eHEALTH Magazine
Strengthening India’s Healthcare System Public and private sector initiatives in building a better model for healthcare
Manikandan Bala, Managing Director, Elekta Medical Systems India Private Limited Richard Guest, CEO, Siemens Healthcare, South Asia
Naveen Jain, Mission Director & Special Secretary, National Health Mission, Department of Medical, Health & Family Welfare, Government of Rajasthan
Dr K V Raman, Director, Department of Health & Family Welfare Services, Government of Puducherry
Raveendran Gandhi, Senior Director – Radiology, Philips Healthcare
Molecular Diagnostics | CT Scanners | Radiation Oncology Equpiment
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Contents
JUNE 2015 | VOLUME - 10 | ISSUE - 06
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Cover Story - Molecular Diagnostics
Splitting Molecules, Easing Diagnostics
The emergence and growth of personalised and pharmacogenomic medicine is providing tremendous revenue opportunities for molecular diagnostics industry
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Focus - CT scanners
From Beatlemania to Manic Slice Wars The government’s desire to increase the reach through PPP models and make primary care available in remote areas will give impetus to growth
EXCLUSIVE INTERVIEWS 20
AshaSoft Raises Hopes in Healthcare Naveen Jain, Mission Director & Special Secretary, National Health Mission, Department of Medical, Health & Family Welfare, Government of Rajasthan
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NHM Streamlines Health Services in Puducherry Dr K V Raman, Director, Department of Health & Family Welfare Services, Government of Puducherry
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Benzodiazepines Beta-2 Microglobulin Bile Acids Bilirubin (Direct & Total) Calcium Canine CRP Cannabinoids Carbamazepine Ceruloplasmin Chloride (Non-Direct) Cholesterol Cholinesterase Cholinesterase (Butyryl) CK-MB CK-NAC CO2 Total Cocaine metabolite Complement Component 3 Complement Component 4 Copper Creatinine (Jaffe) Creatinine Enzymatic CRP
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EXCLUSIVE INTERVIEWS
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Advanced Technology: The Winning Leap
Manikandan Bala, Managing Director, Elekta Medical Systems India Private Limited
VIEWPOINT
36
The Great Indian Standardisation Drive
There are interesting times for India’s eGovernance, in general, and the country’s eHealth, in particular
FEATURE
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Radiotherapy – The Future is Here
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eAushadhi – Setting Benchmarks in Drug Supply Chain Management INDUSTRY SPEAK
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The Changing Landscape of MDx
Nitin Sawant, General Manager, Diagnostic, Trivitron Healthcare Private Limited
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Simplicity and Speed - Need of the Hour
Dr Rajas Warke, R&D Director – Molecular Biology and Virology, HiMedia Laboratories Private Limited
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Empowering the Patient Revolution
Richard Guest, CEO, Siemens Healthcare, South Asia
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Moving towards Low Dose CT Scans
Raveendran Gandhi, Senior Director – Radiology, Philips
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Technological Advancements in Radiation Protection
Satyaki Banerjee, Director – International Operations, Trivitron Healthcare Group of Companies
SECOND OPINION
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How CT Scanners Continue to Revolutionise Healthcare
Dr Avik Bhattacharyya, Consultant Interventional Radiology, CK Birla Hospitals
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JUNE / 2015 RAVEENDRAN 8 ehealth.eletsonline.com GANDHI
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Improving Diagnostic Capabilities
Dr Ajay Aggarwal, Director, RadioDiagnosis, Saket City Hospital
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Technological Advancements
Dr Sona Pungavkar, Consultant, MRI Centres, Global Hospitals
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Towards Personalised Medicine & Targeted Therapy
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RICHARD GUEST
Dr Kirti Chadha, Divisional Head Oncology Group and Surgical Pathology, Metropolis Healthcare Limited
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Advances in Cancer-Bone Marrow Transplant
Dr Niranjan N Rathod, Head of Department of Haematology & Bone Marrow Transplantation, Global Hospital – Super Speciality & Transplant Centre
PRODUCT LAUNCH
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Clearvue Elite – New Affordable Ultrasound Solution from Philips
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HPC Novel Parameter in Hematology Analyser PRODUCT SHOWCASE
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Carestream Health India Pvt. Ltd. and Appex Medical Corp India Pvt. Ltd. NEWS
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Healthcare Start-ups Government Desk International News Company News Hospital News Pharma Buzz
editorial
Balancing Act First anniversary of the new government has been a mixed bag for the health sector in the country. Besides cutting down budgetary support for National Health Mission (NHM) and AIDS control, as many as 15 centrally-funded schemes have not been allocated any separate funds for fiscal 2015-2016. To make matters even tough, the health ministry has been informed that all these 15 schemes will now be part of NHM. It is an ironical and a difficult scenario for the health sector in the country as the budget for NHM itself has been slashed and it is difficult to understand how NHM is going to accommodate more schemes. Also, NHM was set up with a specific mandate of improving primary and secondary healthcare and merging of tertiary care schemes could hamper the money flow to these schemes at the cost of primary and secondary care components. With reduced funding, securing universal access to healthcare for all seems to be a distant dream for most Indians. While public health may be in a dilapidated state, the healthcare industry is trying to keep pace with global changes and also trying to grab a share of the world health pie. Our cover story on molecular diagnostics, that offers the power of advanced analytical techniques to diagnose infectious diseases, explores how the emergence and growth of personalised and pharmacogenomic medicine is providing tremendous revenue opportunities for molecular diagnostics industry. According to global researches, India and China are slated to be two of the most lucrative markets to rollout the diagnostics business. Our other story on the CT scanner market explores how rapidly changing and continuous upgrading of CT technology is one of the major contributors to the growth of medical imaging industry in India. The government’s desire to increase the reach through PPP models and make primary care available in remote areas will further give impetus to growth of the CT scanner industry. The story is also accompanied with viewpoints of the major players of the industry sharing their ideas and their future plans for the growth of their business plans and technological advancements. Continuing with our initiative to encourage entrepreneurship in the healthcare sector that can open up further investment opportunities, we have again profiled two interesting start-ups. One looks at a medical networking mobile application that creates a network between doctors across the country while the other facilitates and compliments healthcare at home. The information laden edition also looks at the eAushadhi scheme in Maharashtra and how the Maharashtra Public Health Department is changing the rules of performance in its drug inventory and supply management. Hope you enjoy reading the edition.
Dr Ravi Gupta ravi.gupta@elets.in JUNE / 2015 ehealth.eletsonline.com
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Cover Story
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Cover Story
Splitting Molecules, Easing Diagnostics A
The emergence and growth of personalised and pharmacogenomic medicine is providing tremendous revenue opportunities for molecular diagnostics industry, writes Anshuman Ojha of Elets News Network (ENN)
dvancing technologies are pushing the diagnostics industry to the fore, and the molecular diagnostics (MDx) industry in particular is emerging as a powerful healthcare player with tremendous potential. MDx are a class of in vitro diagnostic (IVD) tests that identify nucleic acids, such as DNA. Molecular diagnostic tests may identify nucleic acids that are the genetic material of foreign organisms or the genetic markers of an individual patient. New genes and biomarkers are continually being identified and clinically validated, increasing the number of different tests available. The requisite technology and instruments are advancing in tandem. Molecular diagnostic tests continue to be the fastest growing segment within the IVD space, driven by high sensitivity, fast turnaround time, easy workflow and relatively low-cost compared to other techniques. While many companies offer tests that detect only one or a few genetic changes, some companies have now developed tests capable of detecting large numbers of these changes. Many companies are taking their tests through the traditional diagnostics market strategy
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Cover Story
of gaining FDA clearance, while others have chosen a different strategy and are offering tests through their own CLIA-certified laboratories. These and other dynamics are effecting rapid change in this evolving field.
Market Dynamics
The global molecular diagnostics analysers and reagents market is witnessing a period of profound growth. The growth is coming from different regions and markets. The various application and technological sub-segments of molecular diagnostics are also giving the market a big push. The increase in the ageing population and incidences of various chronic diseases are driving the demand of molecular diagnostics world over. The industry is getting a push from every side and many factors collectively are fuelling the growth in this industry. Molecular diagnostics is a vital and dynamic field in which yesterday’s new technologies and platforms are today becoming populated with novel, diverse, and useful content. According to a report published by Transparency Market Research, the global molecular diagnostics analysers and reagents market is anticipated to expand at a CAGR of 11.1 per cent during the period from 2013 to 2019 to reach a value of US$ 8.7 billion by the end of the forecast period. Reagents occupy the largest market share and will also register the maximum growth rate in the forecasted period 2013-2019. These reagents include assays that detect and diagnose diseases and are also used as biomarkers that predict the biological properties of the potential drug compounds. Based on end users, hospitals was the largest segment in 2014, whereas reference laboratories will grow at the highest CAGR between 2013 and 2019. Reference laboratories carry out complex, specialised, and obscure
The government regulations to cut down healthcare costs will lead to the rise in the reference laboratories segment tests. The government regulations to cut down healthcare costs will lead to the rise in the reference laboratories segment. Therefore, reference laboratories are estimated to grow at highest CAGR. The infectious diseases market segment dominates the global molecular diagnostics market based on application, holding 60 per cent of the overall market. The market for genomics and for blood donor screening jointly hold the remaining portion of the industry. The rising prevalence of hospital acquired infections (HAI) has stimulated the market for molecular diagnosis in the field of infectious diseases, resulting in the rise of the HAI testing market within the segment. This market is expected to grow at a CAGR of 15.1 per cent during the forecast period. Additionally, the rise in the incidence of cervical cancer caused by human papilloma virus (HPV) is giving rise to HPV testing, supporting the infectious diseases market segment. The HPV testing market is expected to develop at a CAGR of 14.8 per cent between 2013 and 2019. Furthermore, the markets for HLA typing testing and oncology testing within the genomics segment are also anticipated to register a rapid growth rate during the forecast period. The future growth is expected to come from genetic testing, blood screening testing and neurological testing.
Market Share
Geographically, the United States and EMEA (Europe, Middle East and Africa) markets are the most Global Molecular Diagnostics Market, by Technology, 2014 (US$ Million) advanced in terms of 4,973 adoption of molecular testing and make up the majority of the existing market. However, Japanese molecular diagnostics market is promising with the ageing population and a declining birth rate is putting the whole Japanese healthcare system under Total PCR Transcription Hybridization NextMicroarray Others Mediated Techniques generation pressure. Under such Amplification Sequencing circumstances, the role (TMA) of preventive medical
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Cover Story
care is increasingly important. China and India molecular diagnostics market is one of the lucrative markets to rollout the diagnosis business. Rapid economic advancement of China and India has led to an increase in the purchasing power of a growing segment of the populace. This coupled with an emerging mindset toward wellness, preventive medicine, and access to cutting-edge products and services and makes the future outlook extremely positive for this new field in clinical care. The provision of new and cutting-edge molecular tests is likely to be followed by greater affordability with prices coming down due to return on investment, competition, and technology advancement. The technologies that constitute molecular diagnostics--like first-generation amplification, DNA probes, fluorescent in situ hybridization (FISH), secondgeneration biochips and micro-fluidics, next-generation signal detection, biosensors, and molecular labels are influencing the discovery of therapeutic molecules, the screening and diagnosis of patients, and the optimisation of drug therapy.
Molecular Diagnostics Testing Next Level
In the current medical diagnostics market, molecular diagnostics in infectious disease testing offers one of the most promising areas for growth and innovation. The confluence of breakthroughs in genomics and proteomics--along with the development of microarray devices to measure analytes in the blood--has led to this revolutionary market development. Specifically, molecular diagnostics offers the power of advanced analytical techniques to diagnose infectious diseases. Whereas before, the detection of many infectious agents was slow and expensive due to reliance upon culturing methods, researchers are now at the cusp of overcoming such
The infectious diseases market segment dominates the global MDx market, holding 60 per cent of the overall market
• • • • • • • • • • • •
Clostridium Difficile (C-diff) Methicillin-resistant Staphylococcus Aureus (MRSA) Respiratory Syncytial Virus Influenza Pneumonia Trichomonas Vaginalis Genital Mycoplasma Herpes Simplex Virus Norovirus Rotavirus Tuberculosis Meningitis Clostridium Difficile and MRSA, two tests for healthcare-associated infections (HAI), have seen the highest level of adoption. In the U.S. alone, direct medical costs attributed to HAIs total as much as US $34 billion. This creates the incentive for providers to use molecular diagnostic-based screens for risk mitigation. Approximately 800 medical laboratories—600 hospital and 200 independent—now perform high-volume testing requiring automated molecular diagnostic testing
Major Players
Nine companies control more than 75 per cent of the global molecular diagnostics market including: • Roche Diagnostics • Qiagen NV • Gen-Probe Incorporated • Abbott Diagnostics • Siemens • Becton Dickinson • Cepheid • bioMérieux • Beckman Coulter Roche tops the list of large molecular diagnostics companies with an extensive product portfolio including molecular diagnostic tests for oncology, virology, microbiology, and blood screening.
limitations via the use of nucleic acid-mediated molecular diagnostics testing. New molecular diagnostic tests are regularly introduced to the market for screening or diagnosing a wide range of patient types for numerous diseases. Manufacturers are rapidly introducing molecular diagnostic tests for additional types of infectious disease. Following is a list of such tests that are relatively new to the market: • West Nile Virus
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Cover Story
platforms and systems for simplifying and accelerating specimen preparation. The rapidly changing and increasingly competitive landscape of diagnostics continues to stimulate increased demand for molecular testing, particularly in the area of infectious disease. Consequently, accelerating advances in technology and genetic and proteomic research are sure to reveal new and untapped opportunities in molecular diagnostic testing.
Acquisitions and Joint Ventures
When collaboration is not possible or not desired by both parties, an outright buy is often the preferred tactic. A dynamic market also encourages players to bolster their offerings with acquisitions, collaborations, and licensing agreements. The following deals in molecular diagnostics are of particular interest, though scores of mergers have occurred in the past year. Roche and Signature Diagnostics: Roche has acquired Signature Diagnostics for an undisclosed price. The deal is designed to strengthen Roche’s cancer diagnostics effort with Signature’s expertise in both biobanks and next-generation sequencing (NGS) assays, and is the pharma giant’s fifth deal in less than a year focused on molecular diagnostics and data analysis. Signature will be integrated into Roche’s Sequencing Unit and will continue to focus on expanding its genomic signature portfolio. And in April 2014, Roche snapped up IQuum for US$ 275 million upfront and up to US$ 175 million in product-related milestones, with the intent of strengthening its offerings in molecular diagnostics. Qiagen Netherlands and CLC bio: Last year, Qiagen purchased CLC bio, which specializes in bioinformatics analysis software. CLC bio’s primary products are CLC Genomics Workbench, which it describes as a comprehensive and user-friendly analysis package for analysing, comparing, and visualizing next-generation sequencing (NGS) data, and CLC Genomics Server, a flexible enterprise-level infrastructure and analysis backbone for NGS data analysis. CLC bio provides bioinformatics solutions for NGS, which can analyse and visualise genomic, transcriptomic, and epigenomic data from all major NGS platforms. More importantly, CLC’s IT solutions allow nonprogrammers to build resequencing workflows through a graphical user-interface, allowing biologists, clinicians, and other scientists to intuitively build workflows and visualise their datasets through all stages of the analysis at their desks.
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PDI, Inc. and RedPath Integrated Pathology: PDI, Inc., a leading healthcare commercialisation company, acquired RedPath Integrated Pathology, a molecular diagnostics company helping physicians better manage patients at risk for certain types of gastrointestinal cancers through its proprietary PathFinderTG platform. PDI acquired all of the outstanding shares of RedPath. The PathFinderTG testing platform has tremendous untapped potential to deliver a much-needed improvement in diagnostic options for oncologists, gastroenterologists, pathologists and patients – particularly in pancreatic cancer and other gastrointestinal-related cancers. Leica Biosystems and Kreatech Diagnostics: Leica Biosystems, which focuses on workflow solutions and automation for cancer diagnostics, added a maker of DNA fluorescent in-situ hybridization (FISH) probes to its portfolio with its 2013 acquisition of molecular diagnostics company Kreatech Diagnostics. The acquisition, according to Leica, will help support future development of personalized medicine by research and drug-development companies. A provider of probes and target labeling reagents for microarrays, Kreatech will be tasked with developing targeted biomarker menus for Leica’s instrument platforms. bioMérieux and BioFire Diagnostics: French diagnostics powerhouse bioMérieux acquired privately held U.S. molecular diagnostics company BioFire Diagnostics Inc. last September for US $450 million. Specialising in molecular diagnostics, BioFire is the inventor, manufacturer, and marketer of the multiplex PCR FilmArray system, a simple and rapid molecular biology solution designed for the diagnosis of infectious diseases.
Cover Story
Illumina and Advanced Liquid Logic: Last July, Illumina acquired Advanced Liquid Logic (ALL), a provider of liquid-handling solutions. ALL has developed a proprietary, electrowetting-based digital microfluidics technology that performs complex laboratory protocols by manipulating small droplets within a sealed disposable cartridge. Illumina hopes that this technology will enable the delivery of the simplest and most efficient sample-toanswer NGS workflow. Exosome Diagnostics and Eli Lilly: Exosome Diagnostics, a developer of biofluid-based molecular diagnostics tests, announced last September that it had entered into a collaboration agreement with drug giant Eli Lilly and Co. Centered on cancer PGx biomarker discovery and validation using Exosome Diagnostic’s proprietary EXO50 nucleic acid extraction kit, the arrangement allows Lilly to gain early access to Exosome Diagnostics’ technology in order to aid in the identification of key gene mutations and expression levels in blood that may be correlated with drug response and disease recurrence. Illumina and Global Genomics Group (G3): Sequencing and array technology specialist Illumina entered into a partnership last year with life sciences company G3 with the objective of “investigating novel biomarkers and biological pathways involved in the development and diagnosis of cardiovascular diseases.” The agreement states that Illumina will perform whole genome sequencing for the ongoing Genetic LOci and the Burden of Atherosclerotic Lesions (GLOBAL) clinical study, a large, prospective, international effort focusing on cardiovascular disease biomarkers and drug target discovery that organizers say has the potential to transform how clinicians look at heart disease. Life Technologies/Thermo Fisher Scientific US and Merck Serono: Last July, pharmaceutical company Merck Serono entered into a collaboration with biotechfocused Life Technologies—which has since been acquired by Thermo Fisher Scientific—to create new companion diagnostic products. “The nonexclusive agreement covers current and future companion diagnostics projects, with an initial oncology scheme providing the foundation for a long-term collaboration across a potentially broad range of Life [Technologies’] instrument platforms and therapeutic areas,” according to the press release. These partnerships and acquisitions, in each case, illustrate the trend of IVD companies looking to expand
Direct medical costs attributed to hospital acquired infections total as much as US $34 billion their footprint by obtaining access to technologies and capabilities they presently do not have in-house. No let down in such collaborations and acquisitions is anticipated any time soon. According to Kalorama Information, one can expect to soon see a steady stream of molecular tests and technologies come to market. Molecular testing has proven its worth in the area of infectious diseases, but the great promise of personalised medicine in oncology and some chronic diseases has yet to come to fruition. Throughout the developed world, healthcare payers have looked at these tests with great scrutiny and are cutting reimbursement rates. This tenuous environment will continue for the foreseeable future as companies learn to promote the value of their tests for improved patient care that will save the healthcare system money. Rapid growth of genomics knowledge and technology is expected to continue, and with it more life-saving applications in medical science. While analytical instrument companies will remain at the forefront of developing new technologies for scientific applications, commercialising the technologies for clinical diagnostics applications will require an increasingly complex commercial infrastructure.
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Industry Speak
The Changing Landscape of MDx A genetic screening test is a promising area for future expansion of in vitro molecular diagnostic market, says Nitin Sawant, General Manager Diagnostic, Trivitron Healthcare Pvt. Ltd. How do you perceive the Indian Molecular Diagnostics market? What are the drivers that are influencing this segment in India? Molecular diagnostics (MDx) is the fastest-growing segment of the
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Indian in vitro diagnostics industry. The interest in molecular diagnostics has been boosted by the current fears of emerging infectious diseases, and the genes and molecular markers derived by genomics and proteomics. Initial applications of molecular diagnostics were mostly for infections but are now increasing in the areas of genetic disorders, preimplantation screening and cancer. Detection of specific chromosomal translocations has both diagnostic and prognostic value in a variety of childhood cancers. A genetic screening test is a promising area for future expansion of in vitro molecular diagnostic market. Molecular diagnostics is being combined with therapeutics and forms an important component of integrated healthcare. Molecular diagnostic technologies are also involved
in development of personalised medicine based on pharmacogenetics and pharmacogenomics. Blood banking has been the most dynamic testing segment to adopt molecular diagnostics approaches since their introduction. Screening for HIV, HCV and HBV in donated blood, plasma and organs has largely been done by immunoassay procedures. In conjunction with background screening, this has become a very effective approach toward guaranteeing the safety of the blood/organ supply.
What types of Molecular Diagnostics instruments are growing or declining? Recently the Real time PCR technology and instruments are becoming popular because of its ease of use, fast turnaround time,
Industry Speak
sensitivity and specificity. This technology gives qualitative and quantitative results in less than four hours. This helps the physician in patient management and disease monitoring and saves the expenses of patients on treatment, which may be very expensive like the antiviral therapy for AIDS.
What is the brand loyalty of current Molecular Diagnostics instruments users? Considering the importance of molecular diagnostics many authorized international organisations like WHO, NIBSC, CDC are working towards the universal standardization of kits and instruments used for molecular diagnostics, units used for reporting and guidelines for patient therapy. For molecular diagnostics, it is very important to use the instruments and kits, which are licensed, have the traceability and are validated as per WHO criteria and or as per the IVDD guidelines for CE mark or FDA approved. These kits eliminate the possibilities of false results and thus will make molecular diagnostics acceptable and affordable in India.
Please comment on emerging trends and new technologies. Molecular diagnostic methods typically involve probing a sample directly or following an amplification step (as with polymerase chain reaction tests). PCR and variations of this method have become increasingly popular for clinical diagnosis. Nucleic acid primers bounding genetic regions that are unique to the pathogens are used to amplify DNA or RNA sequences within the organism, bypassing the need for the isolation of a pathogen in culture.
Currently the PCR and Real Time PCR is the most popular technology used in India. Other technologies include NASBA, TMA, bDNA and Hybrid Capture. Multiplex PCR is widely accepted.
What factors will impact the future outlook for Molecular Diagnostics over the next five years? India ranks second largest in the number of people living with HIV. Most of the deaths can be prevented with antiretroviral therapy. WHO has also set a target of providing antiretroviral therapy to three million people in developing countries. Molecular diagnostics plays a critical role in diagnosing HIV infection and AIDS management. Tuberculosis is also a major problem in India. More than 10 per cent of patients develop active disease. Drug resistance strains are now found in newly diagnosed, treatment na誰ve patients. Percentage of multi-drug resistant cases is increasing. MDR TB is 100 fold more expensive to treat than the cases of susceptible TB. HIV/TB coinfection is increasing. Prevalence of infections of HBV, HCV, CMV, HPV, leptospira, dengue, malaria, influenza etc is also high. These infections change the social, moral, economic and health status in a short span. Use of sensitive, specific and rapid
technologies is essential for early diagnosis and treatment of these infections, but this important aspect is neglected in India. Many laboratories are still using conventional serological methods. Opposed to serological methods Molecular diagnostics allows a direct verification of the presence of viruses, bacteria and parasites in a wide range of sample materials in very short time. Hence, false negative results due to the absence of specific antibodies during so called window periods are considerably reduced. Molecular diagnostics plays important role in detection of these infections and also in monitoring patient for the effectiveness of antiviral therapy using viral load. The diagnosis of infectious diseases is one of the main applications of molecular diagnostics in clinical testing in India. But, this technology is still very expensive in India because of the investment required for the lab set up, instruments and reagents. Molecular diagnosis offers better sensitivity and specificity, but this technology fails, if the reagents used for this testing are not standardized and validated. Low quality and not standardized reagents can lead to false results and can bring the legal problems, embarrassment for laboratory. India is emerging as the global hub for health industry. Clinical diagnostic laboratory business is also growing. Clinical research is gaining importance. Many hospitals, laboratories prefer to have accreditations like JCI, CAP and NABL to maintain the quality and to be competitive in this market. India also has the higher prevalence of infectious diseases like tuberculosis, AIDS, hepatitis, genetic disorders like thallaeseamia. In this scenario, molecular diagnostics has a huge potential in India.
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Industry Speak
Simplicity and Speed
Need of the Hour
A futuristic approach for the instantaneous and accurate Point-of-Care diagnosis will most likely be PCR based, says Dr Rajas Warke, R&D Director - Molecular Biology and Virology, HiMedia Laboratories Private Limited
M
olecular Diagnostics (MDx) are techniques, which are used to detect and analyse DNA, RNA and protein molecules in order to provide the clinical information associated with a specific disease or a disorder. In the field of diagnostics, the level of automation has reached
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a point where molecular techniques like polymerase chain reaction (PCR) and microarrays are fast replacing the traditional culture based detection to improve speed, accuracy and sensitivity of detection. ‘Simplicity and Speed’ can be defined as the main challenges faced in MDx in today’s world of emerging and re-emerging infections. The conventional traditional detection techniques involve direct examination or culturing of the etiologic agents, which were fastidious, unculturable and bio-hazardous. Polymerase chain reaction has resolved many of these problems. This molecular detection method with its high sensitivity and specificity has allowed accurate detection of even a minute number of organisms. With healthcare becoming increasingly available to a large
number of people there is a greater need for faster detection techniques as the number of samples has increased significantly. This has led to the demand of mobile devices (portable, stand-alone, battery operated and ultra-light), which can be operated under different conditions at various geographical locations. There is also a dire need of a detection technique which would reduce the time of assays from hours to minutes, having better sensitivity and specificity as compared to the current rapid detection tests namely lateral flow and latex. Such technologies can prove to be very imperative to ensure that the line of treatment begins at the earliest. A futuristic approach for the instantaneous and accurate Point-ofCare (PoC) diagnosis will most likely be PCR based.
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Exclusive Interview
AshaSoft Raises Hopes in Healthcare Naveen Jain, Mission Director & Special Secretary, National Health Mission, Department of Medical, Health & Family Welfare, Government of Rajasthan, in conversation with Kartik Sharma of Elets News Network (ENN) talks about how the healthcare sector is witnessing a phase of transformation What all in terms of eGovernance is happening in the healthcare sector of Rajasthan? A number of initiatives have been undertaken in Rajasthan since the ascension of Modi Government at the Centre and quite a few programmes have also been launched. Primarily, our emphasis is on two things: one is how to use our limited resources in a better manner by using IT, and secondly, how to make our employees learn to use these IT tools effectively. We are providing facilities to our patients by using various software. In addition to it, we are also using software and programmes for various services. For example, for our free drug scheme, we have an e-Aushadhi software. To make online payments and managing ASHAs online, we have ASHASoft, and to take care of the children who are discharged from various nutrition treatment centres, we have a voice message-based software. Thus, we are using various programmes in various fields.
Rajasthan’s experiment with ASHASoft software has worked out well. What makes it such a successful initiative?
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The reason behind the success of this software is that we have 46,000 women working for it. These are known as ASHA Sahyoginis in Rajasthan, who get incentives based on their performance on 26 different parameters. When I was Collector in one of the districts, I found that making payments to
Exclusive Interview
ASHAs was not a very smooth affair. It was made in several parts and there were complaints regarding lack of transparency. This was telling adversely on their morale. Also, when I asked these ASHA workers about what they were doing, the parameters and other dash-boarding details on which their work could be evaluated, I came to know there was no such mechanism. Basically, there were two issues: one was lack of payment on time and the other, lack of monitoring parameters. One could see these two as problems, but we saw one problem as the solution to the other. We re-engineered the entire process of incentive payment. We brought out an ASHA incentive claim form, for which ASHAs were given training. Later, a software was devised with the help of NIC. We also issued various circulars and compiled them in a manual called ASHA Manual. It is very informative and anybody wanting to know about ASHASoft can go through it and learn about its programming. ASHASoft was developed nicely and implemented brilliantly. The best thing was done by our team including the district-level ASHA coordinators and supervisors, who indeed worked hard. This team work made it actually possible to implement such a huge software in just three months’ time.
ASHAs are, perhaps, the most basic unit of any healthcare system. How challenging it was to raise such a structure starting with this basic unit of healthcare delivery? Firstly, it is a basic unit, and secondly, the limitation is that out of 46,000 ASHAs, 26,000 are just Eighth standard pass or even below. So, it was a real challenge to train them in implementing a system which is based on IT. There could have been
various apprehensions and confusions. However, ASHAs were so much fed up with the existing system that they were ready to experiment with just anything. So, we started off with their training programmes. We anticipated that one day there would be a shortage of these claim forms. So, we published six lakh forms in advance. 12 of these forms were compiled in a booklet and 50,000-plus booklets were printed, which were distributed among the 46,000 ASHAs. We are hopeful now that more and more people would get involved in the process in the future.
Do you use technology for the provision of medicines as well? When the Rajasthan Medical Services Corporation Limited was incorporated in 2011, those behind it also took care of the future IT requirements. C-DAC came out with the solution, which is now known as e-Aushadhi. The software and its implementation were simply up to the mark. Further, it was implemented starting from our warehouses up to the drug distribution centres level. So, whenever a medicine comes to the Corporation after purchase, it is entered in the software. Also, when a medicine is prescribed by a doctor to the patient, an entry of issuance is made in it. In this way, the software also takes care of the availability of stock at various centres, in the warehouses of the Rajasthan Medical Service Corporation and at different PHCs and CHCs. It is a mandatory practice to make an entry of every drug purchased by the Corporation or sent to warehouses for distribution to various centres.
What are the upcoming initiatives in the field of healthcare in Rajasthan? We have been instructed to make two programmes: one regarding our equipment purchase mechanism, as we purchase a lot of equipment to be supplied to different healthcare institutions; and the second one, to address complaints from the end-users with regard to the quality of services these equipment deliver. Using technology, we have devised a system called e-Upkaran. This covers all the 2,500 facilities of Rajasthan, including medical colleges and hospitals. e-Upkaran is able to give information about the number of equipment that are not functional, the ones sent for repair, status of repair and the likely time required for it. Tracking of repair and maintenance is the first module. The second module is the usage module. Sometimes, we see that a machine is working perfectly, but due to some mischief or some other reason, hospital administration is unable to use it. So, it is important to know how many equipment were not used at all. In this way, we can take stock of the equipment under maintenance and the ones not used at all.
What is your vision for eGovernance in health? We are thankful to our Hon’ble Chief Minister, Ms. Vasundhara Raje Scindia, because she has a vision of IT and she always says that governance is more important than government. We have taken it in the real spirit and our department, with a very limited workforce, is trying to implement this. Whatever innovation technology can bring, we will ensure that it is implemented properly so as to impact the system positively. One of the weak aspect of governance, however, remains that although we create data, we do not necessarily analyse it. But we have decided that whatever system we will use, we will ensure that the data are used for taking informed decisions.
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Exclusive Interview
NHM Streamlines Health Services in Puducherry Despite Puducherry being already rich in healthcare services, the National Health Mission has helped make the delivery of services still more effective and faster, says Dr K V Raman, Director, Department of Health & Family Welfare Services, Government of Puducherry, in conversation with Souvik Goswami of Elets News Network (ENN) As the Mission Director of the National Health Mission (NHM), Puducherry, could you elaborate on the initiatives that are there to provide better healthcare services? The Health Department in Puducherry exists for more than 50 years and some of the hospitals are nearly 200 years old. Owing to the French legacy, Puducherry was famous for its healthcare services and people from other regions used to come in. When NHM came, it did not have much of an impact because all the services were already being provided by the government. However, it did help fill the gaps, which had not been taken care of by the State Government. For example, there are some technical positions such as treatment supervisors, treatment laboratory supervisors in tuberculosis and data entry operators in NHM, which cannot be solely taken care of by the State Government. Puducherry has eight major hospitals, four Com-
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munity Healthcare Centres (CHCs), 39 Primary Healthcare Centres (PHCs) and 81 sub-centres for a population of 2.5 lakh people. Given the rich healthcare facility, people from other regions also visit Puducherry for healthcare services. We have done a networking of PHCs, as they are now equipped with computers and internet connections that enable them to give feedbacks or reports. This also makes the working of PHCs more streamlined.
How NHM has helped in streamlining the healthcare services in Puducherry? Puducherry is divided into four different regions with its small pieces stretching up to different states, thus making the administration difficult. But now under NHM, we are able to streamline things with the advantages of speedy monitoring. Earlier, manual reports from all hospitals would come, but now with online reporting facility, it is easier to move ahead with the facility-based reporting (sub-centre level) and the data is monitored very closely. Now, through NHM, the Government of India is able to monitor the health facilities of the states. Prior to this, each state used to have a different level of healthcare, but now they are bridging the gap and creating an average or even a better healthcare
Exclusive Interview
system. The NHM monitoring is so good that they find the districts with below par immunisation and family welfare, and prioritise them accordingly. Similarly in immunisation, wherever deficit is there, they are covered under a new scheme called ‘Indradhanush’.
What are the major initiatives of NHM in terms of providing healthcare services in Puducherry? We have brought down the infant mortality rate because NHM has supported the antenatal care and also the pregnancy and delivery care. They are funding and giving facilities to patients to visit the hospitals and go back, and also bringing children to hospitals. A major advantage to the people is that now they are visiting major hospitals instead of going to PHCs for delivery. This is because of the good transport services and the level of care hiked up in these institutional deliveries, making people opt for hospitals. The institutional deliveries have gone up beyond 99.5 per cent. Moreover, we are looking after the smallest of things to decrease child mortality rate. For instance, children born with congenial diseases, unless they are treated in the first year, are likely to die. To prevent this, we have started a unique process in Puducherry, called Cardiac Screening Care, where every child born is screened for cardiac defects. We also have tie-ups with Chennai hospitals, who visit thrice a week to screen and diagnose children with cardiac defects, and those with defect are taken to respective hospitals for treatment. We also have a revolving funding at NHM to pay for it. Another initiative that we have undertaken is for non-communicable diseases by screening every person above 30 years. The non-communicable diseases were alarming in
‘We have brought down the infant mortality rate (in Puducherry) because the National Health Mission (NHM) is supporting the antenatal care and also the pregnancy and delivery care’ Puducherry. We did a pilot study of three PHCs and were able to get the basic data of 16 to 33 per cent infection. After this awareness, people are visiting us for screening. Our requirement for drugs has gone up, for which the National Rural Health Mission (NRHM) is supporting us. Besides, the complications of the non-communicable diseases are being planned to be taken care of as well. We have also opened a diabetic clinic in the major hospitals and in every PHC, operating twice a week. Under NRHM, we are going to set up a cardiac care unit, a geriatric care unit and a palliative care unit to the terminally ill patients.
What are the initiatives undertaken in Puducherry in terms of providing mHealth services? All the pregnant ladies are registered under mother-child tracking system and their check-ups are channelised through mHealth mechanism every three months. Mobile numbers of the patients are fed into the computer that is connected to the headquarters. The data is saved in the server on a daily basis and the ANMs receive alerts on when to call the patient. The payment of their services is done through NRHM. We have submitted a proposal of `400 crore eHealth project to the Ministry of Health that includes every electronic facility for health starting from recording all the data at the PHC level, transmitting the data to any hospital and providing smart cards to the patients, using which they can access any hospital which can further access their data through any PHC. We are hopeful to get the project this year. Prior to this, on a trial basis, we are trying to provide five PHCs with tablets having enabled software to record the patient data quickly. The data can be shared with the patients over e-mail and the patients would be given a unique number through which they can access their data at any hospital.
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CT Scanners
From Beatlemania to Manic Slice Wars
The government’s desire to increase the reach through PPP models and make primary care available in remote areas will give impetus to growth
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CT Scanners
64-slice
CAR
NEMA Standard
NEMA Standard
TOF
PET/CT
PPP
128-slice Dual-source
CT
ECG 64-slice
Computerised Axial Tomography
256-slice
NEMA Standard
Dual-source
Cardiology
Oncology
PPP
CAD Computed Tomography C Computerised Axial Tomography
omputed tomography (CT) has emerged as the most useful and practically-feasible imaging modality in a host of clinical conditions in routine practice. This is predominantly due to the speed of data acquisition, excellent spatial resolution and multi-planer capabilities of the present-day CT scanners. In fact, computed tomography is one of the major contributors to the growth of the medical imaging industry in India. Continuous upgradation in CT technologies is a common trend. Due to the introduction of various new applications and the combination of nuclear medicine with CT technologies, the disease coverage capabilities of CT are increasing over time. CT scans can detect various diseases and the continuous improvement in image quality has facilitated greater accuracy in diagnosis. Oncology and cardiology are mainly driving the CT scanner market.
and it is anticipated to reach US$ 1.3 billion by 2017, at a CAGR of 3.7 per cent. North America is expected to see even slower growth. The CT scanners market can be segmented into lowend, mid-end and high-end market. Low-end segment includes single and dual slice CT scanners, mid-end segment includes multi-slice scanners such as 6, 10, 16 and 32 slice and the high-end includes 40 slice, 64 slice, open versions, and cardiac CT. The innovative cycle of CT scanner is becoming very short as the new and latest technology is being introduced in the market with each being more efficient and faster. There is an increasing trend of high slice CT that are expected to improve the clinical utility significantly as the introduction of 256 slice scanner would be having detector width of 10 to 12 cm, which would help in scanning an organ, including brain, heart, entire joints, and lungs and liver, in a single rotation. It is also expected to scan the heart with the single heartbeat. Global Market The combination of product enhancements and the It is estimated that approximately 81.2 million CT need to cut radiation dose levels is fuelling the market. procedures were performed in US in 2014, which is seven A new federal standard passed into law last year, NEMA per cent higher than the procedures performed in 2013. (National Electrical Manufacturers Association) Standard The global CT scanners market is expected to grow 5.5 per XR-29, defining low dose standards and punishing cent to US$ 5.1 billion in 2018. providers not in compliance will help growth of the market. Asia-Pacific market is expected to increase from US These standards include $1.4 billion in 2012 to US$ 2.2 billion in 2017, a Buyers in metro, mini-metro, and tier-I dose structured reporting, dose check features, automatic CAGR of 9.8 per cent. The markets are increasingly showing exposure control and European CT scanner preference for 16-slice CTs over reference adult and paediatric market was estimated at protocols. A provision in US$ 1.1 billion in 2012, single/dual slice CTs
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CT Scanners
federal legislation signed into law in April 2014 to delay Medicare Sustainable Growth Rate cuts required health care providers to comply with those standards. NEMA Standard XR-29-2013 for improved CT radiation safety. Equipment not in compliance by January 1, 2016, will be subject to a five per cent /per scan technical component reduction on diagnostic CT procedures billed in physician office and hospital outpatient settings. The reduction will increase to 15 per cent January 1, 2017.
Major Players
Indian CT Scanners market is dominated by three brands, GE, Philips, and Siemens with a combined market share of 90 per cent. Other aggressive players include Toshiba, Schiller, Sanrad, Cura, Trivitron, Shimadzu, Blue Star, Komega, and Med Rad. GE Healthcare: GE Healthcare has introduced its Discovery IQ PET/CT system, which became US. Food and Drug Administration (FDA) cleared in September. It enables both high image quality and intelligent quantitation. According to the company, it delivers the highest NEMA sensitivity (up to 22 cps/kBq) and the largest axial field-of-view (up to 26 cm) compared to other PET/CT equipment. GE’s new Q.Clear image reconstruction software is a big component of Discovery IQ, eliminating trade-offs between image quality and quantitative SUV measurements. By providing two times improvement in both quantitative accuracy (SUV mean) and image quality (SNR) in PET/ CT imaging, this new tool provides benefits to physicians across the cancer care continuum from diagnosis and staging to treatment planning and assessment. Over the last decade, PET image reconstruction technology has been designed to provide better image quality, reduced acquisition time and lower injected dose. Current PET iterative reconstruction technologies, such as time of flight (TOF) and ordered-subsets expectation maximisation (OSEM), force a compromise between image quality and quantitation, GE said. The Discovery IQ uses GE’s new LightBurst detector
Market Trends Buyers
Y Buyers in metro, mini-metro, and tier-I markets are increasingly showing preference for 16-slice CTs over single/dual slice CTs Y Buyers are looking for more value-added services like marketing support, lifecycle management, business consulting, and upgradeability options from original equipment manufacturers Y The market for high-end CT scanners includes large corporate hospitals that leverage new technologies to assert their international brand and tap into the burgeoning medical tourism industry. For example, Apollo Hospital in Chennai has the 320-detector-row CT scanner from Toshiba Medical Systems. Sir H.N. Reliance Foundation Hospital in Mumbai, another hospital reliant on medical tourism, has the elite Somatom Force CT scanner from Siemens Healthcare Y The trend for mobile scanners has gained strength in the last year with CT, hospitals like AIIMS, Apollo, Sahayadri Hospital, JPN Apex Trauma Centre, Sahara Hospital, and Fortis Hospital are using mobile CT scanners thereby extending radiology reach to point-of-care imaging
Radiation Dose
Y Radiation dose awareness is influencing more buyers to adopt advanced technologies like Time-of-Flight that reduces the radiation dose to patients without affecting the image quality
Wider detector coverage
Y State of the art: 64-slice CT has 3.2 to 4.0 cm detector width Y Work-in-progress: 128-slice and 256-slice CT for up to 16 cm wide detector coverage
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CT Scanners
technology, allowing for whole organ imaging via fast scans at low dose. It also uses fast electronics and a dual acquisition channel that enables high quantitative accuracy for all clinically relevant tracers. Siemens Healthcare: In 2013, Siemens Healthcare introduced the Biograph mCT Flow PET/CT system that overcomes the limitations of conventional bed-based PET/ CT. It uses Siemens’ FlowMotion technology that moves the patient smoothly through the system’s gantry while continuously acquiring PET data. FlowMotion expands quantification in all dimensions for precise disease characterisation in therapy monitoring, while enabling physicians to offer as low as reasonably achievable (ALARA) dose to every patient. The scanner uses a 78 cm bore with five-minute scanning and a continuous sense of progress throughout the scan provides the patient with a more comfortable exam experience. Conventional PET/CT suffers from intrinsic sensitivity degradation from the centre to the edge of the axial FOV. Overlapping sequential bed positions are used to compensate for this constraint, but this approach can lead to axially varying noise sensitivity. This noise can distort the quantitative values of a detected lesion, which may prompt a physician to mischaracterise the severity of a tumour. By continuously moving the patient through the detection system, FlowMotion technology eliminates overlapping bed acquisitions and maintains uniform noise sensitivity across the entire scan range. Philips: The Philips Vereos is the first PET/CT on the market to offer digital PET detectors, allowing improved
Multi-source CT
Y With gantry rotation speed near its maximum, this solution may be the only way to improve temporal resolution
Workflow
Y Computer-aided reading (CAR) and Detection (CAD), Advanced visualisation and 3-D/4-D imaging
More efficient scanner software
Y Improved clinical applications, in particular cardiac imaging packages
Dose reduction
Y Improvements in hardware allow faster procedures, noise reduction Y Advanced techniques and algorithms: Automatic exposure control, tube current modulation, ECG pulsing
Use of CT scan as a primary diagnostic tool
Increasing affordability among patients
Rising demand for improved health services
The government’s desire to make primary care available in remote areas will give impetus to growth
Drivers
More diagnostic centres are being set up will also fuel growth
Increasing health expenditure
Radiation hazards caused from CT Scanners
Regulatory challenges inhibit technology reach to wider market
Higher accuracy in results due to technological advancement
Increasing demand for advanced CT scanners in tier-II cities
Considerable high price of CT Scanners
Challenges Competition from other diagnostic imaging techniques
Lack of training among the users on optimising radiation dose
image clarity over traditional analogue photomultipliers. The system was first unveiled at RSNA 2013. It uses Philips’ digital photon counting technology in its digital silicon detectors. Philips said this result in a step change in performance that approximately doubles sensitivity gain, volumetric resolution and quantitative accuracy compared to analogue systems. These radical improvements can ultimately be translated into high image quality, increased diagnostic confidence, improved treatment planning and faster workflows.
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Industry Speak
Empowering the Patient Revolution Richard Guest, CEO, Siemens Healthcare, South Asia says, since the new government assumed office last year, people are feeling safer to invest in India How do you perceive the Indian CT Scanners market? What are the drivers that are influencing this segment? CT scanner is an evolving technology in India, as it is capable of diagnosing diseases early and accurately. Today, it is one of the most important tools of radiologists in the diagnosis of multiple diseases. Besides diagnosing cancer, CT scans is used in emergency care to diagnose fractures, haemorrhages, and the like. Applications are widely seen in the areas of neurology to diagnose stroke, aneurysms, in cardiology to diagnose coronary anomalies, stenosis evaluation and in many other fields. Drivers that are influencing this segment in India include: Demographic changes: The demographic changes are bringing in lifestyle disorders like cancers, diabetes, cardiovascular diseases. The need for early diagnosis of these diseases is critical for better patient management. The demand for innovative diagnostic solutions like CT scanners is thus increasing. Accessible and affordable healthcare: Expansion of quality healthcare in tier II and III cities is making healthcare available to the people. This is further helping them to avoid travelling to bigger cities/metros for diagnosis and treatment, which is lighter on their pockets. Therefore, standalone diagnostic centres and hospitals are increasingly investing in hi-end diagnostic solutions like CT scanners. Insurance: With large number of people opting for insurance, ability to avail quality healthcare has increased.
Tell us about your current operations in India and your expansion plans. We are one of the few companies
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with expertise in both imaging and laboratory diagnostics, able to provide doctors with a holistic diagnostic approach. In diagnostics, we provide a broad spectrum of immunoassay, chemistry, haematology, molecular, urinalysis, and blood gas testing systems and diagnostic tests, in conjunction with automation, informatics and services, which serve the needs of laboratories of any size. In medical imaging, we provide the entire range of products from ultrasound to molecular imaging, including X-ray imaging, angiography, computed tomography and magnetic resonance tomography/imaging. A link between most of these modalities is the imaging software syngo, which provides a common user interface for all our modalities and supports our customers with a wide range of applications e.g. for workflow efficiency and diagnostic support. At Siemens, we start with an idea and then work backwards to develop state - of - the - art manufacturing facilities, set up replicating global, best-in-class manufacturing systems and practices.
What do you think “Make in India� can do for Indian healthcare industry? The 23 Siemens factories in India manufacture (Make in India) steam turbines, switchgear, remote monitoring systems (RMS), motors and generators, relays and smart
Industry Speak
grid systems, transformers, railway bogies, X-ray machines, and urine strips. The network of factories enables us to do things quicker and better than anyone else. Highly skilled people who are completely motivated to deliver best quality products at competitive prices carry out manufacturing activities.
Is Siemens looking to calibrate its strategies with Prime Minister Narendra Modi’s initiatives such as ‘Make in India’ or smart cities? Siemens is delighted to be part of the CII Smart Cities initiative. Cities drive economic growth, increased investment and job creation for millions of people who are increasingly converging on them with the hope of security and a better standard of living. For cities to be able to deliver true value, they need to be able to provide their inhabitants with the highest standard of living while ensuring sustained protection of the environment. Only cities, which are able to reach this equilibrium, will be capable of meeting today’s challenges and can look forward to a more sustainable future. Siemens has the portfolio, the know-how, and the expertise to help cities become more liveable, competitive and sustainable.
Please comment on emerging trends and new technologies. Healthcare in India is growing at a very fast speed. There is a huge demand for making quality healthcare accessible to the people in India. As a result of which, you will witness increase in venture capital investments in this segment. Unrelated business/corporate houses (i.e. non-medical professionals) have started investing in healthcare. Corporate hospitals have started expanding in tier II and III cities. Amongst other trends, penetration of insurance will see a massive jump.
What are the innovative technologies Siemens Healthcare has been providing? Part of our ultrasound portfolio is the world’s first wireless ultrasound system Acuson Freestyle. This new technology, which eliminates the impediment of cables in ultrasound imaging, expands ultrasound’s use particularly in interventional and therapeutic applications where cables were an infection risk until now. Talking about the “larger” machines, we have lab automation tracks called Aptio that can handle volumes of 100,000 tests in a day. Once such world’s longest track has been installed at Thyrocare Technologies in Mumbai, which is 93.5 m long. One of the latest computed tomography products is the Somatom Force, a dual source computed tomography scanner with two X-ray tubes and detectors. This technology enables considerably quicker and more precise diagnoses at reduced dose. In the field of magnetic resonance our newest scanner is the Magnetom Amira. This entry-level new 1.5-tesla MRI scanner offers the same technologies that are available on the Siemens flagship MRI systems. With so called “dot.engines” many examinations can be scheduled for a 10 minutes scan, enabling a larger throughput of patients in routine applications. The patient-friendly
application “Quiet Suite” reduces sound pressure by up to 97 percent. Power savings of up to thirty percent can be achieved in standby mode compared to when the feature is not activated. Another first is the Biograph molecular MR (mMR) system. This revolutionary system comprises a 3-Tesla MR scanner and an integrated PET detection system with an architecture that performs as one. In this system, Siemens developers have succeeded for the first time in simultaneously capturing MR and PET data with a whole-body system. IT solutions to utilise big data in healthcare are another important part of our portfolio. Teamplay is a cloud-based network connecting healthcare experts and increasing the usability of the wealth of medical imaging data. It links hospitals and healthcare experts to provide them with the ability to exchange data and pool their knowledge. Teamplay as well makes it possible to evaluate information from the radiology department – e.g. scanner capacity utilisation, examination times or radiation doses – and to compare the numbers against in-house and thirdparty reference values. This means imaging devices can be analysed in close to real time and their operation optimised based on the results, right down to individual device level.
What are your views on government regulation or any other challenges faced while operating the Indian market? The government is working toward a permanent solution by trying to get to the root cause. The PM is concentrating on creating the right environment. The private sector will then decide for themselves what will be the right time to invest. Since the new government assumed office last year, people are feeling safer to invest in India.
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Industry Speak
Moving towards Low Dose CT Scans iDose4 iterative reconstruction technique is a breakthrough in image quality and dose reduction with the 4th generation of reconstruction, says Raveendran Gandhi, Senior Director – Radiology, Philips
R
ecent technological advances have markedly enhanced and expanded the clinical application of computed tomography (CT). While the benefits of CT have been well documented and supported, many aspects of modern healthcare, increasing radiation doses to the population have raised attention to the need for reduction of radiation exposure from CT. In response, the radiology community (radiologists, physicists and manufacturers) has worked to adhere to ALARA (As-LowAs-Reasonably-Achievable) principles in CT imaging. Dose management is simplified with Philips Healthcare’s DoseWise philosophy and the advances embodied in CT platforms. Multiple components of the imaging chain have been enhanced to increase volume imaging speed, dose efficiency, and image quality, thereby enabling opportunities for lower dose scan protocols. As the performance of the imaging chain was increased, the limitations of image quality resulting from conventional filtered back projection (FBP) reconstruction algorithms— especially at lower doses — became apparent. This is an in-depth review of an innovative, 4th generation iterative reconstruction technique. iDose4— the latest addition to Dose Right tools — that provides significant improvements in image quality combined with dose reduction capabilities. Benchmarking tests relative to alternate technologies help demonstrate the benefits of this 4th generation iterative reconstruction technique in preventing photon starvation artefacts (streaks, bias) prior to image creation and in maintaining image texture to overcome the artificial or “plastic” look of images that have been frequently reported when using previous-generation iterative reconstruction techniques. Evidence
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from phantom tests and rigorous clinical evaluations with clinical collaborators demonstrate the potential of iDose4 to improve image quality and lower radiation dose levels beyond those previously achievable with conventional, routine-dose acquisitions, filtered back projection reconstructions. iDose4 is a 4th generation reconstruction technique that provides significant improvements in image quality and radiation dose reduction. It provides an innovative solution, in which iterative processing is performed in both the projection and image domains. There construction algorithm starts first with projection data where it identifies and corrects the noisiest CT measurements – those with very poor signal to noise ratio, or very low photon counts. Each projection is examined for points that have likely resulted from very noisy measurements using a model that includes the true photons statistics. Through an iterative diffusion process, the noisy data is penalised and edges are preserved. This process ensures that the gradients of underlying structures are retained, thus preserving spatial resolution while allowing a significant noise reduction. In doing so, this process prevents the primary cause of low signal streaks. Also, since the corrections are performed on the acquisition data (unlogged projections); this method successfully prevents bias error. The
Industry Speak
noise that remains after this stage of the algorithm is propagated to the image space; however, the propagated noise is now highly localised and can be effectively removed to support the desired level of dose reduction. The next major component of the iDose4 algorithm deals with subtraction of the image noise while preserving the underlying edges associated with true anatomy or pathology. This subtraction begins with an estimate of the noise distribution in the image volume. This estimate is used to reduce the noise while preserving the true structure. This estimate also allows the preservation of the image noise power-spectrum characteristic of a higher-dose acquisition and FBP reconstruction. Following this, a selector chooses among noiseless structural models, and the model that best fits the local topology of the image volume is chosen. Once the best model is chosen, it is used to reduce the noise in the image volume. To ensure uniform noise removal at all frequencies, multi-frequency noise removal is performed. iDose4 is a sophisticated and complex reconstruction algorithm that demands enormous computational power. The interaction of information between the projection and image domains requires the support of elegant software and hardware architectures. Running iDose4 on the prior generation of reconstruction hardware would result in clinically unacceptable reconstruction times. The new RapidView IR reconstruction engine was designed from the ground up to benefit from not only higher performance computational cores but also the number of cores. The architecture is highly parallel and the design enables there constructor to scale with the latest multiplecore processors and state-of-theart massively parallel, high-density computing devices. The high-density
computing device on RapidView IR processes and transfers huge amounts of data. The latest generation PCI express bus offers substantially higher bandwidth, and Intel 6-core processors are utilised to address the additional computing requirements. As a result, the new reconstructor is able to deliver exceptional reconstruction performance with iDose4, thus providing reconstruction speeds similar to those previously achievable with FBP on conventional
traditionally achievable. Detailed phantom studies demonstrate that, for routine dose acquisitions, the spatial resolution can be improved by up to 68 per cent. Routine clinical practice often requires the combination of dose reduction and image quality improvement benefits relative to routine-dose acquisitions and FBP reconstruction; hence, iDose4 provides the functionality to combine these benefits in proportions best suited
Detailed phantom studies demonstrate that, for routine dose acquisitions, the spatial resolution can be improved by up to 68 per cent reconstructors. An additional benefit of the RapidView IR is that FBP reconstruction speeds on this enhanced hardware are significantly higher than previously achievable. Optimising the implementation of iDose4 on the Philips CT scanner platforms has enabled the additional clinical benefit of being able to adapt the spatial resolution and dose reduction benefits to the specific clinical indication. For example, for paediatric imaging where radiation dose reduction is paramount, iDose4 enables significantly lower radiation dose while maintaining diagnostic image quality. In other cases, where image quality (e.g., spatial resolution) is of higher priority than the dose reduction, such as in the assessment of coronary stent patency, iDose4 enables significantly improved spatial resolution. Intermediate levels of dose reduction and spatial resolution improvement can be applied in combination for other clinical scenarios. iDose4 can be used to significantly improve the spatial resolution of any acquisition, regardless of the dose with, which it was acquired. It iDose4 can be used to improve the spatial resolution, the contrast-to-noise ratio, or both beyond that has been
to the clinical indication. Routine clinical practice often requires the combination of dose reduction and image quality improvement benefits relative to routine-dose acquisitions and FBP reconstruction; hence, iDose4 provides the functionality to combine these benefits in proportions best suited to the clinical indication. In tube - power - intensive acquisitions, such as those faced in imaging obese patients, the maximum power of a CT scanner tube may not be sufficient to provide the desired image quality for a given indication. The artifact prevention and noise reduction enabled through iDose4, provides image quality that is equivalent to that associated with a significantly higher-dose acquisition without having to actually irradiate the patient with the higher dose. In such scenarios, the effective tube power is increased and can overcome either tube limits (e.g., bariatric imaging) or skin dose concerns associated with higher-dose acquisitions. To summarise, iDose4 iterative reconstruction technique is a real breakthrough in image quality and dose reduction with the 4th generation of reconstruction and paves the way for moving towards low dose CT scans.
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Industry Speak
Technological Advancements in Radiation Protection Future holds the promise of new generation imaging technology that may completely eliminate the use ionising radiation, says Satyaki Banerjee, Director – International Operations, Trivitron Healthcare Group of Companies
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dvancement in medical diagnostics field over the years have led to widespread use of ionising radiation for detection of fractures, infections, tumours, internal injury, blood vessel damage and several other medical conditions. Overexposure to radiation leads to a multitude of severe biological effects, ranging from burns, radiation sickness, to bone-marrow damage, genetic mutation and cancer. The manifestation of such biological effects is dependent on the nature of exposure: the deterministic effect, caused by exposure to high dose of radiation in a short time span may lead to burns and radiation sickness, and the stochastic effect caused by prolonged exposure to low dose of radiation may lead to genetic mutation and cancer. Radiation protection has been a subject matter of intense research over the years with the goal to develop products that would provide effective protection against the harmful effects of radiation to patients and occupationally exposed individuals like healthcare professionals working in radiology centres and surgeons using interventional radiology. Multiple approaches are used simultaneously for radiation protection that includes: structural lead shielding of X-ray equipment and use of filters and anti-scatter grids; use of collimator to limit the X-ray beam to precisely the required area; and use of
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personal radiation protection gear like radiation attenuating apparel, thyroid shields, gonad/ovarian shields, patient oriented computed tomography shields, gloves, mittens and eyewear to protect against scatter radiation
Principle focus of current research Design optimisation to provide precise levels of radiation protection to vital organs without affecting the ergonomics and convenience of the healthcare professional performing the procedure, for example significant research efforts are being made to develop ultra-thin radiation protection gloves with high radiation attenuation for use by surgeons performing cardiac catheterisation or similar interventional radiology procedures where tactile sensitivity is of paramount importance. The world’s
leading manufacturers of radiation protection gloves are able to offer gloves as thin as 0.20mm thickness containing no lead. Eliminating the use of lead considering its many environmental hazards and also the heavy weight associated with lead containing functional core material. State of the art material science research has led to the development of ultra-light functional core materials with no lead at all using a combination of bismuth, antimony and tungsten offering the same level of radiation attenuation as conventional lead containing material. The level of radiation protection obtained by personal radiation protection gear is quantified through its lead equivalency rating (Pb rating). A 0.5Pb rating apron is expected to provide the same protection as a 0.5mm thick sheet of lead. It has been possible to develop zero lead materials with 0.5Pb rating that offers 99 per cent protection against radiation. While the future holds the promise of new generation imaging technology that may completely eliminate the use ionising radiation, but till the time such technology is successfully developed and translated to widespread commercial use, radiation protection gear would continue to play a pivotal role in the healthcare system protecting patients and healthcare professionals worldover and would warrant continuing research efforts for further advancement of this field.
Second Opinion
How CT Scanners Continue to Revolutionise Healthcare Dr Avik Bhattacharyya, Consultant Interventional Radiology, CK Birla Hospitals shares how the lives can be saved with the help of the CT angiography
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rom its first use in 1971, CT Technology has found various uses in numerous walks of life – from archaeologists who use to ascertain the age of an Egyptian Mummy to Airport baggage scanners – CT scanners are in more places than one may imagine. But no field has benefitted more from this technology than the medical sciences and specifically radiological diagnosis. The following case of a patient that had come to The Calcutta Medical Research Centre illustrates the importance of a good imaging department that uses state-of-the-art CT technology. A four year old baby girl fell from a chair. Soon she started to bleed every time she passed urine. The parents were understandably very worried and brought their daughter to Kolkata from their home in Murshidabad. Initial investigations at other hospitals did not reveal the source and an ultrasonography had showed some indication of a blood clot within the kidney. However, the tests could not reveal the aetiology – why is there bleeding and how is it appearing in the urine? One month since sustaining the injury the girl came to The Calcutta Medical Research Institute. By this time they had also spent a large sum of money on diagnosis and in fact had sold the land that they owned. At CMRI we performed a CT angiography. The CT angiography
immediately revealed a pseudo aneurysm. A branch of the renal artery had dilated when she had sustained a trauma to the kidney and was intermittently rupturing into the kidney. She underwent a cath lab procedure post the diagnosis and the aneurysm was treated successfully. The accurate and efficient diagnosis with the help of the CT angiography enabled us to save the little girl. Moreover the procedure itself was painless and took about 10 minutes to complete. Not just in diagnosing the problem but CT scanners are also critical in guiding the needle in FNACs and biopsies, which are really helpful in instituting the treatment in many disease conditions. The CT scanner has truly revolutionised medical diagnosis. In fact the CT scanner itself has evolved and has become far more comprehensive and accurate. CT scanners help doctors and clinicians by providing improved insights into the human body. Modern CT scanners have 3D visualisation techniques that provide almost realistic images and making minimally invasive surgery ultra precise. In the beginning the conventional CT scanners or dual slice scans allowed us to only see parts of the brain. Now with new research and highly evolved CT scanners we can virtually view every part of the body. This in itself is a life changing tool in the hands of doctors and surgeons. In fact, CT scanners at CMRI allow us
to conduct brain tumour studies that enable us to determine the virulence of the tumour even before operating thereby enabling surgeons to choose the best course of action. With new research and transformative studies in the field of imaging and radiology the trend would probably lead us to CT scanners that produce automated analytical data that would make the huge amount of information from each scan easier to process for clinicians and surgeons. The looming case of radiation exposure is also an angle which is being constantly worked on. For instance new technology like Proton CTs look to reduce the amount of healthy tissue exposed to radiation.
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Second Opinion
Improving Diagnostic Capabilities The manufacturers should focus on more cost effective scanners with advanced software, says Dr Ajay Aggarwal, Director, Radio-Diagnosis, Saket City Hospital, New Delhi How do you perceive the Indian CT Scanners market? What are the drivers that are influencing this segment in India?
angiography on the other hand is invasive as it entails an arterial puncture. However the ability to therapeutically treat the patient in the same sitting makes catheter angiography a preferred choice in certain clinical settings.
The healthcare market in India has been growing at a phenomenal pace in the last decade with growth in the healthcare infrastructure in metro cities as well as tier II and tier III cities. Computed tomography (CT Scanners) has evolved as an important primary imaging tool for diagnosis. The modality is operator independent and the digital output allows remote reporting and accessibility to the referral physician. CT is especially relevant in emergency care and trauma. Newer applications such as coronary CT and hybrid technology such as PETCT and SPECTCT have fuelled its growth exponentially.
What do you think “Make in India” can do for the healthcare industry? The “Make in India” initiative will allow cost effective delivery of healthcare. The current equipment is predominantly imported. With rising foreign exchange rates and import duties the acquisition cost makes the financial feasibility a challenge. The other challenge is in sourcing the spare parts of critical equipment, which results in unnecessary delays and downtime. This can be improved by sourcing the spares from within the country. CT angiography is one of the
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What are the emerging trends and new technologies in CT Scanners market Hybrid technologies such as PETCT and SPECTCT have changed the way we look at disease. Not only are we able to comment on anatomical changes but also comment on physiological effect. Newer tracers will allow us to improve clinical outcomes. Dual source CT is another innovation, which shows promise in various clinical settings.
greatest advances in imaging. The newest CT scans allow a completely non-invasive way to get the same information as an invasive catheter angiography. Please comment CT angiography has proven as an important diagnostic tool for screening as in case of the coronary vessels and also in other clinical settings for assessing vessels. However radiation and usage of contrast media still make this test minimally invasive. CT angiography performed on new scanners has made it more patient friendly with faster scanning times and reduction of effective radiation dose. Catheter
What are the changes in the use of CT imaging? CT scanners are used in diagnostic as well as interventional procedures. With hybrid technology such as PETCT and SPECTCT the radiologist is able to improve diagnostic capability. Mobile CT scanners allow scanning close to the bedside of patients.
What are your expectations from manufacturers? The manufacturers should focus on more cost effective scanners with advanced software. New protocols will allow substantial reduction in the radiation to the patient.
Second Opinion
Technological Advancements CT scan technology has undergone remarkable progress, with focus on reduction of radiation dose and improved resolution, says Dr Sona Pungavkar, Consultant, MRI Centres, Global Hospitals, Mumbai
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he original CT machines obtained scans in series, one after the other (2D images). The new generation CT scanners acquire continuous pictures in a helical/spiral pattern (3D images). The newest scanners, called multislice or multidetector CTs, allow more slices to be imaged in a shorter period of time. These scanners provide better resolution and can detect small abnormalities better. CT scan technology has undergone remarkable progress, with focus on reduction of radiation dose and improved resolution. Some of the improved methods include: Dose reduction techniques: Small amount of radiation passes through the body to create an image. Exposure to radiation must be limited, as it can cause several complications including cancer. Newly developed technology allows high quality images with reduction in dosage up to 40 per cent. The machine is optimised to minimise patient dose, limited to guidelines for recommended dose provided by American College of Radiology (ACR) according to the age of the patient. Dual energy CT scanning: Also known as spectral imaging (SI) provides two data sets using low and high energy levels (kVp), which are acquired, simultaneously to freeze patient and gantry motion. It allows options for material analysis and tissue characterisation. A large field of view, upto 50 cm can be obtained using SI. Wider applications: The newer scanners, with multi-slice, multi-detector technology with helical scanning allow acquisition of 300 slices in 0.3 milliseconds. Because of reduced times, CT scan has replaced other high radiation techniques such as conventional Intravenous pyelography. A 30 second CT acquisition provides information about entire urinary tract, detecting small calculi, which could have been missed otherwise. Contrast excretion provides functional information. Cardiac function and physiology: Entire heart can be covered in single heartbeat, allowing accurate assessment of myocardium and coronary arteries. Iodine-alone images of arteries can be obtained, by taking out the calcium. This allows better visualization of stenotic lesions. Deep vein thrombosis is a common occurrence, leading to morbid and fatal pulmonary embolism. These emboli can be lodged in small pulmonary arteries and are difficult to detect.
Pulmonary angiography is now being performed using new technology with satisfactory delineation of the small arteries. Earlier more invasive techniques with catheterisation were required. Peripheral angiography: CT angiography is currently method of choice for evaluation of the peripheral arteries. This has been the result of multi-detector scanners. Previously, images were limited by calcification in the arteries of the leg. These limitations have largely been overcome by the new systems which have 64 detectors. The entire aorta and the lower limb arteries can be scanned in 15–20 seconds. Postprocessing involves stripping of bone and calcium. Artifact reducing technology: Metal inserted in the body after intervention causes artifacts overlapping the area of interest. This allows suboptimal imaging with loss of information. With the new imaging techniques, the artifacts caused by these implants can be reduced considerably, increasing the accuracy of evaluation in the post-operative setting. Post processing techniques: These have also advanced parallely. Earlier, long time was required to make a 3D image using C data on workstation. Currently, it takes few minutes to obtain superior quality images. 3D virtual patient modelling software is available, which enables preoperative assessment, navigation, and fusion with radiotherapy treatment plans and metabolic imaging such as PET.
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View Point
The Great Indian Standardisation Drive These are interesting times for India’s eGovernance, in general, and the country’s eHealth, in particular, says Vinay Venu, Technical Architect, ThoughtWorks, Bangalore
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ver the last couple of years, we have witnessed the government’s concerted effort to standardise data, metadata, communication protocols and processes in the health sector. Looking back at the Mini Timeline of eHealth initiatives:
It was August 2013 when the Ministry of Health and Family Welfare introduced the Electronic Health Record Standards so the country’s hospitals and healthcare providers could benefit from a uniform system of maintaining Electronic Health Records (EHR). In November 2013, a draft version of the Metadata and Data Standards (MDDS) for health domain was published. This will help promote interoperability across different eGovernance and eHealth applications. By April 2014, India became a member of the International Terminology Standards Development Organisation (IHTDSO). This enabled the country’s speedier adoption of Systematized Nomenclature of Medicine-Clinical Terms (SNOMEDCT) as its clinical healthcare terminology. On March 16, 2015, the Ministry of Health and Family Welfare placed a concept note on setting up National eHealth Authority (NeHA) as a promotional, regulatory and standards setting organization. One of the primary responsibilities of NeHA is to setup and maintain health repositories, electronic health exchanges and the National Health Information Network. Interesting times indeed! While EHR adoption in India is still catching up, we have several international national eHealth system use case scenarios to learn from. We are perfectly poised to take stock, clarify our direction and start building the right information systems for the India of tomorrow.
Reality Check This is where we have to remember that the end state we hope to achieve is Utopian and the ask is Herculean. With EHRs installed at every point of care and exchanging data via Health Information Exchanges, the benefit to stakeholders is huge. Medical records are not lost. They are no longer in silos, each with a different healthcare provider. Doctors have a better insight into the patient’s history. This helps the former take better decisions. Test results are not misplaced. The implementation of universal coverage becomes much easier. Public health programmes are better
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focused and more effective with the availability of rich and more accurate data. The list could go on. And for all these benefits to see the light of day, there are challenges to be met and compromises to be made.
The Challenges Apart from the usual technical laundry list of challenges like handling deduplication, legacy data, security, scale, usability and more, there are perhaps a few just as if not
View Point
more important factors to deal with. A successful national eHealth system needs sufficient electricity and network connectivity, which means it has to be much better than it is now. We plan to use Aadhar cards to identify people in the proposed new national eHealth system. However, around 27 per cent of the country still needs to get their Aadhar cards done. The current concept note to create NeHA mentions inter-agency cooperation. How well cooperation is achieved will decide the success of the programme.
The Compromises One of the biggest compromises would be eating into doctors’ time. In a country where the doctor to patient ratio is already skewed, providing additional responsibilities to doctors will definitely affect the care provided. However, as it is imperative that solutions like the Electronic Health Record (EHR) not affect patient care, the EHR systems need to be more robust, tactical remedies like
implementing transcription could help. Apart from this, judicious consideration of how much data is collected might be required. Add to this a long term vision of increasing the number of practicing doctors (by building more medical colleges) and we have the makings of a solution.
Keeping Everyone Happy No easy task especially when stakeholder requirements are in conflict. Here is an example, today, most health data collection happens at the
the complex decision of how much data is enough for a clinician to capture. And this is a hard decision what is better for patient care, is it more data at the cost of a doctor’s time or an incomplete patient record. Here, answers are not simple to find and such decisions are taken based on experience. Keeping the program’s end goal. Bringing a smile to the patient’s face, in mind ensures the right decisions are taken. And what makes these tough decisions worth it? That, in these times of data driven decisions,
Taking the right steps to ensure an excellent healthcare system for our and future generations also means taking bold steps towards that future aggregate level this makes it easier to collect and maintain. Most policy decisions are based on such data. However, while tactical decisions can maximise the system’s’ utility, unless detailed patient records are collected, the system is in fact ignoring patients. What would help, here is making
relevant data analyses performed for public policy be part of the public domain as open data. Taking the right steps to ensure an excellent healthcare system for our and future generations also means taking bold, confident and careful steps towards that future.
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Radiation Oncology Equipment
Radiotherapy The Future is Here
With the growing cancer burden on the healthcare sector, the invention of new technologies for diagnostic and treatment will give more opportunities to the radiation oncology equipment market. Romiya Das of Elets News Networks (ENN) digs out the trends driving the radiation oncology equipment market
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rowing at 15.5 per cent per annum, the Indian medical equipment market is positioned third in Asia and ranks among top 20 in the world. Over the next five years, it would be one of the world’s fastest growing markets. The rapid growth of the industry will reflect high inflation driven by increasing public and private expenditures on health. Market Dynamics The maximum growth of the radiation oncology equipment will be driven by the demand in developing countries, particularly in India and China. The new technologies have changed the way treatments are planned and doses are delivered. In 2014, the global radiotherapy market was estimated at US$ 5.8 billion and it is expected to reach US$ 8 million by 2019, growing at a CAGR of 6.7 per cent (The BCC Research Report 2015). The radiation oncology equipment market is expected to grow in the coming years owing to the increased prevalence of cancer and healthcare expenditure level of the patients. There are more than one million cancer cases diagnosed annually in the country and the numbers are expected to stretch five million over the next decade. However, stringency in the regulatory prices related to medical devices is expected to impede the growth of oncology medical equipment market. The equipment market may be segregated into two broad segments on diagnosis and therapeutics. The therapeutics segments include chemotherapy, hormone therapy, and biotherapy and radiation therapy. The oncology diagnosis can be sub-segmented to biopsy imaging, endoscopy and blood test. Radiation therapy identifies one of the major markets. Also, chemotherapy sees a notable growth owing to a greater useable rate.
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Cancer will continue to be a major challenge for public health, economics, and society in the years to come. In India presently, one in every six cancers is due to infections like Human Papilloma Virus (HPV), hepatitis B, etc. According to WHO report 2015 (World Cancer Day 2015: ‘Not Beyond Us’), the overall mortality from cancer (both male and female) is expected to mount to nearly 8,45,000 in 2020 and approximately touching one million by 2025. This increased number of cancer will overburden the existing healthcare system in India, which is already struggling to cater the present needs. According to The Report Global Radiation Therapy Market Report: 2015 Edition, the United States is one of the largest markets of radiotherapy equipment globally. The increasing incidences of cancers, replacements of older radiotherapy systems and reimbursement levels of radiotherapy are the main drivers for US market growth. The demand for radiotherapy equipment in Asia-Pacific region has also shown a significant growth, mainly driven by China. Radiotherapy is taken as a standard procedure for oncology treatment with the increase in cancer cases. With a prominent rise in their GDP, emerging nations act as the future growth opportunities for the global radiation oncology equipment market. Government funding through constant reimbursement, continuous research and development applied to various applications and considering radiationtherapy as an efficient treatment are some of the major drivers anticipated to boost the radiation oncology equipment market in near future. Factors such as high cost of the equipment, space restrictions and lack of skilled professionals can create obstacles in the growth of the market.
Radiation Oncology Equipment
Technology Trends
With the advancement of technology, the number of hospitals, diagnostic centres, clinics and research centres is making a prompt rise in the country. These healthcare facilities with technological advancements are also increasing the precision and accuracy of radiotherapy allowing treatments that minimise the impact on healthy tissue and reduce treatment-related morbidity. Also, the use of portable cancer equipment that can be utilised in mobile medical units in the rural area in India is high on demand. Looking onto the evolution and improvements in the delivery technologies the recent radiotherapy innovations have led to the rise in the accuracy in treatments allowing improved outcomes and reduced treatment-related side effects. At present, desirable developments are seen in the areas of intensity modulated radiotherapy (IMRT), stereotactic body radiation therapy (SBRT), 4D imaging, particle therapy and nanotechnology. The imaging technology is enhancing the radiotherapy treatments. Radiation oncology is personalised according to the patient’s particular clinical circumstances and anatomy. It is expected that with the unveiling of tumour marker system, molecular and biological imaging techniques will enhance the already personalised radiotherapy treatments. On the basis of applications, the radiation oncology equipment market may be categorised into linear accelerators and Stereotactic Radiosurgery Systems (SRS). Earlier both the conventional radiation therapy and SRS were entirely different technologies for separate treatment systems. Over the past few years, the vendors have expanded system capabilities with the help of stereotactic add-ons and most of the conventional linear accelerators can provide at least some form of stereotactic treatment. These add-ons to the liner accelerators bundles mark the distinct shift towards the more multi-functional radiation treatment systems. Therefore, with the limited budget the majority treatment facilities are looking forward to hybrid systems that are capable of both conventional and stereotactic treatment measures ensuring full utilisation. Also, intensity modulated and image guidance tools have allowed the technology to move into the cutting edge as a more outcome driven solution for radiation oncology treatments. It is seen that the service delivery and models of care are changing with a shift in focus from the delivery of isolated treatments to a multidisciplinary, coordinated approach to cancer care. The multidisciplinary patient management includes radiation, surgical and medical oncology as well as allied health services.
Major Players
Indian radiation oncology equipment market is majorly dominated by MNCs. GE Healthcare, Siemens Healthcare, Philips Healthcare, Elekta Medical Systems India, Accuracy India, and Varian Medical Systems are among the major players in the radiation oncology equipment market. These companies have introduced, and are still continuing to offer, modified cancer diagnostic and monitoring equipment designed for the Indian market. Medical equipment that is easy-to-use, portable, durable, cost effective is what the Indian market demands. Global manufacturers of diagnostic tests for cancer have achieved success in the Indian market. A high demand of mobile cancer screening laboratory units and portable equipment is also noticeable. The advanced treatment options for cancer are also seen making their own space in the Indian radiation oncology equipment market. Many corporate hospitals such as Apollo, Fortis, Manipal, Healthcare Global and Max Healthcare are the important players in this particular market. Apollo had announced a partnership with Belgium’s lon Beam Applications to build India’s first proton therapy centre, which is expected to be operational by the year 2016. Some home healthcare companies have also started offering home chemotherapy services. This assistance is giving rise to the more affordable and access to cancer care without travelling long distances to the specialised hospitals.
Opportunities
With the new cancer cases is doubling with every 50 years with the rising and ageing population of the world the requirement of more cancer treatment systems for medical diagnostics rises, particularly in the growing markets such as Brazil, Russia, India, China and South Africa (BRICS). Increasing demand for advance forms of radiotherapy, radiosurgery, brachytherapy and proton therapy is providing the requisite impetus to the growth of radiation oncology market. All the healthcare providers and medical equipment manufacturers have a market to provide systems for the most advanced forms of radiotherapy, radiosurgery, brachytherapy and proton therapy. Hence, with more growing cancer burden on the healthcare industry, increasing the market share of the diagnostic and treatment opens gates of opportunities for the MNCs to manufacture such products. Equipment that are simpler, portable, easy-to-use and cost-effective versions of diagnostic and cancer treatment products see success in the Indian radiation oncology equipment industry.
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Exclusive Interview
Advanced Technology: The Winning Leap With rising cancer cases in the country, oncology will be a key area of growth in India’s healthcare sector, says Manikandan Bala, Managing Director, Elekta Medical Systems India Private Limited in conversation with Romiya Das of Elets News Network (ENN) What are your views on radiation oncology equipment market in India vis-à -vis the global market? As the incidence cases of cancer diseases continue to rise, along with increasing trends in accurate diagnosis and precise treatment planning system, the radiation therapy devices market for treating these diseases continue to show significant growth. Radiation therapy is one of the main modes of treatment for cancer globally. On an average about 50 per cent of cancer patients need radiation therapy apart from other treatments like chemotherapy and surgery. However, globally for 33 million cancer patients we have a huge gap on the available linear accelerators (LINAC) at present which is almost a gap of 10,000 linear accelerators. In India, this gap is a lot more pronounced, where for about 3 million cancer patients we have a gap of more than 1,200 linear accelerators. For instance, while US has about 12 LINAC per million of the population, India has about 0.3 LINAC per million of the population. Even countries like China and Brazil are way ahead and have a larger concentration of LINAC compared to India. With cancer incidents on the rise because of improved life expectancy, diagnosis and survival rates, this gap is getting
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wider. Even within India, analysing the distribution of LINAC, almost 56 per cent are installed in metros and tier I cities whereas 70 per cent of cancer incidences are reported in rural areas. Nowadays, patients in tier III cities and rural areas have to travel long distances to get the radiation treatments involving huge financial burden and tremendous inconvenience. They need to stay in these cities to get treated as radiation therapy is a long term treatment typically spreading over four to five weeks. So, if one has look at the comparative cost, radiation therapy is still affordable compared to other modes. Hence, there is a huge demand for new linear accelerators as well as the replacement of the ageing cobalt Systems in India and we strongly feel that the growth will be driven by the demand coming in from the tier II and III cities. At present, only about 50 new linear accelerators are added every year in the Indian market.
What are your views on market price sensitivity in terms of radiation oncology equipment industry? Indian market is a very price sensitive one as most healthcare spends is out of pocket. The ability to pay in India is not the same as in other markets. Reimbursement levels of treatment are almost one tenth
Exclusive Interview
of that of developed countries like US, even in corporate hospitals. As a result, the end-users are under pressure to reduce the expenditure on capital equipment purchases as well as maintenance costs to ensure decent return on investment (RoI) - the operation cost also needs to be minimum. Therefore, there is a huge pressure exerted on the vendors to reduce the cost of the equipment as well as the maintenance cost. In simple words, customers want the best equipment at lower prices. The average price realization is one of the lowest when we compare with other countries in Asia-Pacific.
What according to you are the emerging trends in technology in this particular sector? The radiation therapy market is growing at a rapid pace over the past few years on account of rising cancer cases and increase in sophistication of new treatment processes. This in turn is driving the technology innovation on the therapy side. If we talk about emerging trends in radiation therapy, one segment is innovations and advancement towards image-guided radiation therapy. With improved diagnostic options, we expect more and more patients to get diagnosed at early stages of cancer where curative and aggressive radiation therapy treatment can be administered. As radiation therapy treatment gets more aggressive with higher dose rate, hypofractionation and stereotactic radiation therapy treatments, image guidance will be highly important enabling the clinicians to gain that added confidence of removing the tumour with better sparring of the healthy tissues and organs near to the tumour.
How beneficial is the ‘Make in India’ concept in terms of the radiation oncology equipment
market? ‘Make in India’ is an excellent concept, which should result in many benefits for Indian healthcare industry as well as the patients. We already see positive trends across industry especially in healthcare. Software plays a significant role in radiation therapy - be it record verification, treatment planning, and oncology information management systems. We see a great potential of tapping software development talent in India. To further enhance our software solutions, we are keen to actively engage with few of the key customers to make major investment in the sector. We are keen to leverage the talent and skill set in India as we move forward
What are your challenges and expectations from the radiation oncology equipment industry? As the India cancer burden continues to grow at an alarming rate, we continue to see very low expenditure on healthcare spend in the government sector. As a percentage of GDP we have been hearing about some optimistic figures, but are still waiting for these initiatives. As a result, the investment, specifically in the cancer facility, which is a capital intensive, is slow in the government sector. From the industry’s pov Complex RoI for high-end solutions remains a significant market restraint. One of the other major concerns is the shortfall in availability of skills and talent – namely the Radiation Oncologists and the Medical Physicists
What would you like to suggest the buyers of radiation oncology equipment industry? The demand for radiation therapy is growing in tier II and III cities. We anticipate the healthcare providers, mainly the corporate and the government, to spread and penetrate
more into tier II and III cities. The hub-and-spoke model where the centre of excellence can be in a major city with tier II and III cities feeding the technology centers will be the key focus. We also expect the buyers to use more Information Technology (IT) and Clinical Information Management System to ensure the standardised quality and protocol driven care is provided to patients at all the centres in the network. At the same time, all patient-related data generated electronically can be used for improving the care further. With our strength on oncology Information Management systems, we are poised to provide superior solutions for these ventures. With the objective of penetrating patient care to the tier II & III cities, we also are motivated to encourage and facilitate investment in radiation therapy facility in smaller towns by individual or group of oncologists.
What are Elekta’s present operations in India and future expansion plans? We are present in India for last 20 years, and have a large operation with very large install based of Linear accelerators, brachytherapy, after-loaders, and neurosciences specialty equipment such as gamma knife and Leksell stereotactic frames. With our highly trained and passionate staff, we have always provided high quality service and application support to our customers. We facilitate multiple trainings to all our customers, both at our dedicated training centers and at the customer locations, augmenting the skill development on the new and innovative technologies. We have invested on a service workforce ahead of the curve which helps in maintaining high uptime of all the equipment, thereby resulting in unhindered and quality treatment to the patients who deserve nothing but the best.
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Second Opinion
Towards Personalised Medicine & Targeted Therapy Diagnosis today is more widely used for identifying the right course of treatment says, Dr Kirti Chadha, Divisional Head Oncology Group and Surgical Pathology, Metropolis Healthcare Limited
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oday we have better diagnostic technology and facility compared to a decade back when it comes to cancer treatment. Cancer diagnosis attains significance as it is an extremely specialised area of diagnosis and needs to be validated by oncologists. Cancer testing is of different types and a combination of technologies is applied to arrive at conclusive diagnosis. Histopathology: Surgical pathology allows for definitive diagnosis of disease (or lack thereof) in any case where tissue is surgically removed from a patient. Cytogenetics: The cytogenetics lab offers karyotype analysis and
SNP-microarray analysis to detect balanced, unbalanced, and copy number neutral chromosome abnormalities at the whole genome level. The lab also performs fluorescence in-situ hybridization (FISH) analysis to detect targeted chromosome abnormalities. The results from these studies play important roles in cytogenetic diagnosis, prognosis, and guide treatment of specific types of hematologic malignancies and solid tumours. Molecular Pathology: The molecular diagnostic lab offers DNA or RNA based assays. Tests range from simple, routine PCR amplifications to complex tests translated from cutting-edge research findings to clinical utility.
Moving towards a new era in Cancer Testing Cancer treatment has shifted in recent years to the use of biologic therapeutics that target genomic alterations in cancers, creating demand for more advanced and sensitive genomic testing to identify these alterations. It is important to provide diagnostically more significant information and correctly identify mutations present in smaller samples. Today diagnosis is more widely used for identifying the right course of treatment. One size fits all is no more the approach and below is an example of one such extensive study conducted by us.
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Example for personalised treatment Surgery, radiotherapy, chemotherapy and hormone therapy are the four modalities of treatment of breast cancer. Breast cancer patients needs to be treated individually and pathology reports play a significant part. One of the areas where data based analysis has been minimal is in the arena of hormone therapy. We carried out a retrospective analysis of 3500 breast cancer patients for ER, PR, CerbB2 receptor expression for the last three years i.e. 2012, 2013 and till September 2014. Our study proved that with accurate diagnosis, more breast cancer patients in India can opt for hormone therapy rather than chemotherapy as a choice of treatment. Hormone therapy in these patients has better prognosis and is less painful with a lesser degree of recurrence when compared to chemotherapy. What is most important to address in case of cancer is “can I have a report that is conclusive and one that will help me design my treatment?’’ Single point, effective, cost effective and conclusive diagnosis is a void in India and Metropolis is at the forefront in bringing about this change. Through our Oncomet division, we provide conclusive and cost effective cancer testing by correlating all techniques and technology with morphology, which refers to the histological classification of the cancer tissue.
Second Opinion
Advances in Cancer- Bone Marrow Transplant Haematopoietic stem cell transplant is very effective evolving field in cancer treatment, says Dr Niranjan N Rathod, Head of Department of Haematology & Bone Marrow Transplantation, Global Hospital - Super Speciality & Transplant Centre, Mumbai
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ndia’s first successful allogeneic bone marrow transplantation was done in 1983 at Tata Memorial Hospital, Mumbai. Our country has come a long way since then even in the field of hematopoietic stem cell transplantation (HSCT), the correct technical name for bone marrow transplant. Currently more than 10,000 such transplants are done worldwide. India has crossed 1000 transplant per year mark for first time in 2014. More and more transplant centres are emerging with newer generation of haematologist and oncologist trained in transplant leading the way ahead. As HSCT is extremely complex procedure, understanding it and its application in clinical practice requires certain level of experience and expertise. Significant medical infrastructure is required too. It includes facilities for isolation of these patients during their period of very low WBC counts. High-efficiency particulate arrestance (HEPA) filtered positive pressure rooms minimises infections with fungal spores in air. Due to immuno-compromised state out of chemotherapy and immunity suppressing drugs, these patient require antibiotics for preventing infections. Blood products used for transfusion needs to be irradiated to prevent immune hijacking of transplant recipients. Gamma irradiators are typically used for this purpose. Transplant physicians are using
less toxic chemotherapy conditioning regimens now. These are RIC (Reduced Intensity Conditioning) or non-myeloablative regimens, typically called mini-transplants. This type of transplants reduces chemotherapy associated toxicities and can be offered to patient with simultaneous medical conditions like heart or lung diseases and high age group patient, which otherwise would have got disqualified for transplants.
HLA Typing With advances in HLA (Human Leukocyte Antigen) typing, now the process can be performed using high resolution methods. This enables us to look for unrelated donors for transplant from various national and international donor registries. This is required for patient who needs transplant but do not have related HLA matched related sibling donors. These are called MURD (Matched
Unrelated Donor) transplants and typically are more risky due to higher risk of complications like GVHD, infections and so are more expensive. With more donors registering with national registries like Datri, MDRI, Bharat Stem cell registries; we are now finding many unrelated donors in India which substantially reduces time and money required in mobilising donor grafts for these MURD stem cell transplants. Public umbilical cord banks too, offer option of taking matched cord for transplant in patients not having matched donor. Umbilical cord transplant is much longer transplant due to slow engraftment of graft requiring specific ways to handle it and some of centres in India are now routinely doing it. Haplo-identical HSCT is another type of newer stem cell transplant where donor is half matched with recipient. As first degree relatives are all half matched, this enables everybody who needs transplant to get donor. However due to greater level of mismatches these transplant are more risky and requires experienced transplant physician to handle the transplant. To summarise, HSCT is very effective evolving field in cancer treatment and India is rapidly catching up with it. This is enabling larger number of our patient to receive such treatment in India at affordable prices.
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e-Government
eAushadhi
Setting benchmarks in Drug Supply Chain Management Innovation in government processes using IT solutions democratises citizen centric service. Maharashtra Public Health Department is changing the rules of performance in its drug inventory and supply management
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rug supply chain management has always remained a challenge in the public health systems with respect to its efficiency, transparency, tracking and reporting of various state priority parameters. Such a problem also posed in front of Public Health Department of Maharashtra, when the department envisaged and came up with a long term, comprehensive and effective solution. eAushadhi is a turn-key drug inventory management software which encompasses the entire drug supply chain management from drug warehouse to the end patient. The software was envisaged to bring about an overhaul in efficiency and transparency with which the drug distribution was managed. The software has automated all core and secondary processes related to the drug supply chain management and brought about a big change in the drug inventory management with its root level monitoring system, updated payment related
Innovation for Success
u Complete automation of supply chain management system. u Higher management monitoring Reports like Demand Forecasting, Supply status, Stock in hand, Stock forecasting u SMS & alert facility at different level of transaction. u Reorder level feature alerts the user in case drug is running short and needs to be re-ordered again multiuser and multi location storage facility is available in the application. u System is also configurable up to multilevel hierarchy.
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processes, tender statuses and PO management at central and local level. It also provides an array of related reports, dynamic reports and MIS reports for an n-degree review and monitoring of all direct and related parameters. The software is user friendly, easy to use and does not have any special requirements.
Process Innovation
Within less than a year of its commissioning the application has garnered appreciation and support from all its users and stakeholders on the impact made on drug supply chain management. Not only it has boosted morale of the officials at health headquarter by giving them the bigger picture at the state level via its MIS reports, it has seen a lot of success due to a deep engagement with end users. Benefits like deep level of monitoring, access to real time information and rates of medicines going down significantly themselves speak for the success of this application. The
e-Government
upcoming phase promises to be a lot more exciting with bar code systems for quality control and alerts system for escalations, service level agreements etc
From Idea to Implementation
The department then took a decision to go in for a comprehensive drug warehouse management system which will take care of the entire supply chain management too. With a view to overhaul the entire system, the department went through the options of having a COTS (Commercial off the shelf solution) or a custom build drug warehousing software. Based on the effort estimate, time and cost involved it was decided to go for an existing software and custom tailor it specific to the needs of the department. Drug warehousing software from CDAC (Center for Development of Advanced Computing) and was christened as “eAushadhi�. The Department, alongside, standardised its processes as per the Gap Analysis document and related business process re-engineering was done by CDAC. The BPR was primarily aimed at bringing more transparency, standardisation and seamlessness in drug warehouse management procedures.
Output and benefits
With the new software, ground level information started pouring in the software giving everyone from bottom to top a better and much more accurate view of the state of drugs warehouse and inventories across the state. This accurate root level reporting and monitoring has in fact been one of the major achievements of this application. Stock ledgers, as a result of this application, are now up to date and are managed much more efficiently. A separate MIS reporting module, keeping in mind the state health priority parameters and related decision making, was developed under the guidance of Health
Secretary. The MIS module covers critical reports like stock of essential drugs at all Public Health Centers, good receipt not issued in 24 hours, demand received but order not placed, tender status of all vital medicines, sample note tested for more than 21 days etc. More than 3,500 users are using this application regularly updating their information at more than 1,800 locations. The numbers are expected to grow to 5500+ users at more than 2500+ locations in another year. The deep involvement and constant engagement of users has been the driving point of success with this application. Status of medicines gets real time assessment by the department. Quality status is improved as separate interface is given to laboratories. The biggest achievement so far has been the reduction in the cost of medicines due to faster processing of payments.
Key Lessons
The vision has to be clear at the top. It was largely due to a very clear picture and long term vision of the State Health Secretary that this project could come into being in a very small time and so comprehensively. As we had tangible, feasible and measurable benefits to users: Without certain tangible and measurable benefits to users from an early stage, it is difficult to engage them and convince them to use the software. The more measurable the benefits are, the more interest it arouses in the users mind. User involvement makes or break a project especially the ones that involve IT. The project has been a great success due to an active and constant engagement of users with the application. As the numbers suggest, the project was successful on a large scale within first year of its use with 4,000 odd users at 1,800 odd locations. It is important to improvise the system to keep it relevant hence constant monitoring is the key to any project success. Without constant monitoring of the project parameters, an eye on the scheduled deliverables and making sure that the project requirements are adhered to at all times. The component of manpower in the key to last mile implementation and adoption of any project by all stakeholders and so a constant trainings and support cell was designed. e-initiatives in government fail a lot of times due to lack or little support from implementing agencies. Constant trainings and support from IT/ Project Management Unit are required from time to time to refresh users’ mind and remove any difficulty they have on operational basis.
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Start-up
Get Hospital-Like Care at Home HealthCare at Home (HCAH) is a service that complements the work done by the doctors in hospitals or clinics at home with sophisticated technology at an affordable price
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here are various medical conditions where it is more suited for a patient to get treated at home. With the concept of such services that are already popular in countries such as US and Europe, also a trending practice in India, HealthCare at Home (HCAH) incorporated the idea along with the corporate hospitals and doctors offering specialised home healthcare services. This Delhi-based company is a joint venture between the Dabur India’s promoter’s Burman family and Dr Gareth Jones and Charles Walsh, the founders of the UK based Healthcare at Home (HAH). Commenced on April 2013, it has presence in Delhi/ NCR, Chandigarh, Mohali, Punchkula, Jaipur, Bengaluru and targeting states such as Mumbai, Chennai, Hyderabad, Pune, Ahemdabad, Kolkata and Surat to have its footprints. The Burman family owns 65 per cent stake in the joint venture company and the 35 per cent Dr Gareth Jones and Charles Walsh. “The Burman’s has a committed capital of Rs 200 crore for first five years”, said
(L-R) Dr Gaurav Thukral and Vivek Srivastav
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Healthcare at Home India Co-founder and Chief Executive Vivek Srivastava. The servicesprovided by the company include oncology (cancer care), pulmonology (lung care), post-operative care (orthopedic, cardiac, bariatric, weight loss surgery etc), critical care and palliative care it also offers care for elderly care and medical companionship programme. The cost advantage is what attracts the patients. The company claims to provide identical services of a day’s ICU stay in a prominent hospital at half the price. The company provides the nursing and the support staff with a tablet with an installed its own developed Patient Care Service software to store critical date on patients, which is transmitted to the company’s back-end team and the treating doctors. “This helps doctors to monitor patients on a real time basis and make the necessary changes in treatment if needed”, Dr. Gaurav Thukral, Head, Medical Services, Healthcare at Home India. All the data of HCAH is accumulated in a single database. This helps in creating a complete patient history, with exact timelines, which can be shared with the doctors presenting them with a complete picture of patient’s condition. The joint venture presently employees nearly 250 employees and also plans to hire around 2,250 people by the year 2017. “We want to build this company to a thousand crore company by 2020 and to make panIndia presence in the next couple of years”, said Vivek Srivastava. For Further Information visit: www.healthcareathomeindia.com
Start-up
Connecting Dots of Medical Community Curofy is a medical networking mobile application that creates a network enabling communication between doctors pan India
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small town physician needs to connect and communicate with a super-specialist for patient referrals and second opinions. Also, there is a lot of dependency of private practice physicians on the doctors of corporate hospitals. Various specialities are inter-related for holistic patient treatment in its absence from a corporate set up, it becomes difficult to communicate with the right doctor. Therefore, understanding the essential need to connect doctors with each other, three IITian’s - Nipun Goyal, Mudit Vijayvergiya and Pawan Gupta co-founded Curofy they launched it on the play store in February 2015. The company started with 25 employees and still growing got funded through a live event on CNBC called TiE the Knot at TiEcon 2014, a conference organised by The Indus Entrepreneurs in last October. Rajul Garg (Sunstone Business School, Global Logic, Pine Labs), Alok Mittal (JobsAhead, Canaan), India Quotient, Spice Labs, Dinesh Agarwal (Indiamart), Dr Shuchin Bajaj (Cygnus Hospitals), and Presha Paragash (Zostel, Sol Primero) have invested in the company. “We started working in the healthcare sector with a medical tourism company. The business was lucrative and offered good margins just to bring in patients from overseas, but it thrived on a big inefficiency that doctors are not connected enough to each other. It was then we dropped the idea, took jobs with MNCs and continued researching about the concept of medical networking in India. Till May 2014, we met more than 1,000 doctors and the need was evident. We left our jobs and started with Curofy”, says Nipun Goyal, a co-founder of the venture. Curofy offers doctors a spam-free and secure environment to communicate with each other. Doctors can provide referrals, share cases, call other doctors without saving numbers and have access to most recent, specialitywise developments taking place in the fields of medicine, surgery and dentistry, thus providing them a platform for collaborative learning. Although being a doctor only app, it can be helpful for patients, as most of the secondary and
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tertiary treatment decisions for a patient are made by a doctor, who is either the patient’s relative, family doctor or a known physician. “We are continuously improving our verification process and when a doctor registers into the network, a mix of physical and technical tools help us identify the credentials”, remarks Mudit Vijayvergiya, another cofounder. According to the company, within the launch of the product over 4,000 doctors, including super-specialists from top hospitals like Medanta, Apollo, Max and Saket City and physicians from 100 cities, started using the app and actively using it amongst themselves; mostly for, finding other doctors in their speciality, locating old alumni and sharing cases. “Since we have launched the app, we have been approached by many pharmaceutical companies, hospitals and medical equipment manufacturers for partnerships. This clearly shows how valuable such a network can be for these players who spend billions of dollar to reach out to doctors”, says Pawan Gupta, the third co-founder. Curofy aims to be the largest health communication platform of the world by trying to disrupt the global health communication industry by building a healthcare vertical network taking a physician-centered approach. It also recently launched a Job Feed App providing relevant jobs based on doctors’ specialty, location and qualification with a single tap application process. For More Information Visit: www.curofy.com
Government Desk
AIIMS Patna Unveils Health Card AIIMS Patna has launched a scheme of health cards for patients which would cointain the medical history and could be accessed globally. The health card was launched by G K Singh, Director Patna AIIMS at a function. According to media reports, the card containing the medial history of the patient can be accessed anywhere in the world and would be connected to banks and insurance companies so that a patient could come to the hospital without cash and get treated. The card would also help in easy detection of fraud cases.
India, Mongolia to ink pact on cooperation in the field of Traditional Systems of Medicine and Homoeopathy PM Narendra Modi gave its approval for signing of a Memorandum of Understanding (MoU) for cooperation in the field of Traditional Systems of Medicine and Homoeopathy between India and Mongolia. The signing of the proposed MoU will enhance bilateral cooperation between the two countries in the areas of traditional medicine. This will be of immense importance to both countries considering their shared historical and cultural legacy, said a release by PIB. The MoU will provide a structured framework for cooperation between the two countries for the promotion of Indian Traditional Systems of Medicine and Homoeopathy in Mongolia. India has well-developed systems of traditional medicine including medicinal plants, which hold tremendous potential in the global health scenario. Traditional medicine is a significant component of Mongolian health care. ‘Sowa Rigpa’ is one of the Indian Traditional Systems of Medicine which is practiced in the Trans-Himalayan region and higher Himalayan parts of India. It is reported that a system similar to it is widely practiced in Mongolia as Traditional Mongolian Medicine. India and Mongolia have interacted through history over a period of 2600 years. Following the emergence of Mongolia as a modern nation state in the 20th Century, the two countries had continued to build relations based on shared historical and cultural legacy. In the recent years, the relationship between the two countries has been marked by close contacts at high level, including cooperation in the field of health and medicine. The Ministry of AYUSH as a part of its mandate to propagate Indian systems of Medicine globally had signed a MoU with the State Administration of Traditional Chinese Medicine (SATCM), China, Malaysia, Trinidad & Tobago, Hungary, Bangladesh and Nepal for cooperation in traditional medicine. Recently, a MoU on cooperation in the field of Traditional Medicine & Homoeopathy was signed with Mauritius during the visit of the Prime Minister to Mauritius in March. A MoU on cooperation in the field of traditional medicine has already been approved by the Cabinet for signing with Serbia.
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Government Desk
Government Allocates Rs 5,000 crore for Development of AYUSH The centre has allocated Rs 5,000 crore for the growth of Department of AYUSH, along with creating a new portfolio of AYUSH by launching independent National AYUSH Mission aimed at capacity building for the sector. The announcement was made during an event organised by Sandhu Pharmaceuticals in Mumbai. According to media reports, Union Minister of State for AYUSH Sripad Naik said that to create awareness about Ayurveda, the Ministry is considering observing Ayurveda Day. The AYUSH Mission will ensure creation of a centre of excellence for Ayurveda, Yoga, Unani, Siddha and Homoeopathy independently, he added. Naik also said that India and China use largest number of medicinal plants in the world. Traditional Chinese medicines have seen acceptance across the globe, but the Indian Ayurvedic medicines, which have seen a 25 per cent rise in its sales in the last ten years, the highest such increase in the world, are yet to gain global acceptance.
Government Sanctions Rs 61.59 cr for Telemedicine Project The government has recently sanctioned Rs 61.59 crore for telemedicine project to treat severely wounded personnel on board Indian Navy ships. This will ease the treatment as a specialist sitting far away can advise the best possible treatment through videoconferencing via India’s satellite ‘Rukmani’. According to media reports, a senior Navy official said that this would bring a revolutionary change in attending to severely injured patients in remote locations where a specialist is not available. He also explained that a doctor and a medical team is always on board when a ship sails out, specialists are available mainly on the bases. With telemedicine, a super specialist like a neurosurgeon can access the reports on his computer and give step by step directions to the general doctor on board via video conferencing. At present, the Navy has 133 ships, over 200 aircrafts and 13 submarines. The force has strength of 600 doctors, of which specialists would be around 300 and super-specialists around 100. The main is INS Ashwini in Mumbai which as the status of command Hospital. The other two are INS Sanjivani in Kerala and INS kalyani in Visakhapatnam.
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International News
Dehaier to provide Sleep Respiratory Systems to Sonqao Health Checkup
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ehaier Medical Systems has agreed to provide its sleep respiratory solutions to physical examination chain, Sonqao Health Checkup Institution. Sonqao, through its three physical examination centres in China’s Beijing and Inner Mongolia, provides physical check-up and personalised health management services. “Since early this year, hundreds of wearable sleep diagnostic systems we delivered to hospitals and private physical checkup centers have performed well with increasing use for patients for sleep disorders”, said Ping Chen, CEO,
Dehaier Medical Systems. “By the end of the first quarter, we have distributed 250,000 disposable PPG sensors to our regional agents that are actively delivering them to medical institutions all over the China,” he added.
Smith & Nephew Acquires two Software Assets from S2 Interactive
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mith & Nephew, the global medical technology business, has announced the acquisition of two software assets from S2 Interactive, a surgical software development company. Terms of the trans action were not disclosed. Following are the two software applications acquired by Smith & Nephew - Virtual Backtable (VBT) provides a visual map of each surgeon’s preferences covering patient preparation, planning and the surgical sequence. VBT also provides a learning management module that helps train new scrub technicians on the surgical sequence, instrument flow and tray layout – potentially reducing training time by as much as 40 per cent. TrayTouch improves the efficiency, and documents inspection of the central processing department that cleans, reassembles and sterilises the instrument sets prior returning them to the OR’s. Both the applications allow hospitals and ASC customers to access, analyse and manage real-time data related to instrument utilisation during surgery. This data allows central processing and operating room administrators to identify the instruments an individual surgeon uses during a specific procedure, assemble, prepare and streamline the instrument trays accordingly, and train the OR staff using interactive, visual layouts of each tray.
Omron Healthcare Launches Blood Pressure Monitor and Scale
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mron Healthcare, Inc., one of the leaders in home blood pressure monitoring, has announced the launch of a new blood pressure monitor and scale with connectivity via smartphone, tablet, or other gateway devices for telehealth applications. Both the devices can be easily connected to a gateway to transfer data and can be incorporated to Qualcomm Life’s medical-grade 2net Connectivity Platform, 2net Hub and 2net Mobile to capture and aggregate biometric data for transmission to virtually any third party application or portal. The new scale (HN-290T) has a measuring capacity of 550 pounds, covering almost all patients without compromising accuracy. Stepping on the scale automatically turns on the measurement mode while the large surface size enhances stability, and the large font displays easy to read results. The new blood pressure monitor (HEM-9200T) features simple and direct guidelines to ease the users’ experience and improve the quality of care. Features that can be captured and sent to a monitoring centre include one button operation for convenience, wide-range cuff to fit various upper arm sizes, and an irregular heartbeat detector. To ease the integration of Omron’s new devices with various telemedicine and telehealth solution platforms, Omron offers a StarterKit to system developers or solution providers. “These new products were designed to keep patients connected with their healthcare providers”, said Jim Li, Executive Director of Medical Affairs, Omron. These easy to use devices allow chronically ill patients the freedom to monitor their health in the comfort of their homes instead of travelling to a hospital, which can prove to be a challenge, he added.
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Company News
Apex Medical Makes a Debut into Indian Healthcare Market
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aiwan-based medical device manufacturing company Apex Medical Corporation officially launched their operations in India with their product verticals – Respiratory, Support Surface, and Autoclaves. With an initial investment of `100 crore, the company aims to market equipments to various hospitals and nursing homes. Apex Medical would venture into the Indian healthcare market with its products such as nebulizers in the field of respiratory therapy, bubble mattresses for bedridden patients and table top sterilization equipments for dentistry etc. Daniel Lee, CEO, Apex Medical Corp said, “We look forward to be a part of the continuously growing Indian healthcare industry and we see more opportunities with the new government that is willing to make a big change.” The ‘Make in India’ initiative by Prime Minister Narendra Modi and the market growing by 12-15 per cent every year, Apex is open to every option like joint venture with other manufacturing companies or acquiring small Indian companies, he added. The company invests five per cent of its annual revenue on research and development, also has a network of international subsidiaries and partners in Europe, United States, and other markets. “We are excited to introduce FDA and CE approved Apex products with technological excellence to customers in India at affordable prices with high service standards,” Puneet Sahai, President, Apex Medical India.
Remedinet’s App for Cashless Settlement of Health Insurance Claims Remedinet Technologies launched its electronic cashless claims exchange for health insurance mobile apps for Windows 8.1 and Android platforms with Microsoft Visual Studio, for making information on the status of cashless health insurances claims easily available to patients and hospitals. Insurance desks and resources working out of hospitals can download Remedinet - Hospital mobile app to access information regarding claims adjudication while patients can download Remedinet - Consumer app to check the status of their claims. Munish Daga, CEO, Remedinet Technologies said: “Today, information is accessible at the fingertips, and we are trying to play our small role by enabling both hospitals and patients to monitor the status of their cashless claims on handheld devices. The aim of this launch is to make the entire cashless claims process as fast, fluid, and efficient as possible. Without a solid technology backbone, achieving efficient and transparent transactions is next to impossible. Microsoft’s solutions and the Windows 8.1 platform have enabled us to build these future-ready apps, and this makes the process of claim settlement easier and more consumer-friendly.” The Hospital app allows authorised people from the hospital with valid user ID to log in anytime from anywhere and check the status of their claim. While, the consumer app provides the patients and their family to access the latest status of their cashless health insurance claim at kiosks installed in hospitals. The application is easy to navigate and information can be accessed by entering either the name of the patient or the reference number of the claim.
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Hospital News
Fertility Centre at Saket City Hospital in collaboration with Southend Fertility & IVF Saket City Hospital launched a fertility centre in mother and child block to facilitate better access to fertility treatment joining hands with Southend Fertility & IVF Centre. The centre was inaugurated by Jaya Bachchan, MP Rajya Sabha. The Southend Fertility & IVF Centre headed by Dr Sonia Malik (DGO, MD, FICOG) and supported by a highly experienced team of professionals runs infertility programmes in the northern region. It has been providing fertility solutions to childless couples since year 2000 with centres in NCR. “Considering the steep rise in cases of infertility in India in the past decade, and keeping in mind the expertise of Southend Fertility & IVF in handling such issues, this partnership will be greatly beneficial to not only people from adjacent areas but also to those across India and from abroad too,” says Dr. Garima, CEO, Saket City Hospital. According to WHO, infertility is the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Experts believe that lifestyle changes, poor dietary habits, stress, pollution and harmful radiations are the major reason behind the rising incidence of infertility. Talking about the collaboration Dr Malik said “We are looking forward to raising the already high standard of excellence and proficiency at Saket City Hospital by a few notches by providing the best available fertility solutions to childless couples”. “Novel medical advents like In Vitro Fertilization, ICSI etc are nothing short of a blessing for childless couples. The success rate of this treatment is as high as 30- 40 per cent,” she added. The infertility treatments available at the centre are the latest advanced techniques including IUI (Intra Uterine Insemination), IVF (In Vitro Fertilization), ICSI (Intra Cytoplasmic Sperm Injection), PIMSI, and IMSI (Intracytoplasmic morphologically-selected sperm injection).
Ruby Hospital to Establish 200 Bedded Cancer Centre, Rs 100 cr Investment Expected In order to provide better medical facility in Radiation Oncology in West Bengal, Ruby Hospital is coming up with a 200 bedded Cancer Center with advanced Radiation Therapy units. The hospital is expected to invest around Rs 100 crores, creating employment opportunities for more than 750 people. The facility will be operational by mid of August, this year with affordable medical services to middle class society. The centre would feature Radiation Machines such as FFF Varian Clinac IX, Rapid Arc Technology etc. According to a release by the company, the patients will gain benefit out of the modern technology as it will provide precision in Radiation Therapy and more dose of therapy without injuring the surrounding tissues. The hospital has also decided to provide the facility of free beds to 100 cancer patients in a year.
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Pharma Buzz
Government Approves FDI Proposals in Pharma sector
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Approved FDI Proposals in
PHARMA SECTOR Mylan Laboratories
BioMerieux India
Limited, Private Limited, ased on the recommendations of Foreign Investment Promotion Hyderabad New Delhi Board (FIPB) in its meeting held on 9th April 2015, the Central Government has approved four proposals of Foreign Direct `93.43 `124.00 Investment (FDI) in Pharma sector out of 19 proposals amounting to crore crore `2165.04 crore approximately. `128.77 Nil According to PIB release, proposals of Mylan Laboratories Limited, crore Par Formulations Private Limited (PFPL), BioMerieux India Private Limited and Curatio Healthcare (I) Private Limited were approved. Whereas, Par Formulations Curatio Healthcare (I) the proposals of Stericat Gut Strings Private Limited was deferred, and Private Ltd. (PFPL) Private Limited Vivimed Labs Limited tabled by the government. While, the proposal of Kusum Healthcare Private Limited (New Delhi), Sudeep Pharma Private Limited (Gujarat), Conress Labs (India) Private Limited (Hyderabad), and Sai Life Sciences Limited (Hyderabad) have been rejected.
Lupin Acquires Mediquimica in Brazil
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harmaceutical company Lupin Limited announced acquisition of 100 per cent equity stake in Brazil’s Mediquimica Industria Farmaceutica S.A. expanding its presence in the Brazilian market. The pharmaceutical market of Brazil has nearly doubled in the 2009-2013, expanding at a CAGR of 17 per cent, driven by growing public health expenditure and increasing household income. Vinita Gupta, Chief Executive Officer, Lupin Limited said, “We are very pleased with our entry into the Brazilian market through Medquímica. There are a lot of synergies to the acquisition and Lupin would not only leverage its research & technology strengths to build a high quality product pipeline but also use Medquímica’s commercial presence to expand business by targeting niche high-growth therapy segments. The acquisition is also a reflection of Lupin’s commitment to expand into the Latin American market and an important part of Lupin’s Emerging Markets play going forward.” Cristiano Boccia, Managing Director of Graycliff Partners, Brazil (one of the private equity shareholders of Medquímica) commented, “I am delighted with Medquímica joining hands with Lupin. We believe that Medquímica’s future and growth would be better served with the global business management and technology expertise that Lupin brings to table. It offers enhanced capabilities to roll out high quality pharmaceutical products which would benefit customers in the Brazilian market.”
Dr Reddy’s Unveils Somazina for Stroke Patients in India
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r Reddy’s Laboratories Limited announced the launch of Somazina, the innovator brand of Citicoline in the Indian market. The company has partnered with the global innovator of Citicoline, Ferrer Internacional S.A. of Spain, to make Somazina available in the country. This considered to be an important product in the management of stroke and has been used for the treatment of post-stroke patients around the world. Alok Sonig, Senior Vice President and Head of India Business, Dr Reddy’s said, “We are excited about the partnership with Ferrer and launch of Somazina which addresses significant unmet need in patients, whose quality of life gets severely compromised after having a stroke. Somazina has proven benefits in post-stroke rehabilitation and is a critical solution in fighting this debilitating disease. With the launch of Somazina and our recent acquisition of Nootropil, through the UCB brands’ acquisition, we look forward to building our presence in the Neurology segment and making a difference to the lives of patients who have had the misfortune to suffer a stroke.” Cerebral Stroke is the third leading cause of deaths in India, as per the Global Burden of Disease Study 2013. “Stroke is a major cause of disability and death in India. There is a pressing need for novel neuroprotective agents which can salvage brain tissue and optimize the functional outcome.” said Dr Subhash Kaul, senior neurologist from NIMS, Hyderabad.
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Product Launch
Clearvue Elite - New Affordable Ultrasound Solution from Philips
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oyal Philips has launched the ClearVue Elite range of affordable ultrasound solutions, demonstrating Philips commitment to expanding access to ultrasound by leveraging our innovations to develop clinically relevant solutions for ultrasound users in more places around the world. ClearVue Elite is designed with a high level of performance while ensuring simplified work flow at an affordable price. Understanding clinicians’ need for increased diagnostic confidence, the system comes with a new high performance linear probe, which provides enhanced border definition, color sensitivity and harmonics. A new generation PC powers the system resulting in faster processing, superior performance and better output, including faster 4D volume rates that aids in capturing fetal movements. The system features Philips proprietary Active Array technology that reduces bulky circuitry and integrates key broadband beamforming capabilities into the transducer, resulting in excellent image quality. Philips has further enhanced the imaging range by bringing in elements of reliability, scalability, performance and competitiveness. Reliability comes from the new robust and sturdy power supply and faster processing. Scalability comes from upgrade options; high performance meets high value and enhanced competitiveness in the complete product range. The equipment fulfills all these factors as it is equipped with improved hardware; this ultrasound system offers robust and sturdy power supply. Its intuitive user interface allows direct access to frequently used controls, thereby speeding image acquisition and hence improving the workflow. All this with an option to upgrade to 3D/4D Imaging, STIC(Spatio Temporal Image Correlation) and Auto face reveal. Ultrasound is a growing and disruptive technology and new advancements are emerging that continue to expand its use across the healthcare continuum. Advances in technology have created diverse roles for ultrasound in surgery, trauma, oncology, point-of-care and it is playing an increased its role in clinical decision support. The ClearVue Elite range was innovated at the PIC, the company’s innovation and technology hub in Bangalore.
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Product Launch
HPC Novel Parameter in Hematology Analyser
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eripheral blood stem cells (PBSC) are increasingly used to restore hematopoiesis as an alternative to bone marrow transplantation. It is important to determine the precise time for HSCs (hematopoietic stem cells) to be collected for a reliable, rapid and successful hematological recovery. HPC and HSC express high levels of the cell surface glycoprotein,adhesion receptor CD34. The levels of CD34 expression decreases with cell maturation and differentiation. Expression of CD34+ is thus a defininghallmark for HSCs andprogenitor cells (HPCs) in bone marrow, peripheral blood (PB) and cord blood. An accurate quantification of circulating CD34+ stem cells is important to decide the optimal time for collection. Flow cytometric enumeration of CD34+is the standard method of counting. The International Society of Hematotherapyand Graft Engineering (ISHAGE) gating strategy isused for CD34+ cell detection. An alternate method for quantification of circulating HSC minimises the number of CD34 determination, thus saving important resources. Since the introduction of the HPC software in 1997 in the high end Sysmex analyers, many studies of HPC determination versus CD34+ cell enumeration have been performed. The HPC parameter serves as an inexpensive and fast alternative for quantification of the circulating HSC Cells. Sysmex Corporation, Japan offers the latest and best technology in hematology analysers. Marketed in India, exclusively by Transasia Bio-Medicals Ltd., Sysmex offers a whole range of systems ranging from 3 to 6 Part Differential Analysers. Infact the newly launched Sysmex XN series is equipped with a White Precursor Cell (WPC) channel to differentiate abnormal lymphocytes and blasts by using the optical detection system and Fluoroscence flowcytometry. A study (published in December, 2013, in the International Journal of Laboratory Hematology) conducted by the scientists at the National Cancer Center Hospital (Tokyo, Japan) concluded that the HPC count obtained on a Sysmex XN analyser correlates accurately with the enumerated CD34 cells. Cells expressing the CD34+ and HPCs were compared in 76 granulocyte colony-stimulating factor (G-CSF) mobilised blood or apheresis samples taken from 18 healthy donors and 6 patients undergoing autologous PBSCT. CD34+ cells were isolated using MACS magnetic cell separation kits (MiltenyiBiotec – BergischGladbach, Germany). The investigators found a strong correlation between the numbers of HPCs and CD34+ cells. The expected total number of HPCs in the final product was estimated from HPCs in pre apheresis peripheral blood or mid apheresis product. This count was found to correlate well with the total number of CD34+ cells in the final products. Moreover, the change in HPCs in PB closely resembled that of CD34+ cells during mobilization. Further, studies using immunomagnetic beads suggested that majority of CD34+ cells existed in HPCs, and vice versa. The Sysmex XN analyser can carry out an HPC enumeration without the use of monoclonal antibodies. Sensitivity of flagging of blasts is enhanced in the WPC channel of the instrument. It gives a clear demarcation between the blasts and the abnormal lymphocytes. The total number of HPCs in the final products, as well as from pre apheresis PB and intermediate products during apheresis, can be used to predict the final amount of collected CD34+ cells. The detection and number of HPC in the peripheral blood could possibly provide a standard and rapid alternative for predicting the yield of stem cells collected by apheresis. HPCs may also be a good indicator to know the optimal timing for collection of the peripheral blood stem cells. The HPC count can thus be a useful potential parameter in optimizing timing for CD34+ enumeration prior to leukapheresis. No HPC detected
HPC detected
JUNE / 2015 ehealth.eletsonline.com
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Product Showcase
Carestream Earns Highest Rating for DRX-Revolution Mobile Systems and Room-Based DRX Systems
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arestream earned the top rating in MD Buyline’s Market Intelligence Briefing™ (2015 Q1) for both portable and roombased DR systems. Carestream’s DRX-Revolution Mobile X-ray System and its DRX-Evolution and DRX-Ascend systems earned high marks from customers for system performance, reliability, installation and service repair quality. The DRX-Revolution was the highest rated portable system and Carestream’s DRX room-based platform tied for the highest rating in the DR room category. MD Buyline reports for imaging systems are based on user satisfaction ratings in the following categories: system performance, reliability, installation/implementation, applications training, service response time and service repair quality. According to MD Buyline, “the DRX-Revolution boasts a unique system design with a collapsible tube column, tube/line visualization software, grid alignment, high kW power capacity, built-in caddies … and other progressive design features.” The report notes that many hospitals are adding Carestream’s small-format DRX 2530C cesium iodide detectors to meet the need for high-resolution imaging in the neonatal intensive care unit (NICU), as well as orthopaedic surgery and other applications. It also stated that “users praised Carestream’s customer service, troubleshooting and knowledgeable staff.” MD Buyline’s report on DR rooms commended Carestream for “adding an increased level of system flexibility and the ability to be more creative when tailoring an X-ray system to a specific site’s needs.” In addition, technologists stated that Carestream’s DRX detectors provide flexible solution with both retrofit kits and new systems.” The report also spotlighted excellent performance and customer satisfaction with Carestream’s family of DRX-1C and DRX 2530C cesium iodide detectors and the DRX-1 detector. Customers also commended Carestream for its “longstanding reputation for stellar service and support.” Carestream offers a full portfolio of in-room and mobile X-ray imaging systems as well as the ability to retrofit existing equipment. The DRX-Revolution optimizes imaging for inpatients and critical care areas with a small footprint and a long tubehead reach that provides easy access to patients in rooms crowded with bedside medical equipment. Carestream’s room-based systems offer automated, motorized overhead tubes for positioning convenience and productivity or non-motorized tubes for greater economy. Software and hardware features accommodate specialties such as pediatrics, orthopedics and trauma care.
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JUNE / 2015 ehealth.eletsonline.com
iCH Auto – A Holistic Healthcare Formula
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ppex’s iCH series CPAP system provides comfortable and flexible therapy modes with its stylish and attractive design. It is the perfect partner to support the patient and their prescribed treatment goals. The integrated heated humidifier provides comfortable, quiet and reliable therapy and for people on the move, this CPAP therapy system is lightweight, compact and very sleek. The iCH is a CPAP that doesn’t look like a CPAP and its elegant design allows you to place it anywhere in your home. The launch of the iCH series CPAP by Apex introduces a modern and exciting concept: The Holistic Healthcare Formula The product has no user-replaceable fuses. Even when travelling the patient does not have to use the converter for Apex’s CPAP systems can accept 100240V, 50-60Hz, without any special adjustment. An international plug adapter may be required to make the power cord compatible with the power outlets of that country. Apex’s XT & iCH series CPAP (except entry-level model) has Low Pressure alarm function. When there is a large leak, the device will show “Low P” on the display to remind user to check it. If the user activates the audible alarm function, the device will have a beep sound when showing “Low P”. Features/Benefits w Clinically proven auto-adjusting algorithm* w PVA pressure relief function w SD card & USB port for efficacy data retrieval w Stylish, high-quality design w Ultra quiet operation w Small footprint including heated humidifier