IndiaMedToday August 2018

AUGUST 2018, VOLUME 2 ISSUE 8 `200 INDIA MED TODAY

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Reflections in

ART

Changing shape of ART business in India INTERVIEW ELAD BENJAMIN CEO, ZEBRA MEDICAL VISION BOOK REVIEW CAN INDIA SOLVE AMERICA’S HEALTH CARE CRISIS?

AUGUST 2018

INFRASTRUCTURE DESIGNING LEAN HEALTHCARE FACILITIES -NXTGEN HOSPITALS

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AUGUST 2018 EDITORIAL

BOARD OF ADVISORS

Editor Neelam Kachhap editorial@ indiamedtoday.com

Dr Dr Dr Dr Dr

Alexander Thomas Girdhar Gyani Prem Kumar Nair Bhabatosh Biswas Alok Roy

ART & PRODUCTION

CONSULTING EDITOR

5Th eLLemenT sTudio Prasshant

Dr Libert Anil Gomes Dr Salil Choudhary

ADVERTISING Gunjan Chauhan gunjanc@indiamedtoday.com The Media Ant help@themediaant.com DIGITAL MARKETING Vivek Nair

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Assisted Reproductive Therapy in India JULY, 25 is observed as the world IVF day and world embryology day globally. The date commemoratesthe work of Patrick Steptoe, Robert Edwards and Jean Purdyand the birth of first test tube babyLouise Brown on 25 July 1978 at Oldham General Hospital, UK. Recently, the ‘International Committee for Monitoring ART (ICMART) said that more than 8 million babies have been born globally using assisted reproductive techniques in the last 40 years.

India has about 400 registered ART clinics and a sizable number of babies are born through ART every year. However, these therapies are available to only 1 percent of couples who require them. There are about 27 million couples in India who are suffering from some degree of Infertility almost 1 in 4 couples could have problem conceiving.

International Committee for Monitoring ART (ICMART) said that more than 8 million babies have been born globally using assisted reproductive techniques in the last 40 years According to the National Health Profile 2018, India’s fertility is on a downward spiral. What’s more the report says that the fertility is declining rapidly evenamong the poor and illiterate. To focus on these and other issues marring ART progress in India, our August issue focuses on ART. Through dedicated features and articles we have tried to bring to fore the most burning topics in ART. Although we could not include all, we have tried to include the inputs from experts throughout India.

Hope you enjoy reading the issue.

Do send in your views and suggestions to the Editor. Write to mneelam.kachhap@ indiamedtoday.com

IndiaMedToday. No part of this publication or any part of the contents thereof may be reproduced, stored in a retrieval system or transmitted in any form without the permission of the publishers in writing.

Printed and published by M Neelam Kachhap, 301, Grazia, 1st main, 2nd Cross, Lingrajpuram, Bangalore 560084 on behalf of Neelam Publishing (OPC) Private Limited, Printed at Supriya Print Art 143, Pragati Industrial Estate, N M Joshi Marg, Lower Parel West, Mumbai - 400011. and published at 301, Grazia, 1st main, 2nd Cross, Lingrajpuram, Bangalore 560084.

Editor M Neelam Kachhap

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AUGUST 2018

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CONTENTS

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16

Elad Benjamin, CEO, Zebra Medical Vision India will grow to be a large adopter of automated imaging solutions

28

COVER STORY

Reflections in ART

Changing shape of ART business in India. What is affecting ART landscape in India and Is ART Fertile ground for investors in India

IMPACT

Confronting the age shock ART in elderly

Information Security challenges in EMRs for Indian Healthcare systems S. Bhattacharjee, Principal Consultant - Aadhaar Innovation Centre, Centre for e-Governance, Government of Karnataka, Bangalore, India

BOOK-REVIEW

Can India Solve America’s Health Care Crisis?

APPROACH

03 Editorial 05 Letters 06 News roundup 41 Ask the expert 42 Events

HEALTH IT

INTERVIEW

18

UPFRONT

36

30

Onco-fertility and fertility preservation INFRASTRUCTURE

26 4

August 2018

26

Designing Lean Healthcare Facilities NxtGen Hospitals

34

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LETTERS

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n Amendment to the medical device rules wherein case of in-vitro diagnostic medical devices, performance evaluation report by the manufacturer shall besubmitted by the applicant. “This will help manufacturers to get products tested nearer to their facility and is a welcome move for ease of doing business. Earlier they had to get products tested at NIB (National Institute of Biologicals) in Noida and if there was any dispute it was difficult to resolve as the tests were done by the highest decision maker in hierarchy of regulations for IVD testing. Now these accredited labs will be the safe middle ground and disputes can be referred to the higher hierarchy of National Institute of Biologicals for retest of batch and settlement. Industry is hopeful that this initiative will greatly reduce the time taken for issuing the manufacturing licenses as currently its taking 6-9 months against 3-4 months earlier and we were hopeful that with an online application system the process will hasten the process than earlier and not make it lengthier.

We welcome any steps taken by MoH&FW and CDSCO for ensuring Ease of Doing Business Rajiv Nath, Forum Coordinator, AiMeD

On world Hepatitis day “There has been an increase in the incidence of hepatitis (B & C) cases especially among youngsters aged between 20 - 35 years. One of the main reasons of this increase is due to practices like tattooing or needle piercing with unsterilized needles. Apart from tattooing or piercing, hepatitis ( B& C) can also be due to unprotected sexual intercourse and blood transfusions. With regards to chronic hepatitis B & C, while some patients are symptomatic some others exhibit generalized weakness and jaundice. Chronic hepatitis B & C can lead to chronic liver disease and liver cancer, if not treated. Additionally, in some patients chronic hepatitis B & C can go undetected and such patients exhibit symptoms only at the end stage liver disease where they even suffer gastrointestinal bleeding. Hepatitis A & E are usually food borne and requires symptomatic treatment.For hepatitis, like the saying goes prevention is better than cure, it is always important to take necessary precautions to avoid the disease. Firstly disposable needles and razors should be used. One should have protected sex and consult certified artist when it comes to tattooing or piercing. Also, awareness is equally important. Chronic hepatitis B & C are curable and can prevent complications of it like end stage liver disease and liver cancer if treated early. While symptomatic treatment is given to hepatitis A & E as well as acute hepatitis B & C, chronic hepatitis B & C are treated according to standard guidelines.

Dr Nandish HK, Medical Gastroenterologist, Narayana

it is associated with risk of Tubal and Uterine infertility. If your partner is suffering from Hepatitis B you should immediately visit a doctor in order to reduce further risks.

Dr Sweta Gupta Clinical Director and Sr. Consultant, Fertility Solutions, Medicover Fertility says

There are multiple viruses that cause acute self-limiting liver injury and some causes chronic liver injury (chronic hepatitis). Hepatitis-A and hepatitis–E virus infection is commonly seen which are transmitted with contaminated water and food. They are usually self-limiting, although sometimes may lead to severe liver damage.HepatitisB and hepatitisC virus infection usually cause chronic hepatitis, which leads to liver cirrhosis, liver cancer, and death. Around 4% of the population, 40 million are infected with Hepatitis B virus and 8.5-12 million people are infected with Hepatitis C virus in India.

Around 30 % of liver cirrhosis is due to Hepatitis B and 10-12 % of cirrhosis is due to Hepatitis C virus infection in India. Hepatitis B and Hepatitis C are also the major cause of liver cancer in India. So timely diagnosis and treatment is utmost important for the prevention of Hepatitis.

Dr NripenSaikia, Senior Consultant, Gastroenterology &Hepatology, PSRI Hospital

Health City

Hepatitis in simple terms means inflammation of the liver. If the liver is inflamed or damaged, its functions get affected. Most common factors that can cause Hepatitis are - viral infection, heavy alcohol use, toxins, careless medications, and certain medical conditions. The most common strains of Hepatitis are B & C, which affect millions of people in India. These strains generally spread through infected blood. Hepatitis B also spreads through unsafe sexual acts. Vaccines are available for Hepatitis B, but not for Hepatitis C. There are around five types of Hepatitis but Hepatitis B virus is known to lower sperm motility and impairs fertility in male population. However, in women

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NEWS ROUNDUP BANGALORE BAPTIST HOSPITAL INTRODUCES ADVANCED DIGITAL MAMMOGRAPHY IN KARNATAKA Bangalore Baptist Hospital has introduced 3D Tomosynthesis and Stereotactic guided Vacuum assisted Biopsy equipment which will be the most advanced mammography equipment in Karnataka. 3D Tomosynthesis is an advanced technology which takes less than 4 seconds to scan any abnormality in the breast.

Complimenting on the inauguration, R Sampath Raj, the Worshipful Mayor of Bangalore said, “My hearty congratulations to Bangalore Baptist Hospital for bringing first of its kind advanced 3D Digital Mammography technology to Bangalore. Across the world, breast cancer is the No.1 cause of cancer death

in women. Early detection of breast cancer is the key to saves lives. My humble request to all women above 40 years is to get their annual mammogram screening done as this will help them to prevent breast cancer at an early stage.”

Addressing his thoughts about the innovation, Dr. Naveen Thomas, Director, Baptist Hospital said, ‘Bangalore Baptist Hospital is committed to fight breast cancer with world-class technologies and we now have the first of its kind advanced digital mammography equipment in Karnataka with 3D Tomosynthesis technology and stereotactic guided vacuum assisted biopsy. The advanced 3D Tomosynthesis technology removes the overlapping structures and increases the lesion visibility allowing the clinicians to pick up cancer at a very early stage. The stereotactic guided vacuum assisted biopsy system

Bangalore Baptist Hospital committed to fight breast cancer: Dr. Naveen Thomas, Director, Baptist Hospital

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August 2018

helps in localizing and removing the lesion completely resulting in therapeutic treatment as well. The entire procedure is painless and improves the overall patient care. We now have a world-class comprehensive breast care centre in Bangalore that will benefit the people of Karnataka.’

Dr. Asha Thomas, Head – Radiology Services, Baptist Hospital said this machine has unique features: firstly it is a digital mammography unit, providing very high definition, high resolution images. Secondly it has 3D Tomosynthesis which is a technology which gives us 3 dimensional images which we can scroll through to differentiate lesious from overlapping structures. Thirdly this machine comes with stereotactic biopsy systems; this means that lesions which are not palpable and not seen on other modalities can be targeted of biopsied.

MANIPAL DOCTORS REPORT VERY RARE ‘P’NULL BLOOD GROUP For the first time P blood group null phenotype has been detected in India. It is a very rare blood group and only 1 in 1000 people have it. The Blood Bank at Kasturba Hospital, Manipal found this rare blood group when a patient came to the hospital for treatment. Dr Shamee Shastry, prof. Head Dept of Immunohaematology and Blood Transfusion told local media that the patient had a very rare ‘P’null blood group and anti PP1PK antibody in his blood that has a potential to cause acute intravascular hemolytic reaction to incompatible blood transfusion. This antibody is also known to cause recurrent abortions in women. Finding compatible unit for such case is a near impossible task without a wellestablished rare donor panel. A rare donor registry will be of great help in managing such cases the doctor said.

Another rare blood group that was found in India is the Bombay Blood Group. Bombay blood group or hh blood group also a rare blood group was first reported in Mumbai in 1952 by Dr Bhende.

considering the situation that the Neonatal team was ready to take up the case, Nikita was advised to deliver in Perinatal Centre at Rainbow hospitals. Nitika was shifted in ambulance and brought to Rainbow Hospital.

The Perinatal team comprising of anesthetist, senior gynecologist and neonatologist all came together to make a detail plan of delivery.

On 27th February, Nitika delivered baby girl weighing 375 grams. She was only 20 cms in length and fitted in the palm. Parents were assured that the hospital is going to go through this journey together with them.

Dr Shamee Shastry

compromised. There was no way baby would have survived in womb. Parents consulted many hospitals and doctors. No one gave any chance for survival. They were than referred to Rainbow Children’s Hospital.

The parents then met Neonatologist in Rainbow Children’s Hospital. The team assured the couple that they routinely manage babies born as early as 24 to 25 weeks of gestation.

However, the smallest baby saved earlier at Rainbow was 449 grams. Additionally,

Speaking about Cherry’s case, Dr. Ramesh Kancharla, Chairman and Managing Director, Rainbow Group of Hospitals said, “We are able to send baby born with birth weight as less as 375 grams home because of our advance perinatal center”. He said “Close to 20 years of hard work has gone in to developing such expertise to save small babies. We need team of committed Obstetrician, anesthetist, fetal medicine specialist and neonatologist to achieve such results”. He said “A very dedicated and committed Nursing team was instrumental in saving cherry. The Neonatal Intensive Care unit is the most advance and well equipped in the country and has the most qualified team of expert neonatologist. Rainbow is striving

SOUTH ASIA’S SMALLEST PREEMIE, BEATS THE ODDS TO SURVIVE Baby girl Cherry was born to proud parents Nitika and Saurabh hailing from Chhattisgarh and delivered at Rainbow Children’s Hospital in Hyderabad. She was born premature at 25 weeks gestation( nearly 4 months earlier than expected date), under the extensive care received at the hands of a multi-disciplinary team of medical experts led by Dr. Dinesh Kumar Chirla, Director Intensive Care Services at Rainbow Hospitals. The baby was discharged weighing 1.980 Kg. This was Nitika’s 5th pregnancy. She had four previous abortions. This was her only chance to have a baby. Around 24 weeks the ultrasound showed that there was very less amniotic fluid around baby. She weighed just 350 grams. The blood flow from mother to baby was severely

Baby Cherry with her parents and the team of doctors at Rainbow Hospital

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NEWS ROUNDUP each year in establishing clinical excellence in Neonatal, Pediatric and Obstetric care and raising the benchmark”.

Elaborating on the case, Dr Dinesh Kumar Chirla, Director Intensive Care Services, Rainbow Hospital said, “The initial 3-4 days post birth is very crucial as babies are most fragile during this time. Specially, in this case, there were many health challenges like drop in the oxygen and BP level. Owing to the size of the baby, we had to find the smallest possible breathing tube to be inserted. Moreover, the baby had a breathing problem (PDA) which normally closes in everyone after birth but did not close and was large in Cherry’s case causing oxygenation problem for which we had to give special medication and keep the baby under a ventilator for breathing support.

Fortunately for this child, there was no bleeding in the brain.”

On Day 5, Cherry had bleeding in her lungs and needed to be shifted to special ventilator called High Frequency Oscillation ventilator.

She was successfully managed. However, she needed ventilator for nearly 105 days. She had many emergencies from which she was successfully saved.

Cherry’s case was a particularly complicated one with multiple hurdles including jaundice, feeding difficulties, multiple blood transfusion and chronic lung disease. With expert care from the medical team at Rainbow Hospitals, Cherry steadily gained weight and moved towards normalcy. She was discharged home after spending 128 days in hospital. She is breathing without support. She is feeding directly. She is maintaining temperature and looks like any other normal baby. The doctors expect her to be normal like any other baby.

On follow up she weighed 2.14 kg.

USAID AND DHFL SIGN $10 MILLION LOAN GUARANTEE TO IMPROVE HEALTHCARE IN URBAN INDIA The U.S. Agency for International Development (USAID) and the Dewan Housing Finance

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August 2018

L-R- Edgard Kagan, U.S. Consul General_ Harshil Mehta, CEO & JMD, DHFL

Corporation Limited (DHFL) today officially announced the signing of a $10-million loan portfolio guarantee in an effort to improve access to capital for healthcare providers in Tier II & Tier III cities. Through the risksharing agreement signed between USAID and DHFL, the Mumbai-based lender will be able to provide up to $10 million to smalland medium-sized enterprises operating in the health sector in India, prioritizing lending to women entrepreneurs. Through this partnership, USAID and DHFL intend to achieve the following:  Increase outreach to de-risk and improve access to finance for the Indian healthcare sector, especially breaking barriers for women entrepreneurs so they can establish or expand their healthcare enterprises and services, buy equipment to improve diagnosis and treatment in their communities, and improve the viability of their enterprises;  Deepen collaboration with various borrowers throughout India, especially in Rajasthan, Odisha, Madhya Pradesh, and Chhattisgarh; and  Ensure improved access to quality, affordable healthcare and better health

outcomes for underserved communities.  Speaking at the launch of the partnership,

U.S. Consul General in Mumbai EdgardKagan said, “The USAID-DHFL partnership will boost women’s empowerment by prioritizing them for lending, helping women access loans and expand and improve the viability of their businesses.

I am confident this partnership will take us one step closer to achieving the shared vision of improving health outcomes for underserved populations.”  Mr. Harshil Mehta, Joint Managing Director and CEO, DHFL, added: “DHFL’s relationship with USAID is a culmination of joint efforts to improve healthcare facilities across the country. It gives us an opportunity to help develop quality healthcare across India by offering convenient and customized financial solutions, especially for medical practitioners through medical equipment finance and expansion of facilities. DHFL has been undertaking extensive activities at grassroots level for the urban poor and those at the bottom of the pyramid, touching the lives of over millions of people through social programs and its excellent network across 349 locations.”

AMAR UJALA GROUP FORAYS INTO HEALTHCARE DELIVERY WITH 200CR INVESTMENT Amar Ujala Group, India’s leading integrated media company formally announced its diversification into trustworthy and inclusive healthcare. MrProbalGhosal, Director, Amar Ujala commenting on this development said, “Amar Ujala is creating a modern healthcare brand based on the principles of awareness and social equity in Tier- 2 and Tier- 3 cities of India. The business is about care, not just healthcare.” Further, MrGhosal adds, “The idea is not to just run hospitals but introduce global standards to those with limited access to quality healthcare outside the metros. In keeping with the Group’s ethos, there’s a clear social dimension to the business which involves creating awareness for good health, timely need for medical tests, diagnosis,postoperative recovery standards and above all bringing

back the trust in the medical system which is hugely lacking outside the metros.”

Amar Ujala has three to four hospitals in UP and Uttaranchal in pipeline, which will significantly impact existing healthcare ecosystem and set new benchmarks both in terms of access, affordability and offering treatment which were out of bounds for patients in those areas.

The Group has set aside Rs 200 crores for next few years for investment in healthcare and is looking for strategic partners. Amar Ujala as a company has been known for trust and credibility. With a total readership of 4.65 crore readers, Amar Ujala is now India’s No. 3 newspaper in terms of readership. In last 5 years, the group has diversified into digital, digital TV, activations and outdoor, commercial printing and educational books business. Amar Ujala leads in the innovation space and is one of the leading practitioners of integrated media in India.

Ujala Hospital in Kashipur area of Uttaranchal

near Jim Corbett National Park is the first hospital of its kind. Three hundred kilometers away from Delhi, complex surgeries like cranioplasty and laparoscopic surgeries are being performed on a regular basis. Equipped with state of the art Operation Theatres, Cath labs, ICU and Dialysis units, Ujala Hospital, the biggest hospital in the area is a model healthcare centre. In a span of 6 months, Ujala Hospital has earned the trust and respect of patients.

TWO CONSECUTIVE BILATERAL LUNG TRANSPLANTS IN A WEEK: BGS GLENEAGLES GLOBAL HOSPITALS BGS Gleneagles Global Hospitals, known for their robust multi-organ transplant programme, has successfully completed two consecutive bilateral lung transplants saving the lives of two senior citizens. The first

BGS Global Lung transplant team with the patient

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NEWS ROUNDUP patient, 61 year old, Suresh Babu, a native of Kerala and the second patient, Jayanth Kumar Shah, a 62 year old from Madhya Pradesh were operated on in the span of a week. The surgery was performed by a team of experts led by Dr Sandeep Attawar, Program Director and Chair, Cardiac Surgeries and Thoracic Organ Transplant at BGS Gleneagles Global Hospitals in Bengaluru. The patients were suffering from an advanced interstitial lung disease for a prolonged period and were in need of a lung transplant.

Dr Sandeep Attawar, Program Director and Chair Cardiac Surgeries, Thoracic Organ Transplant, Gleneagles Global Hospitals, commented on the case, “Bilateral lung transplants are complex procedures particularly, in the case of senior citizens. Most people with severe, end-stage lung disease can be considered for a lung transplant.

Usually, the time to full recovery after a lung transplant varies widely between people. The particularly quick recovery of the two patients at our hospital is a result of excellent pre-work up and medical care.”

Interstitial lung disease (ILD) may be caused by long-term exposure to hazardous materials, such as asbestos or coal dust, pigeon droppings or it can be caused by an auto-immune disease such as rheumatoid arthritis. Once lung scarring occurs, it is generally irreversible and does

not respond to medical therapy resulting in respiratory failure and death. Symptoms include a dry cough. Shortness of breath can occur either at rest or after exertion. Fewer than 1 million cases a year are detected in India.

The team of doctors who were present on the two unique cases includes Dr Sandeep Attawar, Dr PrabhatDutta, Dr VijilRahulan, Dr Pradeep Kumar, Dr Govini B, Dr Bhaskar B V, Dr Sandeepa H S, Dr VishwanathBellad, Dr Madhusudhan, Dr Srinivas H, Dr Saranya and Dr Nagesh.

cartridges were supplied last year at various centres of Central TB Division (CTD). The GeneXpert® Edge is expected to be available in India later this year.

“The published data point out that Tuberculosis leads to over 400,000 deaths in India every year due to delayed diagnosis and inadequate treatment and there are above 2.5 million new cases of TB every year.

Cepheid recognises the need for technological advancement and is committed to contributing significantly to India’s goal of TB eradication.

Our ‘Make in India’ plans are a testimony to

CEPHEID UNVEILS LATEST TB-TESTING SYSTEM

our commitment towards supporting the Indian Government’s vision of TB eradication by 2025. With this announcement, we aim to establish a manufacturing footprint for Xpert® MTB/RIF test cartridges, thus bringing our global expertise in TB diagnostics to India. Today, we also unveil our latest system innovation, the GeneXpert Edge, which further demonstrates our resolve to participate in India’s fight against TB. We are hopeful that this portable, easy-to-use testing system will help eliminate delays in TB diagnostics by providing definitive results within hours and facilitating fast and easy last-mile delivery even in the remote villages of India,” said Peter Farrell, Executive Vice President, Worldwide Commercial Operations, Cepheid.

US-based molecular diagnostics company, Cepheid Inc. (a wholly owned subsidiary of Danaher, a NYSE-listed science and technology company) unveiled its newest configuration in the GeneXpert® family of systems, the GeneXpert® Edge, in the India recently. The company also announced its ‘Make in India’ initiative by announcing plans to establish their manufacturing footprint in the country for Xpert® MTB/RIF test cartridges which run on the GeneXpert® System. More than 1,200 Cepheid’s GeneXpert Systems have been installed in the last 2 years at various Revised National Tuberculosis Control Program (RNTCP) sites in the country and more than 2.5 million

L To R - Dr. Sanjay Sarin, Head, FIND India and Access Program-Asia Pacific_ Mr. Xerses Sidhwa, Director of the Health Office, USAID India_ Dr. Jamie Tonsing, Regional Director-USEA,

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July 2018

DR. REDDY’S AND UCB INDIA TO CO-PROMOTE, DISTRIBUTE BRIVIACT® FOR EPILEPSY IN INDIA Dr. Reddy’s Laboratories Limited and UCB, a biopharmaceutical company, announced that they have entered into a distribution and co-promotion agreement for Briviact®, a brand of brivaracetam. The agreement grants Dr. Reddy’s the exclusive right to distribute Briviact® in India. Briviact® (brivaracetam) is approved as an adjunctive therapy for the treatment of partial-onset seizures in epilepsy patients who are 16 years of age and older.

V. Ramana, CEO – Branded Markets (India and Emerging Markets), Dr. Reddy’s said, “In our endeavor to make innovative medicines accessible to patients in India, we are excited to partner with UCB India for Briviact®, a novel treatment for epilepsy that will make a difference to the lives of patients living with epilepsy.”

“We know that as many as one third of people with epilepsy are currently uncontrolled on their existing medicines.”

Explained Max Bricchi, Head of International Markets, UCB Neurology Patient Value Unit.

“This partnership is another important step towards us providing value together to patients by making Briviact® available as an additional treatment choice for epilepsy.”

Epilepsy is the second most common neurological condition and as per a recent study, an estimate of 70 million people suffer from it worldwide. There are over 12 million people suffering from epilepsy in India, which contributes to nearly one-sixth of the global burden.

SUVITAS LAUNCHES BANGALORE’S FIRST TRANSITION CARE FACILITY

Completing the largely existent care gap between hospitals and home, SuVitas Holistic Healthcare launched Bangalore’s first dedicated transition care facility in Domlur today. In spite of having one of the fastest growing healthcare ecosystems of the country with

improved tertiary care hospitals, Bangalore has been consistently falling short in providing quality follow up care for the effective management of critical ailments. Filling this need gap, the pioneers of transitional care in India, SuVitas brings to the startup city a 60 bed post hospitalization rehabilitation center with specialized programmes for stroke, head injuries, spinal cord injuries, hip-knee replacements and post cardiac procedures.

Post undergoing prolonged critical care, a patient needn’t be fully recovered to go home and will require skilled nursing care and regular physiotherapy, besides proper nutrition and emotional support. When patients go through transition care before going home, there is improved independence and functional outcomes thereby enabling accelerated and empowered recovery along with enhanced quality of life. Since its launch in Hyderabad in 2015, SuVitas has fuelled a revolution in the country’s healthcare scene by introducing world-class transition care, bringing together protocol-oriented personalized care plan in a home-like relaxing environment through a multidisciplinary rehabilitation team of doctors comprising of physicians, skilled nurses, physiotherapists, occupational therapists, speech therapists, clinical psychologists and dietitians.

Shedding light on SuVitas’ aggressive expansion plans, MrSateeshAndra, Founder and Board Director, SuVitas said, “Post-acute care is gaining greater relevance in today’s value-based care world. The growing base of non-local patients, increasing demand for long-term quality care for neuro cases, nuclear family culture and the flourishing medical tourism industry can significantly scale up the growth of segment. With transition care expected to grow to a 10,000 bed requirement in the near future, we expect SuVitas to emerge as an indisputable leader in the category.”

Dr Harish Kalathil, Director, Operations, SuVitas confirmed the brand is ramping up its expansion plans and is looking at raising an expansion capital of Rs 15 Cr for launching two more centers in Mumbai and Chennai within 18 months’ time. He added, “We are glad the medical circles have recognized the

integral role played by SuVitas in completing the care continuum over the past few years.

In our second stage of expansion, we are looking at raising an additional VC funding to expand our presence to eight cities including Gurgaon, Chandigarh, Kochi and Coimbatore among others.” With an impressive year on year growth rate, SuVitas reported a revenue growth of 140% during the FY2016 to FY 2017 and 50% from FY2017 to FY2018.

Highlighting the niche SuVitas has been able to create overcoming existing challenges in the industry, Dr Ramesh Byrapeni, an interventional cardiologist and Founder, Board of Director SuVitas said, “While transition care is considered equally important to mainstream medicine in developed economies, India is gradually waking up to its necessity. The rise in hospital-acquired infections and re-admissions in hospitals along with inefficient utilization of the critical care facilities have triggered the need to improve patient outcomes by offering to continue care through inpatient rehabilitation.”

AHA ANNOUNCES NEW BOARD MEMBERS Academy of Hospital Administration has recently elected a new Board for the tenure of two years.

Prof. A.K. Gupta, Medical Superintendent-cumProfessor & Head, Department of Hospital Administration, PGIMER, Chandigarh is the new President of AHA. Dr Gupta was trained in U.K. and was awarded Commonwealth Medical Fellowship for one year in 1991-92, availed at University of Liverpool, U.K. He has been short term consultant to World Health Organization (SEARO), New Delhi, an International Consultant to World Health Organization, Nepal and has provided training/consultation in Hospital Administration to the doctors belonging to Government of Nepal, Maldives, and Indonesia. He successfully conducted Management Development Programme for doctors working under National Rural Health Mission, Government of India and was also nominated as Team Leader of Capacity Building Programme for senior functionaries of 6 AIIMS and top officials, administrative functionaries of Ministry of Health and Family Welfare under Pradhan

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NEWS ROUNDUP Mantry Swasthya Suraksha Yojana (PMSSY).

Dr Hem Chandra, Professor/Addl. Medical Superintendent, HOD Hospital Administration, SGPIMS, Lucknow is the Vice-President. He has more than 25 years’ experience in the field of hospital and health administration in addition to his 5 years army medical corp service.

He has more than 106 publications and 9 books authorship in his credit. Conferred with UP Ratan award, Award for excellence, and FELLOW

by All India Management Association.

Gp Capt (Dr) M G Ajmani, Retd is now the Executive Director. He has served in the Indian Air Force for 33 years and held Medical-Clinical and Administrative position at various levels including command of hospital and Medical Advisor at AFRO,New Delhi. Presently he is the visiting faculty at Sharda and Amity university in NCR and IIHMR, Dwarka, New Delhi and was associated with training in Health management courses of YMCA, New Delhi.

Brig (Dr) K S Bhatnagar, Retd. holds the Director Finance post. He has served in the Army Medical Corps for nearly 35 years and was the professor

Narayana Lung Transplant team with the patient

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August 2018

of Hospital Administration at AFMC Pune. Currently he is the Medical Superintendent of 100bed Lions Neuro Sciences Centre, Lions Kidney Hospital and Urology Research Institute.

Dr Anoop Kumar Daga, Associate Professor, Dept. of Hospital Administration, AIIMS is the director Programms. Dr Daga has served earlier in various corporate hospitals in India.

He is member, American College of Healthcare Executives(ACHE),Chicago, USA; Association of professionals for Infection Control(APIC), Washington DC,USA Dr. Ashish K. Gupta, Dr (Surg Cdr) Rajesh Bhalla, Retd., Maj (Dr) Mayank Dixit, Retd., Dr Anil K Hegde, Brig (Dr) Pradeep Srivastav, Dr Pankaj Arora, and Dr Libert Anil Gomes are the other members of the board.

NARAYANA HEALTH CITY PERFORMS KARNATAKA’S FIRST DOUBLE LUNG TRANSPLANT

Doctors at Narayana Health City gives a new lease of life to a 28 year old young man by conducting a double lung transplant. The transplant makes Narayana Health City the first hospital in the state to successfully conduct a double lung transplant.

Hailing from Thrissur, Kerala, Sudeesh MV was a construction worker until he started developing severe bronchiectasis which led to lung failure. In the last one year his condition had worsened making him dependent on oxygen support. In fact, he was finding it difficult to even move around. Every step he took made him feel as though he was climbing a mountain. The family’s search for a treatment led them to Narayana Health City and he was admitted at Narayana Health City in the month of February.

After a thorough evaluation by the doctors, he was advised to undergo lung transplant.

However, as he was suffering from severe infections, the first task at hand for the doctors was to stabilise his condition. Once he was stable, the doctors began the search for

a matching lung. Fortunately, for him within three months, the team was able to identify matching lungs for him. The donor was from Sparsh Hospital, Yeshwantpur. The doctors successfully performed the transplant on June 20th and the patient is recovering fast.

The challenging double lung transplant was performed by the multi-disciplinary team led by Dr. Julius Punnen, Heart & Lung Transplant Surgeon, Dr. Basha Khan, Transplant Pulomonologist, Dr. Julius Punnen, Senior Consultant Cardiothoracic, Vascular and Transplant surgeon, Dr. Syed Tousheed, Pulmonologist, Dr. Sanjay OP, Transplant Pulmonologist, Dr. Varun Shetty, Cardiothoracic Surgeon and team of support staff.

SAFE POINT APPLAUDS GOI ON LAUNCHING NATIONAL VIRAL HEPATITIS CONTROL PROGRAM Pradeep Sarin, trustee of Safe Point, applauded the great initiative “National Viral Hepatitis Control Program” launched by Shri J P Nadda, Union Minister of Health and Family Welfare recently, to mark the World Hepatitis Day 2018 to work towards elimination of viral hepatitis by 2030 in India.

At the function, Shri J P Nadda also released the Operational Guidelines for National Viral Hepatitis Control Program, National Laboratory Guidelines for Viral Hepatitis Testing and National Guidelines for Diagnosis and Management of Viral Hepatitis. Shri Manoj Sinha, MoS (Independent Charge), Ministry of Communication also released the Commemorative Stamp at the occasion.

An elated Rajiv Nath Jt Mg Director of HMD that makes the Kojak brand of Auto Disable Reuse Prevention ( AD- RUP) Syringes, a strong advocate for Injection Safety and seeking a National Swach Injection Abhiyan said “After requesting for a National Nodal Injection Safety Officer since over 10 years we are delighted and optimistic to see a National Consultant for Injection Safety being appointed for the noble initiative,” but he also apprehended “Let’s hope

this National Plan on Safe Injections is not fueled by Chinese Imported Syringes as being done for Immunization and keeping Indian factories capacity idle.”

Dr.(Col) HS Ratti, an epidemiologist and Project Advisor to Safe Point which is working to create awareness about safe injections is hopeful that the ‘National Plan on Safe Injections’ initiative launched is India’s commitment towards elimination of viral hepatitis by well laid out strategy which hopefully will now be covering prevention from unsafe injections, testing patients with safe equipment that prevents Needle Stick injury to the lab technician and free treatment to the patient.

In India, around 40 million people are infected with hepatitis B and at least 6 million people with hepatitis C. About 184 000 people die each year of hepatitis B- and C-related complications – two times the estimated annual number of HIV and malaria deaths together.

Dr Ratti urged the Govt. to accelerate a switch to “Auto Disable Syringes” to limit HIV and Hepatitis Epidemic. There are villages with over half the population infected with Hepatitis or HIV due to reuse of Syringes by quacks. In order to prevent reuse of syringes and contain spread of infection, it is advisable and recommended to use AD syringes specifically designed to prevent reuse. This reuse prevention has been strongly advocated by WHO. Andhra Pradesh government has already taken a lead in this regard and had issued instructions in May for 100% use of AD syringes in its public health facilities from 28th Jul 2018 which is observed as World Hepatitis Day. Shri Ashwini Kumar Choubey and Smt Anupriya Patel, Ministers of State for Health and Family Welfare along with Smt Preeti Sudan, Secretary (Health), Shri Ananta Narayan Nanda, Secretary, Dept. of Posts and Dr S Venkatesh, DGHS were also present at the launch function.

MoHFW has launched the ‘National Viral Hepatitis Control Program’, with the goal of ending viral hepatitis as a public health threat by 2030 in the country. The aim of the initiative is to reduce morbidity and mortality due to viral hepatitis. The key strategies include preventive and promotive interventions with focus on awareness generation, safe injection practices and socio-cultural prac-

tices, sanitation and hygiene, safe drinking water supply, infection control and immunization; coordination and collaboration with different Ministries and departments; increasing access to testing and management of viral hepatitis; promoting diagnosis and providing treatment support for patients of hepatitis B &C through standardized testing and management protocols with focus on treatment of hepatitis B and C; building capacities at national, state, district levels and sub-district level up to Primary Health Centres (PHC) and health and wellness centres such that the program can be scaled up till the lowest level of the healthcare facility in a phased manner.

The National Viral Hepatitis Control Program marks the beginning of the nation’s journey to control viral hepatitis thereby reducing mortality and morbidity attributed to it. The programme will prevent , find, test and treat viral hepatitis.

VISHAKAPATNAM GETS STATE OF THE ART FERTILITY CENTRE Oasis Centre for Reproductive Medicine, a unit of the Sadguru Healthcare Services Pvt. Ltd., was recently inaugurated at Vishakapatnam.

Talking on the occasion of the launch of Oasis Centre for Reproductive Medicine at Vishakapatnam DrDurga G Rao, Co- Founder and Medical Director of Oasis Centre for Reproductive Medicine said,“One of the main reason for starting a Fertility Centre in Vishakapatnam is just not giving anotheroption for the infertile couple but to give an evidence based ethical transparent and protocol basedtreatments to the couple. We at Oasis strongly follow the clinical protocols and algorithm coupled withcutting edge, latest technology in treating the patient thereby ensuring a higher success rates.” Adding tothis Dr Durga also stressed on the fact about the timing of decision to visit a fertility centre is of utmost importance, “Many couples delay the start of treatment, it is of utmost importance that the couple whohave already crossed 30 and have not conceived naturally after trying for year, they need to take helpof Assisted Reproductive Technologies, the sooner the better for best clinical outcomes.”

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NEWS ROUNDUP Present during the launch were Chief Guest, Shri GhantaSrinivasRao , Hon’ble Minister for Human Resources Development , Govt of Andhra Pradesh and Guests of Honour Dr SubbaRaju MD DGO, Former Addl. DME, Prof. & HOD of Ob. & Gyn. AMC Civil Surgeon KGH (Rtd) and Dr R Sasiprabha MD DGO Prof – Ob.&Gyn. (Rtd) Principal, AMC (Rtd) Director of Med Education (Rtd).

Talking on the occasion MrKiranGadela CoFounder and Managing Director of Oasis Centre for Reproductive Medicine stated that “In the past 8 years, we are proud to share that we have built one of the most respected institutions in the field of reproductive medicine in India and have helped over 6000 couples achieve their dream of parenthood,. In addition to delivering quality care, our commitment lies in our compassionate and individualized approach while treating an infertile couple – and from that perspective, today we are dedicating this

facility to the people of Vishakapatnam region.

Vishakapatnam has always been very close to our heart and we are happy to announce the launch of our 8th Centre in the country and 2nd in the state of Andhra Pradesh. We would also like to share that we are ranked No 1 in the two Telugu States, No 2 in South India and No 3 in the country.”

MAY 2018, VOLUME 2 ISSUE 5 `200 INDIA MED TODAY

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MEDICAL DEVICE MARKET IN INDIA Is the medical devices Regulatory environment in India Conducive for business?

WHAT IT MEANS TO BE A CARDIOLOGIST IN INDIA TODAY?

IS HEART FAILURE A PUBLIC HEALTH PRIORITY IN INDIA? SMALL HOSPITALS AND NURSING HOMES BUILD TRUST, REPUTATION

Talking on the Occasion SudhakerJadhav Group Chief Operating Officer commented that “Its our Eight Centre and we are upbeat about opening the Centre in Vishakhapatnam and we are very confident that we will deliver the quality and ethical care to all our patients from this region.

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INTERVIEW

Zebra Medical: India will grow to be a large adopter of automated imaging solutions Elad Benjamin, CEO, Zebra Medical Vision spoke to M Neelam Kachhap during his recent visit to India on the sidelines ofIndia-Israel Innovation Bridge program. Jointly started over a year ago by Indian Prime Minister ShriNarendraModi and his Israeli counterpart Mr. Benjamin Netanyahu along with Israel Innovation Authority and Invest India, the program represents a peak in the relationship between the two countries. The program is designed with the purpose of helping Israeli companies leverage their technologies, develop, adapt and commercialize their innovation in the Indian sub-continent . The India Israel Innovation Bridge is managed by the Israel Innovation Authority and the Department of Industrial Policy and Promotion (DIPP), Ministry of Commerce & Industry, Govt. of India. The programme will be jointly managed by Invest India (on behalf of DIPP).

16

August 2018

Could you give us a general understanding of AI methods, particularly those pertaining to image-based tasks?

Imaging related AI is rooted in machine learning and deep learning methods, which are founded on the technology of convolutional neural networks (CNN). These software infrastructures allow algorithms to be built and trained using large amounts of data. In order to create and train these algorithms, large amounts of well annotated data, representing various medical findings - are ‘fed’ into a CNN, which gradually learns how these findings are represented in images. If enough high quality data has been provided to the software, it will ultimately be able to extrapolate and recognize the visual findings independently. The more data and feedback that is given to the network, the more accurate it will get over time.

How will these methods impact different areas of radiology?

How will these impact oncology imaging?

I believe Radiology will see significant changes in the coming years, with automated software assistants helping radiologists read more cases, in a faster and more accurate way. The huge demand that radiologists are facing can only be met by a technology leap that help this profession be much more efficient in the coming years, without sacrificing quality.

What are the challenges of implementing AI in clinical practice?

Clinical workflow is complex, requires many different inputs, and is not an exact science.

Implementation of algorithmic tools has to be done in a way that benefits radiologists, and is well integrated into their reading methodology.

Creating a software engine that is highly accurate, efficient and enhances workflow will be a challenging task.

What is Zebra Medical’s outlook for India?

We see the healthcare system in India as one that can benefit greatly from our products. The number of radiologists per capita is very low

compared to other healthcare systems. This places tremendous pressure on them, and also leaves many patients waiting long times for results. By deploying our solution in the India market we can create a win-win situation, where patients will receive higher quality, faster care and radiologists will be able to provide better care for their patients.

We think India will grow to be a large adopter of automated imaging solutions and hope to be a leading provider to the Indian healthcare market.

How is “India-Israel Innovation Bridge” program going to help enhance healthcare delivery in India?

The program encourages companies from both countries to work together towards Indiarelevant products, by providing funding that can help kick-start the collaboration costs and alleviate some of the risk involved. This helps companies enter the India market with a better safety net and a willing partner, and increases chances of success.

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COVER STORY

Reflections in

ART

Changing shape of ART business in India

I

ndia is a land of contrasts where different culture, religion, climate and even socioeconomic aspects can be seen to co-exist.

However, today we are talking about fertility and child bearing and no other example could be more perplexing than the fertility profile of India to demonstrate its contrasting nature. India with 1.3 billion people is world’s second most populous country after China, which has a population of 1.4 billion.

One would not think then, that fertility is a big problem here. But surprisingly, India’s total fertility rates are on the decline.

“Infertility is the inability to conceive naturally and is a medical condition with high prevalence affecting nearly 10 to 15 per cent of married couples in India. Nearly 27.5 million couples who are actively seeking children suffer from infertility,” says Dr Durga G Rao, Co- Founder and Medical Director of Oasis Centre for Reproductive Medicine.

In fact, the recently released National Health

Infertility is the inability to conceive naturally and is a medical condition with high prevalence affecting nearly 10 to 15 per cent of married couples in India. Nearly 27.5 million couples who are actively seeking children suffer from infertility Dr Durga G Rao, Co- Founder and Medical Director of Oasis Centre for Reproductive Medicine

Profile (NHP)-2018 by the Central Bureau of Health Intelligence (CBHI) states thatTotal Fertility Rate which is the average number of children that will be born to a womanduring her lifetime; in 12 States has fallen below two children per woman. “Fertility is declining rapidly (in India), including among the poor and illiterate,” the report observes. According to the report, the Total Fertility Rate (TFR) for the country was 2.3 in 2016 whereas in rural areas it has been 2.5 and 1.8 in urban areas during 2016 as per the latest available information.

Fertility Landscape In India, infertility is not only seen in urban areas but rural areas also. According to NHP-2018, rural areas of Andhra Pradesh, Delhi, Himachal Parades, Tamil Nadu, Kerala, Telangana and WestBengal have low TFR ranging between 1.7-1.8; whereas the TFR of Urban areas in these states range from 1.2 – 1.6. These fertility levels relates

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COVER STORY alteration in sperm concentration,motility and morphology in at least one sample of two sperm analyzes,collected 1 and 4 weeks apart. In India, nearly 50 per cent of infertility is related to the reproductive anomalies or disorders in the male,” says Dr Krishna Chaitanya, Scientific Head and Clinical Embryologist of Oasis Centre for Reproductive Medicine.

to the rates seen in some developed countries and some states’ TFR are comparable to the lowest fertility rates in the world.

Another contrasting feature of this problem is that India has a young population and by 2020, 64 per cent of India’s population will be in the working age group. This means that more men and women will be in their reproductive age at this time, but this will also raise the burden of infertility in India. “While there is a rise in the proportion of women in the reproductive age of 20-44years (14 per cent increase estimated between 2010 to 2020) the increase is skewed towards those aged between 30-44 years (20 per cent increase estimated between 2010 to 2020), who typically display lower fertility rates.This shift is likely to increase the burden of infertility in India by 2020,” explains Dr Rao. Delayed marriage age and rising awareness and use of contraceptive have effectively been the reason for low fertility in India.

gamut is just ignored. According to Journal of Reproductive Sciences male factor infertility is seen as an

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August 2018

Women today are delaying childbearing for a number of reasons.

These reasons can include education, career goals, and the desire to be in a stable relationship or even to be financially secure.

Since 40-year-old women today look and feel like they’re 30, they expect their bodies to act like 30. Unfortunately, time is not working in their favor, and their fertility is decreasing as they age Dr Jyothi Patil, Consultant IVF & Infertility Specialist, Rainbow Children’s Hospital IVF Centre

working in their favor, and their fertility is decreasing as they age,” explains Dr Jyothi Patil, Consultant IVF & Infertility Specialist, Rainbow Children’s Hospital IVF Centre.

Assisted Reproductive Technology With the birth of Louise brown in 1978 in UK, Patrick Steptoe, Robert Edwards and Jean Purdy gave the world the technique of assisted reproduction. India was not behind; Dr SubhasMukerji was already busy perfecting his technique. And barely two months after the UK baby in October 1978 world’s second test-tube babyKanupriya’s birthwas announced by Dr Mukerji. Unfortunately, Dr Mukerji’s claims were refuted and he was systematically ostracized which led to his untimely death in 1980. Later, in 1986 India’s first scientifically documented test-tube baby was born with the collaborative efforts of Dr Anand Kumar, the medical director of the Institute for

Research in Reproduction, and Dr Indira Hinduja, a gynaecologist from the King Edward Memorial Hospital. And India finally arrived on the ART scene.

This opened avenues for other reproductive treatments and specialist and several options for infertility like intrauterine insemination (IUI) and in-vitro fertilization (IVF) became available

to commencement of cytotoxic treatment,” says Dr Nandita p Palshetkar, Gynaecologist and Fertility specialist, Bloom IVF and Fertility Center.

Fortunately, after years of oblivion Dr Mukerji received his due, with the efforts of Dr T C Anand Kumar, the ICMR in 2002, acknowledged Dr Mukerji’s contributions as the first successful IVF.

In recent years, fertility preservation has also gained importance due to the rising incidence of cancer in patients of reproductive age.

Most patients today opt forcryo-preservation of egg or fertilized embryo to commencement of cytotoxic treatment Dr Nandita p Palshetkar, Gynaecologist and Fertility specialist, Bloom IVF and Fertility Center

and Lilavati, Manipal, Cloudnine Fertility Clinics like Gynacworld, Rainbow IVF; Clinic chains like Oasis and Akanksha IVF. are Bourn Hall Clinic, Southend Fertility and IVF, Morpheus IVF and Bloom Fertility Center.

Investment in Fertility Centers The problems in this market are two-fold like everything else in healthcare. Cost-to-customer and availability is still a big problem for ART treatments as most of the scientific knowledge is

Dr Duru Shah, Director, Gynaecworld.

However, unlike other systems of care delivery, ART requires much scientific equipment, power

Fertility Centers

India is huge. According to industry reports ART market in India has the potential to be Rs 1000 Cr with around one Lakh IVF cycles being performed annually.

But the market is highly fragmented and only a few centers are doing around 1000 IVF cycles per annum.“About 75 per cent of the in-vitro fertilization (IVF) market in India is captured by the top 500 clinics, comprising says Dr. Ajay Murdia, Chairman Indira IVF Group.

Some of the notable ones are hospitals like Jaslok

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COVER STORY supply, trained embryologists along with medical supplies. “There is an urgent need to address the skill gap and technical expertise required to provide high quality treatment and improve outcomes and patient safety,” says Dr Shah.

The cost of ART therapies are not covered by all insurance

employers to attain and retain employeers. Companies like Google, Facebook and Apple have attractive fertility benefits.

In India, Indian Hotels Company Limited that manages India’s largest chain of hotels, Taj Hotels has recently announced that it would pay for fertility treatment of its staff. In the government sector,

22

August 2018

There is a huge mismatch in the distribution of infertility centers with more than 55 per cent of IVF cycles being performed in the top eight metro cities, which makes access to quality treatment difficult Dr Duru Shah, Director, Gynaecworld

Market for ART is concerned. India performs far fewer cycles per annumthan most European countries, USA and Japan whereas the need for IVF cycles is more. “Of the estimated 27.5 million couples with infertility only one percent seek treatment of which only a fraction go in for IVF treatment,” says Rohit M A, Cofounder and Managing Director of Cloudnine Hospitals.

you look at other treatments like cardiac, transplants and oncology this may seem lower or even at par with the cost of these other treatments, where the market drivers may be similar.

Investment in ART The combination of high start-up cost and limited number of trained specialists has been the major barrier for investors. And yet in the past few years there has been a boom of infertility centers in India. The new investors are transforming an industry that has long been dominated by standalone clinics. According to ICMR’s The National Registry of ART Clinics and Banks in Indiathere are 400 registered ART clinics in India. Some of the big investments in this sector are ďƒŒ

Despite recent private equity interest, IVF and fertility treatment market remains a highly fragmented market but that may be about to change

Looking into the Future Despite recent private equity interest, IVF and fertility treatment market remains a highly fragmented market but that may be about to change says Dr. Murdia, Chairman Indira IVF Group.“We have been asked many times by if fertility clinics are a good investment. They are, but very few investors have put their money here. I feel that one of their (investors) main concern is the lack of sizable businesses. Secondly,

Dr. Murdia, Chairman Indira IVF Group

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COVER STORY

have become organized players in the last few years,” says Murdia.

skilled expertise and self-governance, customer awareness, policy intervention, there has been an up-swing in many organized healthcare providers taking a keen interest in a largely underserved specialty,” explains Rohit.

“With increasing demands in the organized fertility speciality care, choice between organic and inorganic expansion will be a critical decision for organisations like ourselves looking to grow. There

With increasing demands in the organized fertility speciality care, choice between organic and inorganic expansion will be a critical decision for organisations like ourselves looking to grow. There are interesting large format and small format inorganic opportunities across regions of the country, fit and form will be a key metric of such collaborations coming together Rohit M A, Co- Founder and Managing Director of Cloudnine Hospitals

Trends Technology will be a major factor for success in the fertility

A number of Artificial Intelligence based platforms are also evaluating techniques to enhance the clinicians’ efforts to get better success rates.

, while maximizing their chances of having a baby.

On the other hand, experts believe that similar to other industries, automation and scale will have a

but when such technologies come to market, larger players will have the appetite and resources to invest in such high end technologies.

The idea of one central lab for embryology is also gaining grounds.

ensure they drill change and innovation into the core of their culture.

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August 2018

Oasis - Center for reproductive Medicine Combining evidence based treatments with the latest advances in medical technology

Kiran Gadela Co-Founder and Managing Director and Dr Durga G Rao Co-Founder and Medical Director of Oasis Centre for Reproductive Medicine

OASIS CENTRE for Reproductive Medicine is a comprehensive healthcare provider with specific attention toinfertility treatments. Oasis is a ‘onestop’ single-day care clinic where consultations, investigation andtreatment are taken care of during the course of a single day. Oasis is founded

by Dr Durga G Rao and Kiran Gadela. Dr Durga is a specialist in reproductive medicine and minimally invasive surgery with over 18 years of experience in this field. Being the co-founder of Oasis, MrGadela has built theorganization from scratch and has been instrumental insteering Oasis in the right direction to ensure professional,ethical and statistical success.

Oasis also take immense pride in its strict adherence to standards and quality. Oasis is an ISO 2001 certified organization and diligently follows the Indian Council of Medical Research (ICMR) guidelines. Oasis is also amember of The American Society for Reproductive Medicine and The Federation of Obstetric andGynaecological Society of India. Oasis is a unit of the entity Sadguru Healthcare Services Pvt Ltd., whichaims to offer state of art services in the Indian healthcare in-

dustry by leveraging latest technologies coupledwith proven, evidence based international medical practices.

Parenthood is a dream for almost every couple.

However, large number of couple are facing infertility conditions that deprive them of parenthood.

In fact, one in every six couples is affected by some degree of infertility. Oasis strives to give each of its patients a personalized treatment and the care they deserve, doing so with utmost confidentiality. Oasis recognizes couples’ need for an approach that is both compassionate and competent.Since its inception in 2009, Oasis has established itself as a trusted healthcare service provider in the field of reproductive medicine. Presently Oasis has around 8 centres in India.

Dr Durga G Rao, Co- Founder and Medical Director of Oasis Centre for Reproductive Medicine says, “We at Oasis strongly follow the clinical protocols and algorithm coupled withcutting edge, latest technology in treating the patient thereby ensuring higher success rates.” Adding tothis Dr Durga also stresses on the fact that the timing of decision to visit a fertility centre is of utmostimportance, “Many couples delay the start of treatment, it is of utmost importance that the couple whohave already crossed 30 and have not conceived naturally after trying for a year, need to take helpof Assisted Reproductive Technologies, the sooner the better for best clinical outcomes.”

Kiran Gadela Co-Founder and Managing Director of Oasis Centre for Reproductive Medicine says, “In the past 8 years, we are proud to share that we have built one ofthe most respected institutions in the field of reproductive medicine in India and have helped over 6000couples achieve their dream of parenthood. In addition to delivering quality care, our commitment liesin our compassionate and individualized approach while treating infertility. We would also like to share that we are ranked No1 in the two Telugu States, No 2 in South India and No 3 in the country.”

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IMPACT

CONFRONTING THE AGE SHOCK Dr Duru Shah, Director, Gynaecworld, the Center for Women’s Health & Fertility and Founder President, The PCOS Society (India)

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August 2018

ADVANCED MATERNAL age is one of the most challenging fields in reproductive medicine and also the most significant prognostic factor for IVF success or failure.However, there is no universal definition of an advanced reproductive age for women, because the effects of increasing age occur as a continuum. It is a known fact that fertility starts to decline about 10-12 years before menopause. In white women, menopause occurs by 50-52 years of age and fertility starts to decline by 40-42 years of age. While on the other hand, our Indian women reach menopause five years earlier, around 47-48 years and thus their biological fertility starts diminishing from the late thirties.

Understanding The Problem Women have been voluntarily or involuntarily delaying pregnancies to midlife either due to career growth, late marriages, second marriages, medical reasons such as therapy for cancer or even inaccessibility to infertility treatment in our country.

The precise reason for the loss of fertility with female ageing is not fully understood, although it is thought to be due to meiotic dysfunction, mitochondrial dysfunction and

global reduction in oocyte (egg) function. The mechanisms postulated to be responsible for such loss include:  Decreasing ovarian reserve and poor oocyte quality  Lower implantation rate, decreased endometrial function.  Uterine problems like adenomyosis, fibroids and pelvic pathologies like endometriosis.  Lifestyle factors- Obesity, smoking, environmental pollutants and increasing radiation exposure.

Better Diagnostics Various methods are available for detection of ovarian ageing which include serum biomarkers, namely: Serum follicle stimulating hormone (FSH), estradiol, Antimullerian hormone (AMH)&Inhibin levels.Ultrasound markers in the baseline pelvic USG around day 5 of the cycle determines the ovarian volume, antral follicle count (AFC) and ovarian stromal blood flow. Dynamic tests of ovarian reserve are available, but there is limited evidence on the validity of these tests. The AFC is easier to carry out, hence it is better utilized.

Drug Protocols There are various drug protocols that can be used in the advanced age group. In spite of using the best available protocol, the results are quite disappointing in women with advanced age. Adding adjuvants in order to boost the ovarian response has been frantically tried, but only a few show promising results. According to evidence, using DHEAS(precursor for androgen production in ovaries) for a period of 3 months, improves the follicular microenvironment. Evidence shows that the use of Growth hormone helps in implantation and also in decreasing the dose of gonadotropins. Based on the loss of mitochondrial function with advancing age, supplementation with mitochondrial nutrient Co-Q has also been proposed.

From the laboratory perspective, Laser assisted hatchinghelps in increasing pregnancy rates in elderly patients. One valid approach for increasing thepregnancy rates in elderly women is offering them preimplanation genetic testing.

Acupuncture, psychological support and counseling help to reduce the stress of the treatment procedure.

Pregnancy rate in IUI patients No. of patients

Positive pregnancy

Pregnancy Rate

Age < 35 yrs.

516

153

29.7%

Age > 35 yrs.

38

6

15.8%

women aged more than 40 years. Keeping at par with that, at our center, the LBR in women <35 yrs was 37.3%, which declined to 8% in women aged >40 years.Counseling the patients regarding the same is very important at every stage of the treatment because we cannot ignore the fact that success rates with self-eggs after 45 years of age is negligible. With the use of donor eggs, the percentage of LBR in women aged more than 40 years of age is almost 50% (CDC Data-2015).Similarly, at our center, we have observed that there is a significant difference in the live birth rates with donor eggs versus selfeggs according to age group.

In white women, menopause occurs by 50-52 years of age and fertility starts to decline by 40-42 years of age

Ethically, the question arises that at what age should we stop offering themthe option of egg donation? Pregnancy complications with advanced age are again a matter of concern. Hence, correct and timely decision -making is the need of the hour for our advanced age group of women.

Pregnancy rate according to age 60 50 40

%

To Art or Not The impressive improvements in ART in the last few decades have had little impact on the prognosis of elderly women. Although chronological age is an important predictor of ovarian response to FSH, the ovarian sensitivity to gonadotropins varies considerably among individuals. Many studies suggest that women aged 40 years or more with decreased ovarian reserve should undergo ART directly without resorting to lesser effective treatments such as controlled ovarian stimulation with Intrauterine insemination (IUI), because pregnancy rates with IUI decline with increasing age.Also, we have had a similar experience atGynaecworld: the centre for womenâ&#x20AC;&#x2122;s healthcare & fertility.

30 20 10

Oocyte Donation When all the above fail to work, the option of oocyte donation has instilled some hope into the lives of such patients.Global studies (SART2016) show that the live birth rates (LBR) per cycle in women (using self-eggs) less than 35 years was 36%, which reduced to hardly 6% in

0 self eggs% donor eggs%

26-30 yrs 55.31 50

31-35 yrs 38.7 56.66

36-40 yrs 30.88 46.34

41-45 yrs 16.12 40.74

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BOOK REVIEW

Can India Solve America’s Health Care Crisis?

Taking India’s Health Care Successes to America: A Review of Reverse Innovation in Health Care by Vijay Govindarajan and Ravi Ramamurti

Anna Schurmann, Public Health Consultant, Bangalore

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August 2018

THE US has always marketed itself as the country that has all the answers. These days that idea is harder to sell. The US health care system though, has been in crisis for some time – this is not new. The high cost of health carein the US bankrupts households and cripples presidents.

However, India’s health care system is in a similar crisis, with many terrible indicators that we’re all too familiar with. Nevertheless, like lotuses growing tall from a muddy pond, there are many excellent success stories. Will US readers be willing to seek solutions for their health care crisis from India?

Govindarajan and Ramamurti suggest they should indeed do so in “Reverse Innovation in Health Care”. The first part of this book describes a number of innovative social businesses that have developed cost effective, high quality and profitable models of care delivery such as Aravind Eyecare, Wellspring Maternity Hospitals and Deccan Hospital (all from the south, incidentally).

The main focus is Narayana Health (formally NarayanaHrudalaya) which has 31 hospitals across India and one in the Cayman Islands. By leveraging new technologies, cost efficiencies,

task shifting and scale, they are able to perform life-saving surgeries for a fraction of the market rate. The authors suggest these lessons are applicable to America, where hospitals are sluggish, bureaucratic and expensive.

An interesting component of NH’s model is teaching families to conduct post-surgery care through a video tutorial, first in the hospital and then back at home. This is an intervention developed by Noora Health – you can read more about it on my blog. This model reduces anxiety, readmission rates, and post-surgical complications. I am a little bit uncomfortable about this as it seems like this model relies on the fact that women in India often don’t work outside the home, but I suppose you have to leverage the resources you have, and in this case, the resource is low-female workforce participation. I look forward to seeing data about the extent to which this reduces the household economic burden.

The book is by business authors and there is no doubt that by business parameters Narayana Health is a big success (the December 2015 IPO of Narayana Health was oversubscribed 8.6 times). By public health parameters it’s also a massive success. It has made access to high quality surgery within reach for millions of people. In addition, the environment is patientfriendly and pleasant (I’ve had a tour of their Boomasandra hospital). The authors are not the only people interested in these Indian models – the former head of the NHS, The Lancet and the NEJM Catalysthave all promoted them.

The later chapters describe US health entrepreneurs adopting some of these scrappy approaches to strengthen their care delivery settings – proving that the answers to the US’s woes lie in India ;). This was definitely inspiring reading.

My only critique is from a systems perspective. The book recounts how NH & similar models operates a “hub and spoke” model whereby the specialist resources of a tertiary hospital are made accessible to satellite clinics through outreach camps and telemedicine. We have heard of this before and I think it’s all ultapulta- the wrong way around…

With the rise in communicable diseases people are going to need more and more ongoing primary care for disease monitoring and support. At times, they may need surgery, but ideally surgery would be a discrete event.

Their main relationship with allopathic care will be with the primary care doctor. To ensure

improved continuity of care and better health outcomes, that would ideally always be the same doctor, who can refer to specialists as required. NSSO data tells us that out of pocket spending is highest around outpatient care (drugs and diagnostics), not inpatient care.

So isn’t the primary care centre the hub, and the hospital the spoke? This may seem like semantics, but primary care isn’t given enough policy or business attention (because it’s not so profitable) and this is a problem. We need to stop thinking of primary care as peripheral (or a spoke) and put it in the centre. It needs our attention.

Furthermore: I have also worked to spread the news of South Asia’s public health successes to “developed” world audiences. See my blogpost about a facility visit I did with a group of Australian Aboriginal doctors: http://www. publichealthstrategies.net/from-sri-lankawith-love-lessons-in-primar y-care-forremote-rural-australia/

The book is by business authors and there is no doubt that by business parameters Narayana Health is a big success (the December 2015 IPO of Narayana Health was oversubscribed 8.6 times)

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29

APPROACH

Onco-fertility and fertility preservation

Dr Nandita P Palshetkar, Gynaecologist and Fertility specialist, Bloom IVF and Fertility Center; Babies and Us Fertility Center

30

August 2018

A DIAGNOSIS of cancer is a life crisis for any person. The number of reported new cancer cases is increasing however, availability of new modalities of treatment have increased the probability of surviving cancer. Rates of survival today are above 80 per cent for various cancer types.

The overall risk of developing cancer at some time during life for men and women is about 45 per cent and 37 per cent, respectively.

That risk increases with age in both sexes.The diagnosis of cancer at a young age, when individuals may have not yet started their families, poses unique challenges because treatments for cancer are detrimental to reproductive functions as they damage ovarian follicles in fe-

males and spermatogonia in the testis in males.

Male - Spermatogonia are especially sensitive to chemotherapyand radiotherapy. The effect is dosedependent,may not be drastic if the spermatogonialstem cell (SSC) population is not fully depleted.

Female - Chemotherapy and radiotherapy may cause prematureovarian insufficiency (POI) in women. Ovarian damage isdrug- and dose- dependent and its severity increases as the patient ages.In females, the primordial ovarian follicles, including oocytes and granulosa cells, are particularly sensitive to alkylating agents.

Options to preserve fertility potential are currently available, and fertility preservation has emerged as a novel field where disciplines

Table 1: For females Fertility-sparing interventions in female patients Diagnosis

Type of surgery

Description

Obstetric outcome

Oncologic outcome

Cervical cancer stage IAI, IA2, IBI

Radical vaginal trachelectomy

Laparoscopic pelvic Iymphadenectomy.

Vaginal resection of the cervex and surrounding of parametria keeping the corpus of the uterus and ovaries intact

Spontaneous pregnancies described in up to 70%. Risk of second trimester pregnancy loss and preterm delivery

Rates of recurrence mortality are comparable with those described for similar cases treated by radical hysterectomy or radiation therapy

Borderline ovarian tumors FIGO stage I

Unilateral cophorectomy

Removal of the affected ovary only, keeping in place the unaffected one and the uterun

Pregnancies have been reported with a favorable obstetric outcome

Oncologic outcome is comparable with the more radical approach of removing both ovaries and the uterus.

Recurrence 0%-20% versus 12%-58% when only cystectomy was performed

Ovarian epithelial cancer state I, grade I

Unilateral oophorectomy

Removal of the affected ovary only, keeping in place the unaffected one and the uterus

Pregnancies have been reported with a favorable obstetric outcome

7% recurrence of the ovarian malignancy and 5% deaths

Maligant ovarian germ cell tumors/sex cord stromal tumors

Unilateral oophorectomy

Removal of the affected ovary only

Pregnancies have been reported andfavorable obstetric outcome

Risk of recurrence similar to historical controls

Endometrial adenocarcinoma grade I, stage IA (without myometrial or cervical invasion

Hormonal treatment with progestational agents for 6 months

Follow-up with endometrial biopsies every 3 months

Pregnancies have been reported

Recurrence rate 30%40%: 5% recurrence during progesterone treatment

Reference: Clinical aspects of fertility preservation in female patients. Pediatr Blood Cancer. 2009;53(2):254â&#x20AC;&#x201C;260.

Copyright (2009 Wiley-Liss, Inc.).

Fertility preservation techniques in women Ovary

Mature oocyte*

Inmature oocyte

Isolation of oogonial stem cells

Whole ovary*

Ovarian tissue*

Follide activation

from oncology, surgery, reproductive medicine, psychology, and ethics are crossing over, and additional medical and paramedical disciplines are currently joining in.

Fertility-sparing Surgery They aim to preserve fertility potential without compromising the survival outcome.

For males: Successful cases of sperm retrieval from the cancerous testicle and /or noncancerous one in men with azoospermia at the time of radical orchiectomy and sperm extraction from the epididymis and vas deferens of the orchiectomy specimen have been reported.

Sperm obtained by these techniques was cryopreserved and resulted in live births.

In vitro follicle culture*

MM

IVF/ICSI

Embryo*

Embryo Transfer

Live birth

OT transplant (ortho or heterothopic)

Folicle depleted ovary Artificial ovary

Ovarian tissue supporting follicular growth

In vitro follicle differentiation

Differentiation into somatic cells +into oocytes

Embryonic stem cells Induced pluripotent stem cell

Pic: *Cryopreserved. OT Âź ovarian tissue.Reference:Martinez. Update on fertility preservation. FertilSteril 2017.

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31

APPROACH Fertility preservation techniques in women Experimental procedures are indicated in discontinuous boxes, while established ones (i.e. those proven to restore fertility, with live births reported) are indicated in shaded boxes. Vitrifiedthawed oocytes can be fertilized by IVF/ICSI for embryo transfer. Immature oocytes can be matured in vitro (IVM) for IVF/ICSI. Research is undergoing on the potential use of oogonial stem cells to repopulatefollicle-depleted ovaries or differentiating follicle somatic cells and oocytes from embryonic stem cells or induced pluripotent stem cells toassemble de novo follicles for transplantation or IVM and IVF/ICSI. Sperm banking for male patients Cryopreservation of ejaculated semen is the first line of fertility preservation method for adult males and pubertal boys. Cryopreservation of at least three semen samples with an abstinence period of at least 48 hours in between samples is recommended .Testicular sperm ex-

32

August 2018

traction can also be performed to retrieve spermatozoa in young men and adolescents.

Cryopreservation of embryosor oocytes for females Retrieval of oocytes for freezing or IVF of the retrieved eggs and freezing of embryos are now established methods for adult females.

Ovarian stimulation with gonadotropins is needed to obtain more than one oocyte per cycle. Random-start protocols have proved to be efficient for fertility preservation while shortening the delay to egg retrieval to about 2 weeks.

Cryopreservation and transplantationof ovarian tissue for females Ovarian tissue freezing aims at preserving eggs within primordial follicles in the ovarian cortex.

Retrieval of ovarian tissue may be performed by laparoscopy. It is preferable to retrieve ovarian tissue for cryopreservation before a gonadotoxic treatment is started.Transplantation

of frozen-thawed ovarian cortical tissue has demonstrated recovery of ovarian functionand restoration of spontaneous fertility. Ovarian tissue can be transplanted orthotopically (pelvic) orheterotopically,(extrapelvic).

Future possibilities: Ovarian follicles cultured or isolated within a piece of thawed tissue,to transform into mature oocytes have been experimented these methods are still evolving.

Artificial ovaries:â&#x20AC;&#x2DC;artificial ovaryâ&#x20AC;&#x2122;, consisting of isolated preantral follicles alongwith other ovarian cells in a structure- 3D matrix, or scaffold, which allows follicles to grow and develop in an ovarian-like environment .

Prepubertal testicular tissue cryopreservation In prepubertal boys, there is only the possibility to preserve spermatogonia, because no mature sperm exists Cryopreservation of gonadal tissue offers hope for survivors of paediatric cancer, but also requires careful oversight.

Fertoprotective agents GnRH analogues/agonists (GnRHa)may protect follicles from destruction during chemotherapy,probably by suppression of gonadotrophin levels and reductionof utero-ovarian perfusion.Newer research presents use of agents with anti-apoptotic properties (imatinib, sphingosine-1-phosphate, thyroid hormone T3, granulocyte colony- stimulating factor and tamoxifen) that have been shown to reduce follicle loss in animal models only.

Clinical outcomes from fertility preservation techniques in women Author FP technique Women/Indication Doimans et al., (18)

Embryo cryopreservation

Outcome

5-4/Cancer

22% LBR per ET

33 returned/20 ET

nine pregnancies Four deliveries

Oktay et al., (19)

Embryo cryopreservation

33/Breast cancer

45% LBR per ET

18 returned/55 ET

26 pregnancies 18 deliveries

Cobo et al., (20)

Oocyte vitrification

Ovum donation programme

6.5% oocyte-to-baby rate

Cobo et al., (21)

Oocyte vitrification

Delaying chidbearing or non-on-

50% LBR per patient in women < 35 years old

Donnez et al., (22)

Ovarian tissue cryoperservation

CLBR increased with the number of oocytes used cological medical conditions

22.9% LBR per patient in women > 36 years old N = 111 cases, 32 conceived 29.0% LBR per patient

Note FP — fertility preservation; — ET embryo transfer, LBR — live birth rate; CLBR — cumulative live birth rate.

Martinez Update on fertility preservation. Fertl Stonil 2017.

Reference: Martinez. Update on fertility preservation. FertilSteril 2017.

Results after fertility preservation: The live birth rate (LBR) per patient among women withcancer undergoing IVF and embryo cryopreservation, and cumulativelive birth rate (CLBR) to that achieved with fresh embryosis comparable. Martinez et al., reported fertilization rates up to76.6 per cent andfour out of11cancer patients gavebirth at term with no negative perinatal outcomes. Success rates of semen cryopreservation with pregnancy rates of upto 57 per cent has been made possible by advances in ICSI. LBR of 62.1 per cent in a cohortof 272 men with cancer has been reported.

Conclusion Cancer affects current or future fertility, either due to the disease itselfor to gonadotoxic treatment, and need an adequate FPapproach.

These patients should be counselled regardingpotential fertility loss and should be referred to fertility specialiststo discuss options for FP and current results .Embryo and oocyte cryopreservation is first-line Fertility Preservationmethods in postpubertal women. Metaphase II oocyte cryopreservation is the preferred op-

tion. Semen cryopreservation is the only established techniquein men.

REFERENCES 1. Health Improvement Scotland. Long term follow up of survivors of childhood cancer. A national clinical guideline. 2013 2. International Agency for Research on Cancer.EUCAN.Cancer Factsheets. 2013 3. Ethics Committee of ASRM. Fertility preservation and reproduction in patientsfacing gonadotoxic therapies: a committee opinion. FertilSteril2013;100:1224–31 4. Fertility preservation during cancer treatment: clinical guidelinesCancer management and research 2014 5. Update on fertility preservation from the Barcelona International Society for Fertility Preservation– ESHRE–ASRM 2015 expert meeting: indications,results and future perspectivesFertsert September 2017.

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33

DESIGN & INFRASTRUCTURE

Designing Lean Healthcare FacilitiesNxtGen Hospitals Dr Aniruddha Chimote, Director, Hosconnn Consulting Services Pvt Ltd

34

August 2018

HIGH COST of healthcare is always a point of resistance in the society. Inflationary pressures and cost of technology are something that will always have to be accounted for. But can healthcare think of ways to mitigate costs without compromising on quality of healthcare delivery?

Looking Ahead Government of India’s most ambitious Ayushman Bharat – National Health Protection Mission is all set to roll out by 15th August 2018.

It proposed to cover over 10 crore families or about 50 crore people for an annual cover of 5 lakhs. The package rates for various treatments given out by the government have been a sore point of contention between the Private sector hospitals represented by the IMA and the AHPI. They have been demanding upward revision of these rates as they claim the rates are far below their input costs.

While the purpose of this article is not to argue about who has the correct figures, we need to look at ways in which we can contain costs. Two main areas where we need to focus are the design of these healthcare organisations and the control on extravagant expenditure on

fancy medical equipment and gadgets.

Let us look at the second aspect first. While the overall incidence of diseases that fall into the superspecialty category has been pegged at around 4%, we notice a disproportionate number of beds being allocated to this segment.

Along with beds there is a huge allocation to diagnostic and therapeutic equipment. The cost of hiring and maintaining the trained medical staff required to run these facilities is phenomenally high. It is in the overall best interest of the organisation that the promoters should put up facilities which are in sync with the needs of the community they service.

Lean is not Mean !

The design teams of the Healthcare organisations should focus on reducing waste in the design process. We need to apply the principles of LEAN in the design of the healthcare facility. Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. Based on the Toyota model, it focuses on how efficiently resources are being used and ask, ‘what value is being added for the customer’ in every process. A LEAN facility design should focus on

designing a facility that is compact, more energy efficient and should cost less to construct.

A compact design ensures that most essential items of use are accessible to the staff easily. A study conducted in the USA had shown that Nursing staff typically spends only 30% of the time was spent on actual patientcare activities.

Rest of the time was spent on fetching items from storage, fetching drugs and devices, documentation activities etc. If we are able to reduce the time spent on these unproductive activities by designing a facility that allows increase in operational efficiency there is a chance to reduce patientâ&#x20AC;&#x2122;s hospital stay. Nurses can then focus on activities that they are trained for, patient care.

The Slimming & Trimming Matters !

Another area where hospitals bleed is the money spent on â&#x20AC;&#x153;Ornamentationâ&#x20AC;?. This refers to swanky interiors that can compete with a 7 star hotel. Hospitals need interiors that are frugal yet pleasing to the eye while making themselves easy to clean. Hospital interior designs have to focus on prudent HIC practices.

Hence, moving forward, small and mid sized Hospitals (especially from small towns) can attempt the Lean model while designing the facilites and can also go a little Lean on the Interiors budgets too.

Frugal is the way forward to curtail costs to meet Affordable Healthcare needs of the population.

A LEAN facility design should focus on designing a facility that is compact, more energy efficient and should cost less to construct

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35

HEALTH IT

Information Security challenges in EMRs for Indian Healthcare systems S. Bhattacharjee, Principal Consultant - Aadhaar Innovation Centre, Centre for e-Governance, Government of Karnataka, Bangalore, India

36

August 2018

UNDER THE initiatives of the (Ayushman Bharat or Modicare) NITI Aayog (National Institution of Transformation India) formed by the Govt. of India, reforming medical education & practices is coming out with indices to measure incremental annual outcomes in critical social sectors like healthcare with a view to nudge the states into competing with each other for better outcomes, while at the same time sharing best practices & innovations to help each other is the main focus.

Electronic Medical Records While introducing IT and corresponding IT Infrastructure in the health care sector, EMR becomes a very critical component for judgment of the next generation Health care initiative in India. EMR stands for Electronic Medical Records, which isused in the Healthcare sector and very much used by the medical practitioner like doctors, para medical staff and hospitals.

Typically, EMR exists at tertiary care level and EMR is just a database app which typically has two types of data i.e. first part is patient personal details like name, age, gender, ID, address etc and second part consist of medical history (may or may not be fully digital or for that matter complete). It is a structured and standardized health record of a patient who has come for or under-going medical treatmentor medical procedure that is applicable or needed to the

patient. In the standard medical practices this EMR is created for all the patients who require medical attention or advices from the medical practitioner, who may be associated with the hospital or medical centers in the near-by vicinity or area. Unfortunately, there are no standards to store the EMR record in a standard database, however various companies (like Cerner, Care360 or Nextech EMR) have formulated their own structure and they follow the same EMR structure in their ownimplementation.

The Medical Record is stored and preserved by the hospital and the same record is referred over the time by the same doctor or by other series of doctors or medical experts, whenever the patient comes to the hospital and thus the doctor comes to know about entire medical history of the patient i.e. what was the problem; what were the diagnosis done for the treatment and what were the corresponding treatment was given to himor her. India currently does not have EMR portability and hence there is no uniformity among various Healthcare Systems.

Record Keeping Hence, the responsibility of preserving the EMR lays completely with hospital or medical center and in overall the Healthcare system.

This concept i.e. handing over the doctorâ&#x20AC;&#x2122;s prescription or lab reports to the patient is radically different from the current medical

practices followed in Indian scenario specifically to the poor and uneducated citizens. Normally the medical records or prescriptions are written by the doctor and hand it over to the patient and it is his or her responsibility to preserve the records and produce and medical history or lab reports to the doctors during his or her next visit to the same doctor or may be different specialist or doctor, in case he or she misses out a particular diagnosisor Lab report Example: ECG or Sugar Test report, the doctor will never be able to know the history of the patient illness.

For example typically a TB patient will require a series of continuous treatment. If he misses out one visit record, then his or her future treatment will effect drastically. This centralized storage of the medicalrecords free-up the patient to go to any hospitals in the future without carrying the entire medical diagnosis history in the future.

Confidentiality, Integrity and Availability Now by taking the responsibility of keeping and maintaining the EMRs of the patients by the hospitals and Medical Centers it becomes tremendous responsibility of a hospitals in

terms of accessing the proper and latest records and ensuring the Confidentiality, Integrity and Availability (CIA) of the medical records to the doctors, when the patient visits to the hospitals or Medical Centers. The EMRs are also referred before and or during medical procedure is applied to the patient by the Medical Practitioners.

Hence the entire IT Infrastructure of the hospitals becomes very-very important and critical for the patient. Example: if a patient is under-going some medical procedure like Heart Surgery or Cataract operation and the EMR is required by the Doctor – one cannot say that “Server is Down” or “Connectivity is not there” this is not acceptable. The availability of the EMR of the patient to the doctor has to be 100 per cent guaranteed. Hence the availability of the EMR (of the patient) has to guarantee 100 per cent availability to the doctors.

Likewise the “Integrity” of the EMR is also a top priority for the IT Infrastructure. Example: The EMR system has to guarantee that the Medical record of a patient that is referred to has not been tampered i.e. latest reports of the Lab test record or X-ray reports are tampered proof. This is another big challenge for the IT

While introducing IT and corresponding IT Infrastructure in the health care sector, EMR becomes a very critical component for judgment of the next generation Health care initiative in India

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37

HEALTH IT Infrastructure in the Health Care system.

Similarly, maintaining the confidentiality of the medical records of the patient is obviously very important, i.e. disclosure of patient having some particular disease like cardiac patient or HIV infected patient will trigger disclosure of the entire medical history of the patient to the insurance company and who may hike-up the insurance premium charges.

Other Challenges Having talked about CIA issues of Information Security, now we are going to discuss about some other concerns related to Information Security: Identifying the patient in the entire EMR system: When a patient comes to the hospital or health centers, he/she is asked to produce identification. What are the identifier used, which do not have duplicates and how to access the EMR of the right person. This becomes the major challenge in the system. However, Aadhaar and Aadhaar based authentication in India may be used for identifying the right record of the right person. However, the consciousness status of the person to give finger print or IRIS should be taken care by the system to guarantee the right EMR of the right person has been accessed by the system.

The usage of the Standard Medical Terminology is stored and accepted by the EMR system. Typically, very local terms or terminology are used by the local medical practitioner.

Example: Throat Infections are termed as simple Cold & Cough or “khasi”. Similarly, Pelia

38

August 2018

is used for Jaundice in the local terminology in certain places. But the EMR be using/ storing the standard terminology, otherwise the medicines/ treatment can be different for next doctors or by the pharmacy or by the medical insurance company regarding processing the medical treatment given. Hence the standardization of the vocabulary used in the EMR has to be used, which are understood by others or other medical systems around. This requires appropriate training to thedoctors and other medical practitioner’s in-line with the medical Insurance companies and other stake holders. Apart from the training issues, there should be provisions in the EMR system to correct or suggest correction immediately by the system to the doctor’s attention and corresponding changes should be guaranteed (like digitally signing by the doctors).

This throws major challenges to the EMR system to train the entire medical practitioners in the country. However advantages are there in standard EMR system in terms of medical insurance approvals. It will be easier and faster for the insurance companies for approval of the insurance proposal, if the EMR is stored properly with standardized terminology or vocabulary used. Faster approval of the Insurance will be advantageous to the hospitals (in case of Cashless treatment) thus encouraging the training of the medicalpractitioners.

Accessibility of EMR: A typical EMR will have the structure as depicted in Fig 1.0. Hence the EMR should have “data Field segregation”.

The components of a EMR and corresponding

The EMRs are also referred before and or during medical procedure is applied to the patient by the Medical Practitioners

accessibility constraints may be as follows:  Personal deputed in a Front Desk of a hospital or a Medical Center can have access to the Patient General information but should not have any accessibility to the Patient Financial status and Treatment or diagnosis or the details of the medication and any procedure done by the doctors.  The Financial person will have access to the Financial Status of the patient, but should not have any accessibility to the Treatment or diagnosis or the details of the medication and any procedure done by the doctors.

No body, accept doctors will have complete accessibility to the Patient’s medical Records section. To take care of the above mentioned challenges will make the design and architecture of the IT infrastructure more complex for the hospitals. However, there are many hospitals in our country, who have ventured into the automation in the infrastructure design and has done huge investment to ensure High standards of CIA of the EMR.Common and uniform infrastructure may be used for designing the IT infrastructure, which NITI Aayog is working on the “Strategy and Approach” document for “Healthcare Protection System”, which will provide the direction under Health Protection Mission (undertaken by the government of India) in the coming years.







Prescribed Solution Solution should have integrated functionality in a integrated Appliance to be placed in the Hospital IT infrastructure. It should have the following functionality (but not limited to)  Usage of Block Chain Technology and Artificial Intelligence should be explored to arrive at the definition of the EMR structure and corresponding database for security, accessibility according to the type of information and integrity of data.  EMR data entry should have a provision to enter the standardized EMR only like suggested standardized vocabulary with Spell check Provisions like in the Microsoft Word document and the corrected EMR should be digitally signed by the doctor or prescribed medical practitioner.  Provision for well defined access control /





customized access control features should be incorporated i.e. Who has access to read/ write an EMR, Provision should be there to preserve the privacy of the EMR i.e. for example: “Doctors should have accessibility to see the Patient Treatment and diagnosis and results of a patient. Only the prescribed doctors should have an authority to modify the EMR not any doctors or nobody accept doctor’s category to view/ modify the patient’s EMR. EMR display should have only vision of a particular section of the EMR depending on the accessibility rights.

Integrity: Among other types of record integrity checks, there should be checksum implementation of the EMR and the Checksum should be crossed checked even to display.

Any modified EMR should be digitally signed by the doctors. Provision to integrate Aadhaar based “e-sign” should be used for digitally signing the EMR. History of the digital signatures should be maintained by the system and the system should be able to display the history of the digital signatures with appropriated Adhaar number.

The entire IT infrastructure should have provision to display the EMR data to the doctors for critical operations like Patient under-going medical procedures, no matter what happens to the IT infrastructure (alleast the minimum information, which may be locally stored in the server Or a manual procedure to see the EMR).

The IT infrastructure, which NITI Aayog is working on the “Strategy and Approach” document for “Healthcare Protection System”, which will provide the direction under Health Protection Mission

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39

Q&A

ASK THE EXPERT

Running a private medical practice in India comes with the risk of lawsuits and property damage. As a medical professional, you are probably well aware of the devastating effects of legal cases and security threats that await doctors who face the blunt of an angry patient. We encourage you to share your queries and concerns regarding legalities of practicing medicine in India to learn more about legal framework, legal cases and the experience of fellow doctors

Q:

While working in medical college we

often encounter patients of fire arm injury and other medico legal problems from primary health center and district hospital.

Prof ( Dr ) R K Sharma, President, Indian Association of Medico-Legal Experts , New Delhi will answer questions from our readers. Please send in your queries to editor@indiamedtoday.com

Sir please tell us if medico legal x-rays are not prescribed / advised by primary physician , is it negligence, not to prescribe x-ray by treating doctors; are they responsible for it.

Dr Ashok Yadav, Orthopedics ,Nehru hospital ,BRD Medical college Gorakhpur.

Ans: Please remember whether x-rays are needed in a case or not, it is discretion of doctor attending it to prescribe. If he is referring a case to a higher centre, he may not advise x-rays as it would be waste of time. Majority of primary health centres do not have x-rays facilities, so no question of ordering them.

history of fall with femur fracture. She was transferred in from other hospital with

bed-sore

and

sepsis.

She

was

conscious at the time of presentation.

Later she succumbed to her sepsis and dyselectrolytemia.

As

family

did

not

knowing about MLC reporting of the same patient during the time of admission they got agitated. The hospital in turn requests

There is a patient 15 yr-old girl,

inspector to omit postmortem in view of

admitted with complaints of pain abdomen

natural death. I would like to know what

and

investigations

are the medico-legal implications of the

revealed to be a case of a ruptured ectopic

same?What can be done in future if some

vomiting.

Further

pregnancy, with severe hemoperitoneum.

dispute arises?

Urgent laparotomy was done after proper

Dr MohdSabihul Islam, Consultant &InchargeICU ,Anandalok hospital , Siliguri Ans: Please understand that the police can waive off post-mortem in any case. If investigating officer thinks that cause of death is known, he can waive off post-mortem. In Delhi, this power lies with assistant Commissioner of Police. Just explain to relatives that doctors have no power to waive off post-mortem in case of MLC. Above case is a suitable case for waive off if the police wants.

consent. Patient is stable now.

The question is, does the hospital need to make a MLC of this case and report as age of patient is 15 yrs only and below 18 yr of age is minor, hence to come under the preview of rape.

And what else treating doctor should take care of, like as it is a case of ruptured ectopic, there is no sample of fetus only excised fallopian tube is there as specimens and sent for histopathology.

Kindly let us know how to proceed?

August 2018

Q: One of my friend who is a doctor, was treating an elderly lady(75 years) with

my friend to write a letter to police

Q:

40

Ans: Please remember that sex with minor is a statutory rape and needs reporting to the police. Make MLC and inform the police. In this case, preserve whatever tissue is there for DNA fingerprinting to fix responsibility.

Q:

I have seen a patient who had

laminectomy and discectomy done 7 years ago by a senior surgeon. Post operatively patient developed caudaequina syndrome for

which

no

investigation

(MRI)

or

treatment was given. Patient did not have relief from sciatica. He recovered his bladder function subsequently. He had relief from sciatica after 1 yr but still has bowel dysfunction. Now he has developed recurrent sciatica. Fresh MRI shows previous surgery at wrong level. I have seen similar cases which have been covered up because of the name, fame and money power of this doctor. It is a clear case of criminal negligence. What should I do? What is my responsibility for this senior man, patient and society?

Dr. Mahehsa. K Ans: As a doctor, our first duty is towards the patient. Please do whatever you can for patient.

If you think, it is a case of criminal negligence, tell the patient and let him decide what to do with it. He can go to police, civil /consumer court or to medical council. He may also decide not to do anything. Let the conduct of senior man be judged by peer review in medical council.

If you have done this, you have fulfilled your duty toward society. If you wish, you can talk to senior man and listen to his views also on alleged negligence. He may tell exactly what happened seven years ago, and how this patient was treated.

Q:

Iâ&#x20AC;&#x2122;m

consultant

anaesthesiologist

working in corporate hospital. I have a query related to patient. I have one patient who has to undergo total hip replacement. During pre-op assessment the patient gave history of CAD and his echo n ECG werealso suggestive of CAD and

we

advised

cardiologist

opinion

Can we take up such case who is refusing

palpable peripheral pulses and decreased

to involve cardiologist.

urine output.And further he refused for IV

One other situation is that of a patient for knee replacement. Long term DM and HTN advised cardiac consult. Cardio got done stress test which came out to be positive and then advised coronary angiography and now patient is refusing for CAG and gave hand written consent for that. What are medico-legal implications of such cases?

Dr Sneh Ans: Please understand that as a professional person, a doctor is supposed to give treatment as per standard protocol. It is illogical and negligent if he modulates treatment as per wishes of patient and treatment that refuses to follow standard protocol. You would be held negligent in court if patient / relative takes you to court. Please be firm in asking for treatment protocol and refuse to operate if patient does not agree. Discharge patient if he insist.

line, catherisation.

Dr ShailenderRawal,Karepartners Hospital,Yamunanagar Ans: Please understand that a patient is himself responsible for his own health and no treatment can be given if he refuses it. Forced treatment amounts to assault.The best option before you is to discharge him and ask him to go to other centre or wherever he wish to. Donâ&#x20AC;&#x2122;t forget to document your advice and his refusal in case sheet. Ask him or relatives to sign it.

Even if he goes without signing, ask other doctor/ staff to put his signature as witness.

before surgery for risk stratification and optimisation. Patient is refusing to take

Q: I want to know what should be done in

cardiologist opinion and giving hand

a critical case, where patient himself and

written consent for not taking cardiologist

his attendants have refused to sign on the

consult and taking responsibility if some

prognosis, despite the fact that in view of

untoward happens.I want to ask is this

acute diarrheal illness, his presenting BP

type of consent is valid medico-legally ?

in the triage room was 78/42mmHg, non-

Disclaimer: This material has been prepared for informational purposes only, and is not intended to replace, and should not be conveyed or constitute legal advice. You should consult professional lawyer and legal advisors before engaging in any legal matter.

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EVENTS NBE-ANBAI TEACHER’S DAY AWARDS Date: September 22, 2018 Organiser: NBE & ANBAI Venue: Bangalore, Click: www.anbai.org, www.natboard.edu.in Contact: bbharat@nbe.edu.in&anbaiindia@ gmail.

T

and

institutions

/hospitals

to

further

the cause of medical education quality and excellence in the country. Last year the award ceremony was conducted by Association of National Board Accredited Institutions (ANBAI).

This year NBE & ANBAI have joined hands and will be organizing the award ceremony

com

he

National

Examinations national

Board (NBE)

awards

of

confers

to

honor

the contributions made by

together. The awards will be announced and distributed at the Teachers Day awards ceremony to be held at Bangalore on 22 September, 2018.

eminent medical teachers /professionals

HEALTHCARE START-UP PITCH DAY Date: September 8, 2018 Organiser: Healthpod Venue: MS Ramaiah Memorial Hospital City: Bengaluru Click: www.healthpodindia.com Contact: info@healthpodindia.com, +91-

6362029417 o encourage start-ups and aspiring entrepreneurs to pitch their Ideas to the healthcare expertsHealthpod is organizing a Start-Up Pitch Day to get ideas validated, showcase prototypes and help start-ups accelerate to next level. Start-ups will get the opportunity to meet venture capitalists, CEOs, Entrepreneurs, Professionals frombusiness world who shall provide feedback on the business ideas and business plans. Start-ups shall alsohave the opportunity to network with them for further guidance.

Further the selected pitches shall qualify for seed investments uptoRs 25 Lakhs. Start-ups that receive the seed investment will receive mentorship which is a critical factor for theirsuccess. In addition to the same, they are also provided infrastructure and incubation services at very lowcost, important factors to reduce initial start-up expenses.

T

WORLD CONGRESS ON CARDIAC SCIENCES Date: November 28 - 29, 2018

42

August 2018

Organiser: Biogenesis Health Cluster Venue: J.N.TATA Auditorium, IIS City: Bengaluru Click: www.cardiacsciencesconference.com Contact: Ms. Radhika, +91-9886327807

W

orld Congress On Cardiac Sciences - 2018 “International Conference on Cardiology” is designed on the theme: “Building and Beating to the Future of the Heart” that focuses to share novel approaches related to Cardiology field and exploring the challenges concerning excellence in Cardio research and advancements. The motive of the event is to generate awareness that will keep medical professionals abreast of the problems affecting the prevention, diagnosis and treatment of cardiovascular diseases.The scientific program will feature live workshops, interactive education sessions, B2B meetings, round-table discussions apart from the conventional plenary sessions, featured symposia, breakout sessions and oral presentation sessions for abstracts and challenging cases.

EMCON 2018 Date: November 15-18, 2018 Organiser: The Society for Emergency

Medicine India (SEMI) Venue: The LaLiT Ashok Bangalore City:Bengaluru Click:http://emcon2018.org Contact: emcon2018@gmail.com, +91

9880880682, 9632602928 he Society for Emergency Medicine India(SEMI) is organizing its prestigious

T

20th Annual Event on Emergency Medicine – the flagship conference EMCON 2018 at Bangalore, Karnataka India under the SEMI Karnataka Chapter from November 15th to 18th 2018. 15th November 2018 will be for the Pre Conference Workshops and the Scientific fiesta with various research projects from 16th to 18th November 2018.

The theme of the conference is Consensus, Advances and Innovations. It aims to bring in the field of Emergency Medicine an agreement for universal emergency care by bonding our unique needs with the progresses made.

The Conference aims to provide participants working in Emergency Medicine a platform to come together and corroborate to evolve the National guidelines and to stay ahead in our knowledge and skills to match the International standards and thereby aiming to provide universal agreement of guidelines in India in Emergency Medicine

MEDICAL FAIR INDIA 2019 Date: Feburary 21 - 23, 2019 Organiser: Messe Düsseldorf India Pvt. Ltd. Venue: PragatiMaidan New Dehli, City: New Dehli, India Click: http://www.medicalfair-india.com/ Contact: Love Bhardwaj, BhardwajL@md-

india.com edical Fair India is held alternately at venues in Mumbai and New Delhi every year. Focal ranges include: medical products and medical device technology, laboratory technology and diagnostics, equipment and furnishings plus furniture for hospitals and health centres and the global trend areas of Health IT and Mobile Health solutions, to name but a few themes.

The target group encompasses decisionmakers from the medical field (such as physicians and medical professionals), hospital managers as well as representatives from the medical trade and industry. Due to its spectrum of topics covered the event is equally attractive for architects and building planners, for enterprise consultants or for the scientific and research community.

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