have also implemented the programme in South Africa, as they have very high rate of HIV among pregnant women so the researchers have developed content and information for pregnant
global leader
Please throw some light on Mobile Alliance for Maternal Action (MAMA) The Mobile Alliance for Maternal Action (MAMA) engages an innovative global community to deliver vital health information to new and expectant mothers through mobile phones. MAMA is making a three-year, US$ 10 million investment to create and strengthen programmes in three countries – Bangladesh, India and South Africa – and to enhance global capability of new and existing mobile health information programmes for mothers in those countries and beyond. MAMA is a public-private partnership launched on Mother’s Day, May 2011, by U.S. Secretary of State Hillary Clinton. Two main constituents of the programme are the United States Agency for International Development and Johnson & Johnson. The supporting partners for the enterprise include the likes of United Nations Foundation, mHealth Alliance and BabyCenter.
women around the prevention of mother to child transmission and HIV and other protocols in local language. The nature of Indian programmes will vary from what we have in Bangladesh and South Africa. We are looking for partnerships with other organisations and providers to help us run programmes to carry in such large and diverse place. In India, we are carrying research to find out how the Indian women use mobile phones in India. We have found that typically poor women do not have their own mobile phones. Therefore, we are looking at ways where we can cross language barrier and help them own a mobile phone and educate them about the advantages about this device. A recent women survey of 2,500 women identified gender bias and technical literacy as the two main barriers in front of women using mobile phones in the developing world. We have to understand these cultural beliefs and find ways of helping to run this programme within the community. We have women self help groups to help us develop our programme in India. MAMA programmes include a separate service for husbands and this is something that serves the purpose of reinforcing messages that their wives are receiving. Messages are delivered in both voice and text for ease of use. Subscribers register mothers for the service by indicating their expected due-date, or the birthday of their recently-born child, and then receive weekly messages and reminders during the pregnancy and up to the first birthday of their child. Messages are culturally sensitive, relevant to the local context and in the local language. We are partnering with organisations that has programmes that have already started, with BBC media action and BBC world services trust and mutually benefit each other. They are working on a program called maternal messaging service where we intend to collaborate on. Presently in Delhi we don’t have Mama specific services but a baby centre service in Delhi is on the agenda.
How do you think ICT has revolutionised the mobile arena? We focus directly on the end user and patient education. From our perspective ICT is really helpful to gather information to people that is not previously available. You know we have done work across Africa and women are able to receive information who were not aware of certain information except what they heard in their villages from their mother and mother in laws. They just don’t have access to accurate and timely information. This helped us develop where we can find pregnancy therein and they get messages time to time. I think the connectivity issues are more of a challenge. The content is developed on the baby centre, WHO and UNICEF standards and we have global advisory board of global health experts. How are you approaching to various organisations to achieve your goal? MAMA is trying to get a better sense of how we can work with mobile operators to understand the business proposition that they are offering and how we can negotiate with them to provide free services. We are working on how we can mobilise the charge for some people who can afford it. We intend to subsidise the cost for the poorest women. Organisations for telecom players globally, is engaged in trying to understand how we can get the policies, procedures and agreements in place. This is where the discussions need to happen at the industrial level. What are your future plans? We are working to understand the ground realities so that our strategy can evolve. Within the next few months we will the strategy figured out and then we will start the process of selecting our implementing partners. september/ 2012 ehealth.eletsonline.com
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15 - 16 November 2012, Hyderabad International Convention Centre, Hyderabad, Andhra Pradesh, India
Driving Thought Leadership in Healthcare eHEALTH India, an integral part of eINDIA conference and exhibition, is designed to create a unique platform for visioning and knowledge sharing in the domain of ICT-driven healthcare and facilitates multi-stakeholder partnerships and professional networking among governments, industry, academia, civil society organisations and international funding agencies.
Track Chair Rajendra P Gupta President, Disease Management Association of India
Components • Conference for sharing of knowledge, challenges, ideas and best practices driving ICT initiatives in healthcare • Exhibition of most innovative technologies and products in the healthcare IT market • Awards felicitating the most innovative initiatives in healthcare across the globe Themes • Transforming public healthcare through technology • Envisioning hospital of the future – putting technology at the heart of care • Health insurance – Leveraging technology for scalable models • Online and mobile healthcare – exploring technologies, services and business models • Telemedicine: Bridging barriers to revolutionalise diagnosis & care .....and more
Special Sessions Hospital CIO Conclave Health Secretary Conclave
In conjunction with
awards Rush your Nominations Today!
8th
eINDIA health Awards categories •
Innovative use of Healthcare Information and Commu-
•
mHealth Project of the Year
nication Technology by a Hospital
•
HIS Provider of the Year
•
Government Policy Initiative of the Year in Healthcare
•
EMR Provider of the Year
•
Civil Society/Development Agency Initiative of the Year
•
RIS and PACS Provider of the Year
in Healthcare
•
Telemedicine Project of the Year
•
Innovative Use of Technology by a Diagnostic Service
•
Start-up Organisation in Healthcare
Provider
•
Innovative Pharma/OTC Company of the year
•
Health Insurance Initiative of the Year
•
Innovative Teaching-Learning Practices Adopted by a
•
Private Sector Initiative of the Year in Healthcare
•
PPP Initiative of the Year in Healthcare
Medical/Nursing/Paramedical College •
Best Preventive Care Initiative of the Year
Speakers at our Past Events J Satyanarayana, Secretary, Dept of Electronics & Information Technology, Ministry of Communications & IT, Govt of India
P K Taneja Principal Secretary (PH) & Commissioner, Health & Family Welfare Department (PH & FW), Government of Gujarat
Anju Sharma Commissioner, Department of Women & Child Development, Government of Gujarat
Sangita Reddy Executive Director, Apollo Hospitals
Dr B S Bedi Advisor - Health Informatics, C-DAC, Govt of India
Ameera Shah Managing Director, Metropolis Healthcare
Dr K Ganapathy President, Apollo Telemedicine Networking Foundation
Dr Neena Pahuja CIO, Max Healthcare
Gunjan Kumar Head- IT and Automation, Sahara Hospital
For programme details
book your space today!
Shally Makin, +91-8527697687 shally@elets.in
Divya Chawla, +91-8860651643 divya@elets.in
ORGANISERS
eINDIA.eletsonline.com
For Exhibition and Sponsorship
host partner
for award nominations and registration queries Aruna Tiwari M: +91-8860651631 aruna@elets.co.in
CO-ORGANISERS
special feature
mHEALTH
Climbs up the
Airwaves
mHEALTH represents the acme of innovation in cellular services, it enables anytime, anywhere healthcare
By Shally Makin, Elets News Network (ENN)
S
till in its embryonic stage, mHEALTH market brings about integration of computer, networking software and hardware technologies, such as mobile phones, personal digital assistants, tablets, patient monitoring devices, for providing health services to patients. The speed of adoption will vary in different countries determined by how open the various stakeholders are to use of mobile based services. A PwC report states that mobile health services will become a billion dollar opportunity for India, Asia Pacific and global markets by 2017. The report says the market will provide a revenue opportunity worth ` 3,000 crore or USD 0.6 billion for India and USD 23 billion for the world by 2017. mHEALTH services are growing fast due to two basic factors - firstly the mobile subscriptions are ubiquitous in the
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special feature
Anyone, Anytime, Anywhere at AffordAble Cost
A
s every sixth human and every fifth mobile phone is in India we should logically be leading the world in mHealth. However “Anyone, anytime, anywhere at affordable cost,” “Geography is History” “Distance is Meaningless” continue to be just slogans. Most mHealth initiatives continue to be pilots and proof of concept studies. We are a long way from incorporating it into the core of our healthcare delivery system. We are suffering from pilotitis. There are fewer pilots in the Indian Air Force than in mHealth. Worldwide, mHealth is an mVAS driven by network operators and app developers as it assures a rather quick return on investment. An apple a day may have kept the doctor away – now apps a day, will keep the doctor far away. Many medical doctors of yester year feel threatened. They feel that they may become redundant. WiiiFM (What is in it For Me) should not be lost sight of. For this he should view the mobile phone as an enabler, a tool to achieve an end, not his replacement. The potential which mHealth has is truly mind boggling. From simple SMS to act as reminders, to ensure compliance and adherence, to knowledge empowerment, to acting as a peripheral medical device, mobiles can even be used for management of chronic life style diseases and for video teleconsulting. Technology is not the stumbling block. What is required is a business plan, revenue generating, self-sustaining and scalable. Effort and time spent on change management will yield more dividends than talking about 3G and 4G!
Prof K Ganapathy, President, Apollo Telemedicine Networking Foundation
Approximately 70 percent healthcare apps are consumer focused, while the remaining 30 percent are designed for medical professionals. These apps are typically more sophisticated, and can offer clinicians access to patient information and the ability to conduct further analysis, such as creating 3D anatomical models emerging market and secondly consumers in developed market access such services for sake of convenience, cost advantage and quality. Despite demand and the obvious potential benefits of mHEALTH, rapid adoption is not yet occurring. The main barrier is not the technology; rather it is the inherent resistance to change. In order to support the successful roll out and adoption of new health services, governments, regulators and healthcare providers need to work with mobile operators, device vendors and content and application players. september / 2012 ehealth.eletsonline.com
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special feature
Creating Mobility for
the End User
T
Matt Theis, Founder, Dimagi Software
he number of non-mobile subscribers across the globe is falling rapidly. As mobile subscriptions in India alone approach the one billion mark, the penetration, utility, and potential for what a mobile phone can do has created innumerable opportunities. There is a huge rise in the number of organisations that are working to enhance the scope of your mobile. As the number of mobile applications grows, the challenge for us is to figure out which applications make a difference. We need the potential of every application and decide which of them can be scaled up. Making an application usable in the ‘last mile’ is one thing, but making them equally useful for the ‘last user’ is quite another. In India, for instance, literacy rates pose as a challenge to what an application can do. Phone proficiency can be very high – until it comes to texting. Due to lower literacy rates majority of the users prefer to communicate through voice calls and this makes the designing of SMS or text based applications quite difficult. Understanding the local
Engineering mHEALTH To be effective, mHEALTH has to work across geographic, time, social and cultural barriers
M
Annie Mathew, Head of Alliances, RIM India
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phRx connect, an application available on Blackberry smart phones, offers cloudbased and mobile-based solutions for storing, retrieving and sharing patient health records among hospitals, physicians and patients across geographies on mobile devices at all BlackBerry platforms and web interfaces. There are various formats of health reports, which can be accessed on mobile phones. From radiology images and reports to lab results, the application provides solutions to support a hub-and-spoke model for detecting and monitoring retinopathy conditions for diabetes patients. CARE products by i2i Tele Solutions, application developer for Blackberry, connect doctors and patients around the world. The system offers fast data transmission, best image quality, mini-
mum storage space and lowest operating costs. Companies are engineering mobile health to serve patients in need in any geography and any economy. The technology is creating telemedicine a practical reality over standard broadband connectivity. Companies earn rewards by turning the anxious look of a patient in want into reassuring relief that the best healthcare is now only a moment away on the internet. Companies are offering applications, which allow cardiologists to access patient’s ECG reports on BlackBerry smartphones. Dr Pavan Kumar -Head of Telemedicine Department at Mumbai’s Nanavati Hospital was instrumental in conceptualising this solution. On a global basis there simply aren’t enough physicians and specialists to meet the healthcare needs of nearly seven billion people.
special feature
and regional context is of utmost importance – as an application that works in one area, may not work in another. An SMS based application that works fantastically in Malawi, may not work at all for many users in the progressive Indian state of Gujarat. But these problems can be tackled with the use of better technology. Interactive voice recognition offers a fantastic alternative for applications aimed at low literacy users. But, it comes with its own inherent advantages and disadvantages. The 4G revolution provides potential to dramatically alter how bandwidth is used. The regional and user context plays a larger role as the technological barriers come crashing down. The challenge is to figure out which applications make the biggest difference to the largest number of users, how they prove that difference, and whether that difference will be sustainable and effective at scale. The conclusion is simple, but is much easier said than done.
Standardise Operable Methods to Connect This industry lacks stable business models that can help reduce the economic and health divide
A
s per a recent industry study, India’s rural population is well-suited for mHEALTH programmes due to the high penetration of low-cost mobile telephony and given the dearth of qualified medical personnel. Technology still presents a challenge for mHEALTH adopters, as we still don’t have that high level of penetration of mobile and broadband in rural areas. Orange offers health line in partnership with Bhutanese Ministry of Health; it facilitates real time healthcare services, realtime health advice and 24X7 emergency responses for the people of Bhutan. TELUS Health Solutions and Orange joined forces to develop innovative remote monitoring solutions for patients with chronic diseases. A remotely monitored cardiac implant service launched in US and Europe enables patients to wirelessly upload data about their heart condition to a doctor using 3G, 2G or landline.
Other services features long-life SIM cards that can cope with extreme conditions and be used virtually anywhere in the world. Orange is also participating in the fight against counterfeit drugs in Kenya and Cameroon by providing an SMS-based system, where up to 25 percent of drugs are potentially affected.
Apps for m-health The Embedded Area Network (EAN) is a concept where a cellular module, such as a SIM card, is embedded in the medical sensor to communicate to the remote service via wireless networks. This new market opportunity has seen new devices in the mHEALTH category appear recently, the desire is to standardise the method of connecting through mobile networks and enable an interoperable back end with a plug and play front end. The project partners share the belief that the ability to seamlessly embed cel-
Bala Mahadevan, CEO India, Orange Business Services lular services with medical devices will guarantee compatibility and interoperability, and will be a key contributor to the success of mHEALTH. The ultimate objective is to provide an out of the box experience to consumers, so that they can access all kinds of medical services through their devices. september / 2012 ehealth.eletsonline.com
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special feature
Mobile Care
I
n the next few years, innovations in mobile and connected device technology will fundamentally transform the healthcare landscape, providing new solutions to address chronic disease conditions and revolutionise the way treatments are administered. The monitoring devices are becoming smaller, portable and mobile. Technology such as Micro Electro Mechanical Systems (MEMS) is helping in developing miniaturised biological sensing devices. Using such technologies in wearable devices such as insulin pumps in tele-health applications is helping us to stay away from the hospitals thereby reducing the cost and improving the quality of life of diabetic patients. Other examples include implantable diagnostics including patient vitals monitor, smart pills and wearable diagnostics. Use of wearable Personal Emergency Response Systems (PERS) systems is becoming feasible for them to age and live in place and independently. Care providers can now monitor the health and activities of their elderly people using wearable activity monitors and fall detection technologies such as the one developed by Wellcore and MobiWatch. As the cost of quality care is increasing, diagnostic tests are becoming affordable, but not the cure. Therefore people want to stay fit and are focusing on personal wellness programmes using devices like FitBit and Nintendo Wii. Gym equipment such as a bicycle or treadmill can talk with your mobile phone using ANT+ wireless protocol and one can track his activity
and compare against goals. One of the challenges of today’s technologies is affordability. Secondly, recoding of your vital parameters is considered a time consuming activity. One has to measure his weight, blood pressure, heart rate, pulse Abhay Barhanpurkar, rate, temperature separately Solution Architect, and record it somewhere. Symphony Teleca Innovators are trying to use Corporation mobile handsets to perform vital functions like monitoring of temperature, heart rate, pulse rate, BP monitoring instead of having a new device. A solution to automate the capture of data such as a wearable vitals patch is needed. Standards such as IEEE 11073 standard is making it possible to provide seamless connectivity of different systems and provide better and accurate health solutions. Overall the challenge is behavioural and we need a solution which can motivate the user to take required actions. This is possible though mobile based friendly medication reminders, incentive programmes, prizes, medical games and continuous education.
Engineering mHEALTH
Rajesh Razdan, Co-Founder and Director, mCarbon Tech Innovation
W
e live in a world that’s connected wirelessly with almost as many mobile subscribers as there are people on the planet. Mobility by its very nature implies that users are always part of a network, which radically increases the variety, velocity, volume and value of information they send and receive.
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mHealth involves the use and capitalisation on a mobile phone’s core utility of voice and short messaging service (SMS) as well as more complex functionalities and applications including GPRS, 3G and 4G systems, GPS, and bluetooth. Moreover changes in the ICT environment are also affecting mhealth VAS initiatives, such as the shift from SMS to interactive voice response (IVR). Just as SMS-based services have often been linked to voice communications by hotlines and toll-free numbers, IVR offers a more comprehensive toolkit for reaching out to illiterate people. The ubiquity of MVAS solutions offers tremendous opportunities for the healthcare industry to address one of the most pressing global challenges: making healthcare more accessible, faster, better and cheaper. The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of
health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks. mHealth applications can be used for supply chain management, reducing delays in medicine shipments and providing point-ofuse technologies for consumers to verify the authenticity of products they buy. Value Added Products and Services [VAS] for opcos and enterprises has recently developed a product for pregnant women to count their baby’s movement; it is an easy, non-invasive test that one can do at home through a simple service subscription to check their baby’s well-being. ‘Baby Kicks’ is much more than just knowing that the baby moves!
3
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special report
The objective of Nursing Education has been redefined with time. The focus is not only on maintaining uniform quality education, there are many other values that need to be persued
Nurse the Cause By Sharmila Das, Elets News Network
T
he Nursing Education Act came into existence in India in 1948. The objective of the act was to facilitate the rise of quality nursing education in India. For that The Indian Nursing Council (INC) was established in 1947. The body acts as a watchdog and regulates nursing education in the country through prescription, inspection, examination, certification and maintenance of uniform syllabus at each level of nursing education.
A glimpse of the time Nursing Education in India has evolved to a point today where it is seen as a way of eradicating unemployment too besides serving the humanity. A large number of nursing education colleges have come up today and the following top the list.
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• • • • •
All India Institute of Medical Sciences, New Delhi Post Graduate Institute of Medical Education & Research, Chandigarh West Bengal University of Health Sciences (WBUHS) Manipal Academy of Higher Education Christian Medical College, Vellore
Dr Latha Venkatesan, Principal, Apollo College of Nursing, Ayanambakkam, Chennai, says, “The nursing profession continues to evolve and progress at its own pace. The current trends in nursing and care are multifaceted. It includes the changing disease patterns, enhanced consumer awareness, a transition to technology and informatics, a mismatch of nurses strength between
Dr Latha Venkatesan
south and northern states, and an overarching emphasis on specific frameworks for the guiding of nursing practice, including integration of evidence based practice and key performance indicators of quality of nursing care.”
special report
AK Ojha
The six levels of nursing education in India are: • Multi Purpose Health Worker Female training (ANM or MPHW-F) • Female Health Supervisor training (HV or MPHS-F) • General nursing and midwifery (GNM) • BSc. Nursing • MSc. Nursing • MPhil and PhD The last three are the university level courses while the ANM, HV, and GNM are conducted in schools of nursing.
AK Ojha, Director, A K School of Nursing, says, “The present status of nursing education is very bright in India. The education system has third position in education. Doctor, engineer and graduate nurse is the sequence of choice of profession in India today. Students enter in nursing education with the objective of getting a job in India or abroad. It’s a job oriented profession now”.
Prof Jaya Kuruvilla
Changing trends While the healthcare is catching up with more consumer centric services like day care and specialty clinics, the need of trained, skilled nurses is even more acute. To fill the gap, lot of changes are being implemented. Dr Venkatesan says, “ To fulfil the vast requirement of skilled nurses, mushrooming number of colleges have come up over the decade, offering post graduate diploma courses in various specialties. There are short term refresher courses available in the domain. Also integration of technology into teaching and examinations have included in nursing education”. Prof Jaya Kuruvilla, Prinipal, PD Hinduja Hospital College of Nursing says, “Though the numbers of colleges have increased tremendously, the quality of education is compromised in many colleges due to lack of physical and clinical facilities and qualified and experienced teachers. Research need to be strengthened and quality of studies conducted by Post graduate and Ph.d students need be improved so that evidence based nursing practice becomes a reality. In our college, we prepare an
Institutional curriculum which is much more than that of the basic curriculum of INC/MUHS .We incorporate innovative teaching learning strategies and in this line we also have a smart class room which is useful for us and eventually for other colleges because we can practice web based teaching”.
Facing the trends The scientific and technological advances in medicine along with social changes have resulted in emergence of new diseases and the development of specialties and super specialties. To keep pace with the changes, the curricula in nursing education programmes needs to include social trend based syllabus and advances in medicine. Along with new inclusion, curriculum needs periodic revision. Dr Renu Kapoor, Branch Manager, FPA (Full form) India, Hyderabad, says, “The syllabuses are changing and the high standards are being maintained to meet the needs of the society, at the same time it should not be made as profit making business. It is felt that nursing education in India has reached high, but the manpower needs are not met yet.”
The role of INC It is a fact that with large number of graduates passing out every year in this space, it is a challenge to maintain quality in nursing education. Hence INC has to be very efficient in facing the situation. Experts are of the opinion that with more and more clinics, hospitals, nursing homes coming up, an adequate supply of qualified nurses poses a challenge. Besides, good infra structure, clinical facilities and adequately prepared faculty are required. Dr Kapoor says, “Indian Nursing Council has by far been successful in implementing Nursing Education. In order to ensure uniformity of nursing education, INC has implemented policies and regulations that have to be followed by all schools and colleges of Nursing. Admission criteria for nursing schools and colleges have been changed. For instance, for ANM course, the educational qualification has been enhanced for 10th pass to 12th standard from 2013-14 academic year onwards. This has improved the quality. The education is not only classroom based. The students get ample opportunity to practice and polish their skills by way of being posted at various hospitals and communities to get direct field level experience. Linking of nursing education and practice encourages well prepared graduates for better patient care.” It is safe to conclude that while the INC should take appropriate steps to ensure adequate supply of skilled, qualified nurses to the country, the nursing education colleges/institutes should also maintain the benchmark of producing good quality nursing professionals. september/ 2012 ehealth.eletsonline.com
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zoom in
Pertinent Need for
Implementation of EHR
By Indrajit Bhattacharya, Professor, International Institute of Health Management Research
The Institute of Medicine, also referred to as the “IOM,� is an independent organisation dedicated to improving healthcare at the national level by delivering unbiased and evidence-based healthcare advice
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zoom in
A
ccording to a report completed by IOM in 2001, the United States ranked 37th worldwide for quality of healthcare. That same year, the Institute of Medicine compiled a report listing 13 recommendations designed to revamp the nation’s healthcare system. In the last two years alone, EHR adoption rates in the US have doubled. A recent survey conducted in August 2011, showed that 51 percent of physicians’ offices, with three to five providers, and 31 percent of the solo-provider practices, are currently using EHRs. Many of the EHR initiatives have been taken in the past few months, thanks in part to HITECH Act of 2009. Through the HITECH Act, the US federal government has committed billions of dollars to promote both adoption and “meaningful use” of EHRs. The IOM listed six aims in improving healthcare quality: • To make healthcare environments safer for patients • To provide more effective healthcare • To make healthcare more patientcentred, which can be done by ensuring that the patient is more involved in the decision-making process and has a better understanding of the healthcare choices available • To improve the timeliness of healthcare service • To make the process of providing healthcare more efficient • To work toward the elimination of healthcare disparities among diverse populations ensuring that all patients have equal access to healthcare
Electronic Health Record According to the Computerised Patient Record, published in 1991 by the Institute of Medicine, an electronic health record system is defined as “The set of components that form the mechanism by which patient records are created, used, stored, and retrieved.” A patient record system is usually located
of n t tio as a cos of c du s h for val ies. o l r nt stem ntia mo ienc i e y re c Th R s pote nd effi at ns, EH ge gs a e in th ctio hu vin lac ted du sa orkp pec t re th a ient er w s ex cos wi pat uld low It’ ese ined in sho t in ms th mb tion rs, sul miu co duc erro ly re pre es re re ual ice n fe within the healthcare provider setting. It ca ent act tio includes people, data, rules and proceev alpr tiga dures, processing and storage devices m d li (e.g., paper and pen, hardware and softan ware), and communication and support facilities.” The Institute of Medicine (IOM) lists the key capabilities any EHR system as the following: • A longitudinal collection of electronic health information for and about persons • Immediate electronic access to person and population-level information by authorised and only authorised, users; • Provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; • Support of efficient processes for healthcare delivery
Potential Advantages of EHR Systems With an EHR system, the physician can enter the data directly into the system interface, thereby dramatically reducing handwriting errors. With EHRs, massive amounts of data can be stored digitally in a substantially lesser space. This eliminates storage problems and virtually eliminates record search time. With an EHR system, healthcare staff can have critical patient information at their fingertips. These realised efficiencies, combined with value-added software designed to minimise procedural and prescription errors, should, over time, improve overall patient safety in the healthcare environment. The increased ease of updating
records often leads to more time becoming available for conducting those important physician-patient level interactions. The introduction of EHR systems has a huge potential for cost savings and removal of workplace inefficiencies. It’s expected that these cost reductions, combined with a reduction in patient care errors, should eventually result in lower malpractice premiums and litigation fees. F ig 1 Illustrates that, prior to centralised EHR system management software, each organisation or department had to maintain its own system and software designed to capture the data required for each specialty area. This means that multiple databases and patient records existed and the healthcare provider was required to open a different client application for each department and compile the data using a manual process. Fig 2. Illustrates that EHR systems are designed to receive data from each of these organisational silos and compile them within a centralised database. EHR software is designed to compile the data in a more efficient manner, allowing the healthcare provider to access and cross-reference data from all available sources from one convenient client interface. september/ 2012 ehealth.eletsonline.com
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event report
Thought Provoking
Healthcare Leaders Forum
“Achieving Operational Efficiencies in Healthcare Management,” was the name of the latest successful event organised by eHEALTH magazine. The event was held at Le Meridien, New Delhi, on August 23, 2012.
O
rganised in the format of a round table session, the event was focused on highlighting the use of ICTs in the public health domain and the benefits that they offer. The eminent speakers who participated in the lively discussion included: • Anil Swarup, Director General - Labour Welfare, Ministry of Labour &
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• •
•
Employment, Government of India; Dr BS Bedi, Advisor, C-DAC; Dr Rajiv Kumar Jain, Director H&FW, Railway Board, Ministry of Railways; Dr Pradeep Saxena, Director, Central Bureau of Health Intelligence, Dte. General of Health Services, Ministry of Health & Family Welfare;
•
• •
Dr SK Thirunavukkarasu, Deputy Director – HMIS, Tamil Nadu Health Systems Project; Sunil Kumar, Sr Technical Director NIC Dr Tarun Seem, Additional Commissioner of Income Tax, Chief Commissioner of Income Tax, New Delhi.
event report
While dwelling on the subject of recent trends in Indian healthcare, Dr Pradeep Saxena said, “It is a question of willingness. If a new hospital is coming up or a leading hospital wants to use ICT Technology, they can use the dashboard. This can give minute by minute information of patients moving from emergency room to dressing room to x-ray room and connect other related departments. In hospitals every minute is changing and you can’t ask nurse and doctor that what is happening at every moment.” In a thought provoking speech, Anil Swarup, Director General - Labour Welfare, Ministry of Labour &Employment, Government of India, said, “The poor man does not die of kidney transplant or heart failure, he dies much before that. He dies of typhoid and malaria. So this sophistication that came through technologies we are looking at today will serve the purpose. We have to reach out to poor man and we have to see how technology can help bridge the healthcare divide. So my request to the technology provider is to first think to move beyond your city and don’t confine your area of application in emergency places like tsunami affected or earthquake affected locations.” Dr Rajiv Kumar Jain, Director H&FW, Railway Board, and Ministry
Anil Swarup, Director General - Labour Welfare, Ministry of Labour &Employment, Government of India, said, “The poor man does not die of kidney transplant or heart failure, he dies much before that. He dies of typhoid and malaria...”
of Railways, said, “If we talk about healthcare efficiency, then we will have to move away from healthcare centric prescriptions to non-healthcare sector discretions. India is a land of paradoxes and it shall remain a land of paradoxes. In India, if we need to be successful in providing efficient healthcare facilities, only then we will be able to become either felicitators or providers.” Dr BS Bedi, Advisor, C-DAC, opined, “ICT use in healthcare is not debatable; it’s only the use that should make a difference”. Dr Tarun Seem, Additional Commissioner of Income Tax, O/O Chief Commissioner of Income Tax, New Delhi, took the discussion to a new level by his words. He said, “We have a saying that if you manufacture something for the masses, you will live in the classes. But if you define the product for the classes, you will remain in the masses; it’s true in every sector like education, health and every kind of public delivery. We have to look for better solutions, the EMR has to be at our scale and standard of living. The thing is that our scale is different, our possibilities are different. Dr. Sunil Kumar, Senior Technical Director, NIC, expressed some lofty opinions for eradicating the myriad scars on Indian healthcare. He said, “I have only one point to make. By implementing e-Hospital, medical records can be transferred from one hospital to in any other hospital. So that in case of emergency we don’t have to sit down. It should be exported or it should be imported.” The organiser of the Healthcare Leaders Forum, eHEALTH, is a premier print and online monthly publication focusing on the latest and most cutting-edge initiatives in healthcare ICTs and medical technologies. The magazine also takes out a weekly newsletter that delivers rich, relevant and up-to-date information to thousands of readers. The print edition of the magazine enjoys immense popularity in the medical fraternity and in the corporate sector. september/ 2012 ehealth.eletsonline.com
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speciality
Keep up the Breath
The rise in the number of cases of respiratory diseases is a direct consequence of hectic urban lifestyle. Indian medical science has come up with a number of medicines, which serve as advance treatment for such ailments. In our attempt to spread awareness about Pulmonary and Critical Care Medicine, we have contacted a number of renowned respiratory doctors. What follows is a compendium of medical insights from this eminent panel of doctors: Reports generated by: Sharmila Das, Elets News Network (ENN)
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speciality
EBUS
A leap forward L
ung cancer is a deadly disease with a high mortality rate. If lung cancer is diagnosed early, it is possible to treat it. More often than not, people come late for treatment. Individuals come for diagnosis either in 3rd stage or 4th stage where the treatment options are limited. This article is to highlight the importance of early diagnosis of lung cancer. There are time tested procedures like sputum examination, chest X-ray, CT scans and PET scans etc., but the most important issue here is the tissue. Unless a tissue diagnosis is made no medical oncologist would start treatment. No surgeon would think of operating unless staging of the lung cancer is done. The diagnosis of indeterminate mediastinal lymph nodes, masses, and peripheral pulmonary nodules constitute a significant challenge. Options for tissue diagnoses include computed tomography–guided percutaneous biopsy, transbronchial fine-needle aspiration, mediastinoscopy, left anterior mediastinotomy, or video-assisted thoracoscopic surgery; however, these approaches have both advantages and limitations in terms of tissue yield, safety profile, and cost. Endobronchial ultrasound (EBUS) is a new minimally invasive technique that expands the view of the bronchoscopist beyond the lumen of the airway. There are two EBUS systems currently available. The radial probe EBUS allows for evaluation of central airways, accurate definition of airway invasion, and facilitates the diagnosis of peripheral lung lesions. Linear EBUS guides transbronchial needle aspiration of hilar and mediastinal lymph nodes, improving diagnostic yield. EBUS is a bronchoscope that has miniature ultrasound mounted on its tip so that it can do the job of both looking
in to the bronchus and beyond the bronchus. Not only can one look beyond the bronchus but also can take material for bacteriological and pathological studies. The clinical benefit and diagnostic use has been proved in many studies. It may replace invasive methods like mediastinoscopy for diagnosis and staging.
Indications 1.Evaluation of mediastinal lesions, endobronchial nodules and intrapulmonary nodules 2. Staging of lung cancers 3. Guidance of endobronchial therapy Let me narrate the story of a doctor who presented to his physician with complaints of cough and breathlessness of recent origin. He was investigated to rule out a coronary heart disease and was found to have pulmonary embolism and was started on anticoagulants. He was also ordered a CT chest that showed a mass lesion encasing the right upper lobe bronchus and mediastinal lymphadenopathy along vertebral metastasis. An EBUS was suggested to him. He did not agree to it nor did his doctor relatives. He underwent bronchoscopy without a diagnosis. He underwent a CT guided biopsy without success. After all that he reluctantly agreed to EBUS and the diagnosis was made in one day and now is on chemotherapy. But a clean 15 days was lost before the diagnosis was made. The reason for presenting this story is drive home the point that many discoveries goes unnoticed and unless awareness is created it is not possible to make these great inventions popular. In Apollo Hospitals this procedure is fast gaining popularity for diagnostic and staging purposes. In my experience of 200 odd cases (that have been analysed) I had positive results in more than 182 cases. If the suspected lesion
Dr.R.Narasimhan, MD FRCP (UK), In Charge EBUS Services, Senior Respiratory Physician, Apollo Hospitals, Chennai
is malignant lesion my success rate approached 97 percent and if it is TB or sarcoidosis it was around 90 percent. I do it as a day care procedure with an anaesthetic help. Transbronchoscopic needle aspiration report comes the next day thus optimising also on the time. I always suggest if a CT scan shows a lesion and lymph nodes EBUS should be the procedure of choice as both diagnosis and staging can be done in one go. That has become the order of the day and I am sure in India too it would become the same. september / 2012 ehealth.eletsonline.com
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speciality
Dealing with Pulmonary
Dr Puneet Khanna, MBBS, MD, IDCCM, FCCP (USA) Consultant, Department of Respiratory & Critical Care Medicine, BL Kapur Memorial Hospital
T
he field of Pulmonary and Critical Care Medicine provides a comprehensive approach to the diagnosis and management of patients with respiratory system disorders. The Pulmonary division usually provides an active consultation service with subspecialty outpatient clinics for diagnosis and management of patients with acute and chronic lung disease. Special clinical expertise is required to mange patients with asthma, chronic obstructive pulmonary disease, bronchiectasis, sleep disorders, interstitial lung disease, lung cancer, lung transplantation, infectious diseases of the lungs and pulmonary vascular disease. Diagnostic procedures include fiberoptic bronchoscopy with transbronchial lung biopsy and bronchoalveolar lavage, pleural biopsy, and pulmonary
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artery catheterisation. Special facilities often include a pulmonary diagnostic laboratory, an exercise physiology laboratory, a sleep disorders laboratory and specialised procedure suites where diagnostic and therapeutic lung procedures are performed. The critical care services usually focus on a multidisciplinary medical intensive care unit in providing acute care, resuscitation and monitoring of critically sick patients. A typical case presenting to our department is shared below:
Community-acquired a typical pneumonia in a farmer A 42-year-old farmer, a chronic smoker, presented to the Emergency Room in acute respiratory distress with a 1-week history of productive cough, myalgia, and low-grade fever. Three days earlier,
he was diagnosed as having bronchitis by his primary physician and was treated with amoxicillin / clavulanate 625 mg thrice daily and levofloxacin 500 mg twice daily. On presentation, he complained of shortness of breath, fever, and a worsening cough that was productive of blood-tinged sputum. Additional complaints included headache and pain abdomen. A chest roentgenogram in ER revealed bilateral basilar infiltrates. An arterial blood gas on room air revealed a PaO2 of 52 mm Hg with 88 percent saturation on 2L/min of oxygen. His white blood cell count was 9.5 x 107 lacs, with 55 percent neutrophils, 40 percent band forms, and 4 percent lymphocytes. He was admitted to the hospital with a diagnosis of severe community-acquired pneumonia. The patient’s medical history was unremarkable for any previ-
speciality
ous hospitalisations or chronic medical illnesses, including heart disease, asthma, or tuberculosis, though patient reported occasional bouts of cough and upper respiratory infections. He was a chronic beedi smoker, about 20 bidis / day, but denied any alcohol use. On admission, the patient was febrile with a temperature of 39°C, pulse rate of 80 beats per minute, blood pressure of 130/89, and respirations of 20 breaths per minute. The lung examination revealed left-sided creptitations with decreased basilar breath sounds. The cardiac examination was normal, with no murmur or rub and the GIT examination was negative for hepato-splenomegaly. Renal and neurological examinations were normal. Laboratory data revealed a Hb of 11.8 g/dL, a MCV of 76 fL, and platelet counts of 243 lacs/ cu mm. Electrolytes were within normal limits. An ECG showed sinus tachycardia. The patient was started on oxygen with 50 percent ventilation mask and given aero-
solised treatments with salbutamol every 6 hours. Empiric antibiotic therapy with IV cefuroxime sodium and Levofloxacin was instituted. About 24 hours later, patient complained of worsening shortness of breath and chest discomfort. An ABG revealed a Pa02 of 46 mmHg on oxygen of 6L/min so he was transferred to ICU and therapy with a 100 percent oxygen non-rebreather mask was started. The patient was oxygenated via nasal prongs and non-invasive ventilation [BIPAP] was initiated. Further history obtained from the patient’s wife revealed that patient had been regularly feeding his pet pigeons and parrots and since 3 months, and several of these had been ill and died. In light of this information, atypical pneumonia was suspected and intravenous clarithromycin 500 mg BD was added to the patient’s antibiotic regimen and levofloxacin was stopped. Serum samples for antibodies to C psittaci and C pneumonia, along with mycoplasma and legionella were obtained.
Sputum cultures were negative for acid fast bacilli, and antibodies for legionella and mycoplasma were negative. A subsequent white blood cell count was 6.8 x 107 lacs/cu mm. The patient continued to clinically improve and on the 8th day of hospitalisation, ELISA for chlamydial antibody was reported as positive at 0.99 (0.71 or greater indicated a high level of detectable antibody). Two days later, IgG antibody specific for C psittaci antibody was also reported positive at 1:128 (active infection indicated by a titer of 1:64 or greater). IgG antibody against C pneumoniae was positive at 1:64 (active infection indicated by a titer of 1:256 or greater). Intravenous clarithromycin was discontinued and the patient was placed on oral formulation. A third chest roentgenogram showed significant clearing of the bilateral pulmonary infiltrates. The patient was discharged on the 15th day after hospitalisation. At 1 week 1 month after discharge, the patient was well with no further pulmonary symptoms.
Malignant MCA Infarction MIOT Experience Dr Nisheeth T P, MD, DM Critical Care, MRCP (UK), EDIC, Chief Consultant Intensivist, Medical ICU-MIOT Hospitals
H
ere we present a case scenario which was managed in our institution recently. Mrs R aged 43 years not a known Diabetic or Hypertensive presented to MIOT with sudden onset of weakness of left upper limb and lower limbs since previous day evening. On arrival at MIOT she was hemodynamically stable with HR 84 mt and raised Blood Pressure 180/110. She was conscious but drowsy and found to have dense Hemiplegia on left side with power 0/5 and UMN facial palsy. She was diagnosed as having acute stroke and emergency CT brain showed massive middle cerebral artery
infarction – Malignant MCA infarction. She was shifted to the ICU for neuromonitoring and started on antiplatelets and supportive measures. The following day patient had a transient bradycardia, hypertension and unresponsiveness which got corrected after a mannitol infusion. She was electively ventilated and repeat Emergency CT scan showed worsening of edema – infarct with midline shift. She was taken up for emergency Decompressive Craniectomy which was uneventful and shifted back to our Neuro ICU. Gradually over a period of 2 -3 weeks patient stabilized, regained consciousness weaned
out of ventilator and Extubated. Her ICU stay was complicated by episode of MDR – Acinetobacter and Candiduria. A follow up Cerebral CT angio done had showed dissection of internal carotid artery with a partial thrombus. She does not give any history of trauma to neck. She was started on oral anticoagulants. Gradually the power of her left lower limb had improved to 3/5 and was able to communicate, take oral feeds and was mobilised out of ICU by 4 weeks. Decompressive surgery for malignant MCA infarction has increased over the past 5 years after the results of DESTINY, HAMLET, DECIMAL and their pooled analysis.
september / 2012 ehealth.eletsonline.com
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My Journey
Making of a Miracle Rajendra Pratap Gupta has devoted himself to creating a movement that leads to better health awareness amongst the masses. He is recognised amongst the 15 smartest thinkers in the world, and nominated to the World Economic Forum’s Global Agenda council. Currently he serves as the President of Disease Management Association of India. He was recently conferred as the ‘Global Healthcare Leader of the Year’ award by the Sheriff of Los Angeles, Lee Baca, and nominated to the Advisory Group / Technical resource group of Union Ministry of Health & Family Welfare , Government of India
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My Journey
W
ay back in 1995, my mother (she was a class I government employee) was suffering from T4 stage breast cancer. She was the sole earner for the family and I was pursuing my graduation aiming to be an IAS. Suddenly the doctor who was treating my mother informed me that, my mother would last for another six months and the treatment was really expensive. Since my mother was the only earning member and was on bed, we had to find ways to earn and treat her, so I decided to get into job. I am in healthcare by default and not by design. I applied in more than 70 companies and was finally selected by IMS Health as a research officer (lowest level job in the field cadre), but I was blessed with really good bosses, this further encouraged me to rise in the corporate world and in the 7th year of my job I was serving as COO of a MNC retail pharmacy chain. I spent the first 6 years in healthcare market research & consulting and worked for IMS Health & AC Nielsen - ORG MARG and launched new healthcare products and turned around Nepal operations for IMS. Later head Medicine Shoppe Inc – India, as Chief Operating Officer and Member of the board for five years, driving it to become the most successful pharmacy chain in a short span of time. After that I was in the core team of Reliance ADA group driving multiple initiatives in Health from retail, distribution to disease management. It has been quite an exciting time for me. For the past five years, I have been advising large listed corporations on healthcare and retail, and have been a coarchitect of the BOP healthcare model for one of the largest FMCG companies in the world. Besides, I had the unique opportunity to advice the governments across UAE and India on healthcare policy formation and implementation.
On Indian healthcare We are in the perfect situation when it comes to healthcare. It is a challenge to provide good healthcare to a nation of over 1.21 billion, but we can draw important lessons from USA and Europe. If we don’t become ‘populist’ in driving our
healthcare system, we would have lead the world by reinventing healthcare financing and delivery, and set an example for the world to follow or else our economy will suffer terribly due to wrong healthcare policies. We need to be careful about certain things, but we also need to act fast. The right time is NOW. We need to ensure that we don’t make
healthcare free for all, as this is a sure shot formula for failure. Quality healthcare can only come when people are paying for the services that they get. We need to focus on leveraging technology for healthcare, set the right standards and treatment protocols and guidelines, focus on human resource development, invest in rural health and have provision
I am in healthcare by default and not by design. I applied in more than 70 companies and was finally selected by IMS Health as a research officer, but was blessed and in the 7th year of my job I was serving as the COO of a retail pharmacy chain
for sharing the healthcare expenses between centre and states. Above all, we need to move into asset light healthcare models, where the focus is on point of care diagnostics and mHealth. Public hospitals still continue to be the first choice for 75 percent of the population which cannot afford ‘corporatised healthcare’. The fact is that the public hospitals still have some of the best doctors. Government must provide these public hospitals with the latest of technology, training and work environment. For some non-core departments at government hospitals, there can be PPP models. There is a lot that can be done. The government has to move from being a payer, provider and regulator of care to being a part payer and a regulator (except for the BPL population). Over the past 60 years, government continued to be a provider, payer and a regulator and the healthcare delivery system has failed miserably. Time has come to re-look at the september/ july / 2012 ehealth.eletsonline.com www.ehealthonline.org
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My Journey
role that the government plays in healthcare and the way it looks at the private sector.
My thoughts on healthcare model
Up, close & personal birth 5th Jan 1972 ANNIVERSARY 19th May ACHIEVEMENT Yet to come! SUCCESS MANTRA Be clear of your goal, be truthful, don’t take to short cuts, don’t worry about obstacles and never give up Purpose In Life I have been very - very lucky. When my mother died, we had no money to do her last rites, and today I have everything I can dream of. Time has come to work for the poorest of poor and make their lives better in terms of healthcare, education and opportunity for progress and that is the purpose in life
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I was an active team member of the core PPP committee on healthcare that wrote the PPP blue print, and that report was accepted by the planning commission. But with the current mindset of the government PPPs would never work. Citing an example; on 24th August 2011, the Union Health Minister made a public announcement that the ministry would screen 200 million people for diabetes by March 2012, and the fact is that only 56 lakh people were screened! Imagine if the government gave out 10-15 percent of the money allocated for mass screenings to private sector and evaluated the outcomes? For sure, we would not have such a shameful failure! Time has come when the government must accept a fact that it has failed to deliver basic healthcare for more than six decades, and if private sector can deliver, let them make profits as long as they deliver care within the agreed framework . When the bureaucrats and ministers need bribe to allot contracts in the government, why can the industry not earn profits in a transparent manner by delivering healthcare in an ethical manner? It is time to get realistic and remove the taboo from the word ‘Profit’ then only PPPs can work. I have been active in the healthcare space for nearly two decades, and in 2007, I was delivering a lecture in the US, when the CEO of a healthcare organisation came forward and asked me to form an organisation that was just dedicated to healthcare in India. After coming back to India I had discussions on the India healthcare and I felt that there was a huge gap in the thought leadership and thus DMAI - the population health improvement alliance was formed in 2009 to provide high level thought leadership for healthcare in India. Since then, DMAI has been at the forefront of driving healthcare reforms. Most of our recommendations have been accepted by the government at the centre and also by the states. We
We need to focus on leveraging technology for healthcare, set the right standards, treatment protocols and guidelines. We must also focus on human resource development while investing in rural health
continue to be invited by the government bodies in India and global bodies like the United Nations for various discussions on healthcare policy and implementation. I have been associated with eHealth for over 5 years, and eHealth has come a long way since then to find presence amongst the best healthcare magazines in South Asia today . I have been a regular reader of this magazine and have also authored articles for this magazine. Besides, I have spoken at eHealth summits in Kuala Lumpur and India and have enjoyed the quality of discussions and the participative industry leadership in the audience. I cherish my association with eHealth and look forward to participating in the next summit in November at Hyderabad. My best wishes to Team eHealth to work harder to become the leading voice of healthcare in South Asia and become the no.1 magazine in the region, in the times ahead.
4TH Healthcare Technology Resource Guide 2012, October
october 2012
eHEALTH, Asia’s first monthly magazine on the enterprise of healthcare, is pleased to announce its Annual Healthcare Technology Resource Guide special edition in the month of October, 2012. Being the ‘only one–of–its–kind’ for the Indian market, this annual issue is a comprehensive compilation and showcase of latest products and solutions in Healthcare IT & Medical Technology space, helping healthcare delivers to keep abreast about latest technologies, while facilitating their purchase decisions and planning.
Key Features of Listing in Annual Resource of Guide • Brand Profile: Detailed company profile of all advertisers (one page complimentary company profile with every full: page commercial advertisement) • Listing: Alphabetical wise listing of vendors/solution providers with company name and contact details
Highlights • • • • •
One year shelf life Wider reach among key decision makers Strong brand presence and strategic positioning Maximum return on investment Expected number of copies to be published: 50,000
There are three types of listings in the Annual Resource Guide • Basic: The product wise listing includes contact details of the company. • Advanced: The company contact details will be highlighted in a box with company logo. • Premium: The Premium segment will include brand profile of the company with advertisement. Detailed company profile includes photograph of the representative, company logo, products and services, USP, target verticals, achievements, key people in the company, sales and after sales support details, and much else For editorial queries, contact: Shally Makin, shally@elets.in, +91 8527697687 For advertising queries, contact: Divya Chawla, divya@elets.in; +91 8860651643
ehealth.eletsonline.com
news
MEDICALL 2012 Chennai Witnessed an Overwhelmed Response
Medicall has organised a four daylong event at Chennai. The event was able to attract large number of visitors and manufacturers. For the first time in India, MEDICALL organized a Fashion Show on Hospital Garments in cooperation with NID – National
Institute of Design, Ahmedabad. This Fashion Show on Hospital Garments was a huge success and was very well received by the industry. Being held in Chennai for the 9thtime, MEDICALL had 500 medical equipment manufacturers from India, Czech Republic, Germany, Taiwan, Korea, Singapore, China, Italy etc. A wide range of medical equipment and technology product was displayed to over 8500 serious business visitors from all over India, South Africa, Nigeria, Srilanka. Medicall offered four days of focused business platform to explore business opportunities to an exclusive B2B audience. The visitors were the doctors, Medical administrators, Procurement department of the hospital, Nursing homes, Biomedical engineers, HOD’s of the Hospital, Trade dealers and distributors etc. Healthcare professionals benefitted from the show as they could find the entire range of medical equipment and technology under one roof. Some hospitals even placed firm orders at MEDICALL 2012 with Indian Medical Manufacturers.
New Sensor Traces Glucose in Saliva, Tears of Diabetics A new type of bio-sensor can detect minute traces of glucose in saliva, tears and urine, doing away with pinpricks for diabetes testing. “It’s an inherently non-invasive way to estimate glucose content in the body,” said Jonathan Claussen, former Purdue University doctoral student and now a research scientist at the US Naval Research Lab.“Because it can detect glucose in the saliva and tears, it is a platform that might eventually help to eliminate or reduce the frequency of using pinpricks for diabetes testing,” said Claussen, the journal Advanced Functional Materials reports.“Most sensors typically measure glucose in blood,” Claussen said. “Many in the literature aren’t able to detect glucose in tears and the saliva. What’s unique is that we can sense in all four different human serums: the saliva, blood, tears and urine. And that hasn’t been shown before.” Besides diabetes testing, the technology might be used for sensing a variety of chemical compounds to test for other medical conditions. The technology is able to detect glucose in concentrations as low as 0.3 micromolar, far more sensitive than other electrochemical biosensors based on graphene or graphite, carbon nanotubes and metallic nanoparticles, Claussen said.
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IAN & India Innovation Fund Co-invest in Consure Medical, a Medical Devices Startup Indian Angel Network (IAN) and India Innovation Fund announced today an undisclosed investment in Consure Medical; a Delhi based company which has developed a new standard of care for the management of fecal incontinence in non-ambulatory patients. The Series A round was led by India Innovation Fund and Hemant Kanakia of Indian Angel Network. Other prominent co-investors in the round include India Venture Partners, Shrikumar Suryanarayan and Saurabh Srivatsava. Consure Medical was co-founded in 2011 by Nishith Chasmawala and Amit Sharma. Prior to Consure, the duo have commercialised seven products for the US, EU and Japanese markets and have crossfunctional leadership experiences from Cordis Corp. (J&J), Kyphon, Inc. (acquired by Medtronic) and Vascutech, Inc. Consure Medical has developed a disruptive technology that will benefit more than 16 million patients in India and over 100 million patients worldwide. The company competes in the $7 Billion fecal incontinence market with a differentiated product that has patent protection in all key geographies. The company will use the investment to complete product development, execute their clinical & regular strategy, and commercialise its proprietary technology.
news
Portronics Launches Fitness Health Key – 3D Digital Pedometer Portronics, provider of innovative portable and digital devices introduces its new portable device called, the Health Key, a digital pedometer. It is one of the world’s advanced 3D pedometers. The H-key Digital Pedometer utilises latest generation 3D Technology which allows it to provide superior accuracy in any functional position, unlike other similar products that works accurately only if vertically placed. The H-key Digital Pedometer gives accurate readings whether it’s up, down or flat, on its side or at any angle. The Health Key Digital Pedometer utilises a Digital 3D Acceleration Sensor which is more accurate than mechanical sensors used in other pedometers. The H-key Digital Pedometer helps you to record your steps, distance, average speed, calories burned and time spent exercising. The data is displayed on a new bright LCD screen with a dual row display. The Health Key Motion Digital Pedometer filters out vibrations and only begins counting after it detects a sequence of continuous steps for greater accuracy. It runs on Coin Batteries and comes with a bonus strap and an instruction manual.
Gujarat Attracts Global Healthcare Brands Gujarat perhaps going to be the next hub of Indian healthcare enterprise. After Vicks and Colgate Palmolive, US-based Abbott Laboratories plan to set up a manufacturing unit in Gujarat to produce its nutraceutical range-Ensure and PediaSure at Jhagadia. Abbott has acquired 45 acres of land for the plant, which will be its second unit in India. It will be set up with an initial investment of Rs 360 crore.Several leading global pharma and FMCG companies are eyeing the state for greenfield projects. Israel’s Teva Pharmaceutical Industries along with the USbased Procter & Gamble is setting up a Rs 500 crore plant to manufacture its Vicks range of products in Sanand.
Scotland-based pharma and lifesciences companies are also eyeing Gujarat for an entry into the Indian market. Mark Dolan, country manager, Scottish Development International attributes the trend to the quick materialisation of discussions. “Gujarati and Scottish businesses hold many common values and attitudes. Every opportunity to meet and discuss business is maximised with discussion quickly getting down to detail.” Dolan met a couple of pharmaceutical and lifesciences companies in Ahmedabad in the first week of August to explore business opportunities. september / 2012 ehealth.eletsonline.com
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Dräger Opens Design Center in India In the new Dräger Design Center in Mumbai, India, users and planners can work together with Dräger experts to plan and design their medical workplaces under realistic conditions. Located in the Goldline Business Center in Malad (West) in Mumbai, India, the 290 square meters showroom is the ideal setting for medical users, planners and architects to experience cuttingedge Dräger medical technology in real-life setting. “The opening of our newest design center and showroom marks an open invitation for our customers to come and experience this functional space where we have recreated acute care areas” explains Michael Karsta, President of the region Middle East/Africa. Visitors of the “hospital area” can experience their workplace before it is actually set up. The visitors of the Design Center can trace a patient’s progress through the stages of transport ventilation, resuscitation, induction, surgery, post-operative, recovery and intensive care. This gives visitors first-hand experience with various Dräger devices in action, such as anaesthesia workstations (e.g. Fabius Plus, Primus) as well as ICU ventilation, respiratory monitoring or ceiling supply units. “In addition to the devices, we also showcase other solutions along the clinical pathway, such as a modular operation room”, explains Nikil Rao, General Manager of the medical division in India. Using a 3D computer application, the desired configuration can then be created as
Alzheimer’s Affects Women More Quickly
A study reveals men can stave off the effects of Alzheimer’s for longer than women, whose condition deteriorate faster when affected by the disease. The study found that women suffering from Alzheimer’s deteriorate faster than men, even when both are apparently at the same stage of the disease. The findings suggest that women sufferers show greater loss of their
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mental faculties than men, whose brains are better at coping with the ravages of the disease. The stage of progression of Alzheimer’s is measured using general tests, such as those based on behavior, the ‘Daily Mail’ reported. More detailed tests, such as verbal skills tests, on sufferers who were at an apparently equal stage of the disease suggested men have an advantage in coping with its effects. A man with Alzheimer’s consistently outperformed women sufferers in detailed tests of memory and even verbal ability, where healthy women normally have the advantage.
a virtual working environment and can be documented. This results in a customized solution that is tailored to the client’s precise specifications, without the need for costly modifications after installation. The design center offers a training room to accommodate 22 people and an additional meeting facility for 8 people. The market for medical technology in India is rapidly expanding. The medical technology industry is expected to grow from USD 2.75 Billion in 2008 to USD 14.0 Billion in 2020. This growth is fuelled mainly by demand from major cities.
Study Says 206 Million Indians Use Smokeless Tobacco Having nearly 275 million tobacco users, India ranks second globally and very close to China (approximately 301 million users). But unlike China, where nearly all are smokers and nearly 95 per cent smoke manufactured cigarettes, India accounts for more of smokeless tobacco users — 206 million, says a study in The Lancet. The study analysed the data from the Global Adult Tobacco Survey (GATS) conducted between October 2008 and March 2010. The data from 14 low and middle-income countries that “collectively contribute to most of the disease burden attributable to tobacco use” was compared with that of the U.K and the U.S. The number of people surveyed was different in the case of each country. India had the highest number surveyed, both of men and women. Chewing tobacco accounted for almost all of the smokeless tobacco consumption in India. “Various forms of loose-leaf chewed tobacco are commonly consumed in the Indian subcontinent,” states the paper. “Smokeless tobacco use is particularly prevalent in India, Bangladesh, and in Thai women.” In the case of India, 23 per cent of men were smokers during 2008-2010. This is comparable with the percentage seen in the U.S. and slightly higher than the U.K figure.
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