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THINKING OUTSIDE THE BOX
HEALTH INSURANCE Evaluating the current scenario to bring offerings based on core competences and new directions of customer demand.
How IOT
How to prepare
Change management
is transforming healthcare
for MRCOG without going to the UK
& capacity building for smooth adoption of digital health
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JANUARY 2018 EDITORIAL
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Editor Neelam Kachhap editorial@ indiamedtoday.com
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WHICH WAY FOR HEALTH INSURANCE? AS PER National Family Health Survey, less than one-third (29%) of households in India have at least one member covered under health insurance or any kind of health scheme. Health insurance penetration in India is about three percent. While universal healthcare may seem like the obvious step and is welcomed by all, it is no more than political eyewash. Take the present situation of CGHS beneficiaries. The government intends to buy healthcare services from state-of-the-art hospitals, but the rates at which they want to buy doesn’t even cover the cost of procedure let alone the fee of doctors or the cost of equipment. And there is a huge backlog of pending bills which adds to the burden of hospitals. This is the reason why most hospitals do not want to be a part of CGHS schemes and news of deadlock between the two parties keeps making rounds. Looking at the CGHS experience, the road to UHC seems very unsteady. It is a fact that modern means of screening, diagnostics and treatment are expensive. But without patients these new treatments and devices have no value. And the patient cannot afford such expensive treatment. This is the paradox of modern medicine and the only way to break this paradox is to have well researched, participative financial schemes, both in the public and private arena.
Medical savings accounts will encourage more prudent use of the health care system Wellness based insurance products are seen as the most optimistic offerings in future and its direction need to ensure better health outcomes. Another possibility is medical savings accounts which will encourage more prudent use of the health care system rather than overuse. The end goal however is always a healthy population which is the wealth of the nation.
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UPFRONT 03 Editorial 05 Letters 06 News roundup 48 Ask the expert 50 Events
OPINION
WHITHER TO? While we surge forward into the modern era of medicine, we need to clarify to ourselvesthat medicine is an art based on science. It cannot be practiced as an inanimate, heartless,scientific exercise.
19
APPROACH
COVER STORY
HEALTHCARE INSURANCE THINKING OUTSIDE THE BOX
Health insurers are now orientingthemselves to more offerings based on their core competencesand new directions of customer demand
PROGRESS OF TAVIPROCEDURE IN INDIA
FEATURES 44 Health - IT
Change managementand capacity building for smoothadoption of digital health The evolution of health informatics and health information managers in making healthcare delivery more informed
TAVI can be an effective option to improve quality of life and increase the longevityin patients who otherwise have limited choices for repair of their aortic valve
PULSE
34
HOW TO PREHOW IOT IS TRANSFORM- PARE FORMRCOG WITHOUTGOING ING HEALTHCARE To stay ahead and TO THE UK
IMPACT
29 4
December 2017
fulfill patients’ demand, healthcare organisations are investigating in machine-to-machine communicationsand the Internet of Things
Getting a membership of RCOG is a prestigious thing. How do get ahead in exam preparation?
37
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NEWS ROUNDUP ABBOTT AND YRGCARE TO STUDY HIV &VIRAL HEPATITIS PATTERNS IN INDIA Strengthening India’s efforts in combating HIV and hepatitis viruses, Abbott has announced its partnership with Y.R. Gaitonde Centre for AIDS Research and Education (YRGCARE) to study the country’s viral diversity to improve accuracy of diagnostic tests. Abbott will provide study protocol and diagnostic equipment and YRGCARE will help in screening and sequencing rich patient data from infected populations in India. Speaking about the partnership Dr Sushil G Devare, Director of Diagnostics Research at Abbott said, “In the fight against HIV and viral hepatitis, we are pleased to collaborate with YRGCARE as they are pioneers of AIDS research and have extensive experience in understanding the HIV patient communities across the country. With sequence data generated under this partnership, Abbott endeavours to understand new viral mutations and variations of HIV and HCV leading to the development of newer tests and diagnostic kits to improve detection. We are confident that our joint efforts will offer unique insights into the genetic diversity of HIV and HCV including those that are found in higher risk groups like PWID.” Dr Sunil Suhas Solomon, Chairman, YRGCARE said, “We are excited to partner with Abbott to study emerging patterns of HIV and viral hepatitis in India. Drug using populations or PWIDs in India bear a disproportionate burden of HIV and HCV, and it’s critical to understand the transmissions in this group. Sequencing data in these affected populations will help us understand the evolutionary nature of the viruses enabling optimal treatment interventions to maximize impact.”
WOCKHARDT HOSPITAL CONDUCTS INFECTION PREVENTION AND CONTROL CONCLAVE (IPCC) 6
January 2018
Wockhardt Hospitals’ MD, ZahabiyaKhorakiwala; Group Clinical Director, Dr. Clive Fernandes, President, AnupamVerma& CEO, Dr. Ravi Hirwani during inauguration of Infection Prevention and Control Conclave in presence of Dr.GirdharGyani, Director General, AHPI and Thomas W. Kozlowski, JCI
For the fifth consecutive year Wockhardt hospital, a reputed chain of tertiary care super specialty hospitals in India have taken a lead for the Infection control conclave in North Mumbai in association with Indian Medical Association (IMA) and Association of Medical Consultants (AMC) for sharing best healthcare practices to prevent infections. The conclave was inaugurated by Ms. ZahabiyaKhorakiwala, Managing Director, Wockhardt Hospitals and Guest of Honour- Dr. GirdharGyani, Director General, AHPI in the presence of senior leadership of Wockhardt Hospitals – Mr. AnupamVerma, President and Dr. Clive Fernandes Group Clinical Director. The two day conclave witnessed industry experts from across the country delivering lectures on the importance infection prevention and control initiatives in hospitals. Wide range of topics in modern science of infection prevention were discussed through numerous didactics, panel discussion, and workshops by renowned experts across the country. Commenting on the initiative, ZahabiyaKhorakiwala, Managing Director, Wockhardt Hospitals, said, “Prevention is always better
than cure. It is mandatory that healthcare institutions practice infection prevention and control through basic practices and adhere to them for quality care and patient safety. Wockhardt believes in quality care and believes in delivering the same. ” Mr. AnupamVerma, President, Wockhardt Hospitals, commented, “Life Wins – is our ultimate goal providing quality care and safety to the patients. With advancements in science it is important to keep ourselves updated and share our knowledge with fellow healthcare providers.” Dr. Clive Fernandes, Group Clinical Director, Wockhardt Group Hospitals, said, “Wockhardt hospitals aim to advance the philosophy of Infection Prevention and Control. Through Infection control conclave we intend to share best practices in the medical science of infection control across the hospital sector. Different modes and platforms will help build the healthcare industry to a new level.” The conclave focussed on a range of topics on Infection prevention which will be useful to clinicians, nurses and hospital administrators and saw the presence of 500 participants.
Sessions were delivered by industry experts in infection control from across the country, that included speakers from Apollo Hospital, Breach Candy Hospital, Columbia Asia Hospital, DM Aster Hospital, Global Hospital, KokilabenDhirubhaiAmbani Hospital, Aster Medicity, Jehangir Hospital, Narayana Hospital, Sahyadri Hospital, DeenanathMangeshkar Hospital and Wockhardt Hospitals.
GLENEAGLES GLOBAL HOSPITALS HEART AND LUNG TRANSPLANT PROGRAM LAUNCHED
Gleneagles Global Hospitals announced the launch of their Heart and Lung Transplant program in Karnataka in order to serve the local community and promote the benefits of these procedures. This initiative will help boost the healthcare sector of the state while also build awareness regarding end-stage heart and lung conditions, providing options to those who may not have had viable treatment options in the past. With the launch of this program, Glenea-
gles Global Hospitals brings to Karnataka the experience of Dr ThaseePillay, a world renowned cardiothoracic surgeon, and his team of medical professionals experienced in the field of transplants. As a member of the international society for minimally invasive cardiothoracic surgery and former clinical director of the cardiothoracic services overseeing Adult and Paediatric Surgery, Anaesthesia and intensive Care, Cardiopulmonary Transplantation and ex director of the royal college of surgeons, Dr Pillay brings with him 2 decades of experience in the field of transplants, and has been a part of over 500 transplants in the UK. His experience and training will be a great asset to the heart and lung transplant scenario in Karnataka, especially for those patients who have had to travel long distances to receive treatment in the past. Recently, BGS Gleneagles Global Hospitals treated a patient suffering from dilated cardiomyopathy, which had resulted in his prolonged bed ridden state and multiple hospitalisations due to its escalation to cardiac failure. His day-to-day activities and professional life had severely been hampered due
to his condition. After matching him with a suitable donor, the cardiac transplant team successfully performed the transplant. The patient withstood the procedure well and his recovery in the hospital went forward smoothly. He is currently doing well and has been able to go back to his normal life. Dr ThaseePillay, Advisor & Sr. Consultant Cardiac & Cardiopulmonary Transplant at BGS Gleneagles Global Hospitals, said, “Heart transplantation is a major, critical and complex surgery. It should only be considered if the surgery is going to improve the recipient’s chance of survival or quality of life, post-transplant. Over the years, results have shown that the survival rates of cardiac failure patients have risen from 20% to 80% due to the availability of this procedure, making it a true life-saver and game changer for those patients suffering from heart failure.” Dr Sandeep HS, Consultant Transplant Pulmonologist at BGS Gleneagles Global Hospitals, said, “There is no way through which lost lung function can be restored completely in respiratory diseases like COPD and ILDs. Despite medical management these diseases continue to progress and the patients eventually end up
L-R Thomas Mathew, Dr Yogesh Kothari, Patient Mohammed Rafi, Dr K Ravindranath, Dr ThaseePillay, Dr Sandeep AS, Dr Ravindranath Reddy
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NEWS ROUNDUP with respiratory failure. Lung transplantation is the only option to improve quality of life and increase the longevity in such situations. Lung Transplantation is being done worldwide for more than 30 years and the time has come now for our countrymen to utilise this life saving treatment modality.” Dr K Ravindranath, Chairman, Gleneagles Global Hospitals Group said, “With the launch of this transplant program, we hope to educate the public on the benefits of undergoing transplants. These medical procedures offer patients a new lease of life, and a better quality of life than the one they were going through while on medical management. Gleneagles Global Hospitals Group is a pioneering institution in multi organ transplantation in India with cutting edge technology for transplant procedures since it is a world-class transplant center. With our team of experienced medical professionals and a laboratory devoted to transplant immunology, I am sure that this program will be able to benefit all members of the society who need transplant for Heart failure.”
PHILIPS APPOINTS ROHITSATHE AS PRESIDENT OF PHILIPS INDIA HEALTHCARE
Philips India, announced the appointment of RohitSathe as President – Philips India Healthcare, effective from December 4th, 2017. Rohit will be a part of the Philips India Leadership team and will be responsible for bringing in leadership experience, and extensive industry knowledge to contribute to Philips’ overall growth plans. He will oversee key initiatives to improve access to healthcare in the areas of prevention, diagnostics and treatment. The appointment is set to augment Philips’ leadership position and reinforce its market presence with significant value-addition for customers. RohitSathe is a seasoned leader with almost two decades of work experience in the healthcare, construction and e-learning industries in India and UK. He has joined us from Johnson & Johnson Medical India
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January 2018
he will propel Philips India’s growth further across various markets. We will continue to invest in our leaders to ensure we have a strong foundation to support our customers, strategic plans and double digit growth.” Commenting on his new role at Philips India, Rohit said, “I am thrilled to be a part of the Philips family and I am excited with our continued endeavor to provide people with a healthy and improved lifestyle. I look forward to working closely with Daniel and the entire team at Philips, and helping the company achieve its full potential in the Indian market, while strengthening relationships with government and other key stakeholders.” Apart from his professional career, Rohit also enjoys long distance running, experimenting with different cuisines and spending time with his family and friends.
TRIESTA TO COMBINE WITH STRAND LIFE SCIENCES (JJMI) where his last role was Senior Director of Strategy, Key Accounts and International (SAARC) Business. During his 12+ years tenure at J&J, he worked in the Cardiology, Orthopaedics and Neuro segments. His achievements include launching coronary drug eluting stents (DES), integrating the recently acquired Synthes business into J&J and turning around and improving profitability of the Trauma and Neuro businesses. His rich experience in sales, marketing, strategy and project management across diverse industries will help Philips move closer to its target of touching 200 million patients in India by 2025. Welcoming Rohit on board, Daniel Mazon, Vice Chairman & Managing Director, Philips India said, “We are happy to welcome RohitSathe to the Philips India family. Rohit brings a legacy of outstanding customer focused experience and in-depth knowledge of healthcare. I am confident that with his solid background in strategy, commercial execution and his passion for talent development,
Healthcare Global Enterprises, Ltd. announced execution of definitive agreements for the business combination of its Triesta Sciences business unit with Strand Life Sciences Pvt. Ltd. The combination of Triesta and Strand creates an integrated platform with end to end capabilities in precision medicine – proprietary analytics, clinical research, access to the HCG biorepository, genomic technologies, assay development and validation and a network of laboratories offering a broad menu of tests. Dr. B.S. Ajaikumar, Chairman and CEO of HCG, said “Strand and Triesta have been working together in bioinformatics and clinical genomics. We are now excited to combine our strengths and resources towards redefining precision medicine. In an era of data driven healthcare, Strand’s exceptional team of computer and life scientists with access to a well annotated clinical substrate, provides a unique opportunity to create exceptional value.” Dr. Ramesh Hariharan, Founder and CEO of Strand, said “Triesta and HCG have been pioneers in bringing the latest advancements
in molecular biomarkers into clinical practice in the country. Together we are well on the path to building Asia’s leading integrated analytics driven diagnostic and genomics research company. Through this alliance we will work together to be at the forefront of precision medicine”.
health care services through technology. With the help of DocExa, we plan to connect over half a million doctors & 10 million patients by 2019.” Built on latest AI algorithms, the app is cross-platform and can be accessed through a smartphone or a tab at any time and pace.
GLOBALSPACE TECHNOLOGIES LAUNCHED EXCLUSIVE DIGITAL PLATFORM
MEDEQUIP OXYGEN SYSTEM BEST FIT FOR PATIENT’S REQUIREMENT AND LIFESTYLE
GlobalSpace Technologies launched DocExa, “an exclusive digital platform developed using AI technology to help Doctors efficiently manage their patients & other engagements”, during DigiPharmaX (Digital Pharma Excellence) Awards 2017 at Mumbai. DocExa leverages artificial intelligence, cloud & mobility technology to empower Doctor, Patients &Pharma companies for meaningful & transparent engagement. DocExa helps create a transparent engagement between the Doctor and Pharmaceutical communities, while adhering to the Government regulations and guidelines like UCPMP. Additionally, doctors can file ADR through DocExa which provides real-time access of adverse drug reactions reports to Pharmaceutical companies and helps them to improve the quality of drugs. Doctors can also avail medico-legal consulting from a team of trusted, verified and reputed Legal Advisors, with the help of just a click or a tap. Speaking on the launch, Krishna Singh, Founder, Chairman & Managing Director, GlobalSpace Technologies said, “DocExa is the industry’s first AI driven Doctor-Pharmaceutical-Patient Connect Platform. In India, still the Doctor- Patient ratio is abysmally low at 1:1700. In its evolved formDocexa can enable Doctors to carry out differential diagnostics & help more number of patients, efficiently. He further added, “DocExa is a step forward towards digital India and by digitally connecting the critical stakeholders of healthcare ecosystem, irrespective of their location, can access the most advanced
Medequip Healthcare solutions, a Bangalorebased importer and manufacturer of healthcare products showcased enhance range of Oxygen Concentrators. “COPD is widespread throughout India and oxygen concentrators are an effective treatment. The oxygen requirement varies from patient to patient, based on the specific issue they face. Our aim in adding 2 more variants is to meet the specific needs of our
customers and to enable them to choose based on their condition,” SuhasShubhakaran, co-founder, Medequip health care solutions. Chronic Obstructive Pulmonary Disease (COPD) are breathing ailments with a wide range of undesirable side effects ranging from difficulty in breathing to heart disease and cancer. India faces a heightened risk since pollution is one of the leading causes of this ailment. According to a 2016 World Health Organization (WHO) report, India, has 16 of the world’s 30 most polluted cities. People affected by COPD have a shortage of oxygen in the blood supply. Oxygen Concentrators filter out the Nitrogen prevalent in the atmosphere and provide oxygen with a purity of ninety three percent. “The air we breathe contains about 78% nitrogen, 21% oxygen and 1% other gasses. A Oxygen concentrator filters out as much nitrogen and other harmful gases as possible while leaving the oxygen. The resulting air has a much higher concentration of oxygen
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NEWS ROUNDUP which is what COPD patients’ need,” Dr. NarayanaPradeep, Consultant Pulmonologist, Kasaragod, Kerala, (Gen secretary, Chest council of India). COPD is a disease that allows a patient to breathe, but due to inflammation and obstruction, not expel air well, while ILD (Interstitial lung disease) restricts their ability to breathe at all through scarring and damage to the lungs themselves. Patients with ILD requires Oxygen at higher LPM (litres per minute) and hence the introduction of the 10 Litre concentrator. Elaborating on the dependency of the patients using Oxygen concentrators, Ankur Garg, Co-founder, Medequip Healthcare Solutions says, “Our commitment is to provide quality healthcare equipment and to service them to reduce the dependency of customers using Oxygen therapy machines. We ensure that our Pan India Distributor/ Dealer and Techno Service Network ensures minimal down time of machines, giving the customers the much needed support. Also, with our wide range of Oxygen Therapy products and artificial ventilation machines, we are able to provide cost effective solutions to our customers.” Patients suffering with COPD / ILD have low level of oxygen in their blood. Some may need oxygen all of the time while others may need it only during sleep and exercise. Supplementing oxygen to improve the level of oxygen in the blood through can relieve the strain on the heart and lungs and improve symptoms of shortness of breath and fatigue. The aim of Medequip is to provide the oxygen system that best fits the patient’s requirement and lifestyle.
HCG AND CVERGENX PARTNER TO LAUNCH GENOMIC RADIATION THERAPY
Healthcare Global Enterprises, Ltd. and Cvergenx, Inc. announced an exclusive collaboration to develop, validate and launch precision genomic radiation therapy (pGRTTM) technology in India and Africa. HCG and
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January 2018
Cvergenx shall form a joint venture which shall be the exclusive vehicle through which this technology will be made available in those countries. The proprietary pGRTTM platform, developed at Cvergenx by Dr. Javier Torres-Roca, co-founder and Director, Clinical Research, Department of Radiation Oncology, Moffitt Cancer Center & Research Institute, is the first clinically validated approach to guide radiation dosage based upon the Radiosensitivity Index (RSI) of patients. The HCG/Cvergenx joint venture shall be the first initiative to validate and bring into clinical practice a solution that integrates genomics into radiation treatment planning and therapy in India. “We are excited to be the first to bring precision genomics based radiation therapy to India. This pioneering technology will allow oncologists to precisely decide radiation treatment for cancer patients based on their genomic profile. It has the potential to truly revolutionize cancer care” said Dr. B.S. Ajaikumar, Chairman and CEO of HCG. “HCG is redefining cancer care across India and Africa through its network of com-
prehensive cancer centers” said Raymond F. Vennare, CEO of Cvergenx. “Their steadfast commitment to seeking out and adopting the latest advancements in technology aligns precisely with our own desire to bring radiation oncology into the era of personalized medicine. The ability to partner with HCG represents a significant move forward for Cvergenx and the practice of radiation therapy”.
VATSALYA DENTAL TO SET UP INDIA’S FIRST INNOVATION PROGRAM IN DENTISTRY
In a bid to create a spirit of entrepreneurship and innovation in the healthcare space, India’s fastest growing chain of dental centers, Vatsalya Dental has collaborated with Origiin IP Solutions to set up a panIndia innovation programme in Dentistry. To be run from Vatsalya’s world class and expansive 4,000sq. ft. Innovation and Incubation Centre, the programme aims to reach out to 1000 plus students and young
dentists in India by 2018 end, and foster a culture of innovation and entrepreneurship, particularly in the space of dentistry. Origiin IP Solutions, considered to be among India’s top IP firms, along with Vatsalya Dental will help young students and dentists ideate, build and market their product giving them a competitive edge in the ecosystem. Together, they will expand the programme nationally and ensure that it meets the evolving healthcare demands with greater research and innovation. The programme will also include a design and manufacturing partner who will be part of the initiative right from the ideation stage. This is a first of its kind programme, which will bring industry veterans and young dentists together, to build a world class dental infrastructure in India, and also further the cause of the ‘Make in India’ initiative launched by Government of India. Speaking on this initiative, Dr SrivatsBharadwaj, Chairman and Founder, Vatsalya Dental said, “This will be India’s first such programme fostering innovation in healthcare. We will be working with Dental colleges and young dentists across India and provide them with platforms that will help them not just ideate, but also execute and patent those ideas; thereby make a difference in the society. The partnership consists of a core team of innovators who will mentor young students and dentists through the year.” “In addition to the fact that Dentistry or Oral care as a healthcare subject is still a neglected in India, the medical devices used in dentistry are not always compatible to our needs as very often these products are researched and developed in US or UK and don’t take into account the socio-cultural and medical/healthcare requirement of patients in India. These products, therefore don’t adhere to best practices from the Indian context and also comes with an exorbitant cost that ultimately is passed on to the patient. If we really aspire to make healthcare in India meet global standards, I sincerely believe that we need to work together to build, sustain and grow a scientific and
policy ecosystem that promotes and rewards medical innovation. Innovation in the country will also drastically bring down the costs of equipment and treatment in India,” added Dr Bharadwaj while talking about the need to create an innovation friendly environment in India. “We are very excited about launching this programme with Vatsalya Dental, at a time when India is witnessing a surge in entrepreneurial spirit and innovation. In areas such as healthcare, researching and developing innovative products can provide real solutions for better healthcare and transform the lives of people. It can also fuel the growth of domestic innovation and bolster India’s economic prosperity,” said Raghu Ram from Origiin IP Solutions. In fact, some of the young innovators have already started working at the incubation center along with their mentors. “While we can’t disclose the innovation that they’re working on, we are enthused at the ability of these young students to think beyond classroom teachings and carry such powerful and creative concepts that can impact the industry,” said Bindu Sharma one of the mentors.
CYTECARE CANCER HOSPITAL LAUNCHES TELE-CONSULTATION PROGRAM IN BANGLADESH Cytecare Hospital is proud to launch its TeleConsultation program in Bangladesh. With the goal of transforming the tertiary and quaternary healthcare system to be more accessible and affordable, Cytecare along with Expert Chikitsa is taking its fight against Cancer to Bangladesh. According to World Health Organization’s, Global Cancer Project (GLOBOCAN-2012), 1.22 lakh new cancer cases are reported in Bangladesh every year, with the survival rate at a meager 31,000. Such high casualty rates are due to the majority of the patients reporting at the last stage and lack of
treatment facilities. As per WHO guidelines, Bangladesh should have 160 treatment centers in order to cater to its population. However, it has only 16. Suresh Ramu, CEO, Cytecare Cancer Hospitals, said, “There is a tremendous need for cancer awareness and supporting patients in Bangladesh with the right diagnosis and treatment advice. Our dedicated information centers will offer video consultation for the patients and allow them to interact with top specialists of Cytecare Cancer Hospitals. It is important to make cancer treatment affordable and accessible for the common man.” In addition to the launch of the TeleConsultation program, Dr. VikramKekatpure and Dr. Anthony Pais, of Cytecare Cancer Hospital also engaged in various medical education initiatives, such as organizing a seminar on ‘Functional Rehabilitation following Oral resection’ at City Dental College, Dhaka; a Continuing Medical Education (CME) program on ‘Changing paradigm of head and neck cancer management’ which was attended by over 40 doctors; doctor and hospital visits with the intention of building a stronger doctor referral network; and a corporate health talk on ‘Tobacco and Health Effects’. A good healthcare system is the basic right of every citizen of this world. As an expert in Oncological treatment, it is the duty and responsibility of Cytecare to take its specialized care to the doorstep of anyone who may need it.
MULTICENTER STUDY OF 34 ICUS ACROSS INDIA THROWS LIGHT ON THE MAJOR REASONS FOR ICU ADMISSIONS OF TROPICAL FEVER PATIENTS A multicentric observational study of 34 ICUs across India on 456 patients of critically ill adults and children with non-localizing fever has found that Dengue (105.23%) was the most common followed by scrub-
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NEWS ROUNDUP typhus (83.18%) , encephalitis (44.96%) malaria (37.8%) and bacterial sepsis (32.7%) as reasons for ICU admissions across India during post-monsoon season from AugustOctober . The study has been conducted by researchers from Sir Ganga Ram Hospital ,New Delhi ; PGIMER ,Chandigarh ; CMC, Vellore ; PGIMS, Haryana ;Sanjivani Superspeciality Hospital , Ahmedabad ; Apex Hospital, Bhopal ; PGIMS, Rohtak and JeevanRekha Critical Care , Jaipur . The study period was from July 2013 to September 2014 and has been recently published in the December 2017 edition of Indian Journal of Critical Care Medicine . According to Dr PrakashShastri , Author & Vice-Chairman , Department of Critical Care Medicine , Sir Ganga Ram Hospital , “Tropical fevers are caused by number of viruses , bacteria and protozoa and often get transmitted by an insect bite. Some of the common tropical fevers from Asian countries are Dengue , Malaria , Leptospirosis , Influenza A , Typhoid , Scrub typhus , Japanese encephalitis and Chikungunya. The challenge lies in clinically diagnosing them at the time of presentation as they often present as undifferentiated fever and with overlapping signs and symptoms. Laboratory confirmation may not be available or reliable in first few days .Regardless , it is important to treat these patients early as delay leads to increased complications and increased hospital stay and expenditure. Hence, we conducted this nation-wide study to identify the prevalence , reasons and utilization of ICU resources and outcome of a patient with tropical fevers in Indian ICUs. “ According to Dr (Prof.) SunitSinghi , Author and Emeritus Pediatrics , PGIMER , Chandigarh , “ We found that in patients admitted to ICU with acute febrile illness and systemic manifestations , dengue and scrub typhus to be the most common etiological diagnoses. Case fatality in our study was 18.4 % . The outcome data highlights the importance of reaching the diagnosis as those without a specific diagnosis more often required organ supportive therapies and had poor outcome . In addition to this ,
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Tropical fevers also pose a significant burden on ICU health-care resources. Nearly , a fifth of all ICU resources were consumed by these illnesses . “ According to Dr. (Prof.) T.D.Chugh , Emeritus Pathology , PGIMS , Rohtak , “ Our study also shows that Dengue , Scrub typhus , Encephalitis and Malaria are common causes of tropical fevers presenting to Indian ICUs , with organ involvement in postmonsoon season . Point of care testing for these tropical fevers can rule in or rule out these diagnosis at admission and help in instituting specific therapy. “
TOSHIBA MEDICAL SYSTEMS CORPORATION IS NOW CANON MEDICAL SYSTEMS CORPORATION
Canon Inc. and Canon Medical Systems Corporation recently announced the official corporate name (trade name) change of Canon Group Company Toshiba Medical Systems Corporation to Canon Medical Systems Corporation (hereafter referred to as Canon Medical Systems). Since joining the Canon Group in December 2016, Canon Medical Systems has been undertaking the procedures for obtaining regulatory approval for integration with the Canon Group and change of the company name under the relevant national or regional laws concerning pharmaceuticals and medical devices. Canon announced that such procedures have been completed, and that the change of the company name enters into effect today. Since its establishment in 1930, Canon Medical Systems has introduced a number of “first-in-Japan” and “world’s first” medical systems in cooperation with its customers worldwide. With its sales and service network, Canon Medical Systems conducts business globally, providing diagnostic imaging systems to around 140 countries and regions. Canon Inc. first entered the medical equipment business in 1940 with the development of the first domestically produced indirect X-ray camera, and utilizing
its advanced imaging technologies, currently produces equipment such as digital X-ray imaging systems and OCT ophthalmic devices. Since its founding, the Company has maintained a strong commitment to the medical equipment business, and will further strengthen the business with the aim of contributing to a safe and secure society. Through its integration with the Canon Group, Canon Medical Systems—in the spirit of the Canon Group corporate philosophy of “kyosei” and its own management slogan of “Made for Life” (Made for Partnerships, Made for Patients, Made for You.)—will continue to expand in order to accelerate the growth of the Canon Group’s medical equipment business and contribute to better healthcare throughout the world.
DOSE MATTERS: FDA’S GUIDANCE ON CHILDREN’S X-RAYS Most people have had an X-ray taken at some time during their lives — perhaps checking for a possible broken bone or during a visit to the dentist. X-ray exams provide important information to physicians about how to treat their patients. However, X-rays use ionizing radiation, and these imaging exams must be carefully and judiciously used on pediatric patients. While the level of risk from the radiation associated with X-rays is small, especially when compared with the benefits of an accurate diagnosis, health care professionals must be especially sensitive to their appropriate use in children. Pediatric patients generally require less radiation than adults to obtain a quality image from an X-ray exam, so doctors must take extra care to “child size” the radiation dose. In a new guidance FDA recommends that medical X-ray imaging exams be optimized to use the lowest radiation dose needed. These exams, which include computed tomography (CT), fluoroscopy, dental, and conventional X-rays, should be performed on children and younger patients only when the health care provider believes they are
surgery is important, it is essential that that these surgical treatments are safe and effective. Importantly, 95% of deaths in our study occurred in the postoperative period, suggesting that many lives could be saved by effective monitoring of patients who have developed complications and increasing the resources necessary to achieve this objective. Surgical outcomes will remain poor in Africa until the problem of underresourcing is addressed.” The study includes data from 11422 people who underwent an inpatient surgical
necessary to answer a clinical question or to guide treatment. The FDA defines the pediatric population as birth through 21 years old. However, the optimization of image quality and radiation dose in X-ray imaging depends more on a patient’s size than their age. Smaller patients require less radiation to obtain a medically useful image. Technically, the patient’s body thickness (the distance an X-ray travels through the body to create the image) is the most important consideration when “childsizing” an image protocol. Unnecessary radiation exposure during medical procedures should be avoided. However, X-rays and CT scans should never be withheld from a child or adult who has a medical condition where the exam could provide important health care information that may aid in the diagnosis or treatment of a serious or even life-threatening illness.
SURGERY DEATH RATES IN AFRICA ARE DOUBLE THE GLOBAL AVERAGE Despite surgery patients in Africa being younger, with a lower risk, having
more minor surgery, and having fewer complications, their risk of death is double the global average, according to the most comprehensive study of surgery in Africa published in The Lancet. The observational study, which was conducted by a group of more than 30 African researchers and includes 247 hospitals in 25 African countries, suggests that scarce workforce and resources mean surgery is less safe across the region. To improve these outcomes it calls for improved monitoring of patients during and soon after their surgery. Surgery is a cost-effective and important component of universal healthcare, however it is estimated that five billion people worldwide are unable to access safe surgical treatment, and 94% of these people live in low- and middle-income countries. “Approximately one in five surgery patients in our African cohort developed a complication, and, overall, 2% of all patients died,” says lead author Professor Bruce Biccard, Groote Schuur Hospital and University of Cape Town, South Africa. “Our study reveals the scarce workforce resources available to provide safe surgical treatment. Although increased access to
procedure during a set week at each of the 247 hospitals included across 25 African countries. Data on complications were missing for 537 people and data on mortality were missing for 229 people. As well as documenting each patient’s health before surgery, the study monitored their health after the surgery, tracking any complications, admission to critical care, or deaths. The study also reviewed hospital resources, such as numbers of beds, operating rooms, critical care beds, anaesthetists, surgeons, and obstetricians. Overall, most patients (87.3%) had a good physical status and were low-risk for surgery, and were young (average age of 38.5 years). The majority of surgeries in the study were urgent or emergent (57.1% of surgeries) and the most common procedure was caesarean section (33.3% of all surgeries). Complications following surgery occurred in 18.2% of all patients (1977/10885 people), and the most common complications were infections, accounting for 58.7% of all complications (1156/1970). Around 16.3% of patients (321/1972 people) were admitted to critical care to treat complications. One in ten patients with complications died (9.5%, 188/1970 people), and these deaths were spread equally across infectious (112 deaths), cardiovascular (110 deaths) and other complications (112 deaths) Overall, 2.1% of patients died after surgery (239/11193). Of these, 14 people (5.9%) died on the day of their surgery, and the average time to death was five days. Comparisons with international data for elective surgery
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NEWS ROUNDUP suggest that death rates following surgery in Africa are twice the global average. Data from the study published today found that death rates from elective surgery were 1% in Africa, compared with 0.5% for the global average. With most deaths occurring in the days following surgery, the authors note that it is likely that these deaths are preventable, and that the safety of surgery may be improved through increased monitoring of patients on the ward. However, resources are scant, with each hospital included in the study serving an average population of 810000 people, with an average of 300 beds, four operating rooms, and three critical care beds. Having few specialists and low procedural volumes also contributes to the low safety of surgery across African countries. Typically, each hospital completed 29 surgeries in
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a week, equivalent to 212 operations per 100000 people. The authors note that this is low, and indicates that services are not meeting need. Overall, there were 0.7 specialists (a combined total of surgeons, obstetricians and anaesthesiologists) to every 100000 people in the hospital population, which the authors note is well below the recommended levels of 20-40 specialists per 100000 patients needed to reduce mortality. On average, each hospital had three specialist surgeons, one specialist anaesthetist and two specialist obstetricians. The study furthers the work of The Lancet Commission on Global Surgery [4] which was published in 2015, and called for robust data on surgical activity and patient outcomes. The Commission states that structures, processes and outcomes are important parts to improve the quality of surgery worldwide.
“Our study highlights the importance of effective perioperative care to achieve better surgical outcomes in Africa. A continent-wide quality improvement programme might reduce the number of preventable deaths following surgery in Africa.” adds Professor Biccard. The authors note some limitations, including that the study does not include data for all African countries, including many low-income countries, or for smaller, more remote hospitals, and so the findings might not be applicable for detailed health policy decisions in individual countries or hospitals. Additionally, the week-long period of data collection means that wider changes, which may influence health care access – such as seasonal weather, industrial action, available workforce, armed conflict, workload, and when people choose to access healthcare – may not be accounted for. Read more on www.indamedtoday.com
NEWS FEATURE
THE BACTERIAL ‘GAME OF THRONES’ Understanding bacterial wargames inside our body
Photo Credit: Kevin Foster
MUCH LIKE animals and to a degree humans, bacteria enjoy a good fight. They stab, shove and poison each other in pursuit of the best territory. While this much is clear, little is known about the tactics and strategy that bacteria use during their miniature wargames. In a study published in Current Biology, researchers at the University of Oxford have shed light on this area of bacterial behaviour, revealing that bacteria approach conflict in much the same way as an army by responding to a threat with a coordinated, collective retaliation. The team studied pairs of Escherichia coli strains as they fought against each other. Each strain uses a particular toxin to try to overcome its competitor. A strain is immune to its own toxins, but it can kill other strains. This type of competitive interaction plays a key role in how individual bacteria establish themselves in a community, such as the human gut. By engineering the strains to have a fluorescent-green colour, the authors were able to clearly follow their combat in real time. The findings revealed that not all strains of bacteria fight the same way. Each approaches conflict with a different level of attack, some being hyper-aggressive and others much more passive. In addition to these basic differences in aggression, the research also shows that some strains can not only detect an attack from an incoming toxin, but they can also respond quickly to warn the rest of the colony. Cells on the edge of the colony will detect the incoming attack, and share this information with the cells behind the battlefront, allowing them to respond as a collective, in a coordinated and surprisingly sophisticated fashion. While these phenomena are well known in animals, the study is a first of its kind for
Two bacterial colonies fighting on solid media using toxins. Upon detecting an incoming attack from the red strain, cells of the bottom strain pass this information on to others in the colony leading to a massive collective attack against the red strain. Green colour indicates toxin production.
observing this behaviour in bacteria. Professor Kevin Foster, senior author on the work and Professor of Evolutionary Biology in the Department of Zoology at the University of Oxford, said: ‘Our research shows that what appear to be simple organisms can function in a very sophisticated manner. Their behaviour is more complex than we have previously given them credit for. Much like social insects, such as honey bees and wasps and social animals like birds and mammals who use alarm calls, when under predation, they are capable of generating a coordinated attack’. Since the human body plays host to vast numbers of bacteria, particularly our gut microbiome, this effectively means that there is a bacterial war going on inside us. Understanding bacterial com-
petition can help us to understand how bacteria spread, where and why. Professor Foster explains: ‘We know from other studies that toxins are important for whether or not a particular strain will establish in a community. But understanding how bacteria release toxins and out-compete others is very important for understanding the spread of infection.’ The team are in the process of building on this work to understand how bacteria can use toxins to provoke and misdirect aggression in their opponents. Dr DespoinaMavridou, one of the lead authors on the study, said: ‘Warfare based on provocation can be beneficial. It is most likely taking place in the gut, where bacteria may provoke multiple opponents to attack and wipe out each other.’
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NEWS FEATURE
CANCER’S GENEDETERMINED ‘IMMUNE LANDSCAPE’ DICTATES PROGRESSION OF PROSTATE TUMORS Analyzing individuals’ genotypes and immunotypes could yield customized treatments THE FIELD of immunotherapy - the harnessing of patients’ own immune systems to fend off cancer - is revolutionizing cancer treatment today. However, clinical trials often show marked improvements in only small subsets of patients, suggesting that as-yet unidentified variations among tumors result in distinct paths of disease progression and response to therapy. Now, researchers at the Cancer Center at Beth Israel Deaconess Medical Center (BIDMC) have demonstrated that genetic variations driving prostate cancer determine the composition of the immune cells that have been found to infiltrate primary prostate tumors. These immune cells, in turn, dictate tumor progression and response to treatment. The data, published in Nature Medicine, suggest that profiling pa-
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tients’ tumors based on this new information could lead to more successful clinical trials and tailored therapies for patients. “We observed that specific genetic events resulted in striking differences in the composition of immune cells present in and around the tumor - results with important therapeutic implications,” said senior author Pier Paolo Pandolfi, MD, PhD, Director of the Cancer Center and Cancer Research Institute at BIDMC. “Our data may be especially relevant for tailoring immunological therapies and for identifying responsive-patient population.” The third leading cause of cancer-related death in U.S. men, prostate cancer, is linked to a number of diverse genetic mutations that drive the disease. For example, the loss of the tumor suppressor gene PTEN is a frequent event in
Photo Credit: National Cancer Institute, National Institutes of Health
prostate cancer and is well known to promote the disease in combinations with a plethora of other mutations. Researchers also know that the tumor’s microenvironment - the blood vessels, immune cells, signaling molecules and other factors that surround the tumor - plays an important role in tumor progression and response to therapy. Pandolfi’s team - including lead author, Marco Bezzi, a post-doctoral fellow in Pandolfi’s lab - engineered mice models to represent four distinct known genetic variations of human prostate cancer. The models lacked either Pten alone or in combination with other genetic alterations known to drive the disease. When the team analyzed the tumors from these mice, they saw profound differences in the types and relative numbers of the immune cells that had accumulated in and around the tumor, what they call the tumors’ “immune landscape”. For example, specific immune landscapes tumors from the genetic model lacking both Pten and the tumor suppressor gene called Trp53 demonstrated an increased accumulation of myeloid cells, the immune cells that mediate immunosuppression. In stark contrast, tumors from the genetic model lacking Pten and a different tumor suppressor gene called PML lacked intratumoral immune infiltration; that is, the researchers observed no immune cells at all in these tumors, which the scientists dubbed “cold,” or “immune-deserts.” All four mouse models analyzed presented very distinctive immune landscapes and these differences were maintained and exacerbated over time. The research team also demonstrated that these differences in immune cell composition were directly dictated by the tumors themselves because of their genetic variations. Different tumors, they observed, secreted distinct chemical attractants, which in turn recruited - or didn’t recruit, in the case of the immunedesert tumors - different immune cell types into the tumor. Pandolfi and colleagues further demonstrated that these differences hold true
Wild type human prostate cells from an organoid (a man-made construct that resembles an organ). These cells have come from a xenograft where they serve as controls for the study of primary prostate cancer tumor cells, which are also injected into mice and then extracted for characterization
in human prostate cancer. Critically, the immune cells recruited to the tumors were found to be essential in supporting the growth and progression of these tumors. “We observed that when present, these infiltrating immune cells were required for the tumor to thrive and found therapies to block their recruitment to be effective,” said Bezzi. “On the other hand, the cancer genotype characterized by the so-called ‘immune desert’ phenotype, did not respond to such therapies. On this basis, we can predict the tumor response to immunotherapies and tailor treatment modalities to effectively impact tumors that are otherwise
extremely aggressive,” he said. Thus, because immune cells interact with and also affect tumor response to therapy, these findings may be especially relevant for the development of more precise and effective combinations of immunotherapies and targeted therapies on the basis of the cancer genetic makeup. “These profound differences in immunological landscapes among various cancer genotypes further highlight the need to thoroughly investigate and integrate genotypes and immune-phenotypes in the context of exploratory cancer treatments in both preclinical and clinical settings,” said Pandolfi.
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NEWS FEATURE
FIRST ESMO AWARD FOR IMMUNOONCOLOGY GOES TO LAURENCE ZITVOGEL THE EUROPEAN Society for Medical Oncology (ESMO) has granted the newly established ESMO Award for Immuno-Oncology to Prof Laurence Zitvogel for her innovating and internationally recognised achievements in the field. “Prof Zitvogel’s discoveries in the area of immuno-oncology have served as the foundation for important advances and our understanding of the fundamentals of cancer immunology,” said Christoph Zielinski, on behalf of the ESMO Fellowship and Award Committee. “In presenting her with the ESMO Award for Immuno-Oncology we are recognising her preeminent and pioneering role in the field,” noted Zielinski. Zitvogel, MD, PhD, is professor of Immunobiology at the University of Paris XI Medical School and scientific director at the Department of Immuno-Oncology, GustaveRoussy Cancer Centre, in Villejuif, France. She is also the director of U1015 INSERM Tumour Immunology and Immunotherapy Laboratory at INSERM and co-director of the Centre for Clinical Investigation in Biotherapies of Cancer, INSERM. The ESMO Award for Immuno-Oncology was created this year in commemoration of the European pioneer in cancer research in immunology, founding member and first President of ESMO, Prof Georges Mathé. It was presented to Prof Zitvogel during the ESMO Immuno Oncology Congress 2017 in Geneva, 7-10 December 2017, during the keynote lecture about “Introducing the gut microbiome into the complexity of anticancer immunosurveillance”.
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Laurence Zitvogel has dedicated her career to advancing the field of cancer immunology and immunotherapy. She is a devoted educator having directed the work of many postdoctoral fellows. She has authored or co-authored over 350 publications. She is also the Editor-in-Chief and founder of one of the first journals in immune-oncology, “OncoImmunology.” Commenting on the award, Zitvogel said: “I am honoured to receive this award, which acknowledges the work of, not only my team and GustaveRoussy colleagues, but also that of the European pioneers who relentlessly paved the way for the relevance of the immune system in long-term cures obtained in patients treated with chemotherapy, radiotherapy and immune-targeted antibodies.”
Her current research falls into three main categories: studying the modes of action of immune checkpoint inhibitors and seeking predictors of response to immunomodulators; defining the role of the gut microbiome in cancer immunosurveillance, and deciphering the molecular mechanisms of immunogenic cell death. Zitvogel added: “I feel indebted to our inspiring father and chairman, the Nobel Prize winner Ralph Steinman, who introduced us to the arena of dendritic cell biology, as well as to Mike Lotze and the Rosenberg school, for their seminal training. I will finish by acknowledging that I share this award with Prof Guido Kroemer who helped me in deciphering the molecular mechanisms of immunogenic cell death. Photo Credit: INSERM
The ESMO Immuno Oncology Award 2017 goes to Prof Laurence Zitvogel.
COVER STORY THINKING OUTSIDE THE BOX
HEALTH INSURANCE The future of health insurance in India can only be bright as modern medical care will be virtually impossible without affordability and that can be possible only through risk transfer. Health insurers are now orienting themselves to more offerings based on their core competences and new directions of customer demand
PC JAMES Principal Officer, Insure Edge and Author, Understanding Insurance of Health
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COVER STORY
H
ealth and disability insurance is an integral part of social engineering. Disease, accident and disability have expensive downsides in human existence. Managing the risks that affect human wellness is essential not only for the financial security of individuals and families, but also for the community as well as the country. Health care is a growing industry owing to the importance that wellness has in the hierarchy of needs of the society. This has made healthcare the largest industry in the world. As medical capability and services rise, medical costs are also seen to be rising rapidly, making healthcare increasingly unaffordable in day to day settings. A health disaster in the life of a person is an uncertain event, and the payout required is also uncertain and often high. However, since the risk is a frequency risk, it mandates coverage on a universal basis,
Long-term-care insurance can pay for long-term care, either in an institution such as a nursing home or in a residence
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where the rich and the poor, the young and the old are to be covered in one way or the other. Health insurance is set to grow in many ways facilitated by the many compulsions that health economics face to ensure that health care is made available and affordable to all. Health care systems need to work in harmony and seamlessly to ensure that healthcare and wellness is promoted and proper care is provided to everyone who avails it seamlessly. To enable the industry to face the challenge of insuring all, shifting of costs and opaqueness in costing by all concerned has to be avoided. The terms and conditions of the policy need to get better understood not only by customers but also by all those providing the services and interpreting the policy conditions. Customer capabilities - to get the optimal benefits from all service providers in the system - needs to be monitored and strengthened. Health care is an emotional issue and a heavy cost, and hence Regulations, Self-Regulations, best in class corporate/self-governance and professional standards should begin to be seen and felt in the system. Best practices across the value
chain should be competitively implemented, duly evaluated by independent agencies and all institutional oversight bodies should enforce minimum standards as required. Meeting Customer Concerns in Health Care Insurance Consumers incur heavy costs when facing health disasters which may not only include the monetary price, but also more intangible costs such as time cost, energy cost and psychic cost. The concerns that drive consumers of healthcare and health insurance are important in the context of the exigencies faced and should be addressed. These could include the following: Customer / Patient protection measures Ensuring privacy and confidentiality of healthcare information Full information disclosure Immediate 24x7 access to emergency services Participation in treatment decisions, choice of doctors,etc. Respect and non-discrimination Reducing confusions in the policies, practices, procedures of all agencies Cashless, hassle-free care and paperwork and settlement of costs and claims Measurement of patient satisfaction and clinical outcomes. Ensuring that consumer complaints are heard and redressed quickly Customers have expectations as to responsiveness, convenience and trustworthiness. Today, customers are getting empowered and their attitudes and behaviours are evolving. There is more self-reliance and less subservience to the medical or insurance establishment owing to widespread availability of information and relevant knowledge. There are more instances of self-diagnosis, self-monitoring and self-care, appraisal and study. Consumers are getting more and more empowered as they are receiving increasing proactive assistance from consumer groups, employers and others who will intervene for them.
personal priority for consumers and hence, assistance in choosing the right product, full disclosure about policy conditions, and other procedures would be necessary. The Regulator has ensured this in the regulations, but insurers, TPAs and care providers are not yet known for providing clear and useful information in simple language and prices, costs, limitations are not clearly spelt out. Terms of high promise and invitation to insure are used in health protection areas and if they fail in the promises expected, the backlash can affect the entire industry. Clear meaningful information is required to be disseminated which should inform customers that insurance is a complex concept, health insurance more so and that the processes can be many, the benefits cannot outrun the costs and so on. Performance Measurement and Satisfaction in service rendered needed Insurers and TPAs will have to benchmark against not only what has been promised in their documents, but also meet increasing customer expectations both as to the time taken to render service, and as to the quality of service. Parameters of service excellence would have to be developed to ensure that customer satisfaction levels are kept high. Speed and responsiveness need to be measured. How fast and how much in terms
Wellness based insurance products would see a rise in offerings in future & their direction need to ensure better health outcomes
Meet the Rising Aspirations of Consumers Consumer demand for meaningful information Health and health coverage are matters of high
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COVER STORY of the customer expectations which has been created in the mind of the consumer, by the language and promises of insurers and TPAs, need to measured and the gaps addressed, in creating confidence in the system and service providers concerned. Meet customer aspirations for innovative products and services In the anxiety to enroll numbers and make a profit, insurers may overlook the real needs of beneficiaries, especially in group insurances where the concerns of the employer or the group managers may override the concerns of the beneficiaries. New products and services would have to be developed which could base their attributes on the age, gender, lifestyle and other relevant aspects of consumer’s life so as to align the insurance product offerings with their particular health care needs. Meet the challenges of customer empowerment It is possible that over the course of time consumer coalitions, government organizations, industry associations, information websites, and the media may empower customers with avariety of health-related information and services such as: Rating of hospitals, physicians, health plans, their quality and performance.
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Provider directories Guidelines for choosing hospitals, doctors, health plans. Health related news and articles Links to health search engines Malpractice issues and other anti-customer activities Critical information about insurance policies and plans with comparative charts. Evaluation of insurers and TPAs and their services. Policy monitoring Assistance in shopping for health insurance products Insurers have to fine tune the art of informing and advising across all channels of distribution, communication and interaction with the insureds. In the scenario of knowledge empowered customers, insurers will have to expand their capabilities, widen their service offerings and deepen their product options to meet customer requirements. Consumer aspirations and activism coupled with competitive pressures will always threaten the status quo and create new avenues for improved quality of coverage, better care and greater efficiencies and at lesser overall
Health insurers are now orienting themselves to more offerings based on their core competences and new directions of customer demand
costs and hassles. Ultimately, healthcare issues will be evaluated on a comprehensive set of criteria such as quality, cost, patient satisfaction and health promotion. Insurers and their TPAs would have to make efforts to deliver the same to their insureds at affordable costs with optimal outcomes. In the evolution of healthcare, disease management is likely to give way to care management, which will create an integrated system of managing care, and will move from a focus on the inpatient arena to models that offer a continuum of care. Insurers will need to move in tandem with this to move up in the health value chain. Expansion of Healthcare and Protection Concepts Health insurers are now orienting themselves to more offerings based on their core competences and new directions of customer demand. Three areas of interest are emerging which will move forward in future: Wellness Insurance There is a rise in the awareness of wellness concepts, which is driven by the rising affluence levels of the population. Shifts in the income and consumption patterns of individuals and households backed by significant discretionary spending capability and the awareness of the beneficial effects of wellness, is prompting people to invest in wellness to enhance the quality of life and to be disease free. Employers and institutions now focus on health and welfare issues and look to introduce beneficial wellness practices into people’s lifestyles. Insurers need to join this movement so as to incentivise better health outcomes, which will result in reduction of disease manifestation and the consequent need for hospitalisation and critical care. Governments are also focusing on this theme by organising polio eradication camps, encouraging vaccinations etc. as part of the preventive care movement. Private initiatives also encouraging activities such as making school children understand the importance of washing their hands before eating. Wellness can be defined as the process of creating and adapting patterns of behaviour that lead to improved health in various wellness dimensions. Wellness is considered to be the positive
component of good health which reflects how one feels as well as one’s ability to function effectively. Wellness is understood as a state of good health in which a person is in, before a disease starts or the risk factors for it sets in. Wellness also can be promoted at any stage of illness so that further progress of disease and deterioration of quality of life is prevented. Therefore, wellness is not merely the absence of disease, illness, and stress, but the presence of a purpose in life, active involvement in satisfying work and play, happy social relationships, a healthy body and living environment and general happiness and wellbeing. A wellness lifestyle includes a self-defined balance of healthy habits such as adequate sleep and rest, productivity, exercise, participation in meaningful activity, balanced nutrition, social contact, and supportive relationships. The IRDAI in Health Insurance Regulations
Medical savings accounts can encourage more prudent use of the health care system rather than overuse
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COVER STORY 2016 has foreseen the need to introduce ‘’Wellness and Preventive” aspects into health insurance offerings. In sec.19, the Regulation states that while wellness and preventive elements as part of product design is encouraged, no policy of insurance shall promote or offer the products and services of third parties who are not Network Providers. Insurers shall neither offer any discounts to the policyholders, in any form, on the products of the third parties either as part of policy contract or otherwise. However, Insurers may endeavour promoting wellness amongst policyholders of health insurance by offering the following health specific services offered by Network Providers, Outpatient consultations or treatments or Pharmaceuticals or Health check-ups including discounts on all the above at specific Network Providers. Insurers may also endeavour to put in place procedures for offering discounts on premiums on renewals based on the fitness and wellness criteria stipulated and disclosed. Provided further the costs towards the above services are factored into the pricing of the underlying Health Insurance Product. Wellness based insurance products therefore would see a rise in offerings in future and their direction need to ensure better health outcomes, that would reduce the costs of health insurance, to make health care more affordable.
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Savings Linked Health Insurance Plans Insurance products can combine savings as part of its product proposition. This is welcomed because it allows people to build up financial assets while protecting themselves against insurable risks and shocks. It is well understood that the combination can be excellent when savings made by a person can protect him/her against small health shocks, while insurance covers can protect against large or catastrophic losses. Savings-linked insurance also offers an incentive for regular and longer-term savings. Savings Linked Health Insurance Plans are health insurance products which are in vogue in some countries. It goes by names such as Medical Saving Account (MSA) or Health Savings Account (HSA) in these countries. A Savings Linked Health Insurance Plan can be a combination of two components: A High-Deductible health insurance cover A Savings Fund, which can be used to pay for non-covered medical expenses in future.
SAVING LINKED HEALTH INSURANCE Savings Linked
Savings Account
Pay Deductible
High Deducted HI
Protects against health disasters
Tax benefits
Out of the premium paid regularly, a part of it goes towards the coverage of health risks, i.e. the risk premium and the remaining amount is accumulated in the savings fund. The savings fund is an account that the insured owns for the purpose of paying qualified medical expenses for self or dependents. This account is completely at the disposal of the insured and may be withdrawn in times of health care need.
ADVANTAGES OF A SAVINGS LINKED HEALTH INSURANCE PLAN
Reduced contribution of amount towards risk premium. Lower insurance premiums because of the high deductible plans. Coverage of routine illness through savings. Contributions are encouraged by tax exemptions. Choice allowed in the amount of contribution to be made. Choice in the utilization of funds. Tax exemption on the interest earned from the savings. Return of the Surplus amount at the term end. Transfer of the savings fund to legal heir(s) in the case of death.
The main advantages of this product are that unnecessary hospitalisation episodes can come down since the insured will be required to spend from his/her corpus, which can motivate the reduction of unnecessary treatments and costs. They are supposed to reduce adverse selection and moral hazard seen in normal health insurance. Customer stickiness and loyalty also can increase. Since the plan is for the long term, customers who avail of the plan will remain with the plan for a longer period of time. These kinds of funds can be set up by insurers, employers, or by the government. The intent of Savings Linked Health Insurance is to encourage those who do not find the usual health insurance of value, except for high cost treatments
DISADVANTAGES OF A SAVINGS LINKED HEALTH INSURANCE PLAN
Insured may have to bear the investment risk and cost Accumulated fund maybe insufficient for medical needs in times of need
owing to their younger age and/or very sound health status. This makes the cost of health protection much cheaper than the traditional insurance package. Employers or individuals can then deposit the funds saved into MSAs which can be used for health care or even funding future premiums. Medical savings accounts can encourage more prudent use of the health care system rather than overuse which may happen when health insurance of the normal kind exists. MSAs provide incentives for consumers to take a more active role in their consumption of medical care services and in their overall health status. These schemes are supposed to encourage saving for future health care expenses, allow the patient to receive
needed care without a gatekeeper to determine what benefits are allowed, and make consumers more responsible for their own health care choices through the required High-Deductible Health Plans. Savings linked health insurances are criticized that they may eliminate risk pooling in favour of individual managing their risk across years rather than across other people as a solidarity pool. This can add to an overall adverse selection problem at the macro-level. In a system having MSAs along with the usual health insurance covers, it is likely that the younger, healthier and wealthier individuals subscribe to MSAs attracted by their tax benefits whereas older, sicker individuals benefit only from staying in traditional insurance. This may create a “de-insurance” as individuals increasingly switch over. There can be an erosion of solidarity as one moves from social health insurance to private health insurance to MSAs, and make normal health insurance unviable. Therefore, the direction of this insurance will require deep study on how to ensure that those who need care are not deprived of very large pool as cost of increase in treatment and consequent insurance premium goes up on one side, and people migrate out of the normal health insurance policy to an MSA on the other. Long Term Care Insurance Long Term Care Insurance (LTC) is a product created to protect an individual’s assets and help maintain independence by paying for care required due to a cognitive or physical impairment. While these conditions are generally associated with aging, LTC Insurance can benefit all age groups. As the caring society concept expands, it is felt that one out of two senior citizens will need long term care at some point of time. Long Term Care becomes necessary when a chronic physical or mental condition of a person limits his/her ability to perform certain basic tasks, commonly known as Activities of Daily Living (ADL). The policy will cover the cost of benefits provided to the affected insured when the individual is unable to perform one or more ADLs, such as bathing, eating, or dressing. Long term care includes a full range of services, such as nursing home care, assisted living care, rehabilitation, and home and personal care.
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COVER STORY
Long-Term Care is an ongoing care Programme provided for those who are unable to look after themselves without some kind of support. Long term care can range from a couple of hours a day, through to 24 hour a day care. Longterm care insurance is not a single product. It can include any range of insurance products designed to contribute towards the costs of long term care. It is normally a protection product (as opposed to investment), which meets some or all of the costs of care for the elderly who are in need of long-term care. A claim is usually defined by reference to failure of activities of daily living and/or cognitive impairment but can also be expressed in terms of amount of care, or assistance, required. Aging is an irreversible biological phenomenon. One of the major features of demographic transition in the world has been the considerable increase in the absolute and relative numbers of elderly people. Further, the older population itself is aging. At times, old age is associated with unacceptance, denial, depression, loneliness, and a certain degree of alienation from the mainstream of family life. Changing lifestyles, attitudes, values and increasing generation gap compound the problem. The rapidly growing absolute and relative numbers of older people mean that more and more people will be enter-
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ing the age when the risk of developing certain chronic and debilitating diseases is significantly higher. The ‘epidemic’ of chronic disease results in high rates of disability in elderly people. There is a deterioration of health for the majority as they grow older. For many elderly people, this deterioration, mental or physical, will become so severe that they become unable to function independently. Many will have disabling medical conditions, which are exacerbated by the frailty of very old age. Long term care may be required by anyone, not just seniors. Care is usually required as a result of the effects of aging, either because a person has become physically unable to carry out everyday activities or because they experience cognitive impairment, such as Alzheimer’s disease. Other times, long-term care may be needed because of chronic disease or while recuperating from an accident or serious illness. Long-term-care insurance is for anyonewho has assets to protect and not to lose it owing to high medical or care costs; who is not wealthy enough to pay for long-term care out of savings;
Health underwriting and cost control through the optimal health purchase capabilities will form the backbone of the growth in health insurance
or who is healthy now (at present). Some reasons to plan ahead and purchase long-term-care insurance early: A policy is usually guaranteed renewable once the policy in place, for as long as the insured person can continue to pay premiums. The premium is based on the age of the prospect at the time of enrolling in the insurance, and the premium is usually locked in for the life term of the policy. Long-term care can be: skilled nursing care, or custodial care to help with the activities of daily living. The settings for long-term care can be in a nursing home; in an assisted living facility; in the insured’s own home or in an adult day care centre. Long-term-care insurance, like all insurance, requires one to pay a premium on a regular basis so that there is no need to pay a huge amount later on, in the event of a catastrophic illness or condition. The most common reasons that people might need long-term-care insurance are: a prolonged illness, such as cancer a degenerative condition, such as Parkinson’s or a stroke a disability a cognitive disorder, such as Alzheimer’s disease The two categories of help that people need are, custodial or personal care (For disabled or ill people, this is hands-on help with the activities of daily living such as cooking, eating, bathing, dressing, and using the toilet. For people with cognitive impairments, this means supervision, protection, and verbal reminders to do everyday tasks.) In addition, skilled nursing care or rehabilitation, either in the home or at a nursing facility. Long-term-care insurance can pay for long-term care, either in an institution (such as a nursing home) or in a residence, such as an assisted living facility or in one’s own home; because, most people prefer an assisted living arrangement rather than living in a nursing home, they benefit by having insurance to help pay for what they prefer.
In Conclusions Healthcare is an integral part of human welfare as good health is a core component of the human capital. Morbidity conditions are widespread irrespective of age or socio-economic classifications, and the risks therefrom are not only frequent, but can at times be of catastrophic dimensions. Invariably it is seen that health costs are rising and becoming increasingly unaffordable unless such risks are passed on to an insurer or to other types of risk bearers. Insurance of health is a superior option because through insurance everyone gets protection and are able to afford the “deep pockets” that an insurance scheme can offer. Health insurance schemes make the affordability attractive through relevant and differentiated products, which can be offered by the many players who are active in both general (including standalone health insurance) and life insurance.
Health underwriting and cost control through the optimal health purchase capabilities will form the backbone of the growth in health insurance, which is characteristically a high volume low margin business. The potential in health insurance is certainly a very large opportunity area running into thousands of crores of rupees as everyone has to come under the health protection shield. In order to control the runaway costs of healthcare, insurers will have to utilise many underwriting and managed care techniques to sustain the affordability platform over the long term. In this, the role of Third Party Administrators will be considerable, and their service will not only involve management of costs, but also many value added services to assist customers. Universalisation of health insurance is a matter of importance, and in this the Government, the Regulator, the providers, insurers, the TPAs and even the health care providers have a role to play. In offering healthcare to all, social security schemes, community and commercial insurance schemes can exist side by side, obtaining the necessary funds on the one side by taxation and on the other from voluntary premium charges. To make the premium affordable insurers can offer a variety of facilitations, so that the coverage is adequate and continuous. The future of health insurance in India can only be bright as modern medical care will be virtually impossible without the affordability that can be possible only through risk transfer. Without insurance, the vulnerability of persons to loss of health and wealth is inevitable as health costs are both frequent and at times severe. Certainty of health insurance outcome will not only ease the problems for the individuals who are protected but also for the society and the country. It is therefore imperative that proactive measures are taken at all levels including that of the government, regulators, insurers, medical providers, etc. to facilitate and propagate conditions favourable to the rapid growth of health insurance in as many ways as possible.
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DECEMBER 2017, VOLUME 1 ISSUE 3 `200 INDIA MED TODAY
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IMPACT
HOW THE INTERNET OF THINGS IS TRANSFORMING THE HEALTHCARE INDUSTRY
Tim Sherwood, Vice President, Mobility &IoT Solutions, Tata Communications
IN THE face of ever-increasing competition and evolving demands of patients in different geographies, healthcare service providers need to innovate and plan for digital transformation. In the developed world, they need to be equipped to treat an increasingly aging population whereas in the developing world, a big challenge still is how to reach more and more people in regions and communities with not enough healthcare staff. Given these varying demands, to stay ahead, more and more healthcare organisations are investigating machine-to-machine communications and the Internet of Things (IoT). While patients are already used to decentralised treatment centres, self-diagnosis portals and even telemedicine, this is just a beginning. Process management and cloud-based applications are unleashing new ways of working such as remote monitoring and support
of patients, and delivering innovative ways for customers to access healthcare services. The supply chain is changing too, with more and more collaboration across the entire ecosystem to bring down costs, accelerate the digitisation of medical records and introduce more patient-centric treatment models. This brings very real benefits to the quality of patient care, as local practitioners have more up-to-date data on their patients and their conditions at their fingertips, enabling doctors and nurses to make better informed data-led decisions with regards to remedies and patient care. Now the IoT looks set to change the healthcare sector once again. It’s worth investigating the key factors that are going to be crucial during this next evolution. Healthcare will go global Health organisations need to take digital trans-
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IMPACT
formation on board to extend their services and reach in areas and communities where there aren’t enough healthcare professionals to treat a growing number of increasingly elderly patients. To succeed, they’re going to have to get the right strategy in place, combined with bestin-class infrastructure and information tools. Large healthcare groups are international, so connectivity services need to be international too. It’s no longer possible to think on a purely domestic basis. To maintain consistent patient care standards across geographies, healthcare providers need a reliable communications network partner that can provide end-to-end mobile and cloud connectivity as well as data management services. Only by offering excellent service both in a domestic setting and across borders can they win and keep new business. Continuous collaboration and ubiquitous access Multi-platform collaboration across employees, partners and patients is the next step for healthcare organisations. By giving everyone access to the data and applications they need,
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An international partner that offers global mobile network access and connectivity agreements is going to meet the requirements to deliver services such as tele-medicine, remote diagnostics and eHealth services wherever and whenever they’re needed, healthcare organisations can boost productivity and drive efficiency. Let us consider the advances that telemedicine has already introduced. IoT-enabled mHealth solutions could deliver savings of €99 billion in the European Union, so it’s no wonder that healthcare organisations are exploring other new technologies that could bring down treatment costs and make physicians more available for patients. One trend we’re bound to see is ever-better
connectivity, as hospitals and organisations link up their care estate and supply chains to deliver a truly seamless service. These two areas should be a focus point when looking at ways to harness the opportunities unleashed by IoT. By thinking globally and collaborating across ecosystems, healthcare providers can begin to leverage IoT to more effectively to enhance patient care. In part two of this blog I will look at two other areas that will help transform the healthcare industry.
Connected healthcare experiences for everyone Today’s connected consumers – and patients – increasingly expect their healthcare provider to offer them a similar digital experience as they are accustomed to when it comes to managing their finances through online banking, or ordering goods online. Patients want real-time data on their health and the ability to communicate with their doctor or nurse whenever, wherever. More and more clinics are already offering appointments via self-service portals, and alerts through simple application-toperson (A2P) messaging to remind patients of their appointment. Given the pervasive nature of SMS, there is scope for healthcare providers to extend the use of A2P messaging to, for example, remind their elderly patients to take their medications too. Furthermore, the increasingly sophisticated nature of IoT-enabled healthcare devices means that we’re only starting to scratch the surface of the potential of remote healthcare provision and monitoring. However, healthcare organisations don’t simply need to start providing their patients with a seamless experience, they also need to consider how best to interact with partners too. Hospitals, diagnostic labs, consultants, researchers – they should all expect an omni-channel experience to deliver the best possible service. For instance, a hospital porter should be able to identify in-patients and portable medical scanners immediately, all through a mobile app. Furthermore, all parts of the healthcare ecosystem – hospitals, research facilities, pharmaceutical companies, clinics and patients – should be able to communicate and work together more easily, with a more seamless flow of information (with the patient’s consent of course). This is one sector where the customer simply can’t be kept waiting, so reliable connectivity to enable this better communication and information flow is a must-have. That’s not to say connectivity doesn’t come with its own challenges. Patient data is critical,
yet connectivity could introduce a security risk. Organisations may also find it difficult to scale solutions as demand fluctuates. That’s why they have to make sure they’re choosing the right partner for their infrastructure solutions. Trustworthy and reliable As they take advantage of digital transformation, healthcare providers are going to have to take positive steps to manage to risk. That means protecting patient records and other data and applications against external threats. It also means ensuring service continuity and zero disruption in the event of a breach: it is not inconceivable that cyber criminals start to target millions of IoTenabled healthcare devices to stage huge attacks which could put people’s lives at risk. That is why healthcare organisations need to adopt an adaptive security strategy. This means shifting from an ‘incident response’ mind set to a ‘continuous response’ mind set. Typically, there are four stages in an adaptive security life cycle: preventative, detective, retrospective and predictive. Preventative security is all about blocking attacks before they affect the organisation or make it more difficult for an attacker to wreak havoc, giving the organisation more time to disable the attack in process. The aim of the detective security layer is to reduce the time that attackers spend within the system, limiting the subsequent damage. Retrospective security is like a vaccine
To maintain consistent patient care standards across geographies, healthcare providers need a reliable communications network partner that can provide end-to-end mobile and cloud connectivity as well as data management services that protects you against diseases – it turns intelligence about past attacks into future protection. Predictive security plugs into the external network of threats, monitoring hackers underground to proactively anticipate new attack types. If the move to new technology sounds risky, staying with the status quo is riskier still. Organisations have a simple choice: move forward, or get left behind. A healthy transformation It’s time for healthcare providers to offer a crossborder service, with a global network infrastructure and global connectivity. Only an international partner that offers global mobile network access and connectivity agreements is going to meet the requirements to deliver services such as tele-medicine, remote diagnostics and eHealth services. Harnessing the opportunities unleashed by the IoT can help to boost efficiency and productivity, and ensure that organisations stay competitive. By enhancing the patient experience, healthcare providers will enhance their reputation too.
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OPINION
WHITHER TO ?
Dr NJ Mani, Senior Consultant & HOD, Orthopaedics, Baby Memorial Hospital, Kozhikode
OVER THE last three decades, I have witnessed bewildering progress in medical science. While some diseases have been eradicated, others have cropped up, or remained as they have for ages. Scientific discoveries, innovations and genomic medicine have transformed the way we approach a patient. From the moment a patient enters a hospital he is subjected to a spectrum of technological studies including scopies, to peer within the human body, to visualize nature’s beauty, hitherto hidden to the naked eye. In spite of all these advancements the patient is very often left in despair and confusion. He craves for the personal touch and a heart to heart talk with his doctor. Modern day medicine with all its glorious superlatives has left a wrinkle in our confidence. A fundamental question remains unanswered. Is medicine an art or a science? Changing Scenario What is scientifically “True and Correct” today may not be relevant tomorrow. Dogmas change and approaches to disease management swing from one end to the other. In the fifties, an atom was considered the most indivisible form of matter; there can be nothing far from the truth these days! In Orthopaedic practice, the concept of healing of a fracture is a case in point. In the sixties, when I started my career, fracture healing was thought to be perfect with “natural healing with callus formation”. In the eighties, I preached and practiced anatomical reduction and surgical fixation. Healing without a callus became the end point to ensure bone healing
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with normal function. Now the wheel has turned a full circle to revert to callus formation and the accent is on maintaining length, alignment and rotation. Changing Patient Care These experiences make me think of patient care in a whole new dimension - a combination of fluidity, complexity and dynamism. Healing is a by-product of the patient-physician relationship as much as it is due to the complex medical parameters that govern the series of events that start with disease and end with cure, morbidity or mortality. A protocol based and algorithmic approach, chasing shadows, perusing lab data and above all paucity of time have estranged the patient doctor relationship. Decisions are made by us in cozy cold, closed chambers very often without the patient in view. We deliberate inside, while the anxious patient waits outside and sends a prayer to the Almighty, hoping for the right decision to be made. The ritualistic methods of history taking, clinical examination, developing a working clinical diagnosis and finally deliberation and contemplation have become a relic of the past. They have been sacrificed on the altar of evidence based scientific medicine! The Power of Touch The sanctity and intimacy of physical examination legitimate the human connection and this is most powerfully mediated through touch. Touch is a primal and potent act, beyond skin to skin contact, and engages in the emotional domain called praxis. If we apply
Newton’s third law, touch is always reciprocal!! Touch has an affective dimension to care, the power of which extends beyond words. The power of laying hands in healing was known since the time of Asclepius, the legendary Greek god. The Bible reminds us that those who touched Jesus and those who were touched by Him were healed. Nowadays, touch has gained a different connotation. In today’s era of marketing and gimmickry - it is a word that encompasses only the jargon - “Stay-in-touchmarketing”. It is in this context that the concept of human touch gains significance. It sends across a message of assurance to the patient that we are available to them at all times, and that we stand fully committed to stand with them, through thick and thin! We wish to emanate empathy from our dealings with patients. Communication - both verbal and non verbal is crucial to the success of this motto. Any dilution of this standard, puts us at discomfort and the risk of even litigation. While we surge forward into the modern
era of medicine, we need to clarify to ourselves that medicine is an art based on science. It cannot be practiced as an inanimate, heartless, scientific exercise. The utilization of the five senses along with the effective integration of cerebral faculties makes it the perfect recipe for a successful patient - doctor relationship and thereby satisfactory patient outcomes. The quest is short if we realize that the practice of medicine is an art that is played on the solid stage called science. The sight of a new born baby is a marvel and a mystery. But isn’t the mystery of creation the true source of all art and science? Albert Einstein, the great scientist and philosopher once said “The most beautiful thing we can experience is the Mysterious. He to whom the emotion is stranger, who can no longer pause to wonder and stand wrapped in awe is as good as dead - his eyes are closed. The insight into the mystery of life, coupled though it be with fear, has given rise to science as it has to religion”. May I ask -- Modern Medicine, Quo vadis ?
Scientific discoveries, innovations and genomic medicine have transformed the way we approach a patient
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APPROACH
PROGRESS OF TAVI PROCEDURE IN INDIA Dr Ravindranath Reddy, Senior Interventional Cardiologist, BGS Gleneagles Global Hospitals, Bengaluru
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AORTIC STENOSIS is anailment that leads to the narrowing of the aortic valve of the heart, which normally allows blood flow to be pumped from the main chamber of heart to the rest of body. The narrowing of this valve can lead to an increased amount of stress and pressure on the heart muscle, which in turn can lead to symptoms of chest discomfort, shortness of breath, leg swelling, fatigue, lightheadedness, syncope, and even sudden death. The most common cause of aortic stenosis is calcification of the valve, caused due to degeneration that comes with age. Other causes include damage to the heart valves due to diseases like rheumatic heart disease, or
congenital heart defectslike bicuspid aortic valve, misshapen tricuspid aortic valve, or a unicuspid valve. Advent of TAVI TAVR or TAVI stands for transcatheter aortic valve replacement or implantation. It is a relatively new technology which serves as an alternative to standard aortic valve replacement surgery. This procedure is a minimally invasive procedure that allows the cardiologist to cure a severely narrowed aortic valve without opening up the patient’s chest by replacing the valve without removing the old, damaged valve. Instead, a replacement valve is wedged into the
aortic valve’s place. Somewhat similar to a stent placed in an artery, the TAVI approach delivers a fully collapsible replacement valve to the valve site through a catheter. Once in place, the new valve is expands, pushing the old valve leaflets out of the way, taking over the old valve’s job of regulating blood flow. People with aortic stenosis may have a “murmur” that can be detected during a regular doctor’s visit and general physical examination. This may alert the physician to order an ultrasound (echocardiogram) of the heart. This echocardiogram test confirms the presence of aortic stenosis and its severity. Additionally, the doctor may also perform an electrocardiogram, a computed tomography (CT) scan, and an angiogram to completely assess the situation in the heart, and decide if the patient will benefit from this procedure. The TAVI procedure has been done in over 50,000 patients worldwide. It was FDA approvedin November 2011for patients with symptomatic aortic stenosis who are not fit for or carry high risk for conventional surgical aortic valve replacement. This is a savior to these patients, as the prognosis of severe symptomatic aortic stenosis worsens the longer it is left untreated. In general, 50% of patients will not be alive after 2 years from the onset of their symptoms. Case Study Recently, at BGS Gleneagles Global Hospitals, we had a patient, who was 81 years old, with severe aortic valve stenosis. He had a history of undergoingcoronary artery bypass grafting, multiple percutaneous transluminal coronary angioplasties and stenting procedures. He also suffered from a severe left ventricular dysfunction, diabetes and renal dysfunction. This medical history posed him as an unfit candidate for conventional surgery, making him an ideal candidate for TAVI. He underwent successful TAVI procedure and achieved very good clinical improvement without any complications. Conventional surgical aortic valve replacement requires surgical opening of the chest,known as sternatomy, and putting the patient on heart lung bypass machine under general anesthesia. Thediseased valve
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APPROACH is removed and new valve is sutured. The TAVR or TAVI procedure can be done through femoral puncture under local anesthesia. A catheterabout the size of a pen is inserted through the femoral artery in the groin and carefully passed up into the heart, where the replacement valve is implanted inside the narrowed valve resulting in a normal functioning aortic valve. The replacement valve is made of bovine or porcine tissue and supported on a metal stent. With this procedure, the patient does not need general anesthesia, opening of a chest or heart lung machine. The patient’s experience with the TAVI procedure may be comparable to an angioplasty in terms of down time and recovery, and requires a shorter hospital stay. As per research, it has been seen that this proceduresignificantly allows patients to live longer and with a better quality of life as compared to treatment solely through medication. As with any heart procedure, TAVI has its own risks.These risks are similar to those involved in any heart procedure such as vascular injury, arrhythmia, and temporary
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obstruction of the coronary artery. The risks of mortality, stroke, bleeding, duration of hospital stay, and recovery period are much less with TAVI as compared to surgical aortic valve replacement. Currently this procedure is reserved for those people for whom an open-heart surgery procedure poses high risk, or they are not suitable.For these reasons, TAVI is recommend to elderly patients more than 70 years and those with concomitant severe systolic heart failure or coronary artery disease.Patients with complications such as cerebrovascular and peripheral arterial disease, chronic kidney disease, and chronic respiratory dysfunction are also good candidates for this procedure as these complications pose risks to the procedure of open-heart surgery. At times, this procedure may also be suggested to patients who are apprehensive about undergoing surgical interventions. TAVR can be an effective option to improve quality of life and increase the longevity in patients who otherwise have limited choices for repair of their aortic valve.
The most common cause of aortic stenosis is calcification of the valve, caused due to degeneration that comes with age
PULSE
HOW TO PREPARE FOR MRCOG WITHOUT GOING TO THE UK Dr Sujoy Dasgupta, Consultant Obstetrician, Gynaecologist, Infertility Specialist; Bavishi Pratiksha Fertility Institute Kolkata
THE ROYAL College of Obstetricians and Gynaecologists (RCOG) works to improve women’s health care across the world. Founded in 1929, RCOG now has over 14,000 members worldwide and works with a range of partners both in the UK and globally to improve the standard of care delivered to women, encourage the study of obstetrics and gynaecology (O&G), and advance the science and practice of O&G. Getting a membership of RCOG is a prestigious thing and around half of RCOG members practice outside the UK, with over 6000 obstetricians and gynaecologists working in more than 100 countries including India, Pakistan, Saudi Arabia, UAE among others. Passport to the pinnacle of the profession The MRCOG exam is internationally respected as the gold standard qualification for career progression in O&G. The Membership examination, which was first held in 1931, is intended for those who wish to specialise in obstetrics
and gynaecology. The exam is a three-part assessment: Part 1 MRCOG is a written examination to evaluate basic and clinical sciences relevant to the subject Part 2 MRCOG is a written exam that assesses the application of knowledge Part 3 MRCOG is a stand-alone clinical skills exam that assesses candidates’ ability to apply core clinical skills in the context of the skills, as defined in the Part 2 MRCOG curriculum. The Part 3 MRCOG is part of the assessment and validation process for entry on to the UK Specialist Register and progress to a consultant post in O&G. UK specialty trainees must pass the Part 2 and Part 3 MRCOG before progressing from ST5 to ST6. Membership is awarded to those who have passed all three parts of the Membership examination. Members may use the designatory letters MRCOG.This article speaks to those whoare aspiring for part 2 MRCOG from outside the UK.
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PULSE
Mission Impossible Passing the exam is difficult (of course, that’s why you are looking for it) but NOT impossible. Remember, it’s the exam based on UK system, so you have to adapt to that system. Simply because, they have not invited you to appear in the exam, rather it’s you who want to take it. Adapting to the UK system may seem difficult, if not impossible, but just think rationally while going through the guidelines. Talking to somebody who has recently cleared the exam, or is currently in the UK, is of much help than somebody who is not. The exam system is continuously changing. Especially the current Part-3 exam is totally different from the previous Part-2 OSCE. How to prepare Important thing to note is that everyone is not wearing the same shoe. Somebody can prepare for the exams within three months, some may take three years. Somebody may prefer (or get the opportunity) to take time off work, or
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somebody may not be so lucky. However, in the long run, you have to achieve MRCOG and that’s the goal. No matter, how long you take to achieve this. Remember, most of you have the highest post-graduate medical degree in your country and are not doing badly (may be not “well-established) in your place. So, MRCOG is like putting the feather on your cap. There is nothing to lose if you try it. However, it’s worth to run after it, as it will improve your following skills (even you will see improvement, while preparing for the exam) Communication with your patients- especially talking to angry, adamant and difficult patients, breaking bad news Clinical knowledge- you can remain updated on your skills and patient care Patient safety- needless to explain, as you know it better More focused on documentation How to plan Just think that you want to write MRCOG after
Getting a membership of RCOG is a prestigious thing and around half of RCOG members practice outside the UK
your name and give a start. There is no need for formal planning or having a banquet party to declare that “I am preparing for MRCOG”. The less number of people know about it, the better it is. As the famous saying goes ‘work hard in silence, let the success roar’. Remember, Newton’s 1st law of motion. The most difficult part is to break the inertia. Just set a deadline, when you would like to appear for the exam. Once you fix the deadline, you must appear for it, no matter whether your preparation is complete or not. Say, today, you decide to appear for Part 2 in July 2018 but in May 2018, you feel that you need more time (as it can happen because of many other commitments in family, practice, health etc); still you MUST appear in July (think about the amount of money that will get wasted). This is important, to keep yourself in the inertia of motion with acceleration (Newton’s 2nd Law), to check your deficiency and also to know what types of questions are expected.
The less you read the books, the better it is. Only two books are needed. The first one is “Handbooks of Obstetric Medicine”by Catherine Nelson-Piercy. The second book is Luselay and Baker’s “Obstetrics and Gynaecology” you are comfortable with soft copy or need printed format. The way I did it is by making separate folders in computer and then editing them to make charts, to highlight important points in Microsoft Word Format and then took print and kept them in separate files. That’s to cut short a big guideline into a shorter one and then again further shortening it while reading. RCOG website
What materials to collect? This is very much important. If it’s done properly, half the job is done. It’s up to you whether
Download whatever guidelines you are getting. In order of importance are Green Top Guidelines (GTG- The Bible For You), Best Practice
And Good Practice Guidelines And Scientific Impact Papers (SIP). Don’t forget to download RCOG Consent Forms And RCOG Patient Information Leaflet (PIL). All statistics from CONSENT FORMS and PIL are important and you cannot pass the exam without remembering them (no matter, how boring it would appear). PIL will also introduce you to colloquial words, that they use in day to day practice. Remember, these are updated continuously. So, please keep a habit of looking at the site periodically. NICE guideline
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PULSE They are very few in number and are usually more pleasurable to read than GTG. Please read only those related to OBGY. There is no need to read Management of Coeliac Disease, etc,. Sexual and Reproductive health
Must read FSRH (Faculty of Sexual and Reproductive Health), BASHH (British Association of Sexual Health and HIV) and BHIVA (British HIV Association) Guidelines on STI and contraceptives. Remember, sometimes there may be conflict between GTG and these guidelines, especially regarding figures. Again, keep in mind GTG is the Bible in that case. TOG (The Obstetrician and Gynaecologist)
This is a journal from the RCOG. You can get them if you pay subscription of RCOG (valid for 1 year). You have to go through TOG of preceding three years before the exam. They are published four times in a year (so total 12 copies). However, sometimes, you may require older copies of some articles, which has not been covered in any guidelines or in recent TOG. Examples include Cystic Fibrosis, Asthma in pregnancy, Tuberculosis, AV Malformation of the uterus, Azoospermia, Polyhydramnios etc. If there is conflict between TOG and GTG, again GTG is the Bible (for example, NICE recommends only IVF in Unexplained Infertility, but TOG article says IUI can be tried. Your concept should be “No IUI, only IVF in Unexplained Infertility”) Other Guidelines
If time allows, few other guidelines, ESHRE (Endometriosis, POF), ESC (Heart Diseases in Pregnancy). StartOG
You are entitled to avail it if you pay RCOG Subscription (valid for one year). It’s a good practice to start with STRATOG. But beware that it’s the guidelines that you must focus on, not the StratOG. StratOG keeps all materials and guidelines according to chapter (Say, all guidelines related to ovarian cancer are in the same chapter in “Preliminary Reading”). But, that should not stop you from searching for guidelines in RCOG and NICE site, because some articles may not be found in “Preliminary Reading” of StratOG. So, first read the guidelines, and then have a look at StratOG. Read only things, that is not covered in guidelines. No need to read the same topic, which has been covered in GTG,
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from the StratOG. Again, remember, if there is any conflict, GTG is the bible. You can just copy and paste the materials from StratOG, as you cannot access it after your one-year subscription expires, in which case, you have to pay again. Remember, to practice SBA and EMQ from StratOG. Books
The less you read the books, the better it is. Only two books are needed. The first one is “Handbooks of Obstetric Medicine” by Catherine Nelson-Piercy. This is again the Holy book for Medical Disorders in Pregnancy. Especially, look at the differential diagnoses as these often come in EMQ (Headache, Chest Pain, Dyspnoea, Convulsion in pregnancy etc. The second book is Luselay and Baker’s “Obstetrics and Gynaecology”. Again, don’t read line by line (as it would be a luxury), just see the topics not covered anywhere else. Again keep in mind that GTG is the Bible. You can buy from amazon or if you are intelligent enough, just join whatever MRCOG groups are there in the Facebook. There are lots of kind people to upload them there. Practice Materials
These are SBA and EMQ books. Again, the source is Facebook or Amazon. These books may be of two types- some divided in chapters, some not. The first types can be helpfulafter you finish each chapter. Examples include- An-
Once you have done with all guidelines and few questions, have a look at the SBA and EMQ books drea Pilkington/ AmitabhaMajumdar EMQ, Ramalingam/ Palanivelu/ Brockelsby EMQ, Magowan/ Otify/ Shamy/ Pearson SBA, NeelanjanaMukhopadhyay SBA. The books where chapter division is not there, (but you must see them, because no such division is actually there in the exam) include Amanda Jones (RCOG) SBA, ShreelataDatta/ TahiraMahmood SBA & EMQ, RCOG site (In the “Preparing for MRCOG Part 2 in RCOG Site) SBA & EMQ. Your nerve is already stretched after reading the list. Now, how you can summarize and keep in mind. As mentioned before, divide any guideline, TOG or StratOG or book articles into following parts Statistics Part- First, put all statistics from an article in one place. You can gradually understand that few “percentages” are im-
portant (after reading the questions). But never forget percentages mentioned in PIL and the consent form. Clinical Part- If its history and examination, focus on diferential diagnosis (like vulval skin disease, acute pelvic pain, headache in pregnancy etc). If it’s on investigations or management, focus on stepwise approach by making flow chart (“must” for CIN, PMS, Urinary Incontinence, GDM, Ovarian Mass) Organization Part- Be very clear about MDT involvement (like urinary incontinence), Midwife vs Consultant led Obstetric care, Consultant involvement (Physically present or On call from home), Oncology (Cancer Unit vs Cancer Centre), place of delivery (Theatre vsLabour Room), EPU assessment, Day care surgery vs In patient care, involvement of Fetal Medicine Specialist (MCMA Twin, TTTS, SiFD), NHS funding in IVF (Only 3 up to 40 years of age), Risk Management (Incident Reporting in Shoulder Dystocia, Failed Operative Vaginal Delivery), Consent (Verbal Consent for delivery in Labour Ward, Written Consent for Trial in Theatre), Coroner’s Involvement in Maternal death or unattended stillbirth, NHS Stop Smoking Service, Child Safeguarding Issue in Female Genital Mutilation, Interpreter for Non-English speaking population etc.
Try to Coordinate
It’s important to keep your consent clear. While reading article on “Obesity in Pregnancy”, recapitulate the indications of Aspirin Prophylaxis in “Preeclampsia”. While reading Herpes Simplex infection, try to find out the difference in guidelines with Genital Warts. While reading “Epilepsy in Pregnancy”, recapitulate UKMEC for contraceptives in women using Lamotrigine and Phenytoin.
Numbers and Percentages Be very much particular about the cut off, because they are likely to make it difficult for you on these points. Remember whether the cut off means ‘more than equal to” or just “more than”. In thromboprophylaxis, age cut off is 35 years or more but for aspirin it’s 40 years or more. But Aspirin prophylaxis, the pregnancy interval is “more than 10 years” (Not 10 years or more). Be very specific about bio-statistics, level of evidences, ethics, teaching methodology, assessment and appraisal. Never forget risk management and audit. These are the parts, where the overseas candidates really struggle. Try to focus on what particular statistical test is needed in a very case, what type of epidemiological study would fit into it, what level of evidence you require here. Be familiar with formative/ summative, norm/ criterion based assessment.
Be very specific about bio-statistics, level of evidences, ethics, teaching methodology, assessment and appraisal. Never forget risk management and audit Be very clear about different teaching methods in different situations. Some UK LAW must be applied properly. Examples include Caldicott’s principles, Data Protection Act, Abortion Act, Female Genital Mutilation act, Fraser’s guidelines, Montgomery rules etc. Genetics Never miss questions on clinical genetics and the mathematical problems. Be clear about probability of carrier stage and affected in dif-
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PULSE ferent mode of inheritances. Even after taking gallons of alcohol, keep in mind “The carrier incidence of Cystic Fibrosis in Caucasian population is 1 in 25”, because cystic fibrosis is afavorite topic in genetics. Be familiar with some pictures. These include CTG, ultrasound, urodynamics, cystoscopic view, laparoscopic view (especially lateral pelvic wall), MEOWS chart, common surgical instruments, different diameters of maternal pelvis and fetal head. The exam question is in black and white and you sometimes require extraordinary imagination power to interpret the intention of the paper setter and the person who picked up the photo. The 2nd Phase Once you have done with all guidelines and few questions, have a look at the SBA and EMQ books and if you are comfortable with Hard copy only, take print out of the “Modified” (by you) guidelines and mark the points from where the questions usually come. You can make your study material more concise. Finish this phase at least 3 weeks before the exam (That may mean that you may have to keep some SBA or EMQ untouched). If you have time, have a look at Facebook Forum questions. Remember, for SBA, the requirement is “single best answer”. All answers may be correct, but only the best one will give you the marks. If the question is “Most important risk factor for pulmonary embolism in pregnancy” and the answers are “multiparity, multiple pregnancy, previous surgery induced DVT, asymptomatic Antithrombin deficiency and family history of DVT”; then the correct answer would be “asymptomatic Antithrombin deficiency” because it carries the higher risk, although other answers may also be correct. In EMQ, never see the answers first. Read the question, form your answer and then see if your answer is there or not and then select it. If the question is ‘In a lady with OAB where 2 anticholinergics failed, what would be the next approach’, your answer might be “Botulinum Toxin”. But if the EMQ thread contains the answer “MDT Meeting”, the correct answer is “MDT”, not “botulinum”, because botulinum can only be given after MDT review.
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The 3rd Phase At this point, again have a look at the guidelines, with special focus on the parts (which you already marked) from where most of the questions come. If you have time, this phase can be repeated as much as you want. But never think that, you will finish this phase and then you will fill up the form. Never be afraid of the failure. At the end of the day, everyone will see your suffix MRCOG, not the number of attempts. The 4th Phase The 4-5 days, before the exam is crucial. Don’t read too much. If possible, take a break from your work. If you have to fly to another city or another country for the exam, this also takes lots of stress. So, concentrate on those parts.
The Day of the Examination Try to get sound sleep the night before. Reach the exam spot in time. Keep some fruit juice with you. Both full bladder and hypoglycaemia can impair your concentration, so take care of them. Never forget to carry the admit card and photo identity proof. Concentrate on the exam and forget about the rest of the world. Put your details properly in the sheet. Fill up the OMR sheet as you read the question paper (do not tick on the question paper and then transfer, because it will waste your time). If you face any difficulty (get ready, some questions will be definitely very hard), move from it and complete the rest and then return to it. The answers are to be written with pencil and they will provide eraser, so you can change the answer anytime. (Probably, they cannot imagine the level of cor-
ruption that can happen with pencil in the third world countries). They will again take the pencil and the eraser after the exam (Probably they do not want to keep any remnants of the exam with you). There is no negative marking. So, it’s worthy to try each and every question. Give 60 minutes to SBA, 100 minutes to EMQ and 20 minutes to revision. EMQ takes time. If you guess an answer, the probability of being it correct is 1 in 5 for SBA, but its only 1 in 20 (usually) for EMQ. Remember, you have to PASS in all 4 parts separately (Part 1 SBA, Part 1 EMQ, Part 2 SBA, Part 2 EMQ)
The most effective way to use this orientation, is to apply it in your day to day practice, as far as practicable. Some courses are meant for advanced level of preparation. That is, you can try them after your preparation is at certain level. They can help you to brush up. They are long duration or short duration. Some courses are extremely important for the beginners to have orientation and to give a good start. They can tell you what to read and how to approach. These are usually short courses and are worth trying. The rest is of course one and only your effort.
Any Courses required? There are different types of courses. Courses can guide you, but to pass the exam you need only one thing - hard work. Remember, the traditional concept of knowledge matters, but the main essence of the exam is orientation. If you can feel that charm, you are in the track. Then the success is the matter of time and good luck.
In The End MRCOG is not the end of the world. Never forget to live your life irrespective of an exam. Continue your work, surgery, clinics. Have time with family and friends. Check Whatsapp messages regularly and see your Facebook newsfeed. There is no need to declare to the world that you are planning for MRCOG. If possible, discuss
with your peers. Remember, they all are going through the same stress. Avoid discussion with negatively-minded people. Having said that, try to read whenever you have time and you feel comfortable. Maintain consistency. “Slow but steady wins the race”. At least some people passed the exam, without any UK experience. And believe me, they are just like you, they don’t have two brains or four heads. Remember, it’s the 2nd most difficult post graduate examination in the UK (after Royal College of Anaesthesiologists’ examination). So, never compare yourself with your mates in the field of medicine or surgery (with due respect to all). When you feel frustrated (I ensure, you will), just imagine that you are taking the certificate from the RCOG President in the admission ceremony and that time you will thank yourself for having gone through difficult time. The sour journey results in a very sweet fruit and that’s only named as MRCOG. The one and only moto is never give up.
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FEATURE
HEALTH - IT
CHANGE MANAGEMENT AND CAPACITY BUILDING FOR SMOOTH ADOPTION OF DIGITAL HEALTH
Prof. Supten Sarbadhikari, Dean (Academics and Student Affairs) and Professor (Health Informatics), International Institute of Health Management Research, New Delhi
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DIGITAL HEALTH electronically connects the points of care so that health information can be shared securely to help deliver safer, better quality healthcare. The broad scope of Digital Health includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalized medicine. Digital health is about electronically connecting the points of care so that health information can be shared securely. This is the first step to understanding how digital health can help deliver safer, better quality healthcare. Today, Health Information Management (HIM) professionals are well trained in the latest information management technology applications and understand the workflow in any health care provider organization. Health Information managers are vital to the daily operations management of health information and electronic health records (EHRs). They ensure that data quality is maintained, by
applying the principles of change management and continuous capacity building through education and training. They ensure that the health information and records of a patient are complete, accurate, protected and meet the desired and stipulated medical, legal and ethical standards. Therefore, it must be made mandatory to appoint an adequate number of health information managers, according to the size of the healthcare organization, to ensure safe and smooth adoption of digital health in India, leading to informed healthcare delivery. These professionals affect the quality of patient information and patient care at every point in the health care delivery cycle. They work on the classification of diseases and treatments to ensure they are standardized for clinical, financial, and legal uses in health care. HIM professionals care for patients by caring for their medical data. This, in turn, leads to informed healthcare delivery, especially when and where the information is translated into actionable outputs.
I have been tracing the evolution of health informatics and health information managers in making healthcare delivery more informed. Further they also show the role of unlearning and relearning in effectively assimilating information for better healthcare delivery. As the Indian government aims for Universal Health Coverage (UHC), the lack of skilled human resource may prove to be the biggest impediment in its path to achieve targeted goals. Therefore, the model curriculum handbook on health information management has been designed with a focus on performance-based outcomes pertaining to different levels. The learning goals and objectives of the undergraduate and graduate education program are based on the performance expectations. These are articulated as learning goals and learning
objectives. Using this framework, students will learn to integrate their knowledge, skills and abilities in a hands-on manner in a professional healthcare setting. These learning goals are divided into nine key areas, though the degree of required involvement may differ across various levels of qualification and professional cadres: Clinical care Communication Membership of a multidisciplinary health team Ethics and accountability at all levels (clinical, professional, personal and social) Commitment to professional excellence Leadership and mentorship Social accountability and responsibility Scientific attitude and scholarship (only at higher level- PhD) Lifelong learning
Digital health is about electronically connecting the points of care so that health information can be shared securely
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FEATURE
HEALTH - IT Among these nine core competencies, the third one membership of a multidisciplinary health team is perhaps the most important. The student will learn to put a high value on effective communication within the team, including transparency about aims, decisions, uncertainty and mistakes. Teambased health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively to accomplish shared goals within and across settings to achieve coordinated, high quality care. Program objectives will aim at making the students being able to recognize, clearly articulate, understand and support shared goals in the team that reflect patient and family priorities, possess distinct roles within the team; to have clear expectations for each member’s functions, responsibilities, and accountabilities, which in turn optimizes the team’s efficiency and makes it possible for them to use division of labor advantageously, and accomplish more than the sum of its parts. In addition develop mutual trust within the team to create strong norms of reciprocity and greater opportunities for
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shared achievement. Most important of all is to communicate effectively so that the team prioritizes and continuously refines its communication channels creating an environment of general and specific understanding. Last but not the least, recognize measurable processes and outcomes, so that the individual and team can agree on and implement reliable and timely feedback on successes and failures in both the team’s functioning and the achievement of their goals. These can then be used to track and improve performance immediately and over time. As this model curriculum is competencybased, it connects the dots between the ‘know what’ and ‘do how’ for HIM professionals. The National Health Policy-2017 advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system. The policy aims at an integrated health information platform or system which serves the needs of all stakeholders and improves efficiency, transparency, and citizen experience. Delivery of better health outcomes in terms of access, quality,
The National Health Policy-2017 advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system
affordability, lowering of disease burden and efficient monitoring of health entitlements to citizens, is the goal. Establishing federated national health information architecture, to rollout and link systems across public and private health providers at State and national levels consistent with Metadata and Data Standards (MDDS) and Electronic Health Record (EHR) Standards, will be supported by this policy. The policy suggests exploring the use of “Aadhaar� (Unique ID or UID) for identification. Creation of registries (i.e. patients, provider, service, diseases, document and event) for enhanced public health/big data analytics, creation of health information exchange platform and national health information network, use of National Optical Fiber Network (NOFN), use of smartphones/tablets for capturing real time data, are key strategies of the National Health Information Architecture. The policy advocates scaling of various initiatives in the area of tele-consultation which will entail linking tertiary care institutions (medical colleges) to District and Sub-district hospitals which provide secondary care facilities, for the purpose of specialist consultations. The policy will promote utilization of National Knowledge Network (NKN) for Tele-education, Tele-CME, Tele-consultations and access to digital library. The National Health Policy 2017 of India states that recognizing the integral role of technology (eHealth, mHealth, Cloud, Internet of Things or IoT, wearables) in the healthcare delivery, a National Digital Health Authority (NDHA) will be set up to regulate, develop and deploy digital health across the continuum of care. To conclude, HIM professionals are very well trained and suited to ensure that the health information and records (EHRs) of a patient are complete, accurate, protected and meet the desired and stipulated medical, legal and ethical standards. Therefore, it must be made mandatory to appoint an adequate number of health information managers, according to the size of the healthcare organization, to ensure safe and smooth adoption of digital health in India, leading to informed and safer healthcare delivery.
Health Information Management professionals are well trained in the latest information management technology applications and understand the workflow in any health care provider organization
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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
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
Q: There are corporate hospitals which pay fixed salaries to consultants and not on profit sharing pattern. But they give form 16A for tax purposes. How does medical negligence liability workout in such cases? Name withheld Ans: Please note that Form 16 A is issued on income other than salary, so all consultants who get Form 16 A do not fall into category of employees. Hospital is vicariously responsible for mistakes of its employees but not consultants.So, in case of negligence , such consultants should have their own indemnity insurance policies to support medical negligence award.
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Q: I am working as a medical officer in PMS, UP. Sometimes we get patients with sutured wounds for medico-legal examination. In such cases I face difficulty in opining the nature of the wound (simple or grievous). My query is whether I should remove the suture and then opine, Or should I opine without removing the suture, Should I refer the patient to district hospital for expert opinion? Dr Ashok Gupta PMS, UP Ans: Please note that it is responsibility of first doctor who saw case first and applied sutures to opine whether wounds were caused by sharp or blunt weapon. He should also declare whether injuries are simple or grievous.If case is brought before you where stitched wounds are there, never open sutures again but ask for intial report of doctor. If it is not available, then try to opine without opening the sutures and mention it in your reports. Whether injury is simple or grievous can easily be given by inspecting the injuries as per provisions of Section 320 IPC. Q: This is regarding doing or making medico legal cases. Sir are we allowed to make MLC if we are working in private sector. If no then should we take MLC cases and if yes then how do we proceed. Dr. ShashankMaheshwari, Mathura Ans: All doctors who are in private sector can
treat all MLC patients. Just make admission MLC, if already MLC has been made, you need not prepare MLC again. In fresh case, you can make MLC in hospital. If you are in a small clinic, just inform police and give information about patient and on prescription slip, write MLC in BIG letters on top of prescription. Q: For somebody like me working in AIIMS, what is our liability at the time of complaint by patient? (Asked by a senior Professor working in AIIMS, New Delhi) Ans: AIIMS is covered under Consumer Protection Act and hence complaint against doctors and hospital can be taken by consumer court. Since doctors are working there are employees, so vicarious responsibility to pay is of AIIMS in case of award by court. AIIMS is duty bound to provide legal coverage to employees. However, AIIMS can recover the said amount of award from salaries of doctors after departmental enquiry.Criminal complaints can also be filed individually against doctors by patients beside complaint to Medical Council. Q: There are various operative camps being conducted by Government as well as NonGovernment organizations especially in basic health care setups. Surgeons from the private sector as well as the government sector participate in such camps without any financial remuneration. In case there is an intra-op or post-op complication resulting in mortality/ morbidity which can be due to unavailability
of ICU or blood bank or poor asepsis or any other reason, what is the liability of the operating surgeon? Does operating in a camp knowing that there is no back-up in case of an unfortunate event of something going wrong amount to medical negligence? Name withheld Ans: Govt doctors attend such camps on orders of Govt but they should refuse if infrastructure facilities are not adequate. They can easily refuse if supported by their association and govt won’t be able to action against them. Private doctors participate in such camps to promote themselves and do not care if infrastructural facilities are there or not. They should stop all such camps if they do not want cases against them.Please note that while operating in camps if infrastructural facilities are not there and any mishap happen, doctors will be held responsible. Please remember Bilaspur Tragedy where doctors were arrested and put behind bars . Q: Usually when a patient is brought to the casualty and is declared dead especially in case of old infirm patients, the accompanying
relatives don’t want MLC for fear of post mortem. Many a times they bring medical certificate issued by a doctor on proper format. Should this certificate be accepted and dead body handed over to the relatives. Otherwise they create ruckus and scenes in casualty which is uncontrollable by casualty and police is either not available or not effective. Sometimes they insist on dead body being handed over to them without death certificate. Can the casualty staff hand over dead body without issuing death certificate to avoid confrontation. In all other cases ie RTA, homicide, suicide, poisoning etc., we mandatorily do MLC. Lt Gen Retd Dr Kuldip Raj Salgotra, HospDir/Med Suptd MGM Hospital KamotheNavi Mumbai Ans: As a rule, all patients brought to hospital as dead on arrival should be made medicolegal and death certificate should not be issued. But cases like above, you may follow following guidelines and issue death certificate at your own risk. 1. Just check carefully all treatment papers and be convinced that they are genuine.
2. See whether illness was severe enough to cause death. 3. Check whether person is quite old to die naturally. 4. Examine the body in detail for injury, ligature marks, anything strange to point toward un-natural death. If you are convinced then you can issue death certificate at your own risk. Please be careful, in following conditions of brought dead, under no circumstances death certificate should be issued. 1. Death of young male and young woman. 2. Child of any age. There is no harm making a case as MLC. Police has power to waive off post-mortem. In Delhi, this power rests with Assistant Commissioner of Police (ACP).
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 AHPI GLOBAL CONCLAVE 2018 Date: Feb 16-17, 2018 Organiser: AHPI Venue: Le Meridien City: Kochi Click: www.ahpi.in Contact: Shikhar Gupta, Assistant Director
Shikhar.ahpi@gmail.com
H
ealthcare industry will play key role to make the economic growth inclusive all over the globe. On one hand it is key social sector contributing to Human Development Index of nation; on the other hand it provides employment to large segment of population per unit investment. Rightly therefore the healthcare is fast emerging as ‘election
agenda’ in all the developing nations. Governments accordingly are working on plans to provide ‘Universal Health Coverage’. Considering that private sector is playing key role in providing healthcare in general and tertiary care in particular, the mission of ‘Health for All’ can be possible only through joint collaboration between public and private sectors including the allied healthcare industry. Keeping above in view, AHPI has chosen the theme for its 5th Global Conclave as; “Is Quality Healthcare Sustainable? Issues, Concerns & Solutions”. The conclave will also encompass the unique blend of 4th edition of ‘AHPI Awards for Excellence in Healthcare’ which will be presented on the eve of 16th February 2018
SMART TECH HEALTHCARE 2018
Venue: Le Meridien City: Gurgaon Click: http://www.hospitaldesignbuildsum-
Date: Feb 1-2, 2018 Organiser: Explore Exhibitions and
Contact: Upendra Joshi, Conference
Conference LLP Venue: JW Marriott Hotel City: Bangalore, Karnataka Click: www.exploreexhibitions.com/
healthcare/ Contact: Samantha, Conference Co-ordinator info@exploreexhibitions.com n its 2nd year the Smart Tech Healthcare is one among the most dedicated conferences aimed at streamlining new horizons of technology in healthcare which provides a common platform for the industry and other stakeholders to come together to discuss the key challenges, learn from the best practices adopted across the country and ensure their firm is positioned to comply with digital health trends in the evolving industry.
I
INDIA HOSPITAL DESIGN & BUILD SUMMIT 2018 Date: Feb 22-23, 2018 Organiser: Quest Conferences, Quest on the
FRONTIER
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January 2018
mit.com Co-ordinator upendra@questconferences.com ndia Hospital Design & Build Summit 2018 is scheduled during 22-23 February, 2018 at Hotel Le Meridien Gurgaon Delhi NCR, India. The theme for the summit is “Transforming Hospitals”. The event is being organized in association with AHPI, IGBC, CIDC and HIMSS India. The aim of the summit is to Leveraging the latest innovations and best practices in Hospital Build in India to deliver cost-effective projects with effective Project management for timely completion of hospitals.
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XI INTERNATIONAL CONGRESS OF THE INTERNATIONAL NEUROPSYCHIATRIC ASSOCIATION AND THE TS SRINIVASAN-NIMHANS KNOWLEDGE CONCLAVE
Date: Feb 15-17, 2018 Organiser: International Neuropsychiatric
Association Venue: NIMHANS City: Bengaluru Click: www.ina2018.com Contact:ina@target-conferences.com
T
he 3-day event has the contemporary theme “Neuropsychiatry- A Global Approach” the core of our effort being to identify and discuss important transcultural issues in Neuropsychiatry. This congress will be of great relevance to professionals across disciplines. Apart from those who practice, teach & research neuropsychiatry or have a special interest in the field, behavioural neurologists, biological psychiatrists, clinical neurologists and psychiatrists, psychologists, neuroscientists, rehabilitators, public health & epidemiology professionals, nurses, social work professionals, complimentary and alternative health professionals and all others in healthcare interested in mental health and neurosciences, will be warmly welcomed to this forum; to exchange ideas and contribute to the global knowledge pool at this expanding and exciting interface.
10TH NATIONAL ASSEMBLY ON PEDIATRIC EMERGENCY MEDICINE (NAPEM) Date: April 6-8, 2018 Organiser: The Society for Trauma and
Emergency Pediatrics, India & Society for Emergency Medicine, India Venue: MS Ramaiah Medical College City: Bangalore Click: www.napem2018.com Contact: napem2018@gmail.com APEM is designed to meet the needs of all health care providers caring for pediatric patients, in both rural and urban settings. The highlight of this year’s conference will be on Triage in paediatric emergency, Newer practices in PEM, Transport of sick children, PEM residency training, PEM awareness, Prehospital care systems, Challenges in establishing PEM, Innovations in PEM, Paediatric Trauma resuscitation.
N
NAPEM
6 - 8 April 2018 MS Ramaiah Medical College
10th National Assembly on Pediatric Emergency Medicine (NAPEM) organised by
ContaCt +91 9538634563 napem2018@gmail.com
The Society for Trauma and Emergency Pediatrics, India & Society for Emergency Medicine, India
www.napem2018.com Department of Emergency Medicine Columbia Asia Hospital Yeshwantpur, Brigade Gateway, Bengaluru, Karnataka 560055
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