Health IT NEWS.Direct! journal by iLogy iLogy

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Health IT NEWS.Direct! Global Healthcare IT News, Research and Intelligence

CONTENTS Featured Article 5

10 mHealth Innovators Pioneering Community Healthcare Dr Chinmaya Chigateri

Industry Perspectives Editorial Advisory Board

Dr Grant Fraser Chief Medical Officer Medical Wizards Corporation

Making Mobile Health Happen Richard Cockle

Review Article 15

John Lightfoot Chief Technology Officer MedVentive Inc.

Battling Counterfeit Drugs using SMS Nakul Pasricha and Abhijit Acharya

Expert Opinion 19

Technology - an Enabler of Healthcare Connectivity Dr Adam Chee

Interview

Health IT NEWS.Direct! is a global Healthcare Information Technology (Health IT) journal providing research, news, and business intelligence services. We publish several market research and strategic industry reports with key information for top management and decision makers in the healthcare technology industry. Health IT NEWS.Direct! is used by leading healthcare technology companies, hospitals, insurance companies, and media houses from around the globe.

Designed and Published on behalf of Health IT NEWS.Direct! by iLogy Healthcare Solutions

Mobile Healthcare and the Law

Disease Management for Patient-centric Care

Dr Milind Antani

Laurens van der Tang

Mini Reviews eHealth

SA Health ropes in Allscripts for State-wide EHR plan worth A$408 Million

Orion Health Sets up HIE Capability at Florida Healthcare System

New York HIE Integrates with athenahealthâ&#x20AC;&#x2122;s EHR, Boosting Interoperability Measures in NY State

Products and Solutions

Merge Healthcare Spins Off Cloud-Based Image Sharing Solution

Indiaâ&#x20AC;&#x2122;s First Cloud-based PM/EMR System Launched on Apple iPad

Telehealth

Editorial Team

32 Managing Editor Dr B M John

Assistant Editor Amoolya Moses

Research Analyst Dr Raghavendra Rao Dr Chinmaya Chigateri

Insights

Ninety-five Percent Cite Enhanced Efficiency with RTLS: A KLAS Survey

Medical Data Breach Expenditure on American Healthcare Industry to touch $6.5 Billion Annually

Partners and Alliances

Design Veeresh Mathapati Abhilash A

Editorial process: www.healthitnewsdirect.com/?page_id=7

Disclaimer Views and opinions expressed in this publication are not necessarily those of iLogy. iLogy reserves the right to use the information published herein in any manner whatsoever. While every effort has been made to ensure accuracy of the information published in this edition, neither iLogy and its employees nor its information vendors accept responsibility for any errors or omissions. Further, iLogy and its information vendors do not take any responsibility for loss or damage incurred or suffered by any reader of this journal as a result of accepting any invitation/offer published in this edition. No part of this publication may be reproduced in any form without the written permission of the publisher.

TTA and NFC to Add Value to Continua’s Interoperability Efforts

Vendor Watch

Attunity’s RepliWeb-MFT to Secure Information Exchange Among CCCI Partners

News

For advertisements and reprints: sales@healthitnewsdirect.com Terms of use: www.healthitnewsdirect.com/?page_id=9

Ohio Medical Center Deploys Telestroke Technology from REACH Health

Brief alerts on current news

Radiologists Seek Clarity on Meaningful Use through KLAS and RSNA Survey

Jayex Leverages InterSystems Ensemble to Provide NHS Patient Kiosk

January - March 2012

FEATURED ARTICLE 10 mHealth Innovators Pioneering Community Healthcare Dr Chinmaya Chigateri Research Analyst, Health IT NEWS.Direct!

Unparalleled challenges, like increasing healthcare cost and urban-rural discrimination in its access, at the global, state, and territorial levels have led to innovative responses by healthcare stakeholders. These responses, raised to aid governments in their efforts, include a combination of advocacy, and cutting-edge technology that have a social impact. In the healthcare domain, the leveraging of mobile technology to improve accessibility, quality of care, and consumer awareness has been on the rise. Investors, funding agencies, and regulatory bodies have displayed their interest in the innovative ideas conceived by many mHealth companies to tackle longstanding healthcare problems. Among the vast ocean of innovations that the healthcare industry witnesses on a daily basis, we have attempted to profile ten mHealth companies that base their novel ideas on creating a social impact to the community as a whole. *

Connecting Physicians in Developing Countries Switchboard The healthcare worker-patient ratio is high in many developing countries - 1:10,000 in Ghana when compared to 1:415 in USA. Health professionals in resource stricken countries, especially in the African continent, face enormous challenges in delivering healthcare due to the lack of knowledge-sharing through collaborations with other physicians and specialists. In view of this, not-for-profit organization, Switchboard has innovated and designed a program called MDNet. Enter MDNet, a free mobile service for the network of physicians across Ghana and Liberia who are registered with the Ghana Medical Association and the Liberian Medical Council. MDNet helps doctors communicate with each other for peer advice during emergencies and complex medical situations, incorporating specialist care, and patient referrals. While the calls and texts are free within the MDNet network, the services are charged as per the provider tariff when made outside the physician network. The program, in addition, provides a doctor directory that assists in expanding the advisory and referral network of care providers. Its Ensemble Bulk SMS platform helps the government send out public health alerts and notifications in real-time when compared to an average of 10 days for a paper memo. With this service, a study has revealed that, physicians are increasingly consulting better qualified and more experienced doctors for advice. This has improved healthcare delivery indicators like physician connectivity, consultations, referral consultations, and success in diagnosis and improved patient recoveries. The innovative model has induced interest among corporate grant schemes, the latest of them being a $250,000 grant from Google.org to connect healthcare workers in Tanzania. Founded: 2011 Headquarters: San Francisco, California Website: www.switchboard.org *The companies here are profiled in no particular ranking or order.

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January - March 2012

Enforcing Licensed Medical Care Shimba Technologies With a population of about 41 million, Kenya has a severe shortage of doctors. According to a 2008 WHO report, the density of physicians per 10,000 population is about 1.4. This has lead to a large-scale quackery practice in the country, which has in turn affected the quality of healthcare delivered to patients. In a bid to challenge this shortcoming, the founders of Shimba Technologies decided to leverage the nation’s 25 million mobile phone subscriber base to raise awareness and create a channel by contacting legitimate and licensed medical professionals through the doctor directory. The app also features a suite of health services like first-aid information, symptom checkers, and relevant alert services that can be customized to a subscriber’s needs. The content reaching the subscribers is said to originate from credible sources like regulatory bodies, recognized private sector players, academic institutions, and licensed general health practitioners. As a free app, MedAfrica has witnessed an enormous response with an estimated 25,000 downloads since its launch in November 2011. Shimba Technologies is planning to expand this service pan Africa and include additional features. Founded: 2011 Headquarters: Kenya Websites: www.shimbamobile.com

Drug Reference Database for Healthcare Professionals Epocrates, Inc Epocrates has simplified a knowledge process that would heavily rely upon the healthcare professional’s capability to remember information. A comprehensive drug information database, accessible on mobile devices, like mobile phones and laptops, provides caregivers with ready information on drug dosages, drug interactions, and adverse effects. The clinical content information team, comprising of practicing doctors and pharmacists, source the information from the BMJ Group and American Medical Association (AMA) to provide end users with accurate, objective, concise, current, and clinically relevant drug information. Epocrates’ offerings also include a disease reference, diagnostic tools, medical dictionary, and medical billing codes. These databases are programmed to be accessed through various mobile operating system platforms like iPhone/iPod, Blackberry, Palm, Android, and Windows Mobile. Epocrates has recently entered the EHR space with a web-based SaaS model offering, specially designed for solo and small practices. The company claims to cater to over 1.4 million healthcare professionals, which includes 50% of physicians in the US. Founded: 1998 Headquarters: Ewing, New Jersey Website: www.epocrates.com

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FEATURED ARTICLE

January - March 2012

AIDS Awareness through Mobile Phone Gaming ZMQ Software Systems The HIV/AIDS epidemic, affecting approximately 34 million people (as of 2010), has claimed an estimated 25 million lives worldwide (across three decades). Fueled by the belief that HIV/AIDS can be prevented, although not cured, ZMQ rolled out the first ever initiative aimed at its prevention through mobile phone games. This commitment started as ‘edutainment’ programs in schools, but the success seen was limited in the extent of its reach to the masses, especially the under-privileged. Leveraging the potential of mobile devices in gaining access to a mass population on an individual basis and also as the universal medium of entertainment, the company created four games under the ‘Freedom HIV/AIDS’ banner, making the approach not only educative, but also engaging. With an acceptance across more than 9 million handsets on the first day of release in December 2005, 10.3 million game sessions have been downloaded in India within a period of 15 months. The company then replicated this impact in the African continent (Tanzania, Namibia, Uganda, Mozambique, Malawi, and Kenya) and South East Asia. ZMQ also provides m-CST, an application that includes a record of lab tests, patient history, nutrition planner, and drug and dosage alert. Headquarters: India Websites: www.zmqsoft.com www.freedomhivaids.in

Mobile Phones that help you See Better MIT Media Labs Poor vision affects every aspect of an active human being’s daily life. Globally, there are over 2 billion people with refractive error, which is estimated to lead to a significant drop in productivity by US$88.74-133 billion. Although many people in the developing world are aware of having vision abnormalities, accessing a specialist (ophthalmologist or optometrist) with sophisticated, expensive equipments can be difficult. In an attempt to address this need, MIT Media Labs developed Near-Eye Tool for Refractive Assessment, or NETRA-G for short. NETRA-G is a $2 eyepiece attached onto a smart phone carrying the testing app. To obtain the refractive error, the patient needs to peer through the eyepiece and align the red and green parallel lines on the screen using arrow keys on the phone. The app then generates a prescription for near and farsightedness, as well as astigmatism. Furthermore, through its cloud-based Test2Connect platform, patients can link up to service providers like eye hospitals, providers, opticians, pharmacies, and other allied services. Prototypes of the award-winning NETRA-G have been implemented at 29 research teams across 14 countries. Founded: 1985 Headquarters: Cambridge, Massachusetts Websites: www.media.mit.edu web.media.mit.edu/~pamplona/NETRA

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January - March 2012

App that Assists those with Speech Disability Intuary Inc Conceived out of a need to make a difference in a classical singer’s life who lost her speech due to amyotrophic lateral sclerosis (ALS), Intuary Inc. launched the Augmentive and Alternate Communication (AAC) app for iPad called Verbally. The app adopts the predictive text technology to assist people in completing words and phrases based on the initial letters or words typed by them. In effect, the app has been devised in a classical manner to significantly reduce the number of steps to construct a meaningful sentence. The app includes a repository of 50 most commonly used words, and 16 most commonly used phrases in English, built over time in expert consultations with computational linguists and speech therapists. Subsequent to constructing the sentence, a ‘Speak’ button plays the phrase out in either a male or female voice. Despite all the efforts, Ajay Godhwani, CEO, Intuary, recounts the sad demise of the very inspiration of this project, his aunt, one month before the app was launched. In her memory and as a commitment to the community of people suffering from similar adverse conditions, the company has decided to always have Verbally as a free downloadable version, making Intuary a company with a social impact and responsibility. As of July 2011, the app has been downloaded more than 28,000 times since its launch on the iTunes store in March 2011. In addition, it has earned an average 4.5 rating by 80 reviewers who tried and tested the app. The company also offers a paid premium version of the app with customizable features on the iTunes app store. Currently compatible with iPad on iOS version 3.2 or higher, Intuary has plans of making this available on other mobile devices and in languages apart from English. Founded: 2010 Headquarters: San Francisco, California Website: www.verballyapp.com

Conclusion Social entrepreneurships are a value addition to society’s efforts that aim to address some profound issues existing among us. It is encouraging to witness a large number of companies and agencies with a social impact agenda addressing some of the healthcare industry’s challenges. Although it may be argued that these companies require better exploration, considering the infancy in their endeavors, it should in no way negate their potential to continue creating change and impact public health.

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January - March 2012

INDUSTRY PERSPECTIVES Making Mobile Health Happen The world has an unprecedented opportunity to revolutionize healthcare. A bold statement? Yes, but one founded in fact. For the first time in history, a clear majority of the world’s people have access to telecommunications, and increasingly the Internet; thanks to the dramatic expansion of mobile networks over the past five years. These networks now cover more than 90% of the world’s population1 and serve more than six billion mobile connections worldwide.2

Richard Cockle Project Director GSMA

Governments, private companies, and development agencies could use these networks to dramatically increase access to healthcare, vastly improve efficiency, and engage patients directly in the management of their own health and wellness. Harnessing mobile connectivity could literally revolutionize healthcare. However, the speed and scope of this revolution will depend upon the development of scalable, interoperable, and patient-centered mobile health solutions. Today, mobile health is in its infancy. The Asia-Pacific mobile health market, for example, will be worth less than US$500 million in 2012 and will grow by 70% a year to reach US$7 billion in 2017, with India accounting for US$540 million, according to estimates by consultancy firm PricewaterhouseCoopers.3 Given the enormous potential of mobile health, you might expect the market to grow even faster. However, in practice, the deployment of mobile health solutions will often be a complex process dependant on many different stakeholders working together. At GSMA, we believe that the realization of the full potential of mobile health will require the adoption of common standards across the world, the development of open, interoperable systems and devices, and strong partnerships between mobile operators and healthcare providers. What is mobile health? First, we need to define what we mean by mobile health. The concept encompasses a wide variety of different products and services (Figure 1), ranging from simple SMS reminders and call centers to the creation of completely new capabilities that can support clinical transactions. Today, application developers and mobile operators are using voice calls, SMS, and web browsers to deliver mobile health alerts and reminders, as well as symptoms and treatment data. For example, in India, Aircel and Tata Docomo’s Doctor-on-Call services enable a panel of doctors specializing in various fields to give advice to callers. In Hong Kong, the Mobile Link Service run by mobile operator CSL Ltd. and the Senior Citizen Home Safety Association (SCHSA) supplies elderly people with a simple one-button mobile device, they can use to contact a SCHSA call

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January - March 2012

center if they need help. If necessary, the device can identify its location, which the SCHSA can then relay to emergency services. Since its launch in 2008, Mobile Link has handled over 40,000 cases and helped around 500 elderly people in critical conditions to access emergency hospital treatment.4, 5 Some pioneers are also integrating mobile connectivity with medical devices to facilitate rapid diagnosis, ongoing management of health and wellness, and remote monitoring. In China, for example, remote monitoring specialist, Ideal Life Inc., has partnered with telecom operator, China Unicom, and drugs and medical equipment supplier, Novatech Biopharmaceutical to deploy connected health equipment in communities. Individuals can use the equipment to measure their blood pressure, weight, blood glucose levels, and other biometric readings. The resulting data is wirelessly transmitted to a remote information management system, which can be accessed by the individual’s healthcare provider to assist in providing timely and appropriate care-related decisions.6 In a more futuristic vein, Imec of Belgium recently unveiled a body patch, containing an ultra-low power electrocardiogram (ECG) chip, a Bluetooth short-range radio, and a 3D-accelerometer, to monitor physical activity. The data captured by the ECG and the accelerometer is processed and analyzed locally, and relevant events are transmitted via Bluetooth to a mobile device, such as a smartphone, which can then relay that information to the individual’s healthcare provider.7 Sensors and radios are even being embedded into pills. Researchers at the University of Florida have developed a standard-sized pill capsule containing a microchip and digestible antenna. When the pill is swallowed, it transmits information to an electronic device carried by the patient. The device can then relay the signal on to a mobile phone or laptop to inform physicians or family members that the

patient has taken the medication.8 While these innovative services and technologies highlight the immense potential of mobile health, they are typically a discrete solution to a specific problem and lack the economies of scale that will be needed to drive down costs and fuel a healthcare revolution. As these solutions tend to be vertically integrated, closed, and bespoke, it becomes virtually impossible to integrate products and devices from other vendors into an existing solution. Furthermore, few mobile health solutions can be deployed across national boundaries, so developers often have to start from scratch. In other words, most existing mobile health solutions are islands cut off from each other. In search of standards This fragmentation is partly down to a shortage of technical standards. As there is no single standards organization that covers the complete needs of mobile health, the technical architectures in use today have typically been built using an array of components, based on overlapping or unsuitable standards. For example, the existing standards (IEEE 11073) for the transmission of blood pressure reading between two lowlevel devices in a basic binary data format, and the transfer of this data into human-readable format using health messaging standards (HL7) aren’t suitable for mobile health solutions. They contain transport mechanisms that don’t apply to mobile networks, and cumbersome coding standards that are hard to process on low-power mobile devices. These issues are compounded by gaps in the standards, which make it difficult for technical architects to create fully interoperable mobile systems. The standards’ relative immaturity and the speed at which mobile health is developing, mean that the developers adopting the current mobile health standards often end

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INDUSTRY PERSPECTIVES

January - March 2012

up grappling with missing or limited functionality. This issue has been addressed by organizations, like the Integrating the Healthcare Enterprise (IHE) and the Continua Health Alliance, by offering interoperability guidelines that categorize standards into profiles (Figure 2). However, there is still some way to go before the mobile health sector has a fully interoperable set of standards that is adopted universally.

In essence, the emerging mobile health standards face a classic ‘chicken or egg’ situation. The success of any standard depends on its widespread adoption. However, most mainstream developers don’t prefer to be the first to implement new standards due to the risk of them being inappropriate. For this reason, it will take time for mobile health standards to gain the critical mass needed to create the kind of network effects enjoyed by GSM or Internet Protocols (IP).

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Bridging the technology gap To realize the full potential of mobile health, healthcare providers are going to need to open up their IT system architectures and use a standard interoperable interface to share information between backend servers. To encourage widespread adoption, healthcare IT systems will also need to adopt common interfaces that will enable new devices to easily feed them information. In other words, mobile health devices need to be ‘plug and play.’

Until healthcare ICT systems are completely standardized, mobile operators will have to work with a variety of healthcare platforms and systems. What’s the best way to do that? GSMA is advocating the use of a mobile health gateway or robust centralized integration engine, which is positioned between the healthcare systems and mobile network (Figure 3). Although this integration component could

Health IT NEWS.Direct!

January - March 2012

take on many forms, its principal function would be to bridge the technology gap between mobile devices and networks, and healthcare systems. This approach would help standardize the mobile health component of the solution - the only configuration needed would be for the integration of a medical records interface into the legacy healthcare ICT systems.

population-by-2010/17793. Accessed December 30, 2011. 02. Global Mobile Connections To Reach Six Billion Milestone, With Asia Pacific Accounting For Half, Reports GSMA [news release]. Hong Kong: GSMA; November 16, 2011. www.gsma.com/articles/ global-mobile-connections-to-reach-six-billion-milestone-withasia-pacific-accounting-for-half-reports-gsma/20871. Accessed December 30, 2011. 03. Asia Pacific will Dominate the Connected Device Market, Fuelled

Cross-industry collaboration In summary, the mobile industry and healthcare sectors are going to need to work together to develop scalable and interoperable technical platforms that will be needed to bring about a revolution in healthcare. Close relationships between mobile operators and healthcare providers would also pave the way for mobile health solutions to take full advantage of the mobile industry’s highly efficient provisioning, management, set up, and billing processes. Over the last 2 decades, the mobile industry has gained much from a common standards approach, which has promoted the economies of scale, lower costs, innovation, and ease-of-use. GSMA believes that mobile operators and healthcare providers should work together to attempt to create a similar robust technical platform for the delivery of mobile health services.

by Explosive Growth in China, says GSMA [news release]. Hong Kong: GSMA; November 16, 2011. www.gsma.com/articles/ asia-pacific-will-dominate-the-connected-device-market-fuelled-byexplosive-growth-in-china-says-gsma/20873. Accessed December 30, 2011. 04. Mobile Link Service Wins Four Titles in Hong Kong ICT Awards [news release]. Hong Kong: CSL Limited; February 10, 2009. www. hkcsl.com/en/pdf/2009/Mobile_Link_Service_Wins_Four_Titles_ in_Hong_Kong_ICT_Awards(ENG)-with%20photos.pdf. Accessed December 30, 2011. 05. CSL – Mobile Link Service. GSMA Embedded Mobile. Accessed December 30, 2011. 06. IDEAL LIFE Inc partners with Shandong bio-tech firm Novatech to launch Remote Healthcare Monitoring System in China [news release]. Hong Kong: IDEAL LIFE; November 26, 2010. www. ideallifeonline.com/newsroom/Press_Release_ENG_IDEAL_LIFE_ Nov_26.pdf. Accessed December 30, 2011.

Underpinned by rock solid standards, mobile healthcare could eventually become as ubiquitous as mobile connectivity is today.

07. Imec unveils innovative technology for an ECG patch, combining an ultralow-power ECG SoC with Bluetooth Low Energy [news release]. San Diego, CA/Leuven, Belgium: Imec; October 10, 2011. www2.imec.be/be_en/press/imec-news/ecgpatch.html. Accessed

References

December 30, 2011.

01. Mobile Networks to Cover 90% of the World’s Population by

08. Rx for health: Engineers design pill that signals it has been swallowed

2010 [news release]. Singapore: GSMA; October 17, 2006. www.

[news release]. Gainesville, FL: University of Florida; March 31, 2010.

gsma.com/articles/mobile-networks-to-cover-90-of-the-worlds-

news.ufl.edu/2010/03/31/antenna-pill-2. Accessed December 30, 2011.

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January - March 2012

REVIEW ARTICLE Battling Counterfeit Drugs Using SMS Introduction Counterfeit medicines are a serious problem, affecting the lives of thousands of people worldwide each year. A cost-effective scalable solution is required in order to combat the issue, and the rapid proliferation of mobile phones provides an appropriate platform upon which such a solution can be built. This article goes into the background of the issue, and describes the way in which mobile phones can be used in a developing country, such as India, to battle counterfeit drugs.

Nakul Pasricha Vice President – Operations PharmaSecure

The World Health Organization (WHO) has defined the problem: “А counterfeit medicine is one which is deliberately and fraudulently mislabeled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and counterfeit products may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging.”1

Counterfeit medicines and their impact on public health On an individual level, the public health risk of counterfeit medicine is as high as their contents could be dangerous or lack active ingredients. This may result in treatment failure, increased drug resistance in cases of antimicrobials, or even death. On the other hand, for a public health system as a whole, difficulty in tracing the manufacturing and distribution channels of counterfeit medicine makes their circulation difficult to stop. As per a WHO (2010) fact sheet, even a single detection of counterfeit medicine in the system is dissatisfactory, since it exposes the vulnerability of the country’s pharmaceutical supply chain; worse still, eroding the credibility of the national health enforcement agencies.2

Abhijit Acharya Product Manager PharmaSecure

WHO’s response against counterfeiting The public health and economic challenges posed by spurious/falsely-labeled/ falsified/counterfeit (SFFC) drugs were first brought to the international agenda in 1985 at the WHO Conference of Experts on Rational Drug Use in Nairobi, Kenya. The meeting set guidelines for WHO along with other international organizations and NGOs to examine the feasibility of establishing a clearing house to gather information and inform governments about the nature of counterfeiting and its extent.3 The focus on counterfeiting led to the creation of the International Medical Products Anti-Counterfeiting Taskforce (IMPACT) through the Declaration of Rome in February 2006.4 Types of medicines being counterfeited Virtually all categories of medicines have been counterfeited in various countries, especially in the developing world.5, 6 Counterfeiting is found in both branded and generic products, with some containing similar compounds as the original

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January - March 2012

active product, while others either very little of the active compound or a totally different compound that may be harmful when consumed.4, 7 Some of the categories, as described by WHO, under which counterfeited drugs may be classified are given in Figure 1.8

WHO put together reports of counterfeit medications from various countries sent to them from 1999 to 2000, and concluded that virtually no class of medicine was left out by counterfeiters (Figure 2).9 Figure 2: Counterfeit drug reports by therapeutic class received by WHO

government of India has taken certain measures to protect the health of both the Indian and global consumers in the form of regulations and mechanisms. The menace of counterfeit drugs is recognized as an issue by the Indian government as well as by manufacturers, and efforts have been underway to institute regulations and mechanisms by which their proliferation can be slowed or stopped. For drugs to be exported from India, the Directorate General of Foreign Trade (DGFT) has regulated barcoding at three levels of packaging (tertiary, secondary, and primary) in a phased manner starting October 1, 2011 for tertiary; July 1, 2012 for secondary; and January 1, 2013 for primary. This step will go a long way towards ensuring that drugs manufactured in India can be tracked and traced all the way to their destination of export, thereby avoiding infiltration of the supply chain en route. Manufacturers are in the midst of implementing these regulations.11, 12 For domestic production, the Drug Controller General of India (DCGI) has constituted a taskforce to recommend the best mechanism of protection. This taskforce is expected to frame guidelines in 2012. Protection mechanisms Traditional mechanisms to deter counterfeit drugs in the domestic market have been as follows:

during 1999 - 2000

Holograms: This is the most common method used by manufacturers to protect their products. A hologram unique to the manufacturer is sourced and affixed onto every package sold in the market to identify it as an original. This is a cost-effective solution (a hologram typically costs about `.0.02-0.04 [0.037-0.07 cents]), but has the disadvantage of being a one-way protection and a mechanism that is easily replicable. That is, a consumer has no way of knowing precisely what a manufacturerâ&#x20AC;&#x2122;s original hologram looks like, as opposed to the one affixed onto a counterfeit drug that may closely resemble the original. If a consumer has a concern at the time of purchase, he/she has no immediate channel to clear any doubts.

Tackling the menace: Indian scenario The 2009 Report on Countrywide Survey for Spurious Drugs, released by the Central Drugs Standard Control Organization (CDSCO) of India, outlines the level of counterfeit medicine to be around 0.04% in the market.10 While this differs from estimates from other sources, there is significant concern regarding the increasing number of cases of drugs turning out to be substandard. The

Advanced physical protection mechanisms: These include security inks, nanotechnology, and other covert mechanisms that can be detected by specialized equipment and used to expose a counterfeit drug. While these mechanisms are very secure and difficult for a counterfeiter to break, they are again one-way and are quite expensive to implement, making them unfeasible for most manufacturers in a pricesensitive market such as India. Field enforcement: Specialized organizations, often

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REVIEW ARTICLE

January - March 2012

consisting of former law enforcement or military personnel, offer their services, in conjunction with local police forces, to manufacturers in leading raids on suspected counterfeiting operations. These raids often lead to arrests and closures, thus providing some relief. While this is an extremely important activity that must be encouraged and expanded upon, it does not immediately help a consumer purchasing a drug from a retailer. The mobile solution for India India is the land of the mobile phone. According to the Telecom Regulatory Authority of India (TRAI), as of October 31, 2011, there have been 881.40 million mobile phone subscribers in the country.13 This makes mobile phone, by far, the best medium for communication, helping reach out to any individual, especially in geographically remote rural areas of the country. Mobile phones have already been used to disseminate information about government services (e.g. passport application status) and achieve financial inclusion (e.g. opening of bank accounts in villages), not to mention entertainment by means of value-added services such as ring tones or sports scores. They can now be used to save lives by providing a cost-effective and scalable solution for drug authentication at the point of sale.

reasonable length of time; where ‘reasonable’ is of course subject to the scope of the coding mechanism. For example, PharmaSecure has been using 9-character codes that give a total potential code universe of almost 27 trillion. • Usability: Consumers should be able to easily type in and SMS the code for verification. This means that an especially long code may have the drawback of increasing error rates and hence defeat the purpose. Therefore, it is of crucial importance to optimize code length across all three of the above attributes. Implementation methodology The process for implementing this solution involves four steps (Figure 4). Figure 4: Stages of implementation

Unique coding and SMS authentication The idea behind SMS authentication is simple: put a unique, random, alphanumeric code onto every single strip, bottle, or vial of medicine sold to a consumer, and provide a mobile number to which that code can be SMSed to determine authenticity. Figure 3: PharmaSecure coded drug

The code should have the following attributes: • Security: It should not be easy for a counterfeiter to guess or replicate. This is achieved by using randomly generated, alphanumeric codes. • Scalability: Since every single unit in a batch gets its own code, there must be enough codes available to cover the entire spectrum of production for a

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However, there are some intricacies to be tackled in order to ensure a robust solution, as listed below. 1. The code generation and transmission technology must be built using the highest standards of security and stability. The generation of billions of codes is a colossal task that warrants the need for adequate hardware and software that can facilitate the same. 2. The printing of codes onto packages must be done using the best quality printers that are seamlessly integrated into the code transmission software. As the pharmaceutical industry is required to adhere to strict domestic and international guidelines, it must be ensured that there is no disruption to the manufacturing flow at any stage, and all necessary validations (e.g. 21 CFR Part 11) are well understood and complied with. 3. When a consumer sends in an SMS, the cost must be affordable (around `.3-4; similar to premium

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short codes may not be acceptable). Additionally, the consumer must receive the response within seconds so as for him/her to really derive the benefit of authentication before leaving the pharmacy. 4. In a developing country such as India, there should exist a backup of an inbound call center in situations where the required level of comfort with SMS is missing.

References 01. Guidelines for the development of measures to combat counterfeit drugs. Switzerland, Geneva: Department of Essential Drugs and Other Medicines. WHO; 1999. 02. WHO. Medicines: spurious/falsely-labelled/ falsified/counterfeit (SFFC) medicines. Fact sheet. www.who.int/mediacentre/factsheets/ fs275/e. Accessed December 14, 2011. 03. WHO. Spurious/falsely-labelled/falsified/counterfeit (SFFC) medicines. www.who.int/medicines/services/counterfeit/en.

Benefits In addition to the primary benefit of empowering consumers to confirm that they are buying an authentic drug, this solution also has the benefit of establishing a two-way channel of communication between the manufacturer and consumer, or the government and consumer. This channel can be used to disseminate important drug safety information, educate the consumer about the particular ailment he/she may be suffering from, and inform about key government public health initiatives. It is really a platform that makes the consumer a participant in his/her own health plan, what is known as ‘Interactive Medicine.’

Accessed December 20, 2011. 04. IMPACT Secretariat at AIFA. IMPACT – The Handbook: Facts | Activities | Documents developed by the Assembly and the Working Groups 2006-2010. International Medical Products AntiCounterfeiting Taskforce; 2011. 05. Gibson L. Drug regulators study global treaty to tackle counterfeit drugs. BMJ. 2004 Feb 28;328(7438):486. 06. Impact of counterfeits on pharmaceutical industry - counterfeiting poses threats to patient safety and revenues of pharmaceutical companies. companiessandmarket.com. www.companiesandmarkets.com/ Market-Report/impact-of-counterfeits-on-pharmaceutical-industrycounterfeiting-poses-threats-to-patient-safety-and-revenues-ofpharmaceutical-companies-617800.asp?prk=7c4ed5b510c1ffe12b 50d9829eddaba2. Published June 10, 2011. Accessed December

Current scenario Over the past two years, mobile phone-based solutions for combating counterfeit drugs have become better understood and accepted. PharmaSecure is currently coding more than 100 million drugs for domestic production, projected to rise to over 300 million in 2012. In addition, companies such as Kezzler, Sproxil Inc., and HP Labs are offering such solutions. Sproxil, for example, has been providing scratch-off labels to manufacturers and distributors in Africa, and is now offering similar solutions in India. Kezzler has a 15-character code solution that has been in use by some manufacturers in India for the past 1-2 years. With the growing need for such solutions, and imminent regulations to protect domestic drug distribution, the advent of new providers can be anticipated in the coming years.

14, 2011. 07. Morris J, Stevens P. Counterfeit Medicines in Less Developed Countries: Problems and Solutions. London, UK: International Policy Network; 2006. 08. General information on counterfeit medicines. WHO. www.who.int/ medicines/services/counterfeit/overview/en. Accessed December 14, 2011. 09. Effective medicines regulation: ensuring safety, efficacy and quality. WHO Policy Perspectives on Medicines – Issue 7. Geneva, Switzerland: WHO; November 2003. 10. Report on countrywide survey of spurious drugs. India: Central Drugs Standard Control Organisation; January 2011. 11. Deferment in the date of effect for implementation of bar-coding on export consignment of pharmaceuticals and drugs for tracing and tracking purpose. Gazette of India Extraordinary Part I, Section I - Public Notice No. 59(RE-2010)/2009-2014. New Delhi, India: Directorate

Conclusion Counterfeit drugs are a global menace, and it is time to take aggressive measures to prevent the proliferation of this menace. The rapid growth in mobile phone usage provides the opportunity to do so in a low, cost-effective, and scalable environment. Uniquely coding drugs and enabling them to be authenticated via a simple SMS may be just the solution to facilitate consumers to verify the authenticity of the medicine purchased. It is important for both manufacturers and the government to seriously evaluate the potential and take the right steps to put this power in the hands of the consumer.

General of Foreign Trade, Government of India; June 30, 2011. 12. Deferment in the date of effect for implementation of bar-coding on Primary and Secondary level packaging on export consignment of pharmaceuticals and drugs for tracing and tracking purpose. Gazette of India Extraordinary Part I, Section I - Public Notice No. 87 (RE2010)/2009-2014. New Delhi, India: Directorate General of Foreign Trade, Government of India; December 22, 2011. 13. Highlights of Telecom Subscription Data as on 31st October, 2011

[news release]. New Delhi, India: Telecom Regulatory Authority of India; December 8, 2011. www.trai.gov.in/WriteReadData/trai/ upload/PressReleases/849/Press_Release_Oct-11.pdf. Accessed December 6, 2011.

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EXPERT OPINION Technology - an Enabler of Healthcare Connectivity Technology or the application of knowledge, tools, and processes to solve practical problems and extend human capabilities has been fundamentally ingrained into our society and our progressive quest for evolution. The invention of electricity, the light bulb, the telephone, and most importantly till date, the Internet, has elevated our society and existence to a higher plane than we could imagine a decade ago. This is the importance of technology in our lives.

Technology versus science

Dr Adam Chee Chief Advocate binaryHealthCare

It is important, however, to differentiate between science and technology. Science is the accumulation of knowledge, while technology is the application of knowledge; science attempts to answer the question of ‘why’ while technology answers the question of ‘how’. It is therefore obvious that technology plays a much vital role in our society than science. One need not necessarily master the laws of nature in order to harness it via applications beneficial to our daily lives. After all, current science does not explain everything (and its aspects tend to be rectified over time), but the application of the laws of nature just gets better overtime, due to the pursuit of ‘perfection’ by technologists.

Science and technology in healthcare Healthcare as a discipline is intertwined with the intricacies of science and technology from cutting edge research, in the hope of uncovering the essence of life (the why) and the deployment of cutting edge medical devices to aid in disease treatment and care (the how). One cannot imagine that anything less than stellar is to be adopted in the healthcare industry. It is precisely such misconceptions that this article aims to decipher. Technology, in all its wonders, can only serve as an enabler; the ultimate determining factor of success and innovation (depending on the matrix of measurement) should always be the human element. The ‘garbage in, garbage out’ (GIGO) algorithm coined in the field of computer science is, in my opinion, the best descriptive term available. The inappropriate utilization of technology will not miraculously set wrong things right, but will merely spew out the mistakes in a faster and greater magnitude.

Technology in healthcare For technology to function, the consumption of resources is required. These resources include; people, information, materials, tools and machine, energy, capital, and time; and there is no standard equation in determining the ratio of these elements, it depends on the context presented. These restraints or factors, serve as part of the assessment criteria in selecting the most appropriate technology for the given environment.

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It is important to understand that in the selection of appropriate technology, it need not always be the latest or greatest technology available that matters (we must learn to filter the bells and whistles). We need to rather, strive to understand the underlying paint-points and then develop the solution to address the needs by utilizing the most affordable technology available with the ability to deliver the greatest return on investment (ROI) in terms of benefits and value to the healthcare provider (it need not always be for clinicians) and the patients.

Technology as an enabler of healthcare connectivity Mention connectivity in healthcare, and most healthcare informatics professionals will think of interoperability issues between the silos of clinical information systems implemented in hospitals/healthcare enterprises. This area has long been examined and explained: the lack of enforcement in standards (e.g. HL7, DICOM, and IHE) and clinical coding (e.g. ICD-9, 10) in a properly defined structure, coupled with underlying political struggle between the various clinical disciplines on ‘turf issues’, are the main culprits. Let us look beyond the passé debates, and instead, focus on what the new technological wave of Web 2.0 has brought forth. You might have guessed it by now, I am talking about mobility, the new definition of connectivity in healthcare.

Imagine a seamless workflow where healthcare professionals (e.g, medical physician) can access any device, anywhere and retrieve the last accessed state. To provide an example: “A physician is reviewing a patient’s EMR records (in his office, at the 9th level) off his desktop computer, and based on the information at hand, he decides to head down to the ward (at the 5th level) to inspect the patient. All he has to do is leave his office and his desktop computer would ‘lock-down’ (as he would be carrying a RFID chip with him, an out-of-range detection would automatically activate a secure ‘lock-down’). Once he arrives at the ward, he grabs an available tablet unit at the nurse’s station and swipes his identification tag (containing the RFID chip); and the tablet would automatically login to his profile, presenting to him, his last accessed state – all his programs, and the applications are left exactly the way it was before he left his desktop computer. The physician is able to head straight to the patient, perform his inspection/treatment, and update the records on the tablet. This enables him to resume work immediately, wherever he is, and exactly where he left off. Of course, when he is done, he just returns the tablet back at the nurse’s station, which will automatically log-off from his profile upon an out-of-range detection. Now, imagine that the same ability is provided to his Smartphone or any other device left on standby in the healthcare enterprise.” Wouldn’t the above scenario grant medical physicians and potentially any paramedical professional, the true freedom of mobility in their course of work? Futuristic? Not exactly! The technology described is available today and within an affordable reach. Now, mull over the benefits that will be translated to the patients!

Mobility in rural care Mobility as a basis for effective workflow With the proliferation of low-cost, light-weight, and function-rich tablet devices, advancements in unified communications that integrate real-time communication services (instant messaging, telephony including IP telephony, video conferencing, call control, and speech recognition) with non-real-time communication (e-mail, fax, and short message services [SMS]), add the emergence of low-cost, location independent cloud computing to the mix, and suddenly, the rules and boundaries of mobility are being redefined, even as this article is being written.

An excellent real-life example of utilizing the most affordable technology that delivers the greatest ROI in terms of benefits and value to both the healthcare provider and patients, thus truly utilizing technology as an enabler of healthcare connectivity, would be the Global Health Bridge (GHB) project. GHB developed a health information system based on the mobile phone that will allow community healthcare workers in developing countries (e.g, India and Bangladesh) to offer incessant care delivery and follow-up, even in

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the most rural regions of the world. Let us examine the underlying factors that qualify for its success. • Cell phones are extremely affordable and commercialized technology, readily available for procurement. • Cell phones are readily available to rural residents in India and Bangladesh (as well as other developing countries). A study by LIRNEasia found that in about 80% of Indian households that are economically at the bottom of the pyramid, one member uses a mobile phone. This is shared with other members of the family, with almost half of these households sharing the phone with non-family members as well, at usually no expense to the user.1 • The usage of a cell phone is intuitive by design, not requiring any complicated or lengthy training. The existing rate of cell phone adoptions in developing countries (see the point above) also means that most of the users are already familiar with the usage of a cell phone. This breeds familiarity and reduces resistance in the adoption (change management). • The scope of the pilot project covers maternal and fetal health, with the following objectives: ДД Remind: Automatically, daily reminders are sent to mothers and village healthcare workers about prenatal and postnatal visits and what information they need to focus on during that visit. ДД Report: Rural healthcare workers will be able to input information about patients, eliminating the need for paper records. This also speeds up information update (eliminates geographical and distance challenges), as well as potential data errors due to illegible handwriting (either due to bad handwriting by the scriber or damage of paper records during transportation).

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ДД Connect: Relevant patient records can also be accessed instantaneously regardless of the location, speeding up patient care. The solution also serves as a ‘central server’ through which caregivers will be able to connect with each other, patients, and affiliated organizations/government. Should the project scope demand high consumption of bandwidth, for example, for accessing ophthalmic images (provisioning of ophthalmic care for remote rural Indian populations is also an emerging need), then the whole project would no doubt be classified as an inappropriate adoption of technology, simply due to the cost of bandwidth required to transmit the medical images (of huge file size). However, in view of the context presented, as well as considering the resource factors of people, information, materials, tools and machine, energy, capital, and time, for rural healthcare in developing counties, GHB is an excellent example of the utilization of the most affordable technology to deliver the greatest ROI in terms of benefits and value to a healthcare provider (it need not always be for clinicians) and patients. In conclusion, remember, technology serves as an enabler and not as the end goal. It can definitely serve as a great enabler in healthcare connectivity. References 01. Tekes, Finpro. 2009. Village Communications in India: A new booming

market [White paper]. Retrieved from http://194.100.159.181/NR/ rdonlyres/EBFC77D5-EA58-4C43-BBD1-96C999BE371B/12847/ RVillageCommWhitePaper091123ENUv4.pdf.

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INTERVIEW Mobile Healthcare and the Law Q. What are the laws that cover mobile health activities? How stringent are these laws in the current day practice? A. There are no specific laws which govern the process of providing medical guidance through mHealth. What would be applicable are those laws which govern a normal patient/doctor relationship. The question of liability of the application provider would be governed by contract law. In fact, the patientâ&#x20AC;&#x2122;s rights are basically indirect rights, which arise or flow from the obligations of a physician or healthcare provider under the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. Dr Milind Antani Head - Pharma & Life Science Nishith Desai Associates

The basic principle is that medical doctors and associated medical professionals are responsible and liable for wrongs and failures in the performance of their medical duties towards patients. In India, generally, Section 304-A of the Indian Penal Code (IPC), 1860, is the relevant provision under which a complaint against a medical practitioner for alleged criminal medical negligence is registered. Section 304-A provides that whoever commits culpable homicide not amounting to murder shall be punished for life or imprisoned for a term up to 10 years and fined as well. Section 337 of the IPC deals with hurt caused by an act endangering the life or personal safety of others. However, the simple lack of care attracts only civil liability. Therefore, only civil negligence may not be enough to hold a medical professional criminally liable. Q. What are the possible legal liabilities that we could expect with the delivery of health through mobile phones? What are the legal aspects that physicians practicing mHealth should be aware of? A. Negligence and possibility of malpractice is what the providers of mHealth services should be aware of. The courts in India have generally followed the decisions and practices of the English law. The cases of negligence in India are directly related to existing facilities, infrastructure, and level of acumen of medical professionals. In many cases, doctors have been held liable for negligent acts, such as removal of a wrong eye or a kidney, or surgery on wrong limb, based on pecuniary interest or where minimum facilities were available. In this regard, an important example is of eye camps or health camps where operations are performed without proper facilities. The Supreme Court of India in its landmark judgment in the Indian Medical

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Association vs V.P. Shanta1, laid down the law relating to professional negligence under Consumer Protection Act 1986, and enunciated certain principles that medical practitioners, government hospitals, and private hospitals and nursing homes are also covered under the consumer law in the following categories:2 1. Where services are rendered free of charge to everybody availing of the said service 2. Where charges are required to be paid by persons availing of services, but certain categories of persons who cannot afford to pay are rendered service free of charge

so may form the basis of liability.

The services provided in the first category by doctors and hospitals would not be covered by the services under section 2(1) (0) of the Consumer Protection Act, 1986,3 but those rendered by the second and third categories of doctors and hospitals would be covered within the ambit of the service defined in the above provision of the Act.

A. To answer this question, it would entirely depend upon what the doctor has communicated to the patient. From a legal point of view, any recommendations or advice by a doctor shall not constitute a prescription; however, courts have allowed doctors to recommend in acute emergency cases.

Q. What could be the consequences of malpractice by a physician outside the geographical jurisdiction treating a patient remotely?

If the patient already has an established relationship with the physician, there is a risk, just as there is if the physician takes a phone call over a standard landline. When the physician is asked a question of a professional nature, he’s being called upon to make a professional judgment and recommend a course of action to deal with the patient’s problem. In the diagnostic effort or the recommended therapy, one could make a mistake. When there is the possibility of a mistake, that’s where malpractice risk arises. On the other hand, if there was no prior relationship between the two, there is greater risk.

A. In the past, courts would use the standard of the particular locale where the tortuous act took place, invoking the so-called ‘locality rule.’ This was based on the belief that different standards of care were applicable in different areas of the country, e.g., urban or rural. However, this rule has been largely abandoned in favor of a uniform standard, because medical training and board certifications all adhere to a national standard. Telemedicine has further propagated this uniformity. With the erosion of the locality rule, courts now readily allow out-of-state experts to testify on behalf of the opposing parties. This has been especially helpful for plaintiffs who are far less likely to be able to secure willing experts from the local community. Geographical considerations are not entirely irrelevant. Where the local medical facilities lack state-of-the-art equipment or specialists, courts will look at the existing circumstances. However, there is always the duty to refer and transfer to an available specialist, and the failure to do

In a key decision on this matter in the case of Dr Laxman Balkrishna Joshi vs Dr Trimbak Bapu Godbole, the Supreme Court held that if a doctor has adopted a practice that is considered ‘proper’ by a reasonable body of medical professionals who are skilled in that particular field, he or she will not be held negligent only because something went wrong. Q. How will a technology as dynamic as telecommunication be able to abide by privacy and security issues?

If X is Y’s doctor and Y has been X’s patient and Y has been communicating his condition, and if they decide to engage in communication via smartphone, the communication isn’t different, just the mechanism differs. The symptoms are still spoken about and advice is being given on that basis. If with a patient, the doctor doesn’t have a relationship and the doctor doesn’t have a great deal of history or information to help, it becomes a harder job to do. The treating doctor is bound by the code of ethics regulations

AIR 1996 S.C. 550

Id. at 563-6

processing, supply electrical or other energy, boarding or lodging or

Section 2(1) (0) Provides: ‘Services’ means service of any description

both, (housing construction), entertainment, amusement, or purveying

is made available to potential users and includes the provision of

of news or other information, but does not include the rendering of

facilities in connection with banking, financing, insurance, transport,

any service free of charge or under a contract of personal service.

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prescribed by the Medical Council of India regarding the confidentiality of information pertaining to patients. At the same time, doctors have to abide by the Information Technology (Reasonable security practices and procedures, and sensitive personal data or information) Rules, 2011. Q. Do you think that there should be an additional certification for healthcare professionals to practice mHealth? Will there come a time when mobile devices would have to be certified by regulatory bodies like FDA and CCHIT? A. Though additional certification may not be necessary for doctors practicing on mobile health platform, new regulatory changes are likely to come. Q. Do you think that the lack of a regulatory framework is a deterrent to technological advancements in tele or mobile healthcare delivery? A. Lack of a clear, regulated, and mandated structure would allow for a leeway to utilize the loopholes of the law to the advantage of the mHealth service providers. While this can promote an atmosphere of proactive competition, it should

not reach a stage where any monopolistic tendencies come into existence or worst of all, if the patient is not getting any healthcare promised by the companies. So, while at the international scenario, it can be said that there is adequate regulatory framework, the same cannot be said for India. Proper regulatory framework should definitely help the telemedicine industry. Q. What in your opinion is the way forward to meeting these regulatory challenges, globally? A. Various mobile technologies are creating an explosion of mHealth solutions and devices. While foreign regulatory bodies have already taken steps to provide a structure, the same cannot be said of the Indian equivalents. Thus, when a system is established abroad and is effective, the Indian bodies may adopt the same, which would be beneficial to the mHealth providers and the patients/users as well. To meet the possible challenges, one way would be to set up a means of communication between regulatory bodies of different countries and try to implement best practices from all over. As mentioned earlier, to have a comprehensive law covering telemedicine in India is the need of the hour.

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Disease Management for Patient-centric Care Q. Please share your perspectives on the chronic disease management healthcare scenario in India vis-a-vis the global scenario? A. Most, if not all countries are still learning how to deal with the chronic disease challenge. In that sense India is no exception. However, the challenge in India is probably larger than anywhere else in the world, partly because of the enormous population, and partly because of the way the healthcare system works in India. Healthcare in India is reactive. People come to the doctor when they feel they need to, and the doctor tries to help as many patients as he can in an hour. Chronic disease management requires a very different attitude. It is all about proactive and disciplined health management. That is a very different game! Laurens van der Tang Chief Executive Officer Vital Health Software

Q. Within the chronic disease management segment, which are your focus areas? A. First of all, we focus on providing nurses with smart tools with built-in decision support that are based on guidelines to check patients. We also help create individualized health plans with personal objectives. Secondly, we enable multidisciplinary teams to share data. Thirdly, we enable self-management by patients. Last but not the least, we provide reports on outcomes and other parameters and allow clinics to benchmark themselves. We are focused on providing disease management software solutions that are enabled. Q. Patient-centric care is the main focus the world over. How does chronic disease management help achieve this goal? What would be the next phase beyond chronic disease management in empowering patients with their own care? A. First of all, by being proactive rather than reactive. Patients really appreciate providers who watch their health carefully. Then, every patient should get an individualized plan, tuned to their specific needs and possibilities. The plan should cover all health aspects and not be limited to just one disease. Patients should also be encouraged to engage in managing their own health, using a self-management portal. Personalized education is a key aspect of this. Over time, more monitoring can be done at home using advanced remote devices. Q. What is the role played by chronic disease management software solutions in chronic disease care? A. In most countries, the first step is to ensure that patients are being checked at least quarterly based on guidelines. Often it makes sense to set-up specialized clinics to facilitate this. Patient education is to be included in this stage as well. The next step is to measure and evaluate outcomes and use this as a source of

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continuous learning. Another step may be to allow patients to access their data through portals or supporting more complex multi-disease patients. All this is only possible if supported by advanced software solutions. Q. Having a strong global footprint, how do you place the Indian market in terms of size, opportunities, challenges, and trends? What would be your focus areas in the Indian market? What do you think are the market prospects for disease management companies in a country like India? A. The Indian market has great potential, but is currently still relatively small and extremely complex. However, we fully expect that the market will evolve quickly, and we see a lot of potential for impact in this market. Our focus in India will be on supporting specialized clinics for people with chronic diseases, primary care networks and mental health institutions. The Indian healthcare sector is growing at a CAGR of 13 and is predicted to keep at this pace for the next 10 years. There is an increase in the number of hospitals and beds for every hospital chain. Q. Despite India being the second largest mobile phone market after China, with 811.59 million subscribers, and

a respectable 16.2 million internet/broadband users in 2010, why havenâ&#x20AC;&#x2122;t these two modes been exploited to its fullest to deliver care? A. Because it requires new models of delivering care, which are based on different financial models. That takes time. I see the same in other countries. Q. Could you provide us with as insight on the savings that hospitals can realize by adopting personalized health management? A. Initially, it is going to be an investment, and the returns are going to be in terms of improved quality of care, increased patient satisfaction and stronger ties to patients, organised medical records, and new revenue channels like patient portal. Q. What do you think is going to be the future of technology-enabled disease management solutions? A. I see several major trends. First and foremost, there will be a significant move to self-management using mobile devices. Secondly, I expect that more and more attention will be paid to people with chronic diseases other than diabetes. Think about alzheimer, depression, addiction, cancer, and others.

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eHEALTH SA Health ropes in Allscripts for State-wide EHR plan worth A$408 Million Allscripts has been chosen by SA Health and the Commonwealth Government of Australia for its $408 million eHealth project, the Enterprise Patient Administration System (EPAS). Through this agreement, Allscripts will provide the Sunrise Enterprise™ suite as the EPAS solution, for the creation of the statewide electronic health record (EHR) system. SA Health, the public healthcare system of South Australia, constitutes clinics and hospitals that serve a population of 1.6 million. In an attempt to provide seamless and realtime access to patient information, SA Health has chosen Allscripts, a Chicago-based health IT company, as a vendor of choice for its clinical, financial, and access management suite of solutions. The Sunrise Enterprise is developed on an open platform called Helios, a healthcare ecosystem that provides the means to manage information. The Helios-based system has the advantage of enabling easy integration with third party systems through a single platform. The features included in this suite are EHR/computerized physician order entry (CPOE), medication management, clinical content solutions, revenue cycle/access management, and performance management. Sunrise Enterprise’s fully integrated EHR for acute care will act as the EPAS, which will form the foundation for the Australian EHR project. Considered one of the largest projects undertaken so far, the EPAS would be installed for all networking activities across the state’s urban and rural healthcare facilities with the aim of providing an EHR to each person, which would be connected across all public hospitals and health service centers in the state. According to a fact sheet released by SA Health, as a requirement of the national eHealth strategy, the EPAS is meant to provide the following benefits to the healthcare system at large: • Complete and consistent access to electronic healthcare records at the point-of-care • Replace obsolete and stand-alone legacy databases and systems spread across the healthcare system • Connectivity among public healthcare centers across the state • Standard operating and treatment protocol for

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healthcare delivery across SA • Reduce expenditure in receiving, evaluating, and transferring paper-based records • Help save costs through reduction in manpower and maintenance For clinicians and other healthcare provider personnel, the EPAS would facilitate the following: • Improved coordination, speed, accuracy, and efficiency of clinical treatments and processes due to seamless transfer of patient information across the healthcare network • Real-time clinical decision-support, and means to monitor and follow-up patients effectively • Reduced diagnostic test duplication • Ability to manage patients on waiting lists effectively and help in managing bed transfers effortlessly • Option to carry out seamless online referrals, thereby maintaining the continua of care • Reduced cost of capacity building on independent legacy systems for healthcare personnel The complete EPAS solution would be initially rolled out in all metropolitan hospitals, and other sites will follow suit in 2012 with some going live in 2013. This agreement completes the 2010 agreement when Allscripts was selected by SA Health for the Commonwealth Government’s initiative of deploying an integrated EHR across 80 urban and rural hospitals. This announcement was followed by pre-production software license agreement to enforce multi-disciplinary strategy, a pre-production testing environment and ‘clinical working parties’ (at least 14) in preparation for the designing and creation phase of the program. The clinical working parties included leaders from various regions, specialties, facilities, and scope of practice, assigned to experiment with the solution at the test labs. The current agreement follows closely a string of successful business deals for Allscripts’ EHR this year; with clients who include Lompoc Valley Medical Center, California; DMC Children’s Hospital in Michigan; and Scripps Health in San Diego; to name a few.

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Orion Health Sets up HIE Capability at Florida Healthcare System St. Vincent’s HealthCare has roped in Orion Health™ for its Health Information Exchange (HIE), to enable connectivity between disparate software systems and various facilities within its entire enterprise, and allow interactions among community physicians. Florida’s not-for-profit St. Vincent’s HealthCare includes St. Vincent’s Medical Center, St. Vincent’s Primary Care, St. Catherine Labouré Manor, and St. Luke’s Hospital, along with consolidated laboratories, and Seton and consolidated pharmacies. Apart from its own associates, the Healthcare System, founded in 1916, is also a member of Ascension Health, considered the country’s largest nonprofit health system, having over 113,000 associates serving across 500 locations in 20 states. In an attempt to equip its facility with the capability of seamless and real-time viewing of patient histories, St. Vincent’s chose Orion Health as its preferred vendor. Owing to its userfriendly, scalable, and flexible Software-as-a-Service (SaaS) feature, the HIE solution, has the capability of integrating across a wide range of disparate systems. This choice was also made to help attain meaningful use criteria for the American Recovery and Reinvestment Act of 2009 (ARRA) incentives. Orion Health’s HIE includes an enterprise master patient index (EMPI), Rhapsody integration engine, data repository, customizable notifications, physician and Clinical Portal, analytical and quality reporting tools, and provider index. While the solution’s Clinical Portal enables a single view of patient data within and between organizations, facilities and regions, its integration engine allows electronic data exchange and inter-system messaging. Healthcare provider coordination enabled through the solution will further aid in disease management programs and abiding by best-practices guidelines. In addition, physicians associated with St. Vincent’s will be able to transmit orders, normalize the review of clinical data, share discharge summaries, transcribed reports, send and receive lab results, etc. The current deal closely follows the deployment of the HIE solution at Pennsylvania’s Lehigh Valley Health Network (LVHN) for its three hospitals, over 40 primary and specialty

clinics, and nine health centers. Santa Monica, CA-based Orion Health focuses on integration and clinical workflow technology. With over 1,000 clients globally, the company offers its services to US Centers for Disease Control and Prevention, IB Salut of Spain, New Zealand Ministry of Health, South Eastern Norwegian Regional Health Authority, and Canada Health Infoway. A 2009 review (Suter E et al, Healthcare Quarterly) has identified the following universal principles for having successful integrated healthcare systems: 1. End-to-end services across the continuum of care through health and social care organization cooperation, multiple points of access to care, emphasis on health promotion, wellness, and primary care 2. Patient-centric care and population-based needs assessment 3. Geographically accessible care and rostering with minimum duplication of services 4. Standardized care services provided by interprofessional teams, evidence-based guidelines and protocols 5. Performance management 6. Information systems that collect, track and report processes, improve communication, and enable seamless data flow across the care continuum 7. Organizational culture and motivational leadership 8. Physician collaboration with single point of access or universal electronic patient record 9. Focused, strong, diverse governance and organizational structure that encourages collaboration 10. Financial management With the deployment of software and products from heterogeneous vendors, collaborations, mergers, acquisitions, and connectivity to external providers, the challenge faced by organizations is the integration of new systems with legacy systems. This in turn hinders the immediate access of critical patient data from disparate sources. Hence, the implementation of integration platforms forms an integral part of a healthcare organization’s IT strategies.

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January - March 2012

New York HIE Integrates with athenahealth’s EHR, Boosting Interoperability Measures in NY State Healthcare Information Xchange of New York (HIXNY) has linked its health information exchange (HIE) to athenahealth’s cloud-based electronic health record (EHR) platform. This development will allow athenahealth EHR, athenaClinicals® users to access the community health record of their patients on HIXNY’s HIE.

Apart from initiating connectivity with EHRs, HIXNY is also working on integrating its HIE with hospital information systems (HIS), case management systems, etc. It is currently partnering with Northeast Health to extract information from the HIE into the MEDITECH hospital system.

Watertown, MA-based athenahealth, Inc. provides cloud-based practice management (PM), EHR, patient communication, and care coordination solutions for physician practices. The KLAS top-ranked EHR includes Quality Performance Team that keeps clients informed on improvements on workflow, solution enhancements, and best practices. Additionally, the Quality Management EngineSM feature provides a dynamic database that can provide clinical know-how into patient encounters, and add value to the payfor-performance program criteria. The solution streamlines operations with its 5-stage workflow, which helps clinicians focus on patient care rather than data collection.

The EHR and HIS vendors that HIXNY work with to develop similar connections include eClinicalWorks, GE Healthcare, Greenway, HMS, iPatientCare, MDsuite, MEDENT, Meditech, NextGen, Siemens, and STI. Through this approach, while the vendors will manage program installation and training, HIXNY will aid the inpatient consent process. Scott Momrow further hopes that the current collaboration will ignite similar interoperability connections with other vendors.

Through the current contract, athenahealth’s EHR clients can also avail interoperability with HIXNY’s HIE, which is built on InterSystems HealthShare™. Although healthcare organizations are already using the HIXNY HIE, the difference now is that athenahealth’s users will have a twoway connection, enabling easy sharing and accessing of information with other providers who will be participating. In addition, aggregated community health data of patients can be availed by providers in native EHR systems. Enabling a seamless process, providers can benefit from improved workflow and scalable efficiency. HIXNY’s vice president, Scott Momrow states that HIXNY intends on providing multiple options for participants to access its services.

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HIXNY recently merged and combined forces with Adirondack Regional Community Health Information Exchange (ARCHIE), which was initially serving a region overlapping the geographic area of Capital Region and Northern New York. In addition, the HIE has contracted with New York eHealth Collaborative (NYeC) to deploy State Health Information Network – New York (SHIN-NY) 2.0 Services in order to connect regional health information organizations (RHIO) and extend interoperable data exchange across the state. The New York-based HIE, assigned by the New York State Department of Health as an RHIO, is an interoperable network of hospitals with more than 4,000 beds, 500member physician practices, more than 30 health plans, etc., across 17 counties within Northern New York and the Capital Region that can electronically exchange medical data.

Health IT NEWS.Direct!

January - March 2012

PRODUCTS AND SOLUTIONS Merge Healthcare Spins Off Cloud-Based Image Sharing Solution Merge Healthcare, a provider of interoperability and imaging solutions, has rolled out its cloud-based image sharing solution, Merge Honeycomb, to facilitate uploading, downloading, viewing, and sharing of medical images. Chicago, IL-based Merge Healthcare caters to 6,000 clinics and more than 1,500 hospitals in the USA, and has been serving the healthcare industry for over 20 years. The companyâ&#x20AC;&#x2122;s product range includes imaging solutions for cardiology, radiology, and orthopedics; and software for clinical trials, and preoperative management. Touted to be the largest medical image sharing network in USA, Merge Honeycomb was unveiled at the Merge Live 2011 Client Conference, and will be officially launched at the Radiological Society of North America (RSNA) Conference, to be held in Chicago in November, 2011. Merge Honeycomb is expected to provide solutions for a host of issues faced by the healthcare industry. Duplicate scans is about a $35 billion-burden to the industry, and exposes patients to dangerous, unnecessary radiation (A single CT scan of the abdomen is equivalent to 400 chest x-rays, according to the U.S. Food and Drug Administration and Center for Devices and Radiological Health.); these are set to come down significantly with this solution. At present, images are stored in data centers with limited access, and image transfer is done on CDs, a practice involving security issues. Often the CDs cannot be read, which may lead to life-threatening treatment delays.

Transporting images manually on CDs will not be necessary anymore, as images will become accessible to physicians whenever they need, via a web browser. The availability of images in real-time for authorized users makes possible early diagnosis and expedites treatment. According to Jeff Surges, CEO, Merge, cloud computing is being leveraged to promote co-operation among healthcare stakeholders, improve care delivery, and reduce costs. In general, companies are looking to transform the manual sharing of images by moving imaging into the cloud and making it available to not just the radiologist, but all concerned, including patients. A white paper by Symantec has identified that to address the costs of data storage (in compliance with HIPAA standards) and the increased amount of data being stored, there has been an increasing transition to cloudbased storage service vendors. A survey presented in the 2010 issue of Storage Magazine notes that 14% of the study respondents presently use the cloud technology for storage, while another study by the CIO Magazine finds that, in 2010, 26% of IT professionals were planning on using the services in the coming five years. Accounting for this demand, the year has seen the release of other imaging cloud services by Mitek Systems (Mitek Mobile Imaging Cloud [MIC] on mobile phones), SFR Business Team and FUJIFILM (SYNAPSE Cloud), and AT&T (AT&T Medical Imaging and Information Management).

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PRODUCTS AND SOLUTIONS

January - March 2012

India’s First Cloud-based PM/EMR System Launched on Apple iPad Pune, India-based Xtremum Solutions, a healthcare technology solutions and services provider, has introduced Praxify™, a physician practice management (PM) solution based on cloud, integrated with an electronic medical record (EMR) application suite on Apple iPad. A derivative of ‘Practice Simplify,’ Xtremum Solutions’ Praxify has been designed to address the mobility of physicians and anywhere-anytime access to patient medical data. The solution is built exclusively on the iPad platform, unlike other applications that are designed for web, and then made compatible with the iPad. Using this system, physicians will be able to access and view medical history, patient medical records, images, lab results and billing details, and prescribe medication on the go. It enables caregivers to streamline and automate their practices, manage patient interactions, and offer secured patient information at the point of decision through phone or direct consultations, in order to deliver efficient and error-free care. As a Software-as-a-Service (SaaS) offering, the solution eliminates the need for investments in computer systems, software licenses, servers, upgrades, and maintenances. At an average price of approximately ` 2 per patient, monthly, the solution is expected to lower costs incurred in administrative processes involving paper-based records, optimize patient reminders and scheduling; thereby, increasing revenues and overall productivity of healthcare providers. The data stored on Praxify can also be used for publishing research on evidence-based practices.

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Dr Lavanya Gali, a specialist in internal medicine and sleep medicine and one among the early users of Praxify, testifies on the comprehensibility of its core capabilities, user friendliness, and scalability to a wide range of practices from solo to corporate hospitals. Prashant Koirala, Director, SleepCare Solutions, further attributes the scalability and efficiency of the solution to its mobility features, easy-to-use interface, and a cloud-based delivery model, and acknowledges the potential of Praxify for a growing company like SleepCare. According to Kapil Khandelwal, Advisor to Xtremum Solutions, with high-speed 3G connectivity, and the introduction of affordable, lighter, user friendly and easy to carry tablets, physician mobility is experiencing a ‘tectonic’ shift. Now, with the launch of Praxify, 700,000 odd ambulatory practices that don’t rely on electronic medical records to store patient data can benefit with the availability of mobile connectivity and devices. A report by mobile research specialists, research2guidance, demonstrates that the penetration of smart phones is anticipated to reach 14 billion global users by 2015. The report also shows that 43% of mobile healthcare applications are developed primarily for healthcare professionals. Ralf-Gordon Jahns, Head of Research, research2guidance, highlights on the current trend of healthcare providers, as well as consumers adopting smart phones in order to enhance the healthcare experience. These numbers indicate ample growth prospects for the Xtremum Solutions’ Praxify.

Health IT NEWS.Direct!

January - March 2012

TELEHEALTH Ohio Medical Center Deploys Telestroke Technology from REACH Health According to the American Heart Association’s 2011 statistics, approximately 795,000 people have new or recurrent stroke every year. In the US, on an average, every 40 seconds someone experiences stroke. According to the Ohio Department of Health, stroke is the fourth major cause of mortality in the state. This high incidence and the lack of physicians to attend to such patients can be a significant challenge to the management of stroke. Further, the deficit limits both quality stroke care and clinical research initiatives. With these alarming figures in the background, The Ohio State University (OSU) Medical Center has decided to deploy technology from REACH Health, Inc. to expand telestroke capacities throughout its network of hospitals. Physicians in smaller centers will use this technology to consult neurologists in OSU Medical Center where they can examine and review patient information to help arrive at the best course of treatment. Columbus-based The Ohio State University Medical Center, an academic medical facility, nationally ranked by the U.S. News & World Report for its neurological department, specializes in epilepsy, stroke, neuro-oncology, movement disorders, multiple sclerosis, and memory disorders. Employing about 16,000 people, The Joint Commission (TJC)-certified stroke center encompasses a college of medicine, six hospitals, primary and specialty care practices, research centers, and 20 core laboratories. The current deployment of REACH will be leveraged by the network of hospitals, including Cambridge’s Southeastern Ohio Regional Medical Center, Coshocton County Memorial Hospital, and Barnesville Hospital. REACH, which stands for Remote Evaluation of Acute isCHemic stroke, is a web-based solution that provides clinical information for physicians to undertake consultation from any place. In addition to audiovisual communication, it enables exchange of CT images, labs, vital signs, NIH stroke scale, etc., for accurate diagnosis and appropriate treatment. REACH also enables hub (main referral center) and spoke hospitals (facilities in medically underserved areas [MUAs] or rural regions) to predict financial outcomes through ROI calculators; support the development of protocols and policies for acute stroke care, and ongoing

QA programs; and help in administrative process like billing, credentialing, and reimbursement. For stroke patients, for whom every second is vital, the real-time access to specialized care through telestroke technology will help eliminate travel time to OSU Medical Center. According to Michael Racke, Chairman, Department of Neurology, OSU Medical Center, REACH facilitates speedy contact and interaction between physicians and remote patients, leading to rapid assessment, enabling effective management of stroke cases. Treatment outcomes of stroke patients living outside central Ohio, in regions inaccessible to stroke experts, will improve dramatically, feels Sara Widing, Director, Neurosciences, OSU Medical Center. REACH Health, a privately owned corporation, enables neurology specialists to serve remote and underserved populations. It has been chosen as a Top 40 Innovative Georgia Technology Company in 2010. t-PA is considered the primary treatment modality for stroke; a 2006 study (Audebert HJ, et al; Stroke) indicated a more than 10-fold increase over earlier levels in the number of patients treated with t-PA. Having a 3-hour window, access to stroke care can be well achieved through the use of telestroke technologies. A 2007 study in The Journal of Emergency Medicine illustrates the influence of REACH, deployed at the hub Medical College of Georgia, on 50 patients presenting at rural emergency departments from February 2003 to March 2006. REACH was able to help initiate treatment with intravenous (IV) recombinant tissue-plasminogen activator (rt-PA) within two hours in 72% of patients; significantly increasing the chances of outcome with minimum or no disability. Devised in 2003 by the Department of Neurology at the Medical College of Georgia (MCG) as a means to overcome geographic differences in acute stroke care at Georgia, REACH is now being employed across other states, like South Carolina and Ohio, as well. The state of Ohio is considered the hub for the stroke telemedicine network, and is funded by the Ohio Department of Health with a grant of $265,000. The state has initiated the

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TELEHEALTH

January - March 2012

REACH Telemedicine Network Evaluation Project (REACHEvaluation), which evaluates the influence of telestroke on remote access to evidence-based stroke care. Apart from REACH, 20 telestroke networks across North America and Europe have been identified in a systemic review by Demaerschalk BM, et al from the Mayo Clinic Hospital, Phoenix, AZ. Some of these include Emergency Neurology Network-Stroke (RUN-Stroke; France), Stroke Telemedicine for Arizona Rural Residents (STARR; Phoenix), Stroke Network of University of Erlangen (STENO; Germany), Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC; San Diego), Telemedic Project for Integrative Stroke Care (TEMPiS; Germany), Telemedicine in Stroke in Swabia (TESS; Germany). Telestroke, one of the applications of telemedicine, was

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coined in 1999 by Levine and Gorman. The main objectives of telestroke are to overcome specialist shortage and eliminate patient transfer to stroke centers, thereby initiating much faster treatment and saving on costs. Initially, the practice of telestroke included point-to-point models that required consultants to go to designated workstations for consultations. Nelson RE et al (2011) reports incremental cost-effectiveness ratios of $108,363 per quality-adjusted life-years in 90 days, and $2,449 per quality-adjusted life-years in a lifetime with the use of telestroke, when compared to usual care. This demonstrates the cost-effectiveness of telemedicine application when compared to usual care. Leveraging its benefits, improvement in reimbursement for telestroke care will help in overcoming the financial challenges and sustain the telestroke system in the long run.

Health IT NEWS.Direct!

January - March 2012

INSIGHTS Ninety-five Percent Cite Enhanced Efficiency with RTLS: A KLAS Survey A recent report by KLAS shows that 95% of respondents confirm gains in operational efficiency with the use of realtime location system (RTLS) solutions.

Some of the RTLS vendors mentioned by the respondents include AeroScout, Ekahau, Sonitor, Intelligent InSites, GE (Agility), Radianse, CenTrak, Awarepoint, and Versus.

The research surveyed CIOs; CFOs; VPs; logistics, administrative and IT directors and managers; and other executives at more than 150 organizations ranging from 25 beds to large integrated delivery networks (IDNs) of over 1,000 beds.

IDTechEx market research estimates the RTLS industry to be worth $2.58 billion in 2019 from $153 million in 2009, as an effect of an increase in the vendors from 50 in 2009 to 200 in 2014.

With the industry’s focus largely directed towards pressing issues like ICD-10 and meaningful use, some providers may initially consider investments in RTLS as one that may benefit only particular types of organizations. However, the KLAS study indicated that providers have realized the following benefits of employing RTLS solutions, with only 3% undetermined about its advantages, but perceiving it to be better: • Enhanced utilization of equipment and staff efficiency (75%) • Documentation (19%) • Alerts/reporting (19%) • Quick assets finding capability (11%) • Temperature recording and monitoring (11%) • Loss prevention (11%) • Par level management/asset distribution (8%) Lessons learned from RTLS implementation as expressed by providers include: • Strengthen RTLS infrastructure before use for better adoption and optimal ROI • Alter workflow of staff to integrate RTLS use • Increase awareness of RTLS-use cases The report’s author, Steve VanWagenen states that not all deployments are created equal. The success with RTLS is largely dependent on the breadth of the software implementation, the various ways it is utilized, and the extent to which the RTLS integrates with the facility’s other solutions.

A 2010 Frost & Sullivan research shows that the healthcare industry (along with manufacturing) poses the highest potential growth for RTLS in terms of revenue contribution. It has been estimated that 10 to 15% of the healthcare industry is currently employing an RTLS solution. This growth has been said to be driven by inefficient existing processes, requirement for higher operational efficiency, compliance to regulations and laws, higher affordability of tags, convergence of tracking technologies, and organization standards and government regulation. Furthermore, among the various RTLS technologies, Wi-Fi and ZigBee are the two that are currently growing. The current research findings have come a long way from a 2009 KLAS RTLS awareness survey that demonstrated only 29% of respondents capable of listing a vendor and 59% not familiar enough with its offerings to find a technology platform they would consider employing. Despite this “rather rude awakening for RTLS vendors,” the study’s expectations of its 29% acceptance doubling over the next two years may have greatly exceeded. As per industry analyst, Gartner’s Research Note on the top 9 actions for the healthcare facility CIOs, the key to remain competitive in this industry is that health systems should evolve and redesign their vital clinical and business operations to function as “Real-time Enterprises (RTEs).” To successfully function as RTEs, Gartner recommends the extended use of location, automation, condition sensing, wireless, and mobility technologies, to name a few.

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INSIGHTS

January - March 2012

Medical Data Breach Expenditure on American Healthcare Industry to touch $6.5 Billion Annually The Second Annual Benchmark Study on Patient Privacy and Data Security has reported a staggering 32% increase in patient data breaches, from 2010, across a sample of healthcare organizations in the US. The rates of data breaches have been on the rise in spite of data privacy and security being primary concerns globally, and the enactment of federal regulatory frameworks like The Health Information Technology for Economic and Clinical Health Act (HITECH) and Health Insurance Portability and Accountability Act (HIPAA). Research firm Ponemon Institute LLC has conducted a survey, sponsored by data breach solutions vendor ID Experts, on 72 US healthcare organizations, in an attempt to understand the practice of patient privacy and how providers address data breaches. Some of the key findings of this survey show 41% response to unintentional employee actions as the reason for the breach. Other motives identified were loss or stealth of computing devices (49%) and third party business associate errors (46%). The lack of confidence in detecting privacy incidents, and loss or theft of patient data was expressed by 55% and 57% respondents, respectively. Additionally, 61% of them are incapable of categorically providing the physical location of their patientsâ&#x20AC;&#x2122; records. The widespread use of mobile devices has raised concerns in providing confidentiality to patient medical data, with 81% of the total organizations in this study reporting the use of mobile devices to collect, store, and communicate patient records. The research finds that while 49% of the organizations have no measures of protecting their mobile devices, 46% depend upon governance and policies, and 23% use encryption. This adds up to complete confidence of data protection in only 15% while 23% are somewhat confident. Furthermore, the economic fallout of patient data breach on an average, costs healthcare organizations $2.2 million, a 10% increase from last yearâ&#x20AC;&#x2122;s estimation. Most organizations felt that the costs were compounded through productivity and time losses (81%), loss of credibility among

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patients (75%), and abated branding (78%). Applying these figures to the entire healthcare system, ID Experts estimate that privacy breach could cost the American healthcare system an estimated $4.2 billion to $8.1 billion annually, which accounts to an average of $6.5 billion. According to the study, the respondents cited reasons like lack of sufficient budget (54%), sufficient risk assessments (45%), and trained resources (43%), as their prominent challenges to prevent data breaches. Given the enormous expenditure and lack of resources, we feel patient data breaches are likely to prevail or increase in the future. Until recently, HIPAA compliance by a healthcare organization was audited or questioned only when a consumer specifically files a complaint with the Department of Health & Human Services (HHS) or the Office for Civil Rights (OCR). However, there have been some compliance amendments to HIPAA with the enactment of the HITECH Act. The modifications are with regard to breach notification requirements and criminal and civil penalties. The Act requires HIPAA-compliant organizations to notify them when patient data have been compromised. This has now been extended to also include business associates of HIPAA-compliant healthcare providers who need to report any breach to the healthcare organization they are contracted with. In a bid to regulate the security of patient data, HHS and OCR announced that they will be piloting a privacy and security audit program for HIPAA compliant covered entities from November 2011 till December 2012. The findings of this study demonstrate the vulnerability and the risks of data theft, and help organizations to better understand their privacy and security practices. In conclusion, the onus lies on the healthcare organization to provide adequate privacy and confidentiality to the medical records of its patients by strictly complying by HIPAA privacy laws. It will be a reflection of good business practices that would instill confidence in the patient in terms of security and quality of care. It remains to see that in this quest for the American Recovery and Reinvestment Act of 2009 (ARRA) incentives, healthcare providers do not overlook the practices of privacy and security of patient data.

Health IT NEWS.Direct!

January - March 2012

PARTNERS AND ALLIANCES TTA and NFC to Add Value to Continua’s Interoperability Efforts With a mission to promote interoperable, personal connected health products and services, the Continua Health Alliance has collaborated with Telecommunications Technology Associations (TTA) to set up a new Continua test lab at South Korea, for the certification of products released in the Asian market. In an interview with the Health IT NEWS.Direct! team, Kanghae Lee, Continua Certification Expert (CCE), TTA, stated that, “Presently, leading countries, such as Korea, Japan and China in the Asian HIT market are introducing use cases and healthcare services through medical devices integrated with information technology. Along with this, the active development of Personal Health Device (PHD) and mHealth, which can provide health service and information by mobile devices, is in progress. However, in comparison with the number of devices released, there are only a few test labs in Asia which have a full set of facilities and resources required to conduct development, conformance, interoperability, and certification testing for HIT equipments. Due to this, TTA desires to play a significant role in activating the Asian HIT market by cooperating with Continua.” TTA joins AT4 wireless, a global testing and certification service provider, with test labs in Malaga, Spain; Virginia, USA; and Taipei, Taiwan; to certify devices and products as authorized by Continua. TTA has been offering internationally accredited testing services, such as Bluetooth, USB, and GSM, since the year 2003. “With this extensive background in testing and qualification area, TTA developed a Health Device Profile (HDP) tester in collaboration with Bluetooth SIG in 2008, and joined the Continua Health Alliance in the following year,” says Kanghae Lee. “By joining the alliance, TTA initiatively contributed to establishing key policies of the Test and Certification Working Group (TCWG), and organized the interoperability testing program and Continua Certification Expert program.” TTA’s participation in the CCE program, TCWG, and the Plugfests event has aided in supporting the certification program. The company is said to offer a one-stop advantage for the present Continua transport (Zigbee,

USB, Bluetooth) testing and certification services at their laboratory. “TTA will promote and present Continua design guidelines containing references to the standards and specifications that Continua has selected, thereby providing solid foundation for Asian manufacturers to easily access the HIT market,” continues Kanghae Lee. “Furthermore, by assuring the smooth interoperability of HIT devices through the CHA qualification program, more users could access the services anywhere, anytime with comfort.” The product certification program was initiated to indicate interoperability with other certified solutions. Products identified with the Continua Certified™ logo are said to have a strong competitive advantage over other products and enable net savings owing to their ease of use, low labor intensiveness, lack of ineffective technology duplication, and prevent products from turning antiquated impetuously. With many Asian IT manufacturers like Samsung and Toshiba leading the global market, Kanghae Lee believes that key technological aspects of medical services, i.e., assurance of data security, integrity, and reliability can be supported by Bluetooth, USB, Zigbee, and interoperability qualification programs, which Asian IT manufacturers are well known for. He continues, “These advanced technologies in Asia, combining healthcare technology, will create a synergic effect on the Asian HIT market, encouraging it to grow. In addition, TTA is hoping that the vitalization of the HIT industry will influence the revising of the medical law to legalize telemedicine in Korea.” In another attempt to expand the use of standards-based connectivity technology in the healthcare IT market, Continua Alliance joined hands through a Co-operation Agreement with NFC Forum to support the common belief of simplifying digital data exchange. This, they believe, will help establish a system of wellness and personal connected health products and services that allow healthcare providers and consumers to proactively address the ongoing healthcare requirements. Through the agreement between Continua and NFC Forum, a formal plan to promote Internet standards and wireless

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PARTNERS AND ALLIANCES

January - March 2012

telecommunications in the personal healthcare milieu has been made. Technical information will be exchanged between the organizations to help develop Continua criteria for personal healthcare devices. Furthermore, the synergy is expected to streamline the certification process and vendor development, which would in turn accelerate the availability of products in the market. The NFC Forum will bring to this collaboration its Near Field Communication (NFC) technology, connectivity technology to complement Continua’s Tap ‘n Go technology initiatives. Continua Health Alliance’s executive director, Chuck Parker feels that this technology holds the potential to simplify electronic data exchange, making it more readily and accurately available.

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By enabling interoperability among personal connected health products through these strategic ventures, Continua Health Alliance hopes to empower individuals and offers the opportunity for wellness management and personalized health. In view of the accelerated ageing population problem, Kanghae Lee concludes that, “Medical industries are experiencing a paradigm shift from ‘sickness care’ to ‘health care’. Not only are people showing interest in state-of-theart medical technology, but are also adopting them. In line with this trend, in recent times, smartphones have become very popular globally, and many related services using short-range wired/wireless technology will be expected to be released soon.”

Health IT NEWS.Direct!

January - March 2012

VENDOR WATCH Attunity’s RepliWeb-MFT to Secure Information Exchange Among CCCI Partners Looking to better manage information exchange, Connecticut Community Care, Inc. (CCCI), a provider of care services to the elderly and disabled, has chosen RepliWeb Managed File Transfer (RMFT), a file transfer platform from Boston, MA’s Attunity Ltd., to integrate its existing business processes. A nonprofit, private organization, CCCI aims to assist its clients to live secure and independent lives at home. CCCI services are delivered through a state-sponsored Connecticut Home Care Program for Elders (CHCPE), which requires qualification, and a fee-based Care Management Associates (CMA) program, open to all. CCCI partners with over 200 direct service providers who can avail services like adult day care, emergency response, and therapies. According to CCCI’s information systems director, Charlie Forish, information exchange is a vital component of business activities, and a secure and reliable platform for connecting hundreds of partners, a strategic business move. While searching for a solution that would enable data exchange between legacy mainframe infrastructure, applications, and external units and internal business groups, CCCI considered several requirements like functionality, security, and integration. More specific needs included the capability to route and process files depending on the profiles of customers and payers, scalability in architecture to support the expected increase in the volume of file transfer, simplicity in Web interfaces for end users, and enforcement of HIPAA compliance. In order to meet these expectations, CCCI chose Attunity’s RMFT in view of its ability to support a wide array of encryption policies, secure transfer protocols, user validation, and audited delivery options. RepliWeb offers an out-of-the-box, user friendly solution, with a web service API that allows the incorporation of a secure ‘drop box’ into legacy web infrastructure. The solution supports Host, User, Ad-Hoc, and Applicationto-Application (A2A) file transfer processes. It helps manage file transfers of File Transfer Protocol (FTP), FTP

over Secure Sockets Layer (FTPS), Secure Shell (SSH), Secure File Transfer via SSH (SFTP), Secure/Multipurpose Internet Mail Extensions (S/MIME), Server Message Block (SMB), Hypertext Transfer Protocol Secure/over Secure Sockets Layer or HTTP Secure HTTP/S, and FASTCopy, within and outside an organization. Incorporating a twotier demilitarized zone (DMZ) architecture and enforcing security policy, RMFT automates the whole process and conducts audits at every stage of file transfer. In order to enhance file security RMFT has an internal MFT gateway, Business to Business (B2B) file exchange gateway, and Ad-Hoc file exchange. RMFT’s intuitive interface, modular design, new managed folder capability, and business application connectors are touted to facilitate rapid adoption. Through the current contract, RepliWeb-MFT will help automate electronic billing, service orders, and payer information among its healthcare providers and servicer partners in a secure manner. Additionally, the backend functionality of RepliWeb could help process and route files across internal systems to improve business intelligence capabilities. Offering a mix of system, user, and application interfaces, RepliWeb-MFT facilitates tight integration with CCCI’s current IT workflows and business procedures. Attunity’s vice president of sales, Garrick Herrmann remarked that their managed file transfer and data integration products are being increasingly used as essential application infrastructure by organizations. Over the last 20 years, Attunity has been providing data integration software to allow access and sharing of data across disparate systems, organizations, and the cloud, with deployments in over 1,500 organizations. Apart from MFT, the company’s RepliWeb division offers solutions for data replication, real-time data connectivity, realtime change-data-capture (CDC), and enterprise file replication. With the increasing business demands of new clients,

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VENDOR WATCH

January - March 2012

initiatives, and partners, companies are faced with the challenge of managing large volumes and sizes of data transfers, like batch files and email attachments, both within the organization and outside, to business partners and customers. The key issue here is to ensure security and regulatory requirements, as well as compliance with company policies. MFT or managed file transfer software applications securely manage transfer of all corporate files regardless of protocols like WebDAV, FTP, SFTP, Secure Copy via SSH (SCP), FTPS, and HTTP/S.

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Staked at $1.4 billion, the MFT market, as estimated by the research firm, Forrester Research, Inc., is rapidly growing to address the deficiencies of basic file transfer protocol use in external file transfers. With 1.5 million Americans being afflicted by medical identity theft at an estimated total cost of $28.6 billion (Ponemon Institute, 2010), MFT is being used for data security in the healthcare industry. Being offered as a cloud service, MFT facilitates visibility, validation, reporting, and real-time updates on audit trails and data transfers.

Health IT NEWS.Direct!

January - March 2012

NEWS Radiologists Seek Clarity on Meaningful Use through KLAS and RSNA Survey Following the enactment of the American Recovery and Reinvestment Act (ARRA) of 2009, doubt and confusion prevailed among radiologists regarding their inclusion in this federal incentive scheme for the meaningful use of technology. This, considered widely as a misconception, was later clarified through the Continuing Extension Act of 2010, in April, which amended the law by including radiologists as eligible professionals (EPs) for the $44,000 incentive. This delay may have put this specialty of medicine, which has always been in the forefront of IT, behind others in the race for meeting meaningful use. In an attempt to assess concerns regarding this incentive program, and types of guidelines that would aid in their practice, KLAS teamed up with the Radiological Society of North America (RSNA) to conduct a survey on 216 radiologists across the US from hospital-based practices, academic centers, as well as private practices. Among the total number of participants, concerns stated by 40% of them were regarding the lack of clarity in guidelines for meaningful use or lowered efficiency with the adoption of the current guidelines. While only 6% thought they were well informed of the meaningful use criteria, 60% are considering or planning to qualify for the incentives, and 25% are actively involved in the decision-making. Some radiologists feel that the current guidelines do not address the needs of radiology in particular, and recommended the following points that would benefit this branch of medicine as a whole: • The need for clinical decision support (CDS), for

especially referring physicians, which would help ensure that the right imaging test has been ordered, and avoid unnecessary and expensive imaging. • Patient engagement and radiation dose tracking are the least useful criteria. • While patients have a right to reports and images, follow up interviews indicated no apparent medical benefit or need for electronic access. When questioned on vendor preparedness, 25% of the radiologists answered that radiology information system (RIS) and picture archiving and communication system (PACS) providers were not yet ready to support them in qualifying for meaningful use, raising the need for radiologists to be more proactive in communicating their plans to meet the meaningful use criteria. KLAS research director and author, Emily Crane speaks up for the radiology community on the need for guidelines specific to the practice, and hopes that the survey, considered the first of its kind, will serve as a guide to the Office of the National Coordinator for Health Information Technology (ONC) in developing the Stage 2 and 3 criteria. As for the radiology industry, she states that they should act now in getting educated and involved with the meaningful use program. However, it seems like the radiologists have not lost all due to this delay after all. Kathleen Sebelius, the U.S. Department of Health and Human Services (HHS) Secretary, recently announced the extension of Stage 2 deadline from 2012 to 2014 with the intention of encouraging faster adoption.

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NEWS

January - March 2012

Jayex Leverages InterSystems Ensemble to Provide NHS Patient Kiosks London-based Jayex Technology Ltd has entered into an agreement with InterSystems Corporation to leverage its integration platform InterSystems Ensemble® in order to connect its patient self-service kiosks to legacy systems at NHS, clinics, and private hospitals.

self check-in kiosks and patient calling screens, Jayex boasts of lowered patient queuing-times at some of NHS’ busiest trusts. The company is now gearing up to develop solutions that will enable patients to interact with healthcare providers through the internet and mobile phones.

InterSystems Ensemble enables seamless and rapid integration, and development of connected applications capable of exchanging information with other applications. It also establishes an SOA infrastructure or enterprise service bus (ESB) by leveraging initial investments in software through composite applications. Ensemble automates business processes and enables data and applications to be accessed more easily and widely through various devices. It provides a comprehensive view of information collated from disparate sources and enables data consistency across different databases and applications. Apart from these benefits, the platform was chosen in view of its complete support for the NHS Interoperability ToolKit (ITK), which Jayex believes is the strategic factor that will drive the conversion to self-service in NHS.

Established in 1978, Jayex Technology Limited, a subsidiary of Jayex Group Limited, focuses on advanced LCD and LED information display systems, touch screen self check-in and queue management solutions. Having more than 23,000 global clients in industry sectors, such as airports, ferry and container ports, warehouse and distribution, buses/trains, banks, hotels, etc., the company caters to more than 6,000 healthcare organizations across UK. Jayex has collaborated with IT giants like InPS, EMIS, IBM, iSOFT, TPP, and Siemens.

According to InterSystems’ Country Manager for UK and Ireland, Jonathan Selby, self-service technology offers a great opportunity to develop these applications around solutions that abide by ITK. Jayex kiosk services are touted to address NHS’ need for high level automation for standard processes and the government’s requirement of empowering patients with their own care. By pioneering

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In the age when patient-centric care is being endorsed extensively across the globe, kiosks have entered as one of the means by which patients can rapidly update personal information, manage appointments, and offer immediate feedback on the services received, independently. John Lovelock, the research vice president at Gartner sees a potential growth in the self-service kiosks market with the increasing use of patient health records (PHRs). With the healthcare industry moving towards delivering care with the complete involvement of the patient, kiosks, apart from PHRs, will serve as a means of achieving this goal.

Health IT NEWS.Direct!

January - March 2012

EVENT LISTING International Congress on Telehealth and Telecare 2012

NextGen:Health Conference on Innovation in Healthcare Organizer: NextGen:Health Date: March 29-30, 2012 Location: New York City, United States Link: www.nextgenhealth.com

Organizer: The Kingâ&#x20AC;&#x2122;s Fund Date: March 6-8, 2012 Location: London Link: www.kingsfund.org.uk/events/international.html

Med-e-Tel: The International eHealth, Telemedicine and Health ICT Forum

HIMSS Dialogue Singapore12 Organizer: HIMSS Asia Pacific Date: March 6, 2012 Location: Singapore Link: www.himssasiapac.org/Singapore12

Organizer: International Society for Telemedicine & eHealth (ISfTeH) Date: April 18-20, 2012 Location: Luxembourg Link: www.medetel.eu

Innovations in Healthcare Management and Informatics

The World Congress 3rd Annual Data Analytics Summit for Health Plans

Organizer: International Quality & Productivity Center Date: March 13-14, 2012 Location: Bangkok, Thailand Link: www.healthcareinformaticsasia.com/Event. aspx?id=567330

Organizer: World Congress Date: April 25-27, 2012 Location: Las Vegas, NV Link: www.worldcongress.com/events/HW12027

2nd Annual Wireless Healthcare Asia Summit New England eHealth Innovation Conference

Organizer: Magenta Global Date: April 23-24, 2012 Location: Singapore Link: www.magenta-global.com.sg/ WirelessHealthcareAsia2012/

Organizer: World Congress Date: March 15, 2012 Location: Cambridge, MA Link: www.worldcongress.com/events/HT12001/ index.cfm

iHT2 Health IT Summit in Atlanta Global GS1 Healthcare Conference

Organizer: Institute for Health Technology Transformation Date: April 24-25, 2012 Location: Atlanta, GA Link: ihealthtran.com/atlantahome.html

Organizer: GS1 Date: March 20-22, 2012 Location: Sydney, Australia Link: www.gs1.org/healthcare/news_events/200412

Forum 2012 iHT2 Health IT Summit in San Francisco Organizer: Institute for Health Technology Transformation Date: March 27-28, 2012 Location: San Francisco, CA Link: ihealthtran.com/sanfranciscohome.html

Organizer: Council on Health Research for Development (COHRED) and Global Forum for Health Research Date: April 24-26, 2012 Location: Cape Town, South Africa Link: www.forum2012.org

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