Express Healthcare August, 2014 by Indian Express

VOL.8 NO.8 PAGES 94

Cover story Waking up to paediatric imaging Strategy Striving for sustenance: New avenues for TPAs Life Dr Devi Shetty awarded ‘Honoris Causa’ Degree by IIT-Madras

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CONTENTS MARKET Vol 8. No 8, AUGUST 2014

Chairman of the Board Viveck Goenka Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das

VASUDEV HOSPITAL INAUGURATED IN BIJAPUR, KARNATAKA

OVER RS 2,700 CRORES FOR HEALTHCARE SECTOR IN DELHI BUDGET

AYUSHAKTI OPENS ‘AYURVEDIC FRANCHISE CENTRE’ IN MUMBAI

MANIPAL HOSPITALS ON BOARD THE FORCE GURKHA RFC INDIA 2014 AS MEDICAL PARTNER

CENTRE FOR MANAGEMENT OF CHRONIC PAIN OPENS IN BANGALORE

FORTIS TIES UP WITH AASHLOK HOSPITAL FOR PERSONALISED MEDICAL SERVICES

SIEMENS INSTALLS LAB AUTOMATION TRACK AT THYROCARE

LIVEWELL HEALTHCARE GETS PE FUNDING FROM US FIRM

CAMTECH INDIA 'JUGAAD-A-THON' SPURS INNOVATIONS FOR MATERNAL AND CHILD HEALTH

BD AND IAP-COI CONDUCT TIME AND MOTION STUDY

Bangalore Assistant Editor Neelam M Kachhap Delhi Shalini Gupta DESIGN National Art Director Bivash Barua Deputy Art Director Surajit Patro Chief Designer Pravin Temble Senior Graphic Designer Rushikesh Konka Artist Vivek Chitrakar Photo Editor Sandeep Patil MARKETING Regional Heads Prabhas Jha - North Dr Raghu Pillai - South Sanghamitra Kumar - East Harit Mohanty - West Marketing Team Kunal Gaurav G.M. Khaja Ali Ambuj Kumar E.Mujahid Yuvaraj Murali Ajanta Sengupta PRODUCTION General Manager B R Tipnis Manager Bhadresh Valia Scheduling & Coordination Rohan Thakkar CIRCULATION Circulation Team Mohan Varadkar

ICUs are essential for hospitals but are taboo for hospital finances. Identifying cost centres allow hospitals to debunk the taboo and optimise resources, says M Neelam Kachhap | P20

STRATEGY

STRIVING FOR SUSTENANCE: NEW AVENUES FOR TPAS

COMPLAINT MANAGEMENT: KEY TO HEALTHCARE SET-UPS

IT@HEALTHCARE

56 57

MERCOM CAPITAL GROUP REPORTS FIRST BILLION DOLLAR QUARTER FOR HEALTHCARE IT SECTOR NOVARTIS TO LICENSE GOOGLE "SMART LENS" TECHNOLOGY

P26: INTERVIEW: TUFAN GHOSH Chief Executive Officer, Columbia Asia Hospitals

LIFE

78 78

DR DEVI SHETTY AWARDED ‘HONORIS CAUSA’ DEGREE OF ‘DOCTOR OF SCIENCE’ BY IIT-MADRAS SAMEER GARDE APPOINTED AS PRESIDENT, PHILIPS HEALTHCARE, SOUTH ASIA DR MOHAN THOMAS SELECTED TO HALL OF FAME BY WORLD ACADEMY OF COSMETIC SURGERY

P41: SPOTLIGHT: DR HANS RINGERTZ Pioneer of pediatric MR imaging P48: INTERVIEW: DR JOHN ADLER VP and Chief of New Clinical Applications, Varian Medical Systems

Express Healthcare Reg. No. MH/MR/SOUTH-252/2013-15 RNI Regn. No.MAHENG/2007/22045. Printed for the proprietors, The Indian Express Limited by Ms. Vaidehi Thakar at The Indian Express Press, Plot No. EL-208, TTC Industrial Area, Mahape, Navi Mumbai - 400710 and Published from Express Towers, 2nd Floor, Nariman Point, Mumbai - 400021. (Editorial & Administrative Offices: Express Towers, 1st Floor, Nariman Point, Mumbai - 400021) *Responsible for selection of newsunder the PRB Act.Copyright @ 2011 The Indian Express Ltd. All rights reserved throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is prohibited.

EDITOR’S NOTE

Making healthcare delivery more efficient

ften called ‘angels without wings’, nurses are often the only difference between life and death for patients. But the nurses caught in the cross fire between armed rebels and government forces, most lately in Iraq and still in Libya, came face to face with death themselves. For most of these nurses, returning to India was not an easy option. It meant further debt, loss of face and an uncertain future. No amount of financial aid and rehabilitation packages from the government can restore the dignity of these nurses but private sector white knights like Aster DM Healthcare came up with a better solution: an offer to absorb suitable 'Kerala nurses' who returned from Iraq as well as job counselling for the rest. As of July 9, 12 of these nurses were offered jobs across the Aster DM Healthcare network in Kerala while 30 received cash aid of Rs 25,000 each. These nurses will also be offered jobs in the group’s hospitals and clinics overseas , if they meet the job requirements. The 'Kerala nurse' is today an acknowledged prized export from India but unlike the 'Motel Patel' of the US, another stereotype, the former does not seem to have risen above circumstances. We are familiar with the reasons for her flight to 'greener pastures': better remuneration, dignity of service, better career progression. But her flight is the nation's loss: today, we have a serious shortage of nursing talent. There is hope that Health Minister Dr Harsh Vardhan champions these issues at the centre. A proposal forwarded by the Department of Personnel and Training (DoPT) to create a cadre of doctors for government hospitals, called the Indian Medical Service (IMS) is also tipped to be given serious attention by the Health Minister, never mind the fact that it has been gathering dust for the past three decades. The IMS would be designed along the lines of the Indian Administrative Services and other cadres, with similar working conditions, perks and periodic training. Industry experts say an IMS would be a good

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August 2014

Whether it is the shortage of nurses, paediatric radiologists or affordable medicines, the Narendra Modi government has a huge task on its hands.But often it’s not the lack of services or talent,but the lack of efficiency in our healthcare infrastructure

move, as it will attract doctors to public hospitals and solve the brain drain problem. A similar solution can be applied to nurses and paramedical staff as well. But these moves also need safeguards, as another section of health policy experts caution. Such measures could merely lead to more bureaucratic layers and red tape rather than making a difference to health care indices. In this issue of Express Healthcare, an In Imaging special, we focus on paediatric imaging, another sub-speciality that hasn't got the attention it deserves. As our cover story (‘Waking up to paediatric imaging’, pages 28-31) shows, this neglect will only trip us up as we have the world's largest child population (400 million) but as one expert estimates it, hardly 10 radiologists who practice pure paediatric radiology. This is a grave gap in diagnostic services and one that will allow many diseases to go undetected in children. This will unfortunately result in a higher disease burden so it is imperative that this gap is addressed in a strategic manner. Whether it is the shortage of nurses, paediatric radiologists or medicines, the Narendra Modi government has a huge task on its hands. But often it’s not the lack of services or talent, but the lack of efficiency in our healthcare infrastructure. For instance, in spite of India being the third largest producer of generic medicines, we do not have an efficient distribution system to deliver affordable medicines to rural areas. Some states have made a start; Kerala and Tamil Nadu are pioneers in this respect. Plus, there is a fund crunch, with India’s public healthcare spend just 1.2 per cent of GDP. The way ahead is more efficient and transparent partnerships between government and industry as well as overseas partners like governments and regulatory bodies. But it is equally essential that these partners demonstrate and prove that they have no hidden agenda. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

LETTERS QUOTE UNQUOTE 'As a doctor and former health minister, I am more aware than anybody else of the corruption that is eating into the entrails of every aspect of governance, including the health system. Within days of assuming office I had remarked that the Medical Council of India is a corrupt organisation… There is corruption in the approval of drugs. The Central Drugs Standard Controls Organisation, which is supposed to oversee clinical trials, is another snake pit of vested interests.' 'The private sector serves the economically well-off sections of society which places a premium on quality service. But it tolerates corrupt practices by doctors and nursing homes.'

JULY 2014

'In most parts of India, the government health sector is synonymous with overcrowding, apathy, filth and corruption. So they surrender to the corruption of the private sector' 'When the Prime Minister gave me this responsibility, I was conscious that his objective of giving the people a world class and inexpensive public healthcare system would be impossible to realise without a thorough clean-up. Corruption has to be rooted out and there are no (two) views on that. ' Dr Harsh Vardhan, Union Health Minister in an email response to queries sent by Indian Express

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Important: Whilst care is taken prior to acceptance of advertising copy, it is not possible to verify its contents. The Indian Express Ltd., cannot be held responsible for such contents, nor for any loss or damages incurred as a result of transactions with companies, associations or individuals advertising in its newspapers or publications. We therefore recommend that readers make necessary inquiries before sending any monies or entering into any agreements with advertisers or otherwise acting on an advertisement in any manner whatsoever.

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August 2014

MARKET NEWS

Vasudev Hospital inaugurated in Bijapur, Karnataka The hospital group to expand and set up seven cities in Karnataka by 2016 VASUDEV HOSPITALS (VHPL) group recently inaugurated their first hospital in Bijapur, Karnataka. “Living for Others” is the motto of VHPL, informed Tarun Katiyar, MD, VHPL. He also stated that the vision of VHPL is to be the most preferred healthcare provider for patients, medical practitioners and healthcare professionals by providing stateof-the-art medical care with compassion and dignity. VHPL is 51 bedded, centrally located and easily accessible during emergencies. It aims to offer healthcare facilities to the residents of Bijapur and adjoining areas. The hospital boasts of a modular operation theatre and ICU with ultramodern equipment. VHPL offers specialised services like advanced orthopaedic surger-

VHPL team at the hospital inauguration in Bijapur

ies, laparoscopic surgeries, cardiology, gastroenterology, medical and oncology surgeries, general surgeries, emergency services, anesthesiology, dentistry, ENT, ophthalmology, paediatrics,

obstetrics and gynaecology etc. It also boasts of modern diagnostic facilities such as CT scan, digital X-ray, ultra sonography (USG), 2D Echo, TMT, Colour Doppler, and ECG and Stress Test

apart from 24x7 ambulatory care, pharmacy and pathology. VHPL intends to expand its reach to other other cities of Karnataka and has plans to set up seven hospitals by 2016. The event was attended by

Shanta Mallikarjun Swamiji, Ramesh Jigajinagi, MP; CS Nadagounda, MLA; Bhaskar Rao, North region IGP; and Ram Niwas Sept, SP Bijapur. EH News Bureau

Over Rs 2,700 crores for healthcare sector in Delhi Budget The plan outlay of Rs 2,724 crore for health sector is approximately 16.3 per cent of plan outlay UNION FINANCE Minister, Arun Jaitley has allotted Rs 2,724 crores to the health sector in the Delhi budget for the current fiscal. The allotment includes plans to set up centres in each district for victims of sexual assault and a multi-speciality hospital in South Delhi. The government has proposed setting up one stop centres for crisis management and rehabilitation of victims of sexual assault in each district government hospitals. “Three such centres at Deen Dayal hospital, Guru Teg Bahadur hospital and Sanjay Gandhi

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August 2014

Memorial Hospital will become functional in the next three months, where the victims can be provided proper medical care along with legal and psycho-social counselling and support in a secure, genderfriendly environment,” Jaitley said. A new medical college with 100 seats will also come up in Rohini and efforts are being made to ensure that the first batch of students is admitted by next year. The plan outlay of Rs 2,724 crore for health sector is approximately 16.3 per cent of plan outlay (excluding Cen-

Government has proposed setting up one-stopcentres for crisis management, rehabilitation of victims of sexual assault

trally Sponsored Schemes), which is Rs 16,700 crore. The total budget estimate for the government of NCT of Delhi is Rs 36,766 for the year 2014-15. The Government has proposed to sanction one multi-speciality hospital for South Delhi in the current year. Other proposed steps include setting up 50 dialysis centres for providing free dialysis to poor patients suffering from kidney failure and introducing 110 new ambulances with state-of-the-art life support equipment in the Centralised Accident and Trauma

Services (CATS) fleet. Three more Forensic Science Laboratories are also being planned for which land at Sheikh Sarai, Rohini and village Sayurpur at a cost of Rs 11.25 crores has been purchased, informed Jaitley. The Minister informed that online facility has been launched for out patient department (OPD) registration and issuing of free birth registration certificate at the time of discharge of mother and newborn baby from Government hospitals has also been initiated. Source: PTI

MARKET

Schiller India launches mobile Cath Labs in India SCHILLER INDIA, a subsidiary of Schiller of Switzerland and India’s leading medical diagnostics company signed an exclusive tie-up with Italy based INTERMEDICAL Srl to distribute their Cath Lab systems, Radius XP and Radius XP 100 in India. Radius XP, the mobile Cath Lab variety from the two comes with large power reserve of 20 kW, provides highend imaging quality and flexible configuration suitable for all types of examinations. It also has a unique dual cooling system for immediate and effective heat removal which allows steady X-ray assembly for an indefinite period of time. The Radius XP 100 is a high end fixed ceiling mounted Cath Lab system that offers exceptionalmanoeuvrability with a slim-line design and 100kW generator. Sudip Bagchi, Associate Vice President, Radiology said “With the launch of Radius XP and Radius XP 100 in India we plan to enter the Indian CathLab market which is estimated at Rs 435 crore as of 2013.” EH News Bureau

Ayushakti opens ‘Ayurvedic Franchise Centre’ in Mumbai Ayushakti to launch 50 franchises in next three years in Maharashtra AYUSHAKTI AYURVED has launched its first ‘Ayurvedic Franchise Centre’ at Elphinstone Road in Mumbai recently. The centre was inaugurated by Bollywood actress, Juhi Chawla. Spread across 1500 sq.ft area, the first franchise centre is owned by Chiranjeev Shirvastava, CEO, Ayushakti Ayurved. The company is spearheaded by Vaidya Smita Naram, an Ayurvedic practitioner for past 27 years. Talking on the occasion, Naram, Co-founder and MD said, “We are glad to launch our first ‘Ayurvedic Franchise Centre’ in Mumbai. We are looking forward for a robust growth by means of exceptional service orientation and franchise expansion. Ayurveda has immense power to cure diseases and I wish to encourage entrepreneurship to rekindle the strength of our ancient proven science and create remarkable healing experience of Ayurveda across the world.” Chawla, an ardent believer of Ayurveda, also unwrapped the plans for Ayurshakti’s Mo-

Chiranjeev Shrivastava, CEO, Ayushakti Ayurveda; Juhi Chawla and Vaidya Smita Naram, MD & Co-founder, Ayushakti Ayurveda

bile Van, which will reportedly be Mumbai’s first 'Detoxification Mobile Vehicle' to help patients who are unable to travel upto centres. According to Shrivastava, “The Indian herbal industry is Rs 8,000 crores today, which is increasing at the rate of 10-15 per cent year-on-year. Ayushakti Ayurved is also planning for an exponential expansion plan in next three

years. We plan to launch 50 such Ayurvedic Franchise Centres’ across Maharashtra which includes cities such as Mumbai, Pune, Nashik, Satara and Aurangabad. We trust, in the next five years we will be able to take Ayushakti Ayurved for an Initial Public Offering (IPO)”. He wishes to instill confidence in the future franchise owners by spearheading the responsibility of

the first franchise by himself. ‘Ayurvedic Franchise Centre’ will focus on detoxification and will also specialise in therapies which will help in control of BP, cholesterol, blood sugar levels and enhance respiratory functions to improve on ailments like frequent allergies; asthma, bronchitis; cough, cold, sinusitis, etc. EH News Bureau

US-based Comprehensive Prosthetics & Orthotics commercially launches India operations Plans to increase the number of clinics to 20 in the next one year THE US-BASED Comprehensive Prosthetics & Orthotics (CPO) has commercially launched its India operations. The company has been operating a series of clinics in the country on a pilot basis at seven locations, including in Delhi, Noida and Hyderabad. The clinics aims to act as onestop solution for prosthetic and

orthotic patients, offering technologically advanced and cutting-edge products and services. CPO started the clinic in Jammu recently. CPO is a provider of all prosthetics and orthotics products and services in the US, where it has a network of 21 clinics across various locations. The company strategises to

implement a similar patientcentric model in India, where the sector is very fragmented and does not have many specialised players. “We have been running clinics on a pilot basis at various locations in India. Seeing the huge response, we have commercialised our business and plan to launch 20 more

clinics in the next one year. Our customised products help people get on with their lives independently by making them resume their normal activities of living. Our rehabilitation experts work with the patients and their near and dear ones to understand their needs and recommend the best device that will effectively meet their

requirements, functions and lifestyle,” says Amit Bhanti, Clinical Director & Global Chief Executive Officer of CPO. The company offers a complete range of prosthetics, orthotics, paediatrics and pedorthics (foot care) solutions to patients. EH News Bureau

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MARKET

Centre for management of chronic pain opens in Bangalore

Manipal Hospitals on board the Force Gurkha RFC India 2014 as medical partner

RELIV Center for Chronic Pain Management will deal with back pain, neck pain, joint pain,cancer pain, headaches, neuropathy, and other pain conditions such as reflex sympathetic dystrophy

Manipal Hospital will endeavour to provide all necessary medical assistance to the teams at the motor racing event

A SPECIALITY centre dedicated to the management of pain was inaugurated in Bangalore. The launch ceremony of the RELIV Center for Chronic Pain Management was chaired by Dr BS Ajai Kumar, Founder Chairman & CEO, HCG Group of Hospitals; playback singer BR Chaya; Dr Madhu Yelameli, Founder Director of Reliv Pain Center and Owner of Nashville Pain Center in the US; and Dr Vishwanath Siddalingaiah, Medical Director, Reliv Pain Center. The RELIV Center for Chronic Pain Management, also known as the RELIV Pain Center, is reportedly equipped with all medical equipment needed to deal with chronic pain, including back pain, neck pain, joint pain,cancer pain, headaches, neuropathy, and other unique pain conditions such as reflex sympathetic dystrophy. The facility is managed by a team of experienced and qualified physicians, all dedicated to the mission of nurturing the niche healthcare discipline of pain management and bringing worldclass pain treatment to the country. Said Dr Ajai Kumar, “There are many diseases like cancer in which patients require a great amount of care to not only fight for their lives but also to manage constant pain. In fact, pain management is an essential part of their recuperation. Unfortunately, pain is something that we neglect to manage, and it soon becomes an inseparable part of our life. India is lagging behind in not only how pain is

THE FORCE Gurkha RFC India has announced Manipal Hospitals, a healthcare group based in South India and Jaipur, as their medical partner for the launch edition of the event which is set to be held in Goa from August 8-14. Safety is one of the key focus areas of the organisers. The partnership with Manipal Hospitals has been forged with an aim to ensure safety of all the participants and spectators coming for the event. Since the latter stages of the event will be held in unchartered terrains of Goa and the participants will be working against the forces of nature, cooking their own food and dealing with menacing insects during camp nights, Manipal Hospital will endeavour to provide all necessary medical assistance to the teams. A fully-equipped ambulance will be on standby throughout the course to deal with minor injuries, food poisoning, insect bites, skin rashes caused by the rain, fractures et al. “The safety of all the people coming for the event is our primary concern. We are delighted at this association with the Force Gurkha RFC India 2014. This is an extreme offroad event which means a lot of things can go wrong, but that’s why we are here, to make sure nothing does. Our hospital is a multi-specialty one and has all the facilities and infrastructure to deal with injuries and medical problems – small or big – specific to an outdoor event. We have all the safety measures and precau-

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August 2014

The facility is managed by a team of experienced and qualified physicians, bringing world-class pain treatment to the country perceived but also in how it is treated. It is therefore good to see Indian doctors specially trained in pain management coming together through the RELIV Pain Center to enable patients to benefit from the specialised field of pain management and contributes to the Indian healthcare industry.” Said Dr Yelameli, “India has a very high prevalence of

chronic pain. People continue to suffer from debilitating pain for years without realising that effective technologies now exist beyond physical therapy and simple creams and ointments that can give them significant relief. The RELIV Pain Center now offers the latest treatment facilities for effective and safe management of all types of chronic and intractable pain in any part of the body.” Added Dr Yelameli, “Most patients suffering from pain can leave the RELIV Pain Center with relief within hours. All the procedures and surgeries done for chronic pain are same day procedures and do not need hospitalisation.” “During the past few months of operation, we have helped a large number of pain patients who had previously given up all hope of leading a normal life, continuing with their jobs or taking care of their families,” informed Dr Siddalingaiah. EH News Bureau

The event will be held in unchartered terrains of Goa and the participants will be working against the forces of nature, cooking their own food and dealing with menacing insects tions needed for an event of this kind in place,” said Saleem Yaragudi, Head of Marketing of Manipal Hospitals. Speaking about the safety measures employed at Force Gurkha RFC India, Ashish Gupta, Founder and Director of Cougar Motorsport, the company introducing RFC in India, said, “All international motorsport events have the best procedures in place to ensure the safety of all the participants and spectators. Our alliance with Manipal Hospitals is so that we can offer the best medical assistance to our participants. It is mostly a precaution though.” EH News Bureau

MARKET

Fortis ties up with Aashlok Hospital for personalised medical services To add new operation theatres, infrastructure, specialities FORTIS HEALTHCARE has entered into a strategic tie-up with Aashlok, a boutique hospital, located in Safdarjung Enclave, New Delhi, extending its reach further in the National Capital Region (NCR). The 30-bed Aashlok Hospital will reportedly provide an expanded portfolio of medical specialties with two hi-tech modular operation theatres, a modern ICU, emergency and diagnostic services. The wellknown facility has been substantially upgraded and will continue to offer personalised medical attention to its patients many of whom are prominent citizens of New Delhi. This will enable Aashlok to consolidate its position as a high-end secondary care facility with distinctive medical services, that is comfortable yet unpretentious. Aashlok will benefit from Fortis’ comprehensive health programmes, experienced medical talent and administrative expertise and will in turn refer its complex cases to other For-

(L-R) Dr Alok Chopra, Founder Director, Aashlok Hospital, Aditya Vij, CEO, Fortis Healthcare, Dr Ashwani Chopra, Founder Director, Aashlok Hospital and Dr Dilpreet Brar, Regional Director, Operations FMRI Gurgaon

tis hospitals in the NCR. Dr Alok Chopra and Dr Ashwani Chopra, founding Doctors, at Aashlok Hospital, said, “For thirty years, we have treated our patients like family. The bond between a doctor and his patients is very special and we believe in providing individual attention with personal care, so that patients can recuperate from their illness faster. This strategic tie-up with Fortis provides

a great opportunity for us to expand and upgrade the medical offerings at Aashlok, while maintaining our hallmark of personalised service.” Started in 1984 by the twin doctor brothers, Aashlok will now provide secondary care in cardiology, neurosciences, gynaecology, orthopaedics, gastro sciences, gastrointestinal surgery and minimally invasive surgery with 24x7 emergency and critical care. Super-spe-

cialists from across the Fortis network of hospital in DelhiNCR will also be available for regular and on-call consultations at Aashlok. Aditya Vij, CEO, Fortis Healthcare, said, “This arrangement combines the technological advantage and expertise of India’s fastest growing private healthcare network, with the personalised care model offered by Aashlok. Patients will also

benefit from added medical services and the backup of a seamless referral to a Fortis hospital in the NCR for treatment of complexities that need additional management.” To ensure timely and informed clinical care, Aashlok will integrate with Fortis’ revolutionary e-ICU programe, enabling immediate remote consultation with experts from Fortis hospitals. Aashlok will also introduce a bouquet of wellness services providing holistic care to patients, supplementing scientific modern medicine with responsible contemporary therapies and traditional Indian medicine. Dr Alok Chopra, lifestyle management specialist and a renowned cardiologist and Dr Ashwani Chopra, an accomplished gastroenterologist, will provide their expertise to the company’s flagship, Fortis Memorial Research Institute, Gurgaon visiting the hospital regularly, for consultations with patients. EH News Bureau

Siemens installs lab automation track at Thyrocare The installation will help Thyrocare perform approximately 200,000 tests per day THE DIAGNOSTICS Division of Siemens Healthcare successfully installed, reportedly the world’s longest lab automation track at Thyrocare Technologies, Mumbai. The Siemens Aptio Automation installation at Thyrocare is also India’s first lab automation solution. The installation at Thyrocare is 93.5 m long, which is currently the longest in the world. It has 31 instruments (24 Advia Centaur XP Immunoassay systems and

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August 2014

seven Advia 2400 Chemistry systems) docked to the track, 10 rack loading/unloading robots and five decappers. Various features in the solution allow Thyrocare Technologies to apparently perform approximately 200,000 tests per day involving both immunoassay and chemistry. Dr A Velumani, CEO and Founder, Thyrocare Technologies explained, “Aptio is sleek, dynamic and intelligent automa-

tion solution, very ideal for high volume laboratory for pre-analytical, analytical and post-analytical needs. Our floor is more productive and least expensive now.” Sushant Kinra, Head - Diagnostics Division, Siemens Healthcare India, said, “Siemens is aware of how our customers’ needs have evolved. Aptio Automation represents our latest innovation and vision on how we can help laboratories keep pace

in this challenging environment and address their most pressing business and clinical demands.” Aptio is an adaptable solution that allows for a phased implementation to accommodate both current and future needs of medium- to very high-volume laboratories. The solution promises to transform laboratory operations. Aptio Automation’s circular track and modular design ensure adaptability to nearly any lab or testing environment,

claims Siemens. Aptio Automation offers connectivity to Siemens’ portfolio of automation-ready analyzers, and its point-in-space aspiration feature helps streamline workflow by reducing the need to aliquot (or divide) samples and its puck-based system with RFID enables individual sample routing and tracking, along with STAT prioritisation. EH News Bureau

MARKET

Livewell Healthcare gets PE funding from US firm To establish a 120-bedded facility in Cyberabad, Hyderabad, and a bigger hospital in the Republic of Guinea, Africa LIVEWELL HEALTHCARE plans to establish a 120-bedded facility in Cyberabad, Hyderabad, and a bigger hospital in the Republic of Guinea, Africa. Reportedly, the two projects entail a total investment of Rs 55 crores. The Hyderabad-based company has obtained private equity funding from Exhilway Global Opportunities Private Equity Fund, informed AMV Sai Kumar, Chairman & CEO, Livewell Healthcare. The US-based fund has key focus on India and Africabased buyout investment opportunities. It intends to provide Rs 12 crores of the Rs

The speciality hospital situated in Madhapur is expected to be operational in the next couple of months 25-crore project in Hyderabad. The promoters, Sai Kumar Adapa and Uday Kumar Rachakonda, will raise the balance. The speciality hospital situated in Madhapur is expected to be operational in the next couple of months, said Sai Kumar.The African hospital is being established in Conakry, the capital of Guinea, which is also the business hub. The Government of Guinea has offered the Jean Paul II hospital which has 250 beds. EH News Bureau

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MARKET INSIGHT

Cutting cost not corners in ICUs ICUs are essential for hospitals but are taboo for hospital finances. Identifying cost centres allow hospitals to debunk the taboo and optimise resources, says M Neelam Kachhap

he cost of intensive care is on the rise. Hence the cost of running an ICU is not only high but also increasing day-by-day. “The cost of critical care is widely recognised as being both expensive and increasing. More importantly, when it comes to healthcare needs, the emotions and ethics of the society is often compelling and most are willing to accept the cost even in situations where effectiveness is not clearly established,” opines Dr N Ramakrishnan, Department of Critical Care Medicine, Apollo Hospitals, Chennai. The ICU costs make up 20-30 per cent of all hospital costs. ICU accounts for 10 per cent of all hospital beds and 20-25 per cent of the hospital revenue. It is also resource intensive. However, it’s difficult to establish cost-effectiveness in a health system like India which is not only multi-layered but also multidimensional. But, we can look at economic efficiency to reduce the cost of ICU. This, in turn, will reduce the financial burden on the hospital, motivating it to further invest in ICUs. It will also lower the cost of treatment for the patient in the long run.

Need for critical care in India Healthcare need in India is on the rise. It faces the dual burden of communicable diseases and chronic non-communicable diseases. Added to this is the growing number of elderly which is expected to see a 300 per cent rise in the next 30 years. "India has around 100 million elderly at present and the number is expected to increase to 323

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The ICU costs make up 20-30 per cent of all hospital costs. ICU accounts for 10 per cent of all hospital beds and 20-25 per cent of the hospital revenue. Hence, we need to look at economic efficiency to reduce the cost of ICU. This, in turn, will reduce the financial burden on the hospital, motivating it to further invest in ICUs million, constituting 20 per cent of the total population, by 2050," reveals a report jointly brought out by United Nations Population Fund

(UNFPA) and Help Age International. Most of these diseases require ICU treatment and will push the demand for ICUs further.

According to a WHO publication by Dr G Gururaj, Professor and Head, Department of Epidemiology, NIMHANS, Bangalore,

“Every year in India, nearly a million deaths occur due to road traffic injuries, falls, burns, poisoning, drowning, suicide, workplace or occupational injury, natural disasters, violence, etc.” These critically ill patients need ICU infrastructure for better outcomes to avoid death. It is estimated that there are about 70,000 ICU beds in India. “This includes all types of ICU beds across all hospitals and small nursing homes in India that cater to five million patients requiring ICU admission every year,” informs Dr Ramakrishnan. There is both geographical disparity in the distribution of

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these beds as most of the ICU beds are located in or near larger cities. Also, of the ICUs located in large cities, most are in the private sector. These private sector ICUs are state-of-the-art with modern equipment and good intensivists, but they are expensive. In the meanwhile, less costly ICUs in the public sector suffer from lack of funding which results in limited resources, lack of infrastructure, trained intensivists and support staff. “Average ICU cost for a patient on life support systems is around Rs 50000 to Rs 60000 per day in a private hospital,” says Dr Narayana Swamy Moola, Senior Consultant Intensivist, Narayana Multispeciality Hospital, Whitefield.

Cost centres in ICUs There are many cost related problems in an ICU set-up. A working group in the UK identified six ‘cost blocks’ i.e. factors responsible for high cost of operating ICUs. These are costs of staff, clinical support services, consumables, estates, nonclinical support services and capital equipment.

Capital equipment Cost of life saving equipment constitute a major chunk of the total cost of setting up an ICU. “This includes mainly the central and bedside monitors, invasive and noninvasive ventilators, IABP, syringe pumps, dialysis machine and some miscellaneous items,” says Dr Vijay D’Silva, Director of Critical Care and Medical Director at Asian Heart Institute, Mumbai. “This cost will depend on the specification of the equipment (high-end vs low-end) and will also include maintenance and servicing cost of these equipment,” he adds. Most of the equipment used in India are imported. “Capital equipment accounts for nearly 50 per cent of ICU establishment cost in India as most of them are imported from the US or Europe,” explains Dr Moola. If ICUs use equipment

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A working group in the UK identified six ‘cost blocks’ i.e. factors responsible for high cost of operating ICUs. These are costs of staff, clinical support services, consumables, estates, non-clinical support services and capital equipment

manufactured in India then this cost can be substantially contained. “By reducing the import component of equipment and sharing a pool of equipment between ICUs in common geographical location or leasing them one can reduce the capital equipment

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cost,” says Dr Moola. Another option is to negotiate the price with the manufacturer. “Negotiating the cost of equipment and consumables is required to limit capital equipment cost,” says Dr D'Silva. This is easily said than done. Yet there is hope as the market for medical supplies and disposables is dominated by the indigenous manufacturers and less costly disposables are now being imported from China and Vietnam and other East-Asian countries. In recent years, Indian manufacturers have also invested in high-end equipment manufacturing and the government should incentivise such efforts for more Indian life-saving products.

Land cost This is defined as the cost of estate and maintenance and utilities necessary to maintain the ICU structure. Understandably, cost of land in larger cities is at a premium and alternate location which are inexpensive but strategically located should help control this cost factor. “The land cost forms 20 per cent of establishment cost,” says Dr Moola. “It varies widely depending on geographic location,” he adds. Many hospitals in India face space constraints as old infrastructure does not allow for new ICU or extension of existing ICU.

Consumables Consumables constitute a large proportion of the ICU cost. In India, most of the hospitals provide limited consumables. Some even give patients the option to buy consumables from the market. Most government hospitals have limited stock and thus push the patients to purchase these as need arises. Drugs are also purchased by the patient. Some of the life-saving drugs are very expensive and the hospitals do not hold stocks of these medicines. It is then the patient’s family who seek these drugs in the medicine shops. “Blood, blood products and drugs like antibiotics are big cost centres,” says Dr Moola. “More than 50 per cent of the

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expenditure on drugs is for antibiotics. Other expensive drugs such as Activated protein C and Recombinant factor VIIa, are also used exclusively in the ICU in India,” says Ramakrishnan. Use of such drugs have increased considerably in the past few years for better outcomes but have also added to the cost of ICU treatment.

Manpower cost Critical care is labour-intensive. Intensivists and nurses are an integral part of ICUs. And in India it’s difficult to find trained ICU staff. So the cost of manpower is not only hiring good doctors and nurses but also the cost of detaining them. High level of attrition and migration to Western countries is a regular feature of this cohort and it creates a huge shortage of staff, which in turn affects quality of care and hence possibly costs. On the other end, staff are underpaid and non-favourable treatment of the staff, particularly nurses, contributes to high migration rates. Better working conditions based on improved protocols and active training and support are some of the ways to retain staff.

Clinical support service A critically ill patient needs constant support from different departments of the hospital. This is provided by departments which are directly related to patient therapy but are not supplied by the ICU. “Clinical support services includes physiotherapy, radiology, dieticians, other speciality clinical services such as cardiology, nephrology, laboratory services, etc,. in addition to clinical consultation with other specialists,” says Dr D'Silva. In the private hospitals these are billed separately, adding to the overall costs. This is a major profit generating area in private health care sector with unconfirmed anecdotal reports of misuse. In the ICUs of public sector tertiary care centres, laboratory and support service charges are less than private sector costs but are not

Negotiating the cost of equipment and consumables is required to limit capital equipment cost Dr Vijay D’Silva Director of Critical Care and Medical Director at Asian Heart Institute, Mumbai

laundry, uniform, administration costs of the staff directly employed by the ICU and miscellaneous expenditure such as stationery, telephone, photocopying etc,” he adds. Though this constitutes a very small proportion of the overall cost, alignment of these with other departments may prove optimal and thus curb costs in ICU. Reliable data are lacking in this context but earlier studies quoted a low investment as well as operating and maintenance costs for these categories in India.

Cost control measures

Average ICU cost for a patient on life support systems is around Rs 50000 to Rs 60000 per day in a private hospital Dr Narayana Swamy Moola Senior Consultant Intensivist, Narayana Multispeciality Hospital, Whitefield, Bangalore

available due to various reasons. Judicial use of support services will contain this cost in some respect.

Non-clinical support service Apart from direct therapeutic costs, an ICU requires operational and functional support like housekeeping, stationary, etc,. “Non-clinical support services are required for the functioning of the ICU, but are not specifically related to an individual patient's therapy,” says Dr Moola. “These include costs for catering, cleaning

For the cost control measures to work it is important to include all stakeholders in the programme and the strategy has to be drawn internally rather than follow any cost-cutting model made by external consultants. Another determinant is the quality of care. Quality of care is an important consideration and the strategy that focuses only on cost cutting deteriorates quality of care. A balanced approach is the need of the hour. “Rational use of antibiotics and other costly medicines; recycling some of the consumables; minimising errors and prevention of critical events; financial and management training for ICU leaders are some measures that help minimise ICU costs,” opines Dr Moola. “Improving ICU – ED axis, as the relationship is a mutual one, with each affecting the other in a continuous feed back loop also helps,” he adds. “Pointers to reduce cost include measures to reduce wastage; training of staff to improve efficiency; defining polices and having standard operating protocols; antibiotic policy to control unwarranted use; medication policy to reduce medication errors and critical incidents and clinical and financial audits,” says Dr D'Silva. “Re-sterlisation of disposables is also widely practised in India but it is not legally sanctioned and the law is vague on this topic,” he adds. Medical errors are not openly discussed in India, let

alone its impact of cost. “In India, absence of a nation-wide reporting system and blame free culture prevents staff from either admitting or reporting mistakes,” opines Dr Ramakrishnan. “This makes estimating its true incidence and impact on ICU costs difficult. Solution to circumvent this include staff training, close supervision and developing a web-based anonymous reporting gateway,” he adds. Financial education is important for an ICU intensivist to understand and participate in financial decision-making. “This in turn allows the intensivist to execute appropriate accounting methods, capital budgeting and resource management. Also acquiring negotiation skills will be useful in dealing with financial directors, hospital managers and other personnel funding the ICU. All these invariably translate into cost containment,” says Dr Ramakrishnan.

Cautionary intensive care Preventing life-prolonging interventions and providing palliative care to patients in the end-of-life situation is not well defined in India. In most cases, patients' families are advised to take the patient home or to a less expensive ICU. The law of the land is not clear on this, which adds to the burden on the intensivist. “Limiting life prolonging measures and procedures in end stage disease is a very touchy approach and the law is not well defined in this situation also,” says Dr D'Silva. Home care is the last alternative for these patients. Recently, some providers are looking into providing specialised home care in India. These providers help create ICU like set-up at home for the patient, but these are available only in the private set-up and are expensive. It is also important to analyse ways to minimise ICU admissions or practice measures to decrease length of stay by either early optimisation or preventing secondary complications. mneelam.kachhap@expressindia.com

MARKET PREEVENT

AHA to conduct SASH 2014: Safe and Sustainable Hospital The event will be held on 13-14 September, 2014 at MS Ramaiah Medical College and Hospital, Bangalore INDIA IS POSITIONING itself as a major player in the healthcare market for the rest of the world. The major force behind this is its rapidly growing healthcare infrastructure and implementation of policies related to safety of healthcare workers, visitors and patients. The rapid pace with which the technological advances are taking place in the field of hospital planning entails a genuine need to plan and execute periodic updates. Academy of Hospital Ad-

ministration (AHA), to discuss and constantly update healthcare planners and providers on these issues, is organising SASH 2014: Safe and Sustainable Hospital, through its Bangalore Chapter. The event, to be conducted at the MS Ramaiah Medical College and Hospital, Bangalore on 13-14 September, 2014, promises that it is going to be a different experience which will serve as a benchmark for times to come. The National Conference on 'Innovations & Updates in Hospital

The motive is to spread some knowledge on how to make hospitals truly patient and environment friendly healing centres

Management' has been conceptualised as a platform, an attempt to fill up the void that exists and to get updated on the emerging technologies in hospital designing. The organisers aim to offer an experience which would help redefine healthcare management. The goal is to create a platform where one can exchange knowledge; hear the researchers and professionals on the exciting and challenging trends which many may not be aware off. Today, healthcare in-

dustry is one of the fastest growing industries in India and in the coming years, there is going to be a phenomenal demand for hospitals. With this conference, AHA's motive is to spread some knowledge on how to make hospitals of today and tomorrow, truly patient and environment friendly healing centres. The event is expected to attract more than 500 delegates. AMEN Business Solutions is the Organising Partner for the conference.

SASH 2014

The conference will have CME credit points as per Medical Council norms.

For more information please visit

www.sashahaindia.com

MARKET POST EVENTS

CAMTech INDIA 'Jugaad-a-thon' spurs innovations for maternal and child health Top prizes go to technologies that help monitor pregnancies and screen for developmental delays in children CAMTECH INDIA launched its first Jugaad-a-thon, bringing 250 clinicians, engineers and entrepreneurs together with the challenge of finding new solutions to pressing maternal and child health challenges in India. The event was co-organised by Glocal Healthcare, and hosted by GE’s John F. Welch Research Centre. 34 new potential solutions were presented to a panel of judges – ranging from new tools for antenatal care to disruptive technologies for newborn asphyxia. “The energy and level of innovative thinking in this hacka-thon surpassed any expectation we had,” said Elizabeth Bailey, Director of the Consortium for Affordable Medical Technologies (CAMTech) at Massachusetts General Hospital’s Center for Global Health. “Over these 48 hours, we saw clinical challenges drive innovative ideas, which then spawned new life-saving technologies for women and children in India.

34 new life-saving technologies for women and children were presented at Jugaad-a-thon

The Jugaad-a-thon was open innovation at its best.” Judges awarded several prizes at the close of the Jugaad-a-thon, including: ◗ Top prize: Team “Baby Steps” received Rs 2,50,000 ($4,100) for developing a unique and integrated mobile app for early diagnosis of developmental delays in children across India ◗ First runner-up: Team “Pec Dia” received Rs 1,50,000 ($2,500) for developing a solution to diagnose Cephalopelvic Disproportion (CPD) in pregnancies after 37 weeks by any healthcare worker ◗ Second runner-up: Team “Pregmatic” received Rs 75,000 ($1,250) for the development of an affordable wearable device

Jugaad-a-thon winners received three years of incubation support at Mazumdar-Shaw Medical Center’s Healthcare Technology Incubator

that reminds pregnant women about key milestones in pregnancy when they must see a medical professional. All three of the cash prize winners also received three years of incubation support at the Mazumdar-Shaw Medical Center’s Healthcare Technology Incubator.

There were also prizes awarded by three corporate sponsors. Anheuser-Busch InBev championed the cause of road safety technologies for children. Covidien offered several clinical problems in need of innovation, including newborn asphyxia, fetal/maternal monitoring and post par-

tum hemorrhage. The Novartis Foundation challenged the Jugaad-a-thon participants to come up with new approaches to diagnosing leprosy. Each winning team will receive Rs 50,000 and ongoing support from the companies. Additional prizes included in-kind support from Dayanda Sagar Institutions (incubation services), InnAccel (acceleration services), and the Wellcome Trust (fund-raising and grant writing mentorship). The Jugaad-a-thon’s “48 hours of innovation” brought together a far-reaching and diverse group from healthcare delivery organisations across India, as well as academic institutions and large medical device companies. Vikram Damodaran, Director, Healthcare Innovation, India, and GE Healthcare South Asia said, “We have seen several new creative ideas in just 48 hours that can change the way we look at reproductive, maternal and infant care. It is a completely new experience for us and we believe co-creation of solutions can accelerate affordable healthcare innovation. We are very pleased to have been part of this programme led by CAMTech INDIA. We hope to do more Jugaad-a-thons to promote open innovation and co-creation in healthcare industry.”

BD and IAP-COI conduct Time and Motion Study The study evaluated the potential improvement in vaccination with prefilled syringe (PFS) BD MEDICAL-Pharmaceutical Systems, in conjunction with Indian Academy of Pediatrics Committee on Immunization (IAP-COI), conducted

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a Time and Motion Research across Mumbai, Hyderabad, Bengaluru, Delhi and Kolkata to study the impact on vaccination efficiency and patient

safety in India. The study, published in Pediatric Infectious Disease (PID) journal, was also presented in the open merit category at 51 st

national annual conference of Indian Academy of Pediatrics Pedicon 2014 at Indore. Considering the proportion of unsafe injection prac-

tices in India, an evaluation of the potential improvement in vaccination with prefilled syringe (PFS) compared to SDV and MDV (single and multi-

MARKET dose vials) in Indian private market was the objective of the study. Vaccination in India still predominantly uses multi dose vials (MDVs), but prefilled syringe (PFS) reportedly offer many advantages over MDVs in terms of efficiency and safety, especially considering the many chances for errors and contamination that the use of MDVs creates in vaccination. Dr SG Kasi, former IAPCOI Member, Bangalore and the principal investigator of this study said, “The PFS study is the first study done in India which demonstrates the superiority of the PFS over SDV and MDV in terms of time taken for vaccination, vaccinator productivity, vaccine wastage, waste generated and errors occurring during vaccination. Moreover, the PFS had the least scores in terms of errors with significant HHRE scores. Its publication in the PID journal and presentation in Pedicon 2014, has facilitated the dissemination of its findings to a wide audience. The advantages of the PFS have been acknowledged by the CDC, which now recommends it as the ‘preferred’ system of vaccine administration.” The study was an observational, open label, randomised two-phase time and motion study involving comparison in terms of efficiency associated with the vaccine administration process (preparation, injection and disposal) and rate of handling errors with safety implications. Murli Sundrani, Director – BD Medical- Pharmaceutical Systems – India said, “The Time And Motion study has confirmed the advantages of single-dose, ready-to-use devices like PFS as they offer benefits such as lesser injection time, lesser errors and much better productivity to patients, clinicians and public health. We are happy to collaborate with Indian Academy of Pediatrics Committee on Immunization (IAP-COI) to work on this study to be able to confirm that as compared with vials, PFS are risk reducers, as they reduce the occurrence of handling errors

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The study was an observational, open label, randomised two-phase time and motion study involving comparison in terms of efficiency associated with the vaccine administration process (preparation, injection and disposal) and rate of handling errors with safety implications

and associated health hazard risks.” Results of the study: The mean time required to perform a vaccination with PFS was 47.6 ± 11.7 seconds and was twice as fast as with vials. The mean number of handling errors with PFS was 1.1 ± 1.7 and was 3 times lesser than with vials. (p<0.0001)

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‘We will shortly be opening our tenth facility in India in Bangalore’ Columbia Asia Hospitals has launched a new unit in Bangalore, M Neelam Kachhap speakes to Tufan Ghosh, CEO, Columbia Asia Hospitals about the new hospital and their future plans

The new hospital in Bangalore marks ten years of your presence here. It’s been a long journey form 2004 -2014. How has it been? Columbia Asia Hospitals is the only hospital chain to enter India through 100 per cent foreign direct investment (FDI) route. Headquartered in Kuala Lumpur, Columbia Asia’s first hospital in India commenced operations in 2005 in Hebbal, Bangalore. This is our tenth year in India and we will shortly be opening our tenth facility in India here in Bangalore itself. The Columbia Asia 'model hospitals' are the result of a 15-year development effort that brings together ‘best care’ with ‘best technology’ practices, all under one roof. Our model is rapidly being replicated throughout Asia and in India. In a short span of time our model has proven to be effective and efficient. Out of the nine hospitals we have today, five of our hospitals have been accredited by NABH, while for the others the process is underway. Over these ten years we have also striven very hard to deliver excellence in healthcare. We are glad that today we are the preferred choice of healthcare services for our communities. Our philosophy over the

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years has been that patients are the centre of our attention and their convenience and comfort is our No.1 priority. Our patients and customers also appreciate our flat and transparent pricing structure. What sets us apart is the quality of people we have and the organisational focus on training and development. Our employees are passionate about what they do and have the spirit to serve. When you meet a Columbia Asian, you’ll be greeted with a smile and a warm sense of pride. What is the strength of Columbia Asia’s network in India at present? Can you give us a sense of the size of the company? We are in the tenth year of operations in India and in these past nine years, we have started nine hospitals and the hospital in Whitefield – Bangalore is the tenth. We are now present in Bangalore, Delhi-NCR, Patiala, Pune, Kolkata and Mysore. We will also be starting our eleventh hospital in Ahmedabad very soon. Most of your projects are greenfield projects. This is radically different from the growth path of the other private hospital groups

We are now present in Bangalore, Delhi-NCR, Patiala, Pune, Kolkata and Mysore.We will also be starting our eleventh hospital in Ahmedabad very soon

who prefer acquisitions or JVs and go for brownfield projects. Your comments. The Columbia Asia model has evolved after more than a decade of research. We follow certain guidelines for hospital design and layout and as a result we do tend to prefer greenfield projects. However, we have also undertaken a few brownfield projects. This is dictated by the size, availability of land and the market. We follow standard specifications with respect to measurements for various areas such as OPD, clinics and for various modalities like chemotherapy, dialysis, endoscopy, etc. In no case do we compromise on these standards. We are very particular about ensuring optimal width for corridors, staircases and fire exits. A brownfield building that fulfils these requirements does make it to the consideration set. I must mention here that Columbia Asia Hospital - Whitefield l is a brownfield project. Do you feel you have consolidated your position at Bangalore or there are more projects in pipeline? In Karnataka, are you looking at other locations? Our hospital in Whitefield will be the fourth unit in Bangalore and fifth in Karnataka. We do have an

active interest in setting up more hospitals in Bangalore as well as Karnataka. Was there any learning from other hospitals that helped in setting up the new hospital? How is the Whitefield hospital different from the other existing hospitals in Bangalore? We have garnered plentiful learnings during our journey in India and more importantly, put the same into practice. This is evident in the form of optimisation of the infrastructure and medical programmes in Whitefield. Even for the existing ones we have actively worked towards capability building and additions to medical programmes wherever required. Over the years, Columbia Asia has become synonymous with highest standards of clinical expertise and care. The same levels of service would be available at Columbia Asia Hospital – Whitefield from day one. Columbia Asia Hospital Whitefield has been designed specifically keeping in mind the needs of the community with services and specialities to cater to the needs of the corporate houses, families and in general population living in the area. mneelam.kachhap@expressindia.com

EVENT BRIEF AUG - SEPT-2014 9

Gynaecworld Fertility Evaluation Camp

GYNAECWORLD FERTILITY EVALUATION CAMP Date: August 9, 2014 (12 pm to 4 pm) Venue: Gynaecworld, 1st Floor, Kwality House, Kemp's Corner, Mumbai 400 026 Summary: It is a one day free fertility screening and evaluation camp for couples who are planning to start a family. The camp will also provide gynaecological testing and nutritional counselling Organisers: We Foundation, Gynaecworld and Metropolis Healthcare Contact Urmila/Rukhsana Tel: +91 22 2380 3965/2380 2584 Website: www.gynaecworld.com

Annual World Dental Congress 2014

ANNUAL WORLD DENTAL CONGRESS 2014 Date: 11-14 September, 2014 Venue: India Expo Centre, Greater Noida, India Summary:The Indian Dental Association will be hosting the FDI Annual World Dental Congress 2014 in Greater Noida, NCR New Delhi, India. A cutting-edge scientific programme designed in tune with FDIâ&#x20AC;&#x2122;s social responsibility of leading the world to optimal oral health, it will satisfy the curiosity of the participants by dwelling on subjects that are of growing importance to the profession. It offers a unique opportunity to share knowledge with colleagues from around the world, while discovering the professional landscape of a

different region. Contact: Indian Dental Association (Head Office) Sane Guruji Premises, Block No. 6, 1st Floor, 386 Veer Sawarkar Marg, Opposite Siddhivinayak Temple, Prabhadevi, Dadar(W), Mumbai - 25, Tel: +91(22) 43434545, 43434535 Email: info@fdi2014.or.in Website: www.fdi2014.org.in

11TH HEALTHCARE EXECUTIVE MANAGEMENT DEVELOPMENT PROGRAMME Date: 7-13 September, 2014 Location: Hyderabad

11th Healthcare Executive Management Development Programme

Summary: The programme is designed for professionals occupying or likely to occupy leadership positions in government/private organisations with atleast 15 years of progressive experience in the field of healthcare. The aim is to enhance healthcare leaders' abilities to plan, organise, control, and lead their organisations and enable them discover new ways to handle issues, seize challenges and take their organisations and people to new directions. Participant profile: Those involved in policy formulation, project management, programme development and implementation at hospitals/ medical colleges /healthcare organisations and responsible for healthcare capacity

building, efficiency and excellence in medical service delivery, etc. would be the ideal participants. Intake capacity: 50 participants only Organisers: Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS) Contact Programme Co-ordinator, HxMDP Room No. 6 A, MS Wing, Department of Hospital Administration, All India Institute of Medical Sciences (AIIMS) Ansari Nagar, New Delhi - 110029 Tel: +91 9013956633, 9968953731, 9582222521 Email: info@hxmdpaiims.com Website: www.hxmdpaiims.com

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cover )

WAKING UP PAEDIATRIC IMAGING to

Paediatric imaging is highly specialised and caters to the uniqueness of human development and its disparities from infancy through adolescence. While paediatric sub-specialities are flourishing in India, paediatric imaging has few takers BY M NEELAM KACHHAP

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(

FO C U S : PA E D I AT R I C I M AG I N G

EXPERT SPEAK

Dr Sanjay Prabhu, Assistant Professor of Radiology, Harvard Medical School

Dr Arjun Kalyanpur, CEO, Teleradiology Solutions

10 400

LESS THAN

IN INDIA,THE RADIOLOGISTS WHO PRACTICE PURE PAEDIATRIC RADIOLOGY WOULD BE LESS THAN 10

Dr Bhavin Jhankaria, President, Indian Radiological and Imaging Association

MILLION

IS INDIA’S CHILD POPULATION. IT IS EXPECTED TO INCREASE STEADILY IN THE NEXT FEWYEARS

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cover )

Gaining insights

Recent advances

All the imaging modalities, including X-ray, ultrasonography, CT scan, MRI and PET scan are used in children for diagnosis and getting more information for treatment planning, depending on the illness. Each of these imaging modalities have pros and cons, for example X-ray, CT scan and PET scan involve ionising radiation. Ultrasound and MRI are radiation-free but ultrasound has limited visibility of certain areas while MRI takes long time (about one hour). For MRI, and in certain cases, CT scan, smaller children are put under sleep/anaesthesia for the test. “We, as paediatric healthcare workers, always do risk benefit analysis and decide about what imaging test to use that will provide the best answer for a particular illness and no harm to the child. For some illnesses, for e.g. pneumonia, simple X-ray is all that is required for the diagnosis while for others like cancers, CT scan, MRI, PET scan or a combination of all may be required to obtain the information so that appropriate therapy can be given to the child,” says Govind Chavhan, Pediatric Radiologist. The Hospital for Sick Children and Assistant Professor, Medical Imaging University of Toronto.

Paediatric imaging is evolving rapidly. Research and studies are focusing on efforts to make radiology safe, child friendly and cost effective. Some of the notable advancements are in the application of 3D data obtained from the modality and styling it to harvest added information. “There are numerous ongoing advancements in each of these imaging modalities with attempt to get more information in shorter test time, less radiation doses and avoiding or minimising anaesthesia time,” says Dr Chavhan. “Apart from these, 3D imaging data is now used in surgical planning and during actual surgery (for e.g. 3D CT scan or MRI is displayed during brain surgeries in the operation theatre and the surgeon knows how deep is the tumour and in what direction he has to go). 3D data is also used for creating synthetic material 3D models for heart, skull and other bones that can be used for understanding anatomy and virtual surgery can be practised beforehand on these models,” he adds. Another area in which it is seeing rapid growth is in MRI. Most children with complex congenital heart disease are now imaged on MRI instead of CT in most specialised paediatric imaging centres.

Equipment and exposure settings designed for adults may result in excessive radiation exposure if used on smaller patients

Paediatric imaging centres are now designed with childfriendly colours to make the place look less intimidating for the young child

Paediatric imaging requires greater sensitivity on the part of the radiologist to radiation dose and safety

Training in paediatric radiology in India is inadequate. This translates into inadequate and perhaps poor care

Dr Krishan Chugh

Dr Sanjay P Prabhu

Dr Arjun Kalyanpur

Director & HOD, Paediatric ICU, FMRI

Asst Professor of Radiology, Harvard Medical School

CEO, Teleradiology Solutions, Bangalore

Dr Bhavin Jhankaria

hildren are different from adults when it comes to disease – presentation and treatment. Diagnosing these diseases and disorders are difficult and challenging. “Paediatric diseases form a unique spectrum of pathology and require specialised understanding, including from the imaging perspective. The advances in paediatric imaging parallel the growth of the paediatric sub-specialities, such as paediatric surgery, cardiology, neurology, pulmonology, etc.,” says Dr Arjun Kalyanpur, Chief Radiologist and CEO, Teleradiology Solutions, Bangalore. Non-intimidating painless techniques take precedence over sophisticated diagnostic procedures, which is why paediatric imaging is popular among paediatricians. Assistance in accurate diagnosis without pain is the most attractive trait of radiology. No wonder that it is the most sought after technique in this age group. “Imaging as a diagnostic modality is one of the most frequently ordered investigations. This is for the simple reason that it is non – invasive and painless, which is such an important issue in paediatrics,” says Dr Krishan Chugh, Director & HOD, Paediatric ICU, Fortis Memorial Research Institute.

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“Motion compensation techniques combined with faster and higher strength MRI scanners allow imaging of neonates and young infants without sedation using a ‘feed and wrap’ technique and even moving foetuses in utero in greater detail than ever before,” explains Dr Sanjay P Prabhu, Assistant Professor of Radiology, Harvard Medical School and Director, Advanced Image Analysis Lab; Pediatric Neuroradiologist, Boston Children's Hospital “The availability of ‘baby MRI’ scanners suitable for installation next to the neonatal unit and MRI-safe equipment allows young, sick and often very prematurely born infants to be transported to MRI scanner without disrupting vital treatment that the child needs,” he adds.

Children-friendly The benefits of imaging goes hand in hand with patient preparation. Technically it’s the same as adult guidelines, but reducing fear and acclimatisation techniques enhance the paediatric patient experience. “Patient preparation depends upon the investigation ordered. For e.g. Chest X-rays do not require fasting, but one usually prefers a full inspiratory film unless you are suspecting a

President, IRIA

pneumothorax,” explains Dr Chugh. “Swallow studies , GER Scans and Barium meals require the patient to be fasting. CT Scan, MRI need sedation, hence patient has to fast for 4-6 hours prior to the procedure. In Barium follow-through scans and GER Scans , delayed images upto 6–24 hours may be required,” he adds. “One of the aims of the imaging study is to ensure patient comfort and minimise pain,” says Dr Prabhu. “Paediatric imaging centres are now designed with child-friendly colours and designed to make the place look less intimidating for the young child. Having dedicated personnel including radiation technologists, nursing staff and radiologists trained and experienced in dealing with children and well-versed in the most effective and optimal use of the technologies tailored for the paediatric patients is extremely important to ensure an overall improved experience for the child and family,” he adds. Efforts are being made to reduce unnecessary needle use in children. “Many centres now try and minimise the number of needles that children require during their stay in the hospital by educating providers and instituting system practices that encourages use of dual-purpose

Radiation exposure from imaging puts children at a extremely small but definite risk of cancer development later in life Dr Govind Chavhan Pediatric Radiologist, The Hospital for Sick Children

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catheters that can be used for multiple imaging procedures and administering medications,” explains Dr Prabhu. Pre-play to familiarise the child with a particular modality also helps reduce fear. “In young children, use of ‘mock MRI’ where a play therapist helps the child acclimatise to the noises and closed space of the scanner on a non-working scanner replica before the real scan is another innovative method used in some paediatric centres,” Dr Prabhu explains.

Assessing the need Although imaging answers a lot of questions about the disease one should tread carefully while prescribing them. “Paediatric imaging should be done only when really required. We generally order an X-ray or other modality of imaging like CT or MRI when it is actually going to affect the course of treatment, or make a diagnosis, or affect the future outcome. It should be remembered that radiation exposure has its own hazards and the most dangerous one is the risk of cancer following exposure to radiation,” says Dr (Maj) Manish Mannan, Consultant and Coordinator, Paediatrics and Neonatology, Mother and Child Unit, Paras Hospitals, Delhi. Agreeing Dr Chugh says, “Children are more radio-sensitive than adults (i.e., the cancer risk per unit dose of ionising radiation is higher), have a longer expected lifetime for any effects of radiation exposure to manifest as cancer; and use of equipment and exposure settings designed for adults may result in excessive radiation exposure if used on smaller patients. Hence most definitely in ordering radiological investigations in children, one should be absolutely sure whether it is necessary and not just a part of a basic or routine work up.”

Risks involved Dr Chugh says, “Risks from X-ray imaging are due to exposure to ionising radiation and possible reactions to the intravenous contrast agent, or ‘dye’ that is sometimes used to improve visualisation.” He further explains, “These risks include tissue effects such as cataracts,

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skin reddening, and hair loss, which occur at relatively high levels of radiation exposure; more importantly, ionising radiation has enough energy to cause damage to DNA and thus puts the patient at risk of developing cancer in later life. Talking about the risk of

exposure to children, Dr Kalyanpur says, “Radiation dose and safety are issues that while not unique to the paediatric population, nonetheless have their greatest impact on children. This is because their cells and tissues are actively growing and developing and are therefore

most sensitive to cumulative radiation damage resulting in potential mutation and carcinogenesis. Paediatric imaging therefore requires a much greater sensitivity on the part of the radiologist to the issue of radiation dose and safety.” Echoing his concerns, Dr Chavhan

says, “One important point I would like to emphasise is radiation risks in children from imaging. There is now some evidence that radiation exposure from imaging puts children at a very small but definite risk of cancer development later in life Continued on Page 38

cover ) OPINION

Advances in paediatric imaging

DR SANJAY P PRABHU Assistant Professor of Radiology, Harvard Medical School, Boston

Dr Sanjay P Prabhu, Director, Advanced Image Analysis Lab, SIMPeds3D Print team, Boston Children's Hospital; Assistant Professor of Radiology, Harvard Medical School, Boston, MA opines that the advances in paediatric imaging has been exponential and takes us through a journey of the important developments in this segment

ecent advances in paediatric imaging can be broadly divided into the refinements of well-established techniques like radiography, fluoroscopy and CT, developments in the fields of MRI and ultrasound, advances in patient preparation like minimising the need for sedation, use of play therapy techniques and increased recognition for the need for child-friendly environments in radiology departments.

Refinements in radiography, fluoroscopy and CT The widespread use of digital radiography has led to increased dose efficiency, and the greater dynamic range of digital detectors with possible reduction of radiation exposure to the young paediatric patient. Dependence on paediatric fluoroscopy has decreased over the years with the increased availability of alternative techniques like ultrasound, MRI, CT and endoscopy. However, in some conditions, fluoroscopy is a critical diagnostic tools. When fluoroscopy has to be used, it is imperative that optimised techniques, best summarised as â&#x20AC;&#x2DC;Pause and Pulseâ&#x20AC;&#x2122; campaign sponsored by The Alliance for Radiation Safety in Pediatric Imaging are utilised. This

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3D printed model of a brain with electrodes overlaid on the brain to simulate patient anatomy

includes always considering alternative means to image the patient and avoiding use of radiation, preparing the patient adequately, scanning only the area that is required, using last image hold, storing images acquired during screening with no additional dose, minimising use of magnification (which can

increase dose) and scanning without the anti-scatter grid in place. Advances in multi-slice CT technology including faster scanners with sub-millisecond rotation times now allow imaging of larger areas of the patient anatomy with less motion artefact and reduced need for sedation in children.

Newer scanners have the capability to reduce radiation dose to account for the smaller size of the child. Paediatric imaging departments are implementing indication-based dosing (i.e. reducing tube current for certain indications where high detail is not needed). Improvements in paedi-

atric imaging contribute to the growth of non-invasive, radiation-free procedures. Even in conditions like intussusception, where fluoroscopy was the mainstay of the imaging during reduction, some centres are employing ultrasound to image the child, thereby avoiding radiation.

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Advances in MRI The latest generation of higher field magnetic resonance imaging (MRI) scanners with improved coil technology allows for faster, non-invasive imaging of smaller, moving subjects and in many cases avoids the need for anaesthesia or radiation. In young children, use of ‘mock MRI’ where a play therapist helps the child acclimatise to the noises and closed space of the scanner on a non-working scanner replica before the real scan is another innovative method used in some paediatric centres. Motion compensation techniques combined with faster and higher strength MRI scanners allow imaging of neonates and young infants without sedation using a ‘feed and wrap’ technique and even moving foetuses in utero in greater detail than ever before. The availability of ‘baby MRI’ scanners suitable for installation next to the neonatal unit and MRI-safe equipment allows young, sick and often very prematurely born infants to be transported to MRI scanner without disrupting vital treatment that the child needs. Cardiac MRI has advanced in the last several years and most children with complex congenital heart disease are now imaged on MRI instead of CT in most specialised paediatric imaging centres. The use of MRI for surgical planning has increased exponentially. Techniques like diffusion tractography which allows mapping of white matter tracts in the brain and functional MRI which allows mapping of eloquent areas involved in motor, sensory, language and visual function help guide the neurosurgeon during delicate surgical procedures and minimise damage to vital structures. Use of three-dimensional reconstructions and in some cases, printing of 3D models using the patient’s imaging studies allows the surgeon to plan and simulate the procedure before going into the operative room.

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Most children with complex congenital heart disease are now imaged on MRI instead of CT in most specialised paediatric imaging centres

The availability of intra-operative MRI (inside the operative suite) allows surgeons to confirm that a tumour has been completely removed or not before closing the surgical site. This is incredibly useful to avoid repeat procedures

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cover ) and ensure complete resection of tumours in many cases. More recent innovations include use of MRI in children to guide minimally invasive therapeutic procedures like laser ablation of tumours and other lesions in various parts of the body. Real-time visualisation of the area being targeted allows effective treatment and at the same time, minimising patients discomfort and post-procedure stay in the hospital.

Advances in ultrasound As mentioned in the section on fluoroscopy, the increasing use of ultrasound has been instrumental in significant reduction in radiation exposure. For example, in some centres contrastenhanced ultrasound has replaced conventional radiologic methods used for vesicoureteral reflux, a condition in which urine refluxes back from the bladder into the ureters causing kidney infections and scarring. Introduction of harmonic imaging, which allows higher spatial and contrast resolution has resulted in improved image quality in areas like intestinal ultrasound. Use of threedimensional [3D] ultrasound offers not only an improvement in diagnosis in selected cases, but also increases acceptance of ultrasound by clinicians and enhances parentsâ&#x20AC;&#x2122; understanding of the findings. 3D-ultrasound in paediatrics has been used in foetal scanning, brain ultrasound and volume measurement of the kidneys in children with suspected urinary tract abnormalities. Availability of smaller transducers and refinements in Doppler techniques allows very detailed study of flow and function even in small sized organs in the neonate and young infant.

Patient preparation, personnel training and environment modification One of the aims of the imaging study is to ensure patient

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CT scan of the brain reconstructed with overlying electrodes in patient with seizures

comfort and minimise pain. Paediatric imaging centres are now designed with child-friendly colours and designed to make the place look less intimidating for the young child. Having dedicated personnel including radiation technologists, nursing staff and radiologists trained and experienced in dealing with children and well-versed in the most effective and optimal use of the technologies tailored for the paediatric patients is extremely important to ensure an overall improved experience for the child and family. Many centres now try and minimise the number of needles that children require during their stay in the hospital by educating providers and instituting system practices that encourages use of dualpurpose catheters that can be used for multiple imaging procedures and administering medications.

Summary Advances in paediatric imaging in the last few years have been exponential. It is imperative that medical personnel dealing with children acquaint themselves with these developments and parents should ask their medical providers for adequate measures to minimise risk to their child and choose the most optimal test to help diagnose the childâ&#x20AC;&#x2122;s illness. In many cases, this requires more of an attitudinal change towards the young child and his/her family. Some of the changes can be accomplished with very little or no additional financial investment.

References Tracts in the brain overlaid on a tumour using MRI

Advances in paediatric imaging in the last few years have been exponential. It is imperative that medical personnel dealing with children acquaint themselves with these developments

1.Pause and Pulse: Ten Steps That Help Manage Radiation Dose During Pediatric Fluoroscopy- AJR:197, August 2011 2.Image Gently campaignhttp://www.imagegently.org/ 3.Neonatal NeuroimagingPrabhu SP, Grant PE, Robertson RL, Taylor GA in Averyâ&#x20AC;&#x2122;s Textbook of the Newborn 9th Ed. Editors; Devaskar and Gleason

cover ) INSIGHT

Paediatric imaging in India - Challenges and solutions DR ARJUN KALYANPUR Chief Radiologist and CEO, Teleradiology Solutions

Dr Arjun Kalyanpur, Chief Radiologist and CEO, Teleradiology Solutions elaborates on evolution of paediatric imaging and enlightens on its peculiarities and challenges

t is a fact that the health of a country is measured by the health of its children, as healthy children grow into healthy adults. Children under 14 constitute a significant one third of our population. Prevention and care of paediatric diseases therefore constitutes the cornerstone of our nation's healthcare system. Radiology, the science of medical imaging, has come a long way since the days of Roentgen. It is now realised that it is virtually impossible for a general radiologist to adequately address all clinical issues that may come to his or her attention. The tremendous advances in medical science have of necessity given rise to medical sub-specialisation. From the perspective of medical imaging, this has given rise to a number of radiologic subspecialities, an important one of which is paediatric radiology. A relevant aphorism states that 'children are not merely small adults'. Paediatric diseases form a unique spectrum of pathology and require specialised understanding, including from the imaging perspective. The advances in paediatric imaging parallel the growth of the paediatric subspecialities, such as paediatric surgery, cardiology, neurology, pulmonology, etc. A distinct set of clinical entities, congenital lesions - such as atresias (failures of certain anatomic structures to develop), genetic syndromes and dysplasias, etc, require specific and distinct management decisions and

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challenges, and in turn a completely different approach to imaging analysis than in the adult. Neonatal diseases in particular tend to be at the most challenging end of this spectrum. Issues such as paediatric trauma also require a different approach than trauma in the adult. Child abuse or non-accidental trauma is another issue of medico legal and public health significance which the specialised eye of a paediatric imager may be needed to detect, in order that steps may be taken to prevent further repetition of such trauma to the child by a caregiver. Compounding the issues are the soft skill challenges related

to obtaining history and conducting an examination or procedure on a young child, that require specialised training, expertise and sensitivity on the part of the imager. Of particular importance, radiation dose and safety are issues that while not unique to the paediatric population, nonetheless have their greatest impact on children. This is because their cells and tissues are actively growing and developing and are therefore most sensitive to cumulative radiation damage resulting in potential mutation and carcinogenesis. Pediatric imaging therefore requires a much greater sensitivity on the part of the radiologist to the issue of radiation dose

and safety. Programmes such as â&#x20AC;&#x2DC;Image Gentlyâ&#x20AC;&#x2122; are initiatives of the Alliance for Radiation Safety in Pediatric Imaging whose mission is to minimise the diagnostic radiation dose to children to a level that is as low as reasonably achievable (ALARA). The Alliance is a coalition of healthcare organisations driven by, among others, the Society for Pediatric Radiology. Development of mindfulness of the importance of minimising radiation in the imaging of the child is an important part of paediatric radiology training and practice. How is a paediatric radiologist made? The process begins with lectures and rotations during the postgraduate train-

ing of a radiologist. Recognising that paediatric imaging needs to be given a separate focus and training, the US has traditionally had dedicated paediatric radiology rotations as an integral part of their radiology residency training. When I did my residency and appeared for the American Board of Radiology examination in the late 90s, I spent several months rotating through the Children's Hospital at Yale New Haven. Further, paediatric imaging was one of the ten sections that it was mandatory to pass in order to clear the boards, highlighting the importance of this sub-speciality. This is still the case. Further, the American Board of Radiology (ABR) website currently states that other sections/modules such as musculoskeletal, cardiovascular etc. will also include items relevant to paediatric radiology, further highlighting its importance. Additionally paediatric radiology fellowships of 1-2 year duration that follow residency training have been well established for many years in the US, Canada and the UK, including sub-speciality board examinations and certifications. Given the number of specialised children's hospitals that exist in that part of the world this seems a logical accompaniment. In the past in India, paediatric radiology has traditionally been a self-taught speciality that has grown to support the departments of paediatrics and paediatric surgery. However, as

( the paediatric sub-specialities in India have evolved and modalities including sonography, CT and MRI have proliferated, further sub-speciality training in paediatric radiology in India has become necessary for those wishing to master the field. In India, such fellowship training programmes have only recently been instituted with fellowship training currently available at certain premier institutes such as the PGIMER Chandigarh and CMC Vellore. More such programmes are needed. At this time the relatively small number of sub-speciality fellowship trained paediatric radiologists in India have in several cases received their fellowship training overseas. Why does India not train more paediatric radiologists? There is an acute radiologist shortage in India and from an employment perspective there are sufficient opportunities and more for general radiologists in the community. There is therefore no great incentive (and there is perhaps actually a disincentive) for a radiologist to go through an additional year or years of sub-speciality training in paediatric radiology, unless out of a genuine love and academic interest in the field, which is what characterises most sub-specialists. In fact there may actually be concern that sub-specialisation will lead to a reduced value in the job market, as stated in an editorial in the Indian Journal of Radiology and Imaging in 2010. Employment opportunities specifically for paediatric radiologists are also few, and paediatric radiologists, except at tertiary centres will tend to be drawn into spending some of their workday performing adult imaging. As a result the attraction for focussed training in paediatric radiology is currently lacking. With reference to the quality of current training, Sidhu et al in an article on paediatric radiology state that in a survey conducted by them at a paediatric radiology education programme, of 86 respondents, 82 per cent indicated that their academic institutions did not place emphasis on dedicated

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paediatric radiology training, and 63 per cent indicated they received less than two weeks of dedicated training. Of the respondents, 77 per cent said their institutions practised paediatric radiology with inadequate standard of care. The

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authors conclude that education and training in paediatric radiology in India is currently inadequate. There are however beacons of hope. Saxena et al in their article in the Journal of the International Medical Sciences

Academy state that there are over 300 members of the Indian Society for Pediatric Radiology (ISPR), indicating a growing interest in the field among radiologists. The Society conducts conferences and midterm continuing medical

education activities in paediatric imaging for postgraduates and practising radiologists. There is now even a Society for Pediatric Interventional Radiology. Such societies further and protect the cause of the speciality and create

cover ) opportunities for training in this niche domain. It is evident that the need of the hour for paediatric radiology in India is training, whether it be training of dedicated paediatric radiology sub-specialists or of general radiologists to increase their understanding and awareness of paediatric imaging issues. However, as in medical education in general, the challenges tend to be a) a shortage of educators b) constraints in physical access to training c) time constraints. In such a setting, technology innovations can be transformational. E-learning is a powerful means to spread learning in the field of paediatric imaging. In another paediatric sub-speciality, paediatric cardiology, an innovative online training curriculum has been developed and achieved significant success (http://heartstrings.linkstreetlear

ning.com/). A host of excellent teaching websites exist in paediatric imaging. The website www.wfpiweb.org is an excellent online resource for information on paediatric imaging. Online training portals such as www.radguru.net, supported by the Telerad Foundation also provide an opportunity for postgraduates to obtain training in paediatric (and other) sub-speciality imaging in a live interactive virtual classroom environment. The use of technology offers an additional paradigm changing solution in the space of paediatric imaging. Teleradiology is a technology-enabled reporting process that has the potential to greatly increase the reach of sub-speciality imaging in India, and paediatric imaging is no exception. By using data networks to electronically transfer digital paediatric images from hospitals and imaging

centres to sub-specialist paediatric radiologists, the quality of reporting and analysis can be enhanced. Access to sub-specialist paediatric radiologists from even remote and backward areas can be facilitated. Teleradiology can be used for reporting of paediatric examinations by sub-specialists, both in the emergency setting as well as in the elective or outpatient setting, and also to provide second opinions to general

radiologists on their complex paediatric cases. Rapid turnaround time of reports can be achieved by the use of highspeed telecommunications and advanced teleradiology workflow platforms, thus enhancing patient care in the paediatric age group. Further the use of teleradiology allows the paediatric radiologists time (a scarce resource to begin with) to be utilised more efficiently and productively, and permits them to focus more effectively on their sub-specialisation. In summary, the imaging of children requires specialised training given the unique clinical challenges and radiation issues involved. Paediatric radiology is an established subspeciality in Western countries, however India lags in this regard for a variety of reasons as discussed. There is a need to train more sub-specialist paediatric radiologists as well as to

train general radiologists in paediatric imaging. Societies such as the Indian Society of Pediatric Radiology are making sincere efforts to this end with their CME activities. The use of innovative technologies such as teleradiology and e-learning have the potential to enhance paediatric radiology as well to facilitate the dissemination of knowledge in this critical space.

References Saxena et al JIMSA JanuaryMarch 2013 Vol. 26 No. 1 77 Sidhu et al Pediatr Radiol. 2014 Jun;44(6):657-65. Jankharia, B. Editorial, Indian J Radiol Imaging. 2010; 20(1): 1. Indrajit, IK. Pediatric Imaging Web Review Indian J Radiol Imaging. 2009: 19(1) 89-90 http://heartstrings.linkstreetlearning.com/ www.wfpiweb.org http://www.ispronline.com/ www.radguru.net

Continued from Page 31

Waking up to paediatric imaging CT scan is the biggest culprit for the radiation exposure because of high radiation doses. Smaller the child when he/she is exposed to radiation more is the chance of cancer development because of immature tissues and more years they liver as compared to adults. Because of this, the current educational and research efforts in paediatric imaging are either directed towards reduction in radiation doses for CT scan or utilisation of radiation-free modalities. In our hospital, we have decreased the use of CT scan and are using more ultrasound and MRI.”

ALARA The knowledge of risks of exposing children to ionising radiations has always been there and the current focus of paediatric radiologists around the world is to keep radiation dose as low as reasonably achievable (ALARA). “One should follow the recommendation of ALARA. When a child is being exposed to X-ray of one part of the body,

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it is very important to shield other parts, particularly the genitalia. Similarly, if a child in the ward is being exposed to an X-ray by means of a portable X-ray machine, it is important that other children in the vicinity are shielded from unnecessary radiation,” recommends Dr Mannan. Concerns over radiation risk to children led to the formation of the Alliance for Radiation Safety in Pediatric Image Imaging (Image Gently Alliance). Their aim is to improve safety and effectiveness of imaging care of children worldwide. This is achieved through increased awareness, education and advocacy on the need for appropriate examination and amount of radiation dose when imaging children. Recently, Dr Stephen J Swensen, Radiologist, Mayo Clinic called for standardisation of safe imaging protocol for children. In a commentary published online in the Journal of Patient Safety, he called for the American College of Radiology,

Joint Commission, Intersociety Accreditation Commission, and the Centers for Medicare & Medicaid Services to require three safety practices for accreditation of all American hospitals and advanced diagnostic imaging facilities. His mantra for imaging children is 'The Right Exam, ordered The Right Way, with The Right Radiation Dose'. “We have the knowledge and the tools today that can substantially improve the safety and quality of care for our children (while also decreasing costs). We have a compelling opportunity to reduce harm for the most susceptible population: our children,” Dr Swensen said in a press release.

Advances in India Paediatric radiology is yet to take off in India. There are very few dedicated children's hospitals in India though most hospitals have a paediatric unit. Radiologists in these set-ups are therefore expected to multitask. In fact, there are very few avenues for radiologists to train

in paediatric radiology and even fewer financial incentives to practice it. “In India, the radiologists who practice pure paediatric radiology would be less than 10. Given that we have a population of 1.2 billion with one-third below the age of 15, this is woefully inadequate,” says Dr Bhavin Jhankaria, President- SRL Diagnostics Jankharia Imaging and President, Indian Radiological and Imaging Association. An editorial he wrote for the journal of IRIA in 2010 highlighted the plight of paediatric radiology in India. He wrote, “training in paediatric radiology in India is inadequate, the focus on training is all but absent and this translates into inadequate and perhaps poor care in the majority of radiology centres and departments across the country.” The creation of Indian Society of Pediatric Radiology (ISPR) in 2003 has given some hope to radiologists who are passionate about paediatric imaging. The society conducts

annual conferences and CMEs but has not been able to successfully advocate for separate paediatric radiology training. This leaves a lot to be desired in paediatric imaging in India, specially in the area of dose management. “Having worked both in India and Canada, I find the radiation risk awareness amongst the medical community, leave alone the general public, in India negligible as compared to North America. Here, it is not uncommon for us when parents come and ask how much radiation dose my child is getting and is there any alternative test that can provide the answer,” says Dr Chavhan. “This kind of awareness needs to be created in India as well,” he adds. India has the world's largest child population at 400 million and it is expected to rise. Demand for dedicated paediatric imaging continues to rise, but the radiologists have not yet woken up to the unique opportunity. mneelam.kachhap@expressindia.com

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OPINION

Paediatric radiology in India Dr Bhavin Jhankaria, President, IRIA opines that subspecialisation and adequate training in paediatric imaging is the way to give a boost to the segment

n February 2010, I had published an editorial in the Indian Journal of Radiology and Imaging, where I had discussed a survey on the status of paediatric radiology among the radiologists who had attended a paediatric radiology update in November 20091. Paediatric radiologists from the Hospital for Sick Children in Toronto, Canada and local radiologists from India with an interest in paediatric radiology had conducted this meeting jointly. These findings have recently also been published in Paediatric Radiology2. The main findings as reported in the editorial were quite interesting. Almost 63 per cent of the radiologists surveyed said that they had received less than two weeks of dedicated paediatric radiology training with 82 per cent believing that their institutions did not really place any importance to dedicated paediatric radiology training. Having said that, 45 per cent on a scale of 1-5 believed that it was not really important to have adequate training in paediatric radiology (scores 1 and 2), whereas 23 per cent were equivocal (score of 3), while

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DR BHAVIN JHANKARIA President, Indian Radiological and Imaging Association

cover ) 57 per cent agreed that the training was inadequate as well (scores 1 and 2), 17 per cent being equivocal (score 3). When the questions were rephrased from a patient’s perspective, 77 per cent believed that children were receiving inadequate care with respect to medical imaging (scores 1 and 2), while another 17 per cent were equivocal. When the question was reworded and they were asked whether the radiologists were competent or not when handling children, 47 per cent were equivocal, 30 per cent thought they were not competent, but 22 per cent believed that they were competent. This is not surprising since radiologists will in general blame the system rather than themselves for deficiencies in care and will also believe that they are better than the others around them. However, surprisingly, 75 per cent of those present thought that paediatric radiology will gain more and more importance in the future. What the survey revealed is that training in paediatric radiology in India is inadequate, the focus on training is all but absent and this translates into inadequate and perhaps poor care in the majority of radiology centres and departments across the country. It is obvious that we have to sub-specialise. That is the only way we will be able to speak the language of our clinical colleagues and answer the questions that they have. In India, there is some semblance of sub-specialisation in neuroradiology and interventional and vascular radiology, but beyond these two disciplines, there is a significant resistance to subspecialisation. So ultrasonologists who can very well afford to sub-specialise in obstetrics will still do Achilles tendon scans and mammologists will also handle the testes. We often have CT scan and MRI sub-specialists, but chest, cardiac, bone, gastrointestinal and genitourinary or abdominal sub-specialists are few and far between.

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Radiologists who understand how to adjust protocols, and who can speak the same language as the paediatricians and paediatric surgeons, are sorely required, if we are to be an integral part of the teams that manage infants and children. Until then we will remain image-producers, not doctors who can make a positive difference! The reasons are many; lack of training or focus during residency; a fear that organ sub-specialisation will lead to a reduced value in the jobmarket, if and when jobs have to be changed; a sense of not wanting to let go; a lack of peers around who can serve as role models, etc. Paediatric radiology more than any other discipline needs sub-specialists. Infants and children are not just young

adults. Radiologists who understand how to adjust protocols, and who can speak the same language as the paediatricians and paediatric surgeons, are sorely required, if we are to be an integral part of the teams that manage infants and children. Until then we will remain image-producers, not doctors who can make a positive difference! In 2012, I was invited by the Indian Society of Pediatric

Radiology to deliver the Arcot Gajaraj Memorial Oration. I decided to speak on “The Challenge of Pediatric Radiology in India” I repeated another survey in 2012. The main question I asked was, “What is the role of a paediatric radiologist in a private practice group and a hospital?” The vast majority said that a paediatric radiologist is an asset in a hospital, but there is very little role in

private practice and the reasons ranged from economic to the fear of being sub-specialised and then perhaps unemployable. All of this gets further complicated by the fact that while we think of paediatric radiology as a sub-speciality, adult sub-speciality radiologists are branching out into their respective paediatric organ sub-speciality. For example, neuroradiologists are now becoming exclusive paediatric neuroradiologists. They don’t come from a paediatric radiology background, but typically from a neuroradiology background. Similarly, paediatric musculoskeletal (MSK) experts come from an MSK background, not from a paediatric radiology background. In major paediatric institutes around the world, the main role of a generalist paediatric radiologist is now limited to body radiology, typically the chest and abdomen. This still however constitutes a large volume, especially in paediatric hospitals. In India, the radiologists who practice pure paediatric radiology would be less than 10. Given that we have a population of 1.2 billion with one-third below the age of 15, this is woefully inadequate2. But then we have only around 15,000 radiologists for the whole country, clustered in metros, with so much work to be done in all other sub-specialities, that there is no reason for anyone to branch out into paediatric radiology, unless one has a passion for the subject and even then it may be difficult to find a hospital that supports this passion. Unless there is a structured, government/Medical Council of India (MCI) led directive on adequate sub-specialisation, the situation is unlikely to change.

References 1.Jankharia B. The subspecialization conundrum. Ind J Radiol Imag 2010;20:1 2.Sidhu A, Sheikh N, Chavhan G et al. Ped Radiol 2014;44:657

IN IMAGING IN SIGHT

Digital data storage for enhanced radio-diagnosis M Bala subramaniam, CEO, CURA Healthcare recommends replacing expensive film or unwieldy paper records with low-cost optical media solutions designed to make information easy to use, durable and unalterable

M BALASUBRAMANIUM CEO, Cura Healthcare

Strike the perfect

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he radiology segment of healthcare plays an important role in qualitative diagnosis, interpretation and reporting which helps physician/surgeon plan their line of therapy. The diagnostic tools range from age old basic X-rays/digital X-ray and ultrasound system to high-end instruments like MRI, CT, mammograms and hi-tech technologies such as PET scans, Gamma camera etc. Radiologists have been playing a subtle yet highly significant and essential role in patient care. Digitisation is the buzz word in current set up of radiology department. Keeping science intact, rapidly changing technologies have brought a paradigm shift in the way radiology departments have functioned so far. Almost every imaging equipment of the erstwhile era has undergone multi-fold changes in terms of scanning accuracy, speed, image resolution, patient turnaround time etc. Conventional X-ray with an average turnaround time of over six min-

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IN IMAGING utes per patient has been replaced with digital X-ray system with a turnaround of less than a minute. Similar is the case with CT (single slice CT to multi-slice CTs) and MRIs (0.3 T to 3.0 T, permanent magnet MRI to highend, superconducting MRI). Also, progress in software have offered better features and expanded the applications. While X-ray/ultrasound was the mainstay for cancer detection, today, 9 out of 10 suspected cancer patients go through CT/MRI scans as primary cancer diagnosis. In essence, today, imaging diagnosis (radiology) has undergone an incredible change in offering the highest quality patient care. Indian healthcare has changed much with increase in purchase parity, lifestyle diseases/disorders taking over communicable disease, medical insurance (though a small percentile) gaining momentum, government-sponsored health insurance, availability of technologies in metro and semiurban markets, government sponsored healthcare initiatives etc. India also scores over other developing countries on medical travel count due to its quality as well as cost-effective offerings. While imaging diagnosis in India has surged ahead at par with any developed country, it is still lagging behind in few areas, especially patient data storage. Although most radiology departments in the developed and many developing countries are today digital and filmless, Indian imaging diagnosis has been and is even today largely a film-based practice, thus compromising on patient care as well as cost. For an abnormal image in a CT or MRI, the scan centre has to provide the patient with three to four films as reference doctor demands for it. This adds to the total cost as per film is charged between minimum of Rs 100 to Rs 250. Similar is the case with mammography/master health check-ups etc. Apart from cost, this also proves cumbersome to the patients as they need to carry these film every time they go to hospital/reference doctor. Except emotional needs, films do not serve much. Alternatively, storage device will help bring down the overall cost and ease the patient’s plight of carrying several films. In the

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DICOM images to CD or DVD instead of expensive film ◗ Significant cost savings (around 40 per cent) for distributing images compared to film. ◗ Rimage disc publishing systems integrate with PACS and modalities to automatically distribute and archive patient medical images and record ◗ No mix-up of patient images with print information through fully automated disc recording and direct-to-disc printing. ◗ High system availability and long term reliability through true professional, rugged design ◗ Comprehensive system status information in all DICOM applications ◗ Rimage API for complete system integration with all medical software and hardware systems ◗ Long-term printed disc stability, preserving all relevant information against humidity, UV or mechanical exposure through pioneering thermal retransfer disc printing technology ◗ Easy integration with radiology work-flow ◗ Adding the capability to automatically record and print CDs, DVDs and Blu-ray discs, from any PC, Mac, or other workstations on hospital network, this can have a profound effect on productivity

Conclusion

digital age, hospital/physician does not require the radiologist to be in the hospital for reporting of the scans, as the images can be electronically transmitted to the location of the radiologist through teleradiology.

Medical imaging/records The amount of digital information generated in medical applications that needs to be distributed and archived is increasing every day. This growth, caused by digital imaging modalities and standardised patient information (medical health records), shows no signs of slowing down.

Demand digital publishing Digital publishing systems are the gold standard for digital asset management, disc publishing and printing. Disc publishing is the market leader in automated digital publishing and provide unparalleled global service and support. Businesses throughout the world rely on such systems— from day-to-day disc publishers to organisations that duplicate and print a variety of media as a mission-critical component of their daily operations. For instance; Rimage Medical Disc Systems contribute

by replacing expensive film through low cost optical media in radiology whenever medical images have to be stored or distributed. Rimage Medical Disc Systems exceed the demanding requirements regarding system reliability, integration with PACS and modalities, data longevity data and print stability in healthcare and therefore have become the clear industry leader and key partner of all major healthcare companies.

End user/patient benefits ◗ Reduce costs and automate your work-flow by outputting

Currently, world-wide, radiography films are being produced mainly for India as healthcare delivery system in almost all countries have stopped using films for reporting. As a progressive country, we need to shift from radiography films to disc publishing as reporting and storage device. Disc publisher is an ideal solution to burgeoning cost, both to healthcare provider as well as patient. Also, disc publisher serves as the best storage device for long term and medico-legal purpose as the image quality remains intact. For the hospital, there is an additional advantage of retrieving patient information in case of PACS server break-down. Handy and cost effective for patient over long years, disc publisher serves as the best replaceable solution.

IN IMAGING IN FOCUS

Saket City Hospital and Philips Healthcare launch AlluraClarity Biplane Neuro DSASystem It is touted to be a big leap towards safer environment for patients and physicians in complex neuro intervention procedures

aket City Hospital’s (SCH) Institute of Neuroscience has added a significant advancement in the diagnosis and treatment of stroke, brain aneurysms, brain and spinal AVMs and tumours, and other complex neurovascular conditions with the acquisition of a state-of-the-art neuro interventional biplane system from Phillips. SCH is the first hospital to acquire this latest generation Philips AlluraClarity Biplane Neuro DSA system and one of the few centres in the country which have a neurointerventional biplane system. Divya Modi, Vice Chairperson, Smart Health City said,

“We are all excited about the launch of Bi-Plane facility at SCH as it would help us to to perform less invasive procedures that would facilitate the recovery of the patient. This new, efficient technology will transform healthcare taking it to a new dimension. We offer advanced technology to minimise invasiveness and improve patients’ rate of healing. The Bi-plane technology will help us continue to provide outstanding treatment to our patients.” She further adds, “It will transform healthcare professionals’ workflows, allowing them to care for patients more quickly. Bi-plane cath

lab will also help doctors to ensure accuracy and to remain accountable”. Speaking at the launch event, Krishna Kumar, Vice Chairman and MD, Philips India said, “In the past, it was difficult to combine great image quality and low radiation dose, and it often resulted in trade-offs. The Philips AlluraClarity incorporates powerful imaging technology to bring superb image quality at a fraction of the dose, further proving Philips’ commitment to improving patient’s health, well-being and quality of life.” The current global trend is that neuro endovascular procedure are replacing an open

surgical procedure, particularly in brain haemorrhage, aneurysm management, AVM treatments and rescue of brain vessels blockage in acute stroke. Neuro intervention is a minimally invasive approach to repair brain vascular diseases resulting in a shorter hospital stay, quicker recovery time, reduced pain, and less risk of complications. Biplane Neuro DSA systemis, an advanced system by Philips is currently available in the world. Neuro interventional biplane system produces three-dimensional views of blood vessels leading to the surface and deep portions of brain and their relationship to the tissues of the head and neck. The Biplane system is an integral part of a comprehensive stroke service, which reportedly harbours a dedicated well-equipped interventional stroke care unit (ISCU) with dedicated specially trained staff. “The biplane technology represents a big leap in visualisation of the brain arterial network for quick and better understanding for a safe intervention.” Minimally invasive neuroendovascular procedures require a precise deployment of sophisticated endovascular devices in the brain arteries to repair the defects in the vessels. Keeping balance between image quality and X-ray dose is a continuing challenge with the increase number of high risk patients, and more complex procedures. One hand, you need to reduce the

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IN IMAGING

ADVANTAGES OF BIPLANE NEURO DSA SYSTEM amount of contrast concentration and X-ray dose which affects the image quality, and on the other hand for more complex procedures, there is a need to increase radiation dose to get the image quality needed. Complexity increases procedure time, hence higher accumulative dose. AlluraClarity claims to have provided a new paradigm for balance between dose and image quality. Evidence has been shown proving dose reduction levels in the range of 50 to 83 per cent compared to conventional systems. Dr Shakir Hussain, Director, Interventional Neurology

◗ SCH biplane neuroendovascular system produces images simultaneously from two regions of the patient’s head, in combination of any of frontal view, lateral view and oblique views.This reduces the amount of contrast material required, improves visualisation for diagnostic and therapeutic procedures, and shortens the time it takes to complete a cerebral angiogram. ◗ It has two-dimensional and three-dimensional capabilities that allow the interventional neurologist to view the brain, arteries and spine with one single injection of X-ray dye. In addition to being safer and faster than current technology, the biplane can reduce risk, length of stay and burden to a patient and family for many neurological disorders. ◗ Other advantages of a Biplane Neuroendovascular Suite is that a CT scan can be obtained in a minute during procedure without shifting patient to the neuroradiology department thus saving a significant time which is very crucial in stroke intervention. ◗ The images produced by the biplane system aid interventional neurologist in performing neurointerventional procedures such as aneurysm repair by detachable coils and intracranial stents, treatment of brain and spinal arterio-venous malformations, clot removal in acute stroke case and opening blocked brain arteries by carotid artery angioplasty and stenting. It also helps physicians for dealing with complex highly vascular tumours of brain and neck specially in skull base region, intracranial haemorrhages, spinal compression fractures, trauma to the brain arteries in poly trauma patients and refractory epistaxis (severe nose bleed).

& Stroke Program, Chairman, Neurology, speaking on the benefits of this technology said, “We have state-of-the-art equipment at par with best centers in the world at least in major metropolitan cities of India. However on the other side there is poor infrastructures and inadequate equipment in the other India. So there is a mammoth task of doing things for the development of interventional neurology, an effective minimally invasive method of treatment of neurovascular diseases and stroke cases. Saket City hospital has taken that bold initiative."

I N T E R V I E W

‘The burden of stroke would be 10 times in a country like India’ Dr Shakir Hussain, Director, Interventional Neurology & Stroke Program, Chairman, Neurology, Saket City Hospital, in an interview with Shalini Gupta How do we define interventional neurology? It is a relatively new subspecialty, as the name suggests it pertains to the interventional aspects in neurology. These are vascular interventions, done inside the vessels, however they can be done outside the vessels also. Globally and the most commonly it is synonymous with vascular intervention. Because majority of our interventions are stroke, our department is called interventional neurology and stroke. We do not deal with other interventions, such as pain management. What is the stroke burden globally and in India? Out of every 10 patients coming to a hospital, four to five patients on an average might be stroke patients, however that is variable, depend-

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ing on practice patterns. It would not be a true reflection of what an ideal number would be. Upto 100,000 new stroke patients are added every year in America. However, if were to extrapolate the burden of stroke would be 10 times in a country like India. A look at any hospital’s neurology casualty services, would reveal that 70 to 80 per cent of the cases would be amounting to stroke. Could those with cardiovascular diseases be susceptible to neurological conditions? Many heart patients have artherosclerosis in heart arteries and none in brain arteries and vice versa. Roughly 50 to 60 per cent patients would have an overlap, the rest (40 per cent would have an isolated disease in one or-

gan only). Particularly in the young population, isolated brain involvement is more common. The nature of disease is unknown. This is more common in Asian population. In the West, such incidence is 10 per cent, but in South Asian population it varies from 40 to 50 per cent.

The instruments of today are in tune with the needs of the physicians

How has the advancement in radiology helped neurosciences? Brain imaging systems use an X-ray based mechanism to visualise the brain. Initially, they were primitive since they did not have many applications for finer analysis of the vasculature. It is a huge leap to the instruments of today, in tune with the needs of the physicians. When we 're doing an intervention, it’s a blind procedure, to make it relatively semi blind, we need

some pathway to see, else we were using our own visual imagination of the anatomy of vessels, which is very complex. These equipment offer us a roadmap, so when we inject a contrast, it would hold that image on the screen and it would convert it into a negative image. Subsequently when we take a positive image, it would superimpose over the negative image. It will show the path of the vessels on the screen, an evolution which happened 10 years ago. New applications such as 3D rotational angiography, wherein we create volume rendering, develop mathematical algorithms, give us precise measurements of the vessels and arteries for precise deployment of devices within the body. The end goal is patient safety. shalini.g@expressindia.com

IN IMAGING SPOTLIGHT

PROF HANS RINGERTZ

PIONEER IN PAEDIATRIC MR IMAGING Recently, world renowned radiologist, Prof Hans Ringertz was in India to conduct Specialized Training in Advances in Radiology (STAR), an internationally coveted education programme by Siemens Healthcare and Bayer Zydus Pharma. M Neelam Kachhap interacted with him to know more about his work and views on radiology

n the world of radiology and imaging, Hans G Ringertz, Sweden needs no introductions. The proverbial man, Dr Ringertz is the pioneer of paediatric MR imaging, a world leader in radiation safety, and a prominent figure in the Nobel Assembly for Physiology and Medicine. He has been the custodian of emerging radiology for over 50 years, working at prestigious university radiology departments around the world and collaborating with various global radiology societies. Since 2013, he has been Consulting Professor at the Department of Radiology, Stanford University. However, he shares a long history with the Karolinska Institute,Stockholm, Sweden where he obtained his medical degree(1964) and a doctorate in biophysics (1969). Since 2006, Dr Ringertz has been a Professor of Radiology at Linköping University Hospital in Linköping, Sweden, and Chairman of the Board for the University's Centre for Medical Imaging Science and Visualization. He was a Professor and Chairman of Radiology at the Karolinska Institute in Stockholm from 1984 to 2006 and has served as a professor emeritus since. Author of 230 scientific articles and six books, Dr Ringertz serves as

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editor or ad hoc referee on the editorial board of a dozen medical publications worldwide. He is a member of more than two dozen professional organisations and has acted as an invited lecturer or chairman at many scientific and professional meetings and workshops. He has been honorary member of 16 radiological societies including the Society for Pediatric Radiology, and the European Society for Pediatric Radiology. Dr Ringertz received RSNA honorary membership in 1997, Gold medal of the European Society of Radiology 2005, Asian Oceanian Society of Radiology 2012. He chaired Nobel Assembly for Physiology and Medicine in 2003 and has served the assembly for 20 years. Dr Ringertz has done extensive work in paediatric imaging. In his illustrious career, he has worked on paediatric cardiac, urogenital, and oncologic imaging. His focus over the years has been in the specific area of measurements in paediatric radiology, especially for evaluation of normal versus abnormal size of structures, organs. His protagonism of radiation protection is legendary, specially his work with many organisations including the International Commission on Radiation Protection.

E XC E R PTS F R O M

ATETE-A-TETE WITH PROF RINGERTZ RADIOLOGY IN THE EARLIER DAYS I came into radiology in 1964. The plain film diagnosis dominated and we performed a very large number of barium examinations of the esophagus, stomach, small bowel, and colon as no CT, no ultrasound, and no MRI was available. The advanced imaging was angiography with special catheters to make the contrast injections as selective as possible.

OPTING FOR BIOPHYSICS/RADIOLOGY I started in biophysics as a laboratory assistant even before medical school. The research of my PhD thesis was based on X-ray crystallography and it became natural to select radiology for my elective internship training in 1964.

SPECIALISING IN PEDIATRIC CARDIAC IMAGING The paediatric radiologists at Karolinska in Stockholm where I trained were internationally well known in research and they wanted my expertise in physics, statistics, and mathematics. So, I was directly involved with that subspecialised field. Later, after residency as Assistant Head of Paediatric Radiology, when need for more knowledge in the advances in paediatric cardiac imaging aroused I did a fellowship in that field from the University of California in San Francisco.

RADIOLOGY EDUCATION TODAY We have been able to increase the length of training in radiology to five years in Europe. That is not the case all over the world. The development is such that longer training

is needed e.g. three year of a common trunk of radiology and nuclear medicine, then one year of one subspecialised anatomical area and another year of one modality. Finally a fellowship year to become sub-specialised in what you did during the fourth year or two years if you want to sub-specialise in a new area.

ON COMMON MISTAKES MADE BY RADIOLOGISTS The most common radiological healthcare error is use of imaging when it is not needed or when the treatment is independent of the radiological findings. The most common radiologist error is probably inexperience but ‘satisfaction of search’ is frequent, which means that once something has been observed a second more important finding is missed. Other errors are mistaking an abnormal structure for a normal, or right and left errors. With good training the average number of all errors (important or not important) is said to be around four per cent. This can be reduced to about two per cent by double reading - that is two radiologists read the cases independently.

RADIOLOGY TALENT IN INDIA Indian radiologists are very well trained and many are working abroad. The continuing medical education system in radiology is well developed which keep the radiologists up-to-date. A lot of good radiological research comes out of India but a higher percentage published in the international journals rather than the local could probably be achieved. The size of the population makes it possible to study large numbers even of rare diseases if co-operation between

IN IMAGING

centres are set up.

University hospital for board meetings at the Center for Medical Imaging science and Visualization.

ADVICE TO YOUNG RADIOLOGISTS IN INDIA Get a good complete radiological training in an established department. Then sub-specialize in one anatomical area of radiology (chest, body, musculoskeletal etc.) and in one radiological modality (ultrasound, CT, MRI etc.).

MAN BEHIND THE PROFESSOR

ROLE OF RADIOLOGICAL SOCIETIES They all consist of radiologists and all nurture radiologists in some ways. Some are more like unions and nurture the economic and similar aspects of our professional lives. The majority is scientific in nature and stimulate all versions of research in biomedical imaging. This can be with funding of educational or scientific projects or e.g. travel grants.

ON HIS AREAS OF RESEARCH A lot of the publications of an old academic person comes from the MD, PhD students that you work with. When I retired by age from Karolinska Institute, I ended all of my mentorships but a few new have been added. One project is about the imaging and epidemiological aspects of necrotizing entero-colitis in premature neonates, another in assessment and quantification of acetabular osteolysis and aging of hip prosthesis’s, others are in the area of bone densitometry.

ON SPECULATIONS ABOUT INDIAN RADIOLOGISTS TAKING AWAY US RADIOLOGY JOBS Teleradiology is a good way of increasing local and sub-specialised expertise. It is also a good way to handle on-call services for small units with few on-call cases. Indian radiologists will not take away US radiology jobs for medicolegal reasons. But, UStrained and licensed Indian radiologists reading US-cases from India will increase.

ON THE BREAST SCREENING DEBATE ABOUT THE BENEFITS AND RISKS OF MAMMOGRAPHY The cost-effectiveness of mammography screening for the society can be debated but a screening mammogram

is always a statistical advantage for the woman. There are other more efficient ways to save women’s quality of life years at a lower price e.g. stop smoking advice to young women. If society or individuals can afford it, mammographic screening is a proven lifesaver.

ON TEACHING VS CLINICAL PRACTICE Both are satisfying but teaching never stops. When you go home after your clinical practice and you look back at the day you feel that you have actually done something measurable. You do not need to ask yourself, what did I actually do today?

ON STRIKING WORK/LEISURE BALANCE There has to be some version

of leisure to look forward to but when work is stimulating and fun, the need for a lot of leisure is reduced. Thus, the balance varies depending of what type of work you are doing.

A DAY IN HIS LIFE At Stanford I have an average working day from 7:30 am to 6:00 pm. It comprises a lot of meetings with persons and groups but also many opportunities for paediatric radiology conferences and very high quality scientific lectures. And in between it all, computer work, mostly e-mails from around the world. In Sweden, I work shorter hours but I double read radiological examinations at Karolinska. On a couple of days per month, I take the train to Linköping

I try to exercise, mostly taking long walks, Nordic-style with specially designed poles. In the winter I ski both cross-country and downhill. Besides that I work a lot with my hands, making furniture, building houses in our summer house, or repairing water pipes, electrical installations etc. My favourite book could be ‘Tortilla Flat’ by John Steinbeck and a favourite movie could be ‘Being there’ with Peter Sellers. I am sure there are many wonderful cities around the world. One where I have spent a lot of time and where there is always more to see is Vienna. Fantastic cultural offerings and a city of classical b eauty.

LOOKING BACK AT LIFE When I was a newly appointed chair at Karolinska the research activities needed to be strengthened. I chose to use my senior faculty and encouraged them to work through their research groups. Too many did not produce and I should have set up my own research network and stimulated the next generation instead of assuming that the old generation was still ‘hungry’. mneelam.kachhap@expressindia.com

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IN IMAGING I N T E R V I E W

â&#x20AC;&#x2DC;I expect India to become a leader in many areas of radiation oncologyâ&#x20AC;&#x2122; Recently, Dr John R Adler, Professor of Neurosurgery at Stanford University and VP and Chief of New Clinical Applications, Varian Medical Systems was in India to attend the Onco Summit India 2014. M Neelam Kachhap spoke to him about radio-oncology and his views on radiosurgery in India CyberKnife has not experienced a widespread adoption in India? What is the reason for that? The cost of CyberKnife combined with the length of treatment, which relates to utilisation, are challenges in the Indian market. Moreover the field of image-guided radiosurgery is new and many physicians are not yet adequately trained in this discipline, both in India and around the world. You met Indian radiation oncologists and surgeons at the event, what is your impression of the radio oncology work in India? Indian radiation oncology is up and coming. As the physician community gets experience with the newest

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generation of radiation equipment I expect India to become a leader in many areas of radiation oncology. Any outstanding clinical work that has caught your attention? The volume of cancer patients being treated with radiation therapy and the extremely low cost of such treatment is quite notable. What are the new technologies in the radio-onco space? The newest equipment enables more accurate and faster treatment of a broad range of cancers. Meanwhile, ever improving information systems are helping to disseminate best practices between all doctors.

Radiation is very costeffective despite the cost of equipment

Why are technologies in this space so costly? The equipment is still quite large and exceptionally complex. In addition, one does not get the advantages of mass production the way one would with disposable catheters, where literally tens of millions of the later might be used every year. The worldwide installed base of linear accelerators is only a little more than 10,000. However, when one spreads the capital cost of initial installation of a complex radiation therapy system over a lifetime in a very busy clinic, the cost of the equipment per patient can be as little as a few hundreds of dollars. Radiation is very cost effective despite the cost of equipment. One machine

does the work of a small hospital! Is there a possibility of an Indian chapter of Cyber Knife Society? Although there are not enough CyberKnifes to justify such an organisation there should be an Indian Society of Radiosurgery. What is your advice to budding surgeons venturing into radiooncology? Do it! Seriously, surgeons have a lot to offer the field of radiation oncology because of their training and philosophy, and their capacity to deal with any potential patient complications. mneelam.kachhap@expressindia.com

IN IMAGING I N T E R V I E W

‘Varian will ensure that our focus on customer experience and product quality remains on top’ Vivek Phalle, Business Head, Varian ICB, India region speaks on the current trends in radiology, his company's contributions to this field and more, in an interaction with Express Healthcare Tell us about Varian's contributions in the field of radiology? Varian Medical Systems, Imaging Components Businesses is a premier supplier of X-ray tubes, digital detectors, and image processing workstations for X-ray imaging in medical, scientific, and industrial applications. Varian ICB has extensive experience providing high-quality, safe, long lasting and cost effective X-ray devices to diagnostic imaging markets worldwide. Varian ICB serves original equipment manufacturers (OEM) in the diagnostic imaging industry and a network of independent service providers.

What is Varian's focus area in the field of radiology? What are the latest trends in this field? Varian’s experience with proven high-performance electronics provides the highest quality imaging devices to the radiology market. This market expects us to develop and manufacture the tubes and detectors to meet evolving technology requirements for high resolution imaging, faster patient throughput, longer life, smaller dimensions and greater efficiency. Varian focusses exactly on the same. In comparison with the rest of the world, where would you rank the Indian

radiology market? The high level of service requirements combined with a competitive environment, makes the Indian market different and unique. Varian will ensure that our focus on customer experience and product quality remains on top.

Varian is committed to provide quality products

What are the innovations that Varian wishes to bring to India? Tell us about your latest innovations? Varian is committed to provide our Indian customer base with quality products and 'on demand' service. We have a dedicated facility able to guarantee rapid and valuable services to the Indian customers. We

directly distribute medical X-ray tubes for immediate delivery throughout India. By having inventory in India as well as a responsive technical and marketing team, we can make our products more cost effective and readily accessible to the Indian market. On top we work closely with Indian equipment manufacturers, customising and developing solutions together with their R&D department. This allow our Indian partners to compete in such a demanding market place, in both the domestic and the international markets.

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IN IMAGING I N T E R V I E W

‘SimpliCT augments the natural abilities of the interventionist to perform CT-guided procedures’ NeoRad, a medtech company, has invented SimpliCT, a laser-based navigation solution for CT guided interventions, such as ablations, nephrostomies, biopsies vertebroplasties and nerve blocks. The product’s advantages include reduced number of needle position confirmation scans, effectively reducing radiation dose both to the patient and the interventional radiologist. Dr Vaibhav Jain, Interventional Radiologist at Medanta— the Medicity, Gurgaon has been using this product in his day-to-day practice. He shares his experience of using this novel device and the benefits he accrued, in an interaction with Express Healthcare What is the difference between freehand technique and laser technique? In the former, you are guided by your experience and ability; whereas the latter compliments your technique to achieve the desired result. What made you opt for the product? I am a firm believer in technology and willing to try newer devices that help doctors like us with our workflow and patient-care.

How has it helped enhance healthcare delivery? This product; SimpliCT, is a compact, portable and convenient device which augments the natural abilities of the interventionist to perform CT-guided procedures. The laser guidance is accurate and covers a wide range of angles in both the transverse as well as the z-axis. It is easy to get familiar with the mechanism and it does not require any complex calculations or preparations beforehand.

What are the benefits to doctors and patients? SimpliCT augments the performance of the CT interventionist by providing an accurate guidance. It increases the consistency and reproducibility of good results by an experienced interventionist and will definitely shorten the learning curve for beginners. In my experience, it shortens the procedure time and saves on the unnecessary check scans. All these lead to benefits to the performer, hospital and patient. Lesser passes and

lesser check scans, all translate to lesser radiation dose to the patient, lesser tube damage, more throughput and most important; lesser chance of complications due to repeated punctures. What are its three unique features? I believe that the three unique features of this product are wide range in transverse and z-axis; simple and convenient mechanism of guidance and ability to reduce the procedure time.

HIGHLIGHTS

Zubair Kazi of KFC fame to invest in new prostate cancer diagnostic device Artemis and ProFuse devices are now in use as diagnostic tools for prostate cancer at more than 20 major research universities ZUBAIR KAZI, an investor renowned for making a fortune in fast foods, is diversifying his portfolio and investing in a medical imaging device developed by Eigen, a California company. Kazi is the sole owner of Eigen, and Founder and Director of the company’s Artemis Project, an imaging platform, ‘fusing’ ultrasound and MRI, that detects prostate tumors, views images

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in 3D and allows for targeted, rather than conventional “blind” biopsies that take painful, exploratory samples. The Chair and CEO of Kazi Management, a privately held, US-and Virgin Island-based institutional investor says,“Ways to save lives and help spare people needless pain—that’s what I’m especially looking for now.” Reportedly, Eigen’s Artemis

and ProFuse devices are now in use as diagnostic tools for prostate cancer at more than 20 major research universities, including UCLA, Cornell, Emory, NYU and Stanford. “In particular, a multidisciplinary UCLA team headed by Leonard Marks, with members of the Radiology, Pathology and Biomedical Engineering departments, have been actively involved with

the development and improvement of our system,” says Michael Ahmadi, Executive VP, Eigen.“Our company and products are years ahead of the competition, and poised to enter manufacturing and sales partnerships with leading international medical brands,” says Dr Mahtab Damda, Eigen President.“Kazi is changing the standard of care for prostate

biopsy through his forwardthinking vision,” Ahmadi says. “Eigen is a 40-year-old cuttingedge tech company, and its future is shaped around his vision,” he adds. Also in Eigen’s pipeline are products adapting its fusion platform to the diagnosis and biopsy of ovarian, pancreatic and liver cancers. EH News Bureau

IN IMAGING

Carestream ships 9,000 units of digital DRX X-ray detectors Company continues adding new DRX Systems and advanced software features that help enhance X-ray exams CARESTREAM HEALTH has shipped more than 9,000 DRX detectors since launching the CARESTREAM DRX-1, a wireless X-ray detector that quickly and affordably retrofits existing X-ray rooms or portable diagnostic imaging systems from CR to DR technology, or powers new DR rooms and mobile systems. Carestream DRX systems and detectors are used in surgical suites, ER/ICU areas and radiology departments—as well as clinics, imaging centres, nursing homes and field military hospitals. These detectors deliver high-quality, affordable digital X-ray images in about five seconds. “Our innovative family of wireless DRX detectors, imaging systems and specialised software delivers excellent image quality while enabling healthcare providers to improve productivity and control

costs,” said Diana L Nole, President, Digital Medical Solutions, Carestream. The company’s DRX systems help streamline workflow and improve patient care in both room and mobile environments. In addition to the DRX-1 detector, the DRX portfolio also includes the CARESTREAM DRX-1C that utilises cesium io-

The DRX-1C detector can be used to treat patients in trauma, orthopaedic and other clinical environments

dide technology and offers excellent image quality and improved DQE (detective quantum efficiency). The DRX-1C detector can be used to treat patients in trauma, orthopaedic and other clinical environments. Carestream’s newest cesium-iodide-based detector, the CARESTREAM DRX 2530C, fits into paediatric incubator trays and is also used for orthopaedic and extremity imaging. The small-format DRX 2530C detector is intended for use with DRX-Revolution systems or DRX-Mobile Retrofit Kits for mobile imaging of neonatal and paediatric patients. It also can be used with DRX-Evolution and DRX-Ascend systems, as well as DRX-1 room retrofit systems, for orthopaedic applications and other tabletop exams that can benefit from a smaller detector. Patient care in ED, ICU, paediatric ICU and other envi-

ronments can be enhanced with advanced Carestream software that uses a single exposure to produce a companion image with algorithms designed to accentuate specific devices or conditions. For example, the companion image can produce a clear view of tubes and PICC lines, display free air in the chest cavity, or suppress the appearance of posterior ribs and clavicles to deliver a better view of soft tissue in the chest. Use of this software can help physicians deliver a higher level of patient care while simultaneously reducing the need for additional exposures. To maximise utilisation and flexibility, Carestream’s DRX detectors can easily be moved to any DRX room or mobile DRX system—a feature referred to as the ‘X-Factor’.

are also offered and it includes built in Wi-Fi for DICOM data transfer to hospital or cloudbased PACS. VISIQ is commercially available in China, East Africa, France, Germany and India. EH News Bureau

EH News Bureau

The mobile option can, reportedly, increase access to quality diagnostic scans for more OB patients, and provide a solution that is easily transported with a long battery life turised solution’. The mobile option is an effort to increase access to quality diagnostic scans for more OB patients. The VISIQ system features a transducer and was manufactured using advances in miniaturisation to integrate a sophisticated broadband mi-

crodigital beam former and powerful acquisition module. The system is targeted for OB and abdominal applications. User can capture images, take measurements and share data. Many of the automatic image optimisation features found on Philips’ EPIQ system

The deal marks CURA Healthcare's foray into the ultrasound market CURA HEALTHCARE, a medical technology company has acquired Chennai-based DE Healthcare for an undisclosed sum, thereby entering the ultrasound imaging industry. "It is a strategic deal. Following the acquisition, CURA Healthcare would foray into the ultrasound equipment device business ," said M Balasubramanium, CEO, Cura Healthcare informing that the DE Healthcare brand would be retained. "DE Healthcare would focus on sales of ultrasound equipment under CURA's banner with its sales force pan-India. We are having pipeline of opportunities. We are now trying to consolidate. In next five years, we are aiming to become a Rs 500 crore company,”. he said. This CURA Healthcare's second acquisition in three months. In June, the company had announced that PE firm Peepul Capital's $ six million capital infusion would support its expansion plans. S Balaji, Director, DE Healthcare said, "The ultrasound imaging industry is about Rs 850 crore market, growing 20 per cent (year-on-year). This year, post this acquisition, we are looking at a revenue of Rs 20 crores from DE Healthcare."

Philips get US FDA approval for ultra mobile ultrasound VISIQ ULTRASOUND system by Philips has received 510(k) clearance from US Food and Drug Administration (FDA). According to Philips, the ultrasound system ultra mobile and combines 'greater mobility, performance and simplicity into a single minia-

CURA Healthcare acquires DE Healthcare

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August 2014

STRATEGY INSIGHT

Striving for sustenance: New avenues for TPAs

JP PATTANAIK Senior Business Analyst, Optum Global Solutions

JP Pattanaik, Senior Business Analyst, Optum Global Solutions provides insights on various avenues for TPAs to explore and utilise their decades of expertise

he Third Party Administrators (TPAs) are important stakeholders in health insurance industry. Since their arrival around the new millennium, TPAs’ contribution to the growth of the industry cannot be ignored. Being a touch point for consumers and clients- insurance companies and hospitals, TPAs have served to over millions of customers. In recent times, the industry is witnessing a shift. Most insurance companies are moving to in-house claims administration model thereby impacting the opportunities of TPAs. TPAs have been challenged to explore new avenues for sustenance.

claims ratio by greater pro-active involvement in the area of claims administration. However, introduction of TPAs as a stakeholder in health insurance business brought in its own complexities into the health ecosystem.

Functions of TPAs

Primary functions of a TPA

Health insurance sector in India Health insurance sector is one of the rapidly growing industries in India. At present, the insurance coverage is about 15 per cent of total population through different forms of health insurance. Most of the public funding is for preventive, promotive and primary care programmes while private expenditure is largely for curative care. High financial burden due to health related expenses is a major cause of debt among the lower middle class and poor families. The fact that cost of healthcare expenses is growing at a rapid pace, the importance of health insurance as a financial risk management tool is bound to grow. According to industry estimates, the sector will continue to witness double digit growths.

The arrival of TPAs The year 2001 witnessed the rise of the TPAs in health insur-

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August 2014

TPAs perform a varied range of functions like creating an efficient network of hospitals and facilitating cashless medical service to customers

The Unhappy Triangle

ance industry. TPAs are regulated by Insurance Regulatory and Development Authority (IRDA) and mandated to provide administrative services. The claims servicing and other administrative activities are

outsourced to the TPAs, at a remuneration of four to six per cent of the premium collected. As on date, there are about 30 TPAs in operation. Cashless medical service became a reality with the arrival of TPAs.

It was expected that the introduction of TPA will ultimately benefit the consumers. The objective of introducing TPAs was to improve overall customer services, and also bring about a reduction in the

TPAs perform a varied range of functions. Creating an efficient network of hospitals and facilitating cashless medical service to customers are some of the primary functions. TPAs being in the centre of provider and payer relationship, their role are very critical for smooth operation of health insurance business. Some of the key functions of a TPA are as follows: ◗ Customer enrolment: Enrolment involves enrolling the policy holder and dependents, assigning of unique identifiers, defining the benefits and coverage criteria. ◗ Provider network management: This involves activities such as identification of providers for empaneling, verifying the credentials, negotiating and contracting for service tariff. ◗ Preauthorisation and claims management: This involves the process of authorisation for cashless facility and the entire claims cycle right from claims submission until the right amount is reimbursed to the provider. ◗ Fraud control: Planning necessary measures and controls for prevention of misuse of health plans and making sure the right amount is paid to the right person for the right ailments as per the contract. ◗ Data analysis and reporting: TPAs prepare various stan-

STRATEGY dard and non-standard reports for their internal consumption and external use such as reporting to insurance companies and regulatory authorities.

The unhappy triangle TPA’s role as an important stakeholder seemed to be a good choice first few years. However, over last couple of years, TPAs have been blamed for the issues faced. The expectation that TPAs would bring transparency into the system is kind of fading very fast. TPAs have been at the receiving end for the issues like increased claims ratio, increased customer complaints, poor service quality, fraud etc. The TPAs have existed as part of an ‘unhappy triangle.’

The paradigm shift During the early days, most insurance companies had engaged one or more TPAs for claims administration. TPAs are paid for the services provided, usually a fixed percentage of the premium collected. The fee varies from four to six per cent based on the individual negotiations. However, few companies like Bajaj Allianz have been processing the claims on its own for years now. The stand-alone health insurance companies such as Max Bupa and Star Health Insurance have their own in-house claims administration units. The public sector insurers have set up a JV TPA for in-house claims administration. The consumers believe that an insurance company with in-house claims administration unit is an USP along with the policy features. The current trend of moving towards in-house claims administration practices by the health insurance companies is going to impact the existing TPAs in terms of opportunities. The JV TPA by public insurers going to take away most of the current volume from the TPAs as the public insurers make up to 60 per cent market share. Already a few private insurance companies have their own in-house claims administration cells and others are in the process of such initiatives. TPAs are left with a smaller market share to

compete with. So is it the end of the road for TPAs?

TPAs are here to stay! It is evident that the business opportunities for the TPAs are going to be reduced in near future. Unless TPAs revisit current business model and focus for new avenues, their continued sustenance would be difficult. The current market forces would force gradual extinction of the TPAs or with time they are bound to be acquired by some of the major insurance companies. However, TPAs due to their immense expertise have the ability to sail through the current phase of turbulence. They can still maintain their identity in the industry.

Avenues for exploration Given the demands of the hour, TPAs have to rethink over the current business models they are engaged in. TPAs can leverage their expertise in the industry and look out for related diversification. Some of the areas which TPAs can explore are as follows: ◗ JV with insurance companies: With the promise that the health insurance industry offers, more and more insurance companies will enter the health insurance market. Even the proposed plan of increasing the FDI cap up to 49 per cent will attract more foreign players to the Indian market. The existing TPAs have an opportunity to float joint ventures with the new players especially because of lack of experience in Indian healthcare industry. TPAs can add value to the insurance companies at the same time can maintain their own identity. ◗ Claims administration practices for PSUs: India has several PSUs who manage the funding as well as the entire administration of health insurance offered to the employees and their dependents. It is a lesser known fact that these organisations spent enough time and money, yet are inefficient in terms of administration. TPAs can look out such PSUs for business opportunities and help them with the claims administration for fee. This cost would be

much lesser if compared the overall opportunity cost. PSUs can be relieved from such activities can redirect their employees to the core area of functions. A win-win situation for both! ◗ More proactive role in plan design: Health insurance sector as portfolio has not been profitable. The overall industry has registered a claims ratio 100 per cent or more for past several years. It means the premium amount collected paid in terms of claims pay outs. Contributions from other sectors have helped the insurance companies to sustain health insurance business in spite of heavy losses. One of the contributing causes is inappropriate underwriting practices. TPAs being aware that how each penny collected being spent can play a more proactive role in plan design and pricing. So far TPAs have not ventured into this zone. Certainly, TPAs have an opportunity for exploration. ◗ Proactive role in medical management : Though there have been several initiatives for standardised clinical guidelines across the hospital, there is still a huge variation for its implementation. Today insurance companies are of the opinion for performancebased payment. TPAs can help hospitals in showcasing the benefits of implementing

best clinical practices. TPAs can also play a role of utilisation reviewer for cost analysis and overall healthcare outcome. ◗ TPA as Credentialing Verification Organization (CVO): In India we do not have rigorous credentialing practices like some of the countries in the West like the US. A CVO provides professional services for verification of the authentication and maintaining the quality of healthcare services. With more and more foreign players venturing into the health insurance space, demand for such organisations will grow in future. TPAs have the potential to convert themselves or carve out a unit for such services. ◗ Opportunities within existing business segments: Though many insurance companies are moving away from their engagement with TPAs, there will be quite a new insurance companies who would still associate with TPAs. Insurance companies will incur additional costs related to administration which may impact their profit margins. The outsourcing of administration comes with a price; however, it reduces the hassles for insurance companies and helps in staying focused in other core activities. TPAs have to find new methods to reduce cost incurred and stay healthy in terms of

profitability. It has been estimated that investment in automation of manual interventions in the areas of claims administration can bring down the overall cost by 30-40 per cent. A little invest in mobility solutions like mobile-based preauthorisation and claims processing solutions can further bring down the cost related to infrastructure and human resources. TPAs can continue with the current engagement model – the very reason for existence and make the best of the opportunities available to them.

Conclusions In spite of industry challenges, the contribution of the TPAs for the growth of the industry has been immense. With changing times, the market dynamics will have impact of one’s continued sustenance. TPAs have to study and analyse the current industry signals and revisit the organisational strategies. Continuous innovation in business models, revitalisation of current strategies with a focus on future industry needs can bring in plenty of new opportunities.

References 1.‘Staying in Safe Hands’ http://ehealth.eletsonline.com/2013/ 07/staying-in-safe-hands/ 2.‘Conflict between insurers, TPAs and healthcare providers leaving Andheri consumers in financial turmoil’ http://articles.economictimes.indiatimes.com/2012-1206/news/35647632_1_tpas-medicalinsurance-health-insurance 3.‘TPAs in Trouble’ http://www.moneymantra.co.in/ detailsPage.php?id=209&title= Insurance 4.‘Tackling Teething TPA Problems’. http://healthcare.financialexpress.com/200902/strategy01.shtml 5.‘Future of TPAs in India. Is it the End of the Road for TPAs? http://www.medimanage.com/healt h-insurance-expertsblog/post/2010/03/25/What-is-thefuture-of-TPAs-Is-it-the-end-of-theroad-in-India.aspx

Disclaimer

New avenues for TPAs

Ideas and opinions shared in this article are personal viewpoints of the author and have no bearing or impact on the official policy or position of Optum Global Solutions.

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STRATEGY INSIGHT

Complaint management: Key to healthcare set-ups

DR AK KHANDELWAL Medical Director, AnandaLoke Hospital and Neurosciences Centre

Dr AK Khandelwal, Medical Director, AnandaLoke Hospital and Neurosciences Centre gives insights on the importance of handling complaints effectively to maintain goodwill and reputation of a healthcare organisation

n the present private healthcare industry, handling of consumer complaints is of paramount importance due to the radically changing scenario of relationship between the three stakeholders. Consumer awareness has increased due to IT. Consumer Protection Act and judicial activism have also contributed significantly in empowering the consumers. Needless to say, in the present era of competition, healthcare organisations are becoming more customeroriented as patient satisfaction is increasingly gaining recognition as an important business process. It is no longer enough to ensure that patients are simply satisfied; rather healthcare organisations must also strive to guarantee customer service excellence in daily operations. Complaints provide organisations with an opportunity to identify common failure points in the service that in turn enable the organisation to improve the quality of healthcare delivery. Managing complaints well should be the cornerstone of an organisation's customer-satisfaction strategy. But timely and appropriately complaint management practices seem to elude many organisations. Most customers are dissatisfied with the way their complaints are handled.

Need for complaint management The private healthcare industry is living through an era of competition, communication technology, consumer aware-

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Managing complaints well should be the cornerstone of an organisation's customersatisfaction strategy. But timely and appropriately complaint management practices seem to elude many organisations. Most customers are dissatisfied with the way their complaints are handled ness and activism. Competition: Complaint handling should matter to healthcare organisations in a competitive industry. Research indicates that service failure cost organisations in terms

of money and reputation, however most dissatisfied cus1,2 tomers do not complaint. The same research indicates that customers who have used an organisationâ&#x20AC;&#x2122;s complaints procedure feel that they have been treated properly and are likely

to remain more loyal to the company over the long term and provide a positive word-ofmouth review to their acquaintances. Financial loss: In the present era of information technology,

dissatisfied customers are no longer restricted to word-ofmouth comments about companies to their neighbours and acquaintances. They can now publicise their complaint through different media rapidly and cause irreparable damage to the hospital's image. Needless to say, errors, misunderstandings, client dissatisfaction and unexpected problems occur in all administrative systems but they can also adversely affect the organisation's reputation and hit the financial bottom-line. Litigation: A dissatisfied customer often resorts to litigation. Timely and appropriate complaint man-

STRATEGY agement can significantly reduce litigations. Quality improvement: Assessment, monitoring and exploration of patient complaints and patient satisfaction data provide an indicator of the quality of care and contribute to clinical care improvement strategies as well as provide healthcare consumers’ input into improvement of healthcare services and delivery 3, 4

What is a complaint? A complaint is defined as. “Any expression of dissatisfaction by a customer or potential customer about service delivery by the organisation or its service providers, and/or about organisation policy.” The dimensions of patient satisfaction include art-of-care (caring attitude); technical quality of care; accessibility and convenience; finances (ability to pay for services); physical environment; availability; continuity of care; efficacy and outcome of care.5 Complaints rate: In a study,6 it was revealed that there were 1.42 complaints per 1000 patients. Another study revealed that rate of complaints was 1.12 per 1000 occasions of service.

Types of complaints Analysis of patient surveys carried out in Germany, Sweden, Switzerland, the UK, and the US in 1998-2000 in a study revealed that problems with information and education, coordination of care, respect for patients' preferences, emotional support, physical comfort, involvement of family and friends, and continuity and transition were prevalent in all five countries. In another study6 the major causes for complaints were: Communication: Poor attention, discourtesy, rudeness. Access to healthcare: No/inadequate service, treatment delays Treatment: Inadequate treatment and nursing care

Do all customers complain? Literature reveals that the complaints actually received by healthcare organisa-

tions are only a tip of the iceberg. Consumers in the healthcare industry are reluctant to complain because they fear that they may receive lower service quality if and when the need for future care arises. This is unfortunate, since complaints are important to healthcare providers. The majority of customers who do complain to the provider about some aspect of service actually will use the service provider again if they perceive the complaint as being resolved. So healthcare organisations should take initiatives to encourage customers to file their complaints if there are any. There are several ways in which a healthcare organisation can encourage the consumers to give their feedback. ◗ Patients and families should be informed of the complaint resolution process at the time of admission. ◗ Patient handbooks can provide information on the complaint management process, with a contact number. ◗ Hospital should ensure that the customer care officer visits every patient and their families and communicates the hospital’s commitment to service excellence and includes a customer service hotline number. ◗ Posters that encourage patients to express complaints and concerns can be placed in the hallways, with a contact telephone number listed. ◗ Ensure that complaints can be solicited from patient satisfaction surveys that are mailed to patients after discharge.

Five Ps of complaint management A complaint management system should be built on all the following five elements. ◗ Priority: Top management should give top priority to complaints management of healthcare recipients. This should be percolated and integrated with the organisation’s operational system. Each staff should realise that timely and appropriately management will enhance the reputation of the organisation.

◗ Principles: A complaint management system must be implemented on the principles of fairness, accessibility, responsiveness and efficiency. ◗ People: Persons designated for complaint management must be proficient in the soft skills required for complaint management. Their performance should be monitored and continual improvement should be ensured. ◗ Process: It should perform in the following manner: ■ Accept ■ Apologise ■ Amend ◗ Problem analysis: All complaints should be analysed by management tools: ■ Root Cause Analysis ■ 5 Why Analysis

Advantages of complaint management Timely and appropriately complaint management provides many advantages for a healthcare organisation. Complaints provide direct information from the healthcare recipient about poor service delivery and deficiency in methods, machine, materials and skill of persons. Top management should use this information to the advantage of their organisation. Remedy to a complainant: Timely and appropriate remedy should be provided. Improve business process:

Assessment, monitoring and exploration of patient complaints and patient satisfaction data provide an indicator of the quality of care and contribute to clinical care improvement strategies

Complaints should be used to identify deficiency, analyse causes, develop solutions and implement them to improve existing business process Build clients’ loyalty: Timely and appropriately complaint management makes the customer more loyal to the healthcare organisation.

the complaint management system. Informed top management: Top management should ensure that the complaint manager must keep up-to-date with best practices, regularly review the organisation’s complaint handling system and participate in complaint handling.

Quality dimensions of complaint management (Stauss and Seidel (1998)

Conclusion

◗ Adequacy/fairness of the outcome: Both the problem solution and fairness of any compensation. ◗ Access: Ease of finding competent contact person. ◗ Friendliness: Politeness, courtesy, communication style ◗ Empathy: Willingness to take the customers’ perspective, including understanding the customers’ annoyance. ◗ Individualised approach to complaint handling. ◗ Visible effort to solve the problem. ◗ Active feedback, including notification about procedures, delays and decisions. ◗ Reliability: Keeping promises ◗ Speed of response: Reaction to complaint and resolution

Management responsibility Top management should be responsible for managing the complaint handling system. This person’s responsibilities should include the following: Promoting a positive culture: The complaint manager should be the internal ‘face’ of the complaint handling team and promote a positive culture that values complaint handling. They should be the complaint ‘champion’, ensuring that recovery of the patient is the goal. Integrating complaint information: The complaint manager should be involved in all decision making process of complaint management. He should participate in evaluating the existing system, designing the new system and its implementation. Following up: The complaint manager should give feedback of all strengths, weaknesses; opportunities and threats of

Complaint management can be effective in resolving a problem before it becomes worse, providing a remedy to a client who has suffered disadvantage, and nurture good relations between the healthcare organisation and the healthcare recipient. Complaints also provide agencies with information about the healthcare organisation’s weaknesses and service delivery faults. Hospital management should regularly review existing programmes, and the lessons learnt from the complaints should be used to improve the business process of the organisation. It also helps in building a healthier foundation, stronger brand value and avoiding legal penalties.

References 1.(Stauss, B and Schoeler,A (2004) (2004) “Complaint Management Profitability: what do complaint managers know?” Managing Service Quality, 14, No 2/3, 147-156. 2.Stauss, B. and Seidel,W. (2004) Complaint Management: The Heart of CRM Thomson, Phoenix, USA.) 3. Leino-Kilpi H, Vuorenheimo J. Patient satisfaction as an indicator of the quality of nursing care. Nordic Journal of Nursing Research & Clinical Studies / VÃ¥rd i Norden 1992;12(3/4):22. 4.. Bendall-Lyon D, Powers TL. The role of complaint management in the service recovery process. Joint Commission Journal on Quality Improvement 2001;27(5):278-86. 5. Ware J, Davies-Avery A, Stewart A. The Measurement and Management of Patient Satisfaction: A Review of the Literature, 1977. 6. Taylor DM, Wolfe R S , Camreon P.A.: Analysis of complaints lodged by patients attending Victorian hospitals, 1997-2001.Med J Aust 2004 Jul 5 :181(1) : 31-5

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IT@HEALTHCARE HIGHLIGHTS

Mercom Capital Group reports first billion dollar quarter for healthcare IT sector VC funding doubled over Q1 with $1.8 billion in Q2 2014 MERCOM CAPITAL Group released a report on funding and mergers and acquisitions (M&As) activity in the Healthcare Information Technology (IT) sector for the second quarter of 2014. Mercom’s comprehensive report covers deals of all sizes in healthcare IT across the globe. Venture capital (VC) funding in the sector more than doubled with $1.8 billion raised in 161 deals, a 104 per cent increase compared to the $861 million raised in Q1 2014. Ten of those deals were for more than $50 million each. The $2.6 billion raised so far this year has already exceeded the $2.2 billion raised in all of 2013. There were 263 investors that participated in these funding rounds, with 58 angel investors including some wellknown celebrities and entrepreneurs. The quarter also included 30 corporate venture capitalists. “It was a quarter of several milestones. It was the first billion dollar fundraising quarter for the healthcare IT sector which has now raised almost $7 billion in venture funding since 2010. M&A deals were also at their highest levels this quarter, while mobile health companies continued to outraise other technologies,” commented Raj Prabhu, CEO and Co-Founder of Mercom Capital Group. Practice-centric companies received 61 per cent of all VC investments in the second quarter of 2014, with $1.1 billion in 61 deals. Areas that received the most funding under this category were practice management with $220 million in eight deals, data analytics with $204 million in nine deals, population health management with $144 million in four deals. Consumer-centric companies received $678 million in 100

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deals, with the majority of the funding again going into the mobile health category ($401 million in 45 deals). Within mobile health, $129 million went to 23 companies developing apps, $226 million went to 17 companies developing wearables. Personal health companies received $115 million in 23 deals and scheduling, rating and shopping companies received $61 million in 12 deals. There were 38 early-stage deals under $2 million in Q2. The top VC funding deals over $100 million in Q2 2014 were the $135 million raise by NantHealth, a cloud-based healthcare IT company delivering care through a single integrated clinical platform, from the sovereign wealth fund, Kuwait Investment Authority and BlackBerry, the $130 million raise by Flatiron Health, a developer of a cloud-based business and clinical intelligence oncology data platform, from Google Ventures, First Round Capital and

Laboratory Corporation of America, the $125 million raised by Alignment Healthcare, a provider of population health management solutions, from General Atlantic, and the $120 million raise by Proteus Digital Health, a developer of products and services integrating medicines with ingestible sensors, wearable sensors, mobile and cloud computing, from undisclosed institutional investors in the US, Europe and Asia Globally, US companies raised $1.6 billion from 140 deals. Thirteen other countries recorded at least one deal apiece. In the US, 47 deals came out of California, followed by New York which recorded 12 deals, Massachusetts with eight deals, and Texas and Tennessee with seven deals each. Among cities, San Franciso had the highest number of funding deals among cities with 18 followed by New York with 11. In terms of dollars the order was reversed with

New York coming out on top with $247 million, followed by San Francisco with $206 million. There were a record number of M&A transactions in the healthcare IT sector in Q2 2014, with 57 transactions (12 disclosed) compared to 54 transactions (six disclosed) in Q1 2014. Health information management companies saw the most M&A activity this quarter with 20 transactions, followed by revenue cycle management and service providers with 11 transactions each, and mobile health and personal health companies with six transactions each. Of the top 5 M&A transactions, the largest was the $550 million leveraged buyout of ABILITY network, a provider of web-based workflow solutions that aid clinical and administrative tasks for acute and postacute healthcare providers, by Summit Partners, a growth equity investment firm. This was followed by the $532.5 million acquisition of evolution1, a

provider of payment solutions to healthcare companies, by WEX, a provider of corporate payment solutions. St Jude Medical, a medical device company, acquired privately held CardioMEMS, provider of a wireless sensing and communication technology designed to improve management of chronic cardiovascular diseases, for nearly $450 million. Other top disclosed transactions were the $225 million acquisition of ISG Holdings, which through its subsidiaries, provides medical bill review and managed care programmes for the workers compensation industry, by Xerox, followed by the $150 million acquisition of Corventis, provider of a wearable technology with a focus on cardiovascular devices used for remote patient monitoring, by Medtronic, a medical-device company. Announced debt and public market financing in healthcare IT amounted to $1.5 billion in five deals in Q2 2014, compared to $343 million in six deals in Q1 2014. There were two healthcare IT IPOs in Q2 2014, bringing in a combined $1.4 billion. IMS Health, a provider of information services and technology for the healthcare industry, raised $1.3 billion through its IPO in April and Imprivata, a provider of authentication and access management security solutions for the healthcare industry launched an IPO that raised $86.3 million. Total corporate funding in the Healthcare IT sector, including VC, accelerator/incubator, debt, and public market financing, in Q2 2014 came in at $3.3 billion. There were a total of 549 companies and investors mentioned in this report. EH News Bureau

Novartis to license Google "smart lens" technology Innovative technology offers potential to transform eye care NOVARTIS’ eyecare division Alcon has entered into an agreement with a division of Google Inc. to in-license its "smart lens" technology for all ocular medical uses. The agreement with Google[x], a team within Google for finding new solutions to big global problems, provides Alcon with the opportunity to develop and commercialise Google's "smart lens" technology with the potential to transform eyecare and enhance Alcon's pipeline in contact lenses and intraocular lenses. The transaction remains subject to anti-trust approvals. "We are looking forward to working with Google to bring to-

gether their advanced technology and our extensive knowledge of biology to meet unmet medical needs. This is a key step for us to go beyond the confines of traditional disease management, starting with the eye," Joseph Jimenez, Novartis CEO. "Our dream is to use the latest technology in the miniaturisation of electronics to help improve the quality of life for millions of people," said Sergey Brin, Co-Founder, Google. Under the agreement, Google[x] and Alcon will collaborate to develop a "smart lens" that has the potential to address ocular conditions. The smart

lens technology involves non-invasive sensors, microchips and other miniaturised electronics which are embedded within contact lenses. Novartis' interest in this technology is currently focused in two areas: ◗ Helping diabetic patients manage their disease by providing a continuous, minimally invasive measurement of the body's glucose levels via a "smart contact lens" which is designed to measure tear fluid in the eye and connects wirelessly with a mobile device; ◗ For people living with presbyopia who can no longer read without glasses, the "smart

lens" has the potential to provide accommodative vision correction to help restore the eye's natural autofocus on near objects in the form of an accommodative contact lens or intraocular lens as part of the refractive cataract treatment. The agreement aims to combine Google's expertise in miniaturised electronics, low power chip design and microfabrication with Alcon's expertise in physiology and visual performance of the eye, clinical development and evaluation, as well as commercialisation of contact and intraocular lenses. Through the collaboration, Alcon seeks to

accelerate product innovation based on Google's "smart lens" technology. "Alcon and Google have a deep and common passion for innovation," said Jeff George, Division Head of Alcon. "By combining Alcon's leadership in eye care and expertise in contact lenses and intraocular lenses with Google's innovative "smart lens" technology and groundbreaking speed in research, we aim to unlock a new frontier to jointly address the unmet medical needs of millions of eye care patients around the world," he added. EH News Bureau

Report cites Infosys as Leader and Star Performer in Life Sciences ITO Everest Group’s report “IT Outsourcing in Life Sciences Industry – Service Provider Landscape with PEAK Matrix Assessment 2014” evaluated 18 IT services providers, selected on the basis of their success in large life sciences ITO relationships INFOSYS HAS been rated as a 'Leader and Star Performer' in life sciences IT Outsourcing (ITO) in Everest Group’s report “IT Outsourcing in Life Sciences Industry – Service Provider Landscape with PEAK Matrix Assessment 2014.” Infosys scored high in terms of the size and growth of its life sciences revenues in 2013, global delivery capability and overall market success. As per the report, this was aided by investments in proprietary solutions and an expanding portfolio of offerings in the life sciences space. This portfolio includes solutions that support drug discovery, clinical trials, sales force effectiveness, digital marketing, ERP,

supply chain transformation, management of complex compliance processes and solutions to track and trace. Infosys’ clients in the sector include global and mid-sized pharmaceutical companies, biotech organisations, medical devices manufacturers, and drug distributors. Manish Tandon, Executive VP and Global Head – Life Sciences and Services, Infosys said, “The life sciences industry is operating in a very dynamic landscape today with heightened regulatory scrutiny, patent cliffs, and growing incidence of mergers and acquisitions. Technology can play an important role to help life sciences companies embrace

The 18 IT services providers were selected on the basis of their success in large life sciences ITO relationships these changes and stay competitive. For example, Infosys recently launched a cloudbased solution to help enterprises in this industry reduce costs of regulatory compliance and clinical trial management

while accelerating business processes.” Jimit Arora, VP, Everest Group, “The new surge in life sciences in ITO is driven by application portfolio modernisation, infrastructure transformation, and analytics. Life sciences enterprises are increasingly looking at service providers that can provide a blend of traditional and nextgeneration services. In the past year, Infosys has made investments to create a balanced portfolio of offerings across traditional and next-generation services. This has resulted in significant market success in large life sciences ITO contracts for the company and contributed to the rating of

Leader and Star Performer in the Everest Group PEAK Matrix.” The 2014 Everest Group PEAK Matrix for Life Sciences IT Outsourcing report evaluated 18 IT services providers, selected on the basis of their success in large life sciences ITO relationships. Service providers were grouped into three highlevel categories based on their capability, service offerings and market success. The report assessed the 18 companies based on the quality of their disclosures and interviews, Everest Group Transaction Intelligence database and feedback from life sciences ITO buyers. EH News Bureau

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August 2014

ASK A QUESTION What kind of engineering support is required for mortuary designing? DR VISHAL Mumbai

◗ There should be adequate lighting (1500-2000 lux at mortuary table) ◗ 200-300 lux in the body storage /autopsy room. ◗ Ventilation/exhaust system. ◗ To get uninterrupted continuous power supply, alternate sources should be available ◗ AC chambers. (3 sq m /body ) ◗ Railing for sliding the trolleys in and out ◗ Humidity control and temperature control (3.5o to 6.5o) with separate thermostat for every chamber - cold chambers as well for decomposed chambers. ◗ Body storage room with refrigerated chambers, janitor closets, trolley bay, autopsy room, viewing room, change room, shower room, sluice room, etc. is required While designing the interiors of a dialysis room, are there any particular colour restrictions? MANASI Bangalore

Try to avoid yellow coloured interiors or yellow light in a dialysis room which may make the skin appear yellow and jaundiced to the patients which might aggravate

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August 2014

their stress, worry and hence is not advisable . Opting for lighter shades that will maintain the perception of light and make the room space look larger is actually preferable. We are coming up with 200-bedded multispeciality hospital. What should be the number of equipment that should be placed in the hospital? DR PREMPRAKASH Pune

A hospital is a healthcare institution providing patient treatment by specialised staff and equipment. Proper planning and implementation of equipment is one of the most important part of any hospital. According to the requirement of hospital and expected number of patients, equipment planning should be done. You should always concentrate on the quality, purchasing and proper implementation of equipment to enhance the quality of patient care. What is the authorisation for 250-bed hospital ICU? VIVE KULKARNI Pune

Hospitals having 200 or more beds are authorised an ICU at the following scale: ◗ Not to exceed two per ent

of the total authorised beds. ◗ Beds in ICU should not to be less than eight to justify its existence. ◗ Hospitals having bed strength of 200-399 will draw excess of two per cent beds from acute medical and acute surgical wards. What are the major healthcare problems in a project area? ANUPAMA VERMA Gandhinagar

Major problems are infectious diseases and diarrhoea, worm infestation malnutrition, inadequate facility to the injured from LOC, inadequate maternity services, inadequate facility for mother and childcare How is a model of care (MOC) helpful for a hospital and the emergency department? DR TRIPATHI Pune

The information in each MOC will help the ED and hospital to understand: ◗ The key principles of the model. ◗ The key requirements to operate the model. ◗ Considerations to help understand why your ED would use the model. ◗ Benefits and challenges of using the model. ◗ The monitoring measures can be used to assess the model’s effectiveness and success.

TARUN KATIYAR Principal Consultant, Hospaccx India Systems

Express Healthcare's interactive FAQ section titled – ‘Ask A Question’ addresses reader queries related to hospital planning and management. Industry expert Tarun Katiyar, Principal Consultant, Hospaccx India Systems, through his sound knowledge and experience, shares his insights and provide practical solutions to questions directed by Express Healthcare readers

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LIFE PEOPLE

Dr Devi Shetty awarded ‘Honoris Causa’ Degree of ‘Doctor of Science’ by IIT-Madras The degree awarded for his contribution in the field of medical science, with the consent of the President of India DR DEVI SHETTY, Chairman, Narayana Health Group was awarded with an honorary doctorate degree of ‘Doctor of Science’ for his contributions and commitment to the field of medical science. The doctorate was conferred upon him with the consent of the President of India to the proposal made by Indian Institute of Technology Madras (IIT-M). The Honorary Degree was bestowed by Prof Bhaskar Rammurthi – Director, IIT- M as part of 51st convocation at a ceremony in Chennai. Receiving the award, Dr Shetty said, “A tribute to a person is always an acknowledgment of his ideologies, efforts and the purpose to which that person has devoted his life. It has been our constant endeavour at Narayana Health to bring down the cost of healthcare and make quality healthcare accessible to all sections of society. Thus, I share this award with all those who have also dedicated themselves for this cause.” He also

added, “Consolidation is the only way to reach out to a larger level, for which it’s important to partner with multiple stakeholders, including academia.” Dr Shetty is also the recipient of the prestigious civilian award, Padma Bhushan for his contributions in the field of healthcare, especially heart care. After completing his graduate degree in Medicine and post-graduate work in General Surgery from Kasturba Medical College, Mangalore, he trained in cardiac surgery at Guys Hospital in the United Kingdom. He performed the first neonatal heart surgery in the country on a 9-day-old baby. In Kolkata, he operated on Mother Theresa after she had a heart attack and subsequently served as her personal physician. Dr Shetty founded Narayana Hrudayalaya (now Narayana Health) in 2001, which is one of the largest multispeciality hospital chains in India with 26 hospitals across 16 cities.

Dr Mohan Thomas selected to Hall of Fame by World Academy of Cosmetic Surgery He was felicitated for his contribution on the safety aspect of cosmetic surgery and non-surgical procedures WORLD ACADEMY of Cosmetic Surgery, headquartered in Switzerland, selected Dr Mohan Thomas, a leading Indian cosmetic surgeon for his contribution in the field of cosmetic surgery, for their Hall of Fame. The society, formed five years ago, aims to recognise

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August 2014

doctors for their contributions in the field of cosmetic surgery and medicine, technological advances and how they approach cosmetic surgery in their respective countries. The selection is based on two criteria – one, it is evidence based, and two, keeping with recent times (where

everything has to be ‘quick’) the downtime of every procedure has to be minimal. This year the conference was held in Germany where Dr Thomas was felicitated for his contributions on the safety aspect of cosmetic surgery and non surgical procedures.

Sameer Garde appointed as President, Philips Healthcare, South Asia PHILIPS INDIA appointed Sameer Garde as President, Philips Healthcare, South Asia. In his new role, Garde will be based in Gurgaon and be responsible for driving and building the healthcare business for Philips in India. He replaces Krishna Kumar who continued to lead the Philips Healthcare business following his appointment as Vice Chairman and MD, Philips India in December 2013. An industry veteran with an extensive experience spanning over 24 years, Garde started his career in the consumer industry with Nestle and Pepsi before transitioning to the B2B segment with positions in Whirlpool and Dell International. Prior to joining Philips, Garde headed Enterprise Business at Samsung. Commenting on his new role, Garde said, “I am looking forward to this new role in Philips and am excited about working with the Philips Healthcare team to strengthen our leadership in the healthcare space in India.” Commenting on the new appointment, Kumar said, “I welcome Sameer to the Philips team and am confident that he will lead Philips Healthcare to greater scale and excellence. Sameer typifies the high quality leadership that we have on board as we look towards tapping opportunities to provide access to affordable healthcare in India.”

TRADE & TRENDS

SayYES to living healthy with BPLLifePhone Plus BPL LifePhonePlus gives you the freedom of monitoring your health from the comfort of your home, office or even any outdoor location DO YOU feel regular cardiac checkups are a time consuming affair? Do you postpone your checkups owing to your busy schedule? Do the long queues deter you from getting a cardiac check-up done? Do you wish for a device that gives you freedom of monitoring your ECG from the comfort of your home, office or an outdoor location? If you answered YES to any of the above questions then your wish just got fulfilled. Presenting a revolutionary home wellness monitoring device – BPL LifePhonePlus. This product is brought to you by one of the most trusted medical equipment manufacturers in the country –BPL Medical Technologies . BPL LifePhonePlus gives you the freedom of monitoring your health from the comfort of your home, office or even any outdoor location. Now it is easy than ever before to acquire a 12 Lead ECG as and when required. Apart from taking an ECG, this device also keeps track of your daily activities like number of steps walked, calories burnt, changes in heart rate, etc. With BPL LifePhonePlus, comes an Android smartphone application, which documents the user data acquired using the device. The device gets connected to the Android smartphone through Bluetooth connectivity. The user can get specialist opinion on his ECG by sending the acquired data using this smartphone application to a specialist. The specialist will receive the user data on the application installed in his

phone. Within a span of 2-5 minutes the user will receive advisory on his/her ECG from a specialist on smartphone along with an SMS and e-mail

alert. What is more surprising is that one can get a specialist advisory sitting at home, in office or anywhere. The data are stored in a secured

web application from where it can be accessed by both user and doctor. Anyone you ask will advocate the benefits of exercising.

BPL Medical Technologies has introduced a revolutionary home wellness monitoring device – BPL LifePhonePlus. Apart from taking an ECG, this device also keeps track of your daily activities like number of steps walked, calories burnt, changes in heart rate, etc.All you need is BPL LifePhonePlus, a Smartphone and a data connection

Exercise is your best friend and if you get someone who can monitor your vitals while you exercise, what can better than that? BPL Life Phone Plus helps you to monitor your activities like number of steps walked, calories burnt, changes in heart rate while exercising, etc. Now, for home wellness monitoring, all you need is BPL LifePhonePlus, a Smartphone and a data connection. With BPL LifePhone Plus, now, you can now feel healthier than ever before. Contact Ph: 1800-425-2355 Email: sales.medical@bpl.in

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TRADE & TRENDS

SB Group all set to launch Welfare Medical in India Welfare Medical India plans to become the most respected, cost-effective organisation with world-class products

SUSHIL BAGGA Head of SB Group

SUSHIL BAGGA, Head of SB Group was the brain behind the very first medical store opposite to the All India Institute of Medical Sciences (AIIMS) in New Delhi. A modest thought of providing the patients their medical needs at the doorsteps, paved the way for one of the world’s largest healthcare organisations, ‘The Welfare Medical’ to India. A first generation entrepreneur with more than 35 years of experience in the healthcare industry, Bagga was born in a defence family. His father was in the army, hence he travelled entensively throughout India, spending considerable time of his student life in Nepal. A St. Xavier’s Nepal alumni, he was selected for MBBS at the Mahatma Gandhi Institute of Medical Sciences, Sevagram Wardha which he had to opt out, due to unavoidable circumstances. After completing his graduation in Science from Delhi University with an advanced management programme in Marketing, he started his career as a Medical Representative. He worked with different global organisations with the purpose of gaining experience in the healthcare industry. While working with various healthcare companies, Bagga realised that the country lacked superior quality medical products. With a dream of providing India with the best medical devices, Sushil Bagga ventured out independently as a manufacturing garment exporter in the year 1979. A futurist, with in-depth knowledge of the healthcare industry, his first victorious project was establishing a chemist shop in front of All India Institute of Medical Sciences, named “South Delhi Medicos” in the year 1987. To

our innovative devices for the medical community we have a formal quality management system which is certified to the requirements of ISO13485. Every Welfare Medical product is CE marked. We are dedicated to maintain a quality system that provides safe and useful products and services that meet the needs and necessities of our customers.” “To attain the right purpose, it is important to move in the right path, we are moving ahead to create pan-India operations through a variety of channels with a mission to enter the existing healthcare industry with special emphasis on logical and affordable pricing,” says Bagga. “We are a one-stop-shop for all medical device needs; we promise high service standards with commitment and professionalism,” says the idealistic entrepreneur. The Group’s core business is manufacturing products for medical needs and necessities of the healthcare sector in India and the Indian sub-continent. However, the company has also ventured into insurance, garments exports and the construction sector. However healthcare being their specialty, Welfare Medical India, plans to become the most respected, cost-effective organisation with world-class products. The organisation is also dynamically engaged in advanced research and development studies and soon plans to bring in new products under the company banner, SB Group. Welfare Medical India aims to become the most admired global medical company through its world class customer service support, innovation, manufacturing and wide-range of products.

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August 2014

build up his roots in the healthcare trade, he also started importing various medical devices and soon established himself as a major hospital supplier. Today, he is leading his own healthcare brand- SB Group, under which he is ready to launch the globally recognised ‘Welfare Medical’ pan-India, naming the company- ‘Welfare Medical India’, an associate of Welfare Medical Ltd, United Kingdom. With a mission to bring the best medical products in India, Bagga has strategically partnered with the global leader in the medical industry. Welfare Medical is a multinational company that specialises in manufacturing and supply of products created

Bagga is launching the globally known ‘Welfare Medical’ pan-India with an innovative technology. Bagga plans to keep the products cost effective, keeping in mind the current healthcare scenario of the country. The company will focus on providing patients and healthcare professionals, state-of-the-art quality products with supreme

services. Welfare Medical India will deal in wide-ranging products, however the primary range of activity and portfolio will revolve around: ◗ Surgical stapling line ◗ Products for minimal invasive surgery ◗ Anaesthesia – Critical Care ◗ Ligating devices In compliance with CE Marking Regulations and Standards the products aim to achieve excellence in functioning. Bagga has created a channel system for Welfare Medical that formally checks their quality management system on a regular basis and satisfies the requirement of ISO 13485, an internationally recognised standard. According to Bagga, “To ensure the excellence of

TRADE & TRENDS

Use of ITand data analysis in hospitals Prasad Nagool, CEO, ITShastra India speaks on how to optimise the use of IT and data analysis to ensure best clinical outcomes in healthcare set-ups IN THE current economic scenario, healthcare organisations suffer from budget restrictions and increasing healthcare cost. Hospitals are now expected to efficiently and effectively treat patients in a way that ensures best hospital clinical outcomes. There is large amount of clinical and financial data with the hospital but it is rarely used. Having useful software is a key to assemble all this data to achieve better efficiency in working and planning of the hospital. Along with proper and effective healthcare planning and decision making in any hospital or health institution, the data collected needs to be fully analysed. Well analysed data will assist the decision makers to detect and control emerging and endemic health problems, monitor progress towards health goals and maximise profit. Hospital data analytics can help: ◗ In identifying areas of

Well analysed data assist to control health problems, monitor progress towards health goals and maximise profit improvement ◗ In minimising the operational costs ◗ In reducing the costs for chronic illness ◗ In enhancing customer engagement ◗ Lessen fraud in billing issues ◗ Improve return on investment ◗ Identifying the areas for growth Case study: This is a chain of

hospitals. Out of which we have considered one hospital for our analysis. This is a big hospital with daily OPD of around 500-700 patients. There were two counters for OPD registration and one counter for billing. The OPD timings started from 9 AM and due to rush would continue till 4 PM. The patient were required to go to the registration counter, pay the registration/ OPD fees then were directed to the waiting area and

from there to one of the doctor cabins depending on the patient ailment.

Problems with the system ◗ Long queues for patient ◗ Patient waiting time was more ◗ Doctors time was wasted ◗ Hospital needs to pay doctor extra for extra time The hospital used HMIS System. Analysis was done for the average waiting time from

PRASAD NAGOOL CEO, ITShastra India

the time the patient registration was done and then time when patient checked in to the doctor cabin. The average waiting time was 45-50 minutes. After the analysis a solution was proposed. Two registration counters were converted to billing and additional one billing counter was added. So total four billing counters were made. Four tablets with HMIS installed were distributed between the semi-skilled staff and mobility was added for registration. Patient registration was done using tablets at the entry point of the hospitals. Registration data was captured and the patient was directed to payment counter. Once the payment was done the patient name adds in the doctor waiting list, then patient goes to the waiting area. If the doctor’s appointment is full for that day the patient was sent to the enquiry counter for taking future date appointment. By doing this the average patient wait time was reduced to 15 – 20 minutes.

Benefits ◗ Average patient waiting time was reduced ◗ Average patient seen by doctor was increased ◗ Patient management was easy ◗ Helped in smooth operation This is how information technology along with data analysis, provided information to the managing committee or the directors of the hospitals to take decisions efficiently. Data Analysis improved their profit margin, hospital clinical outcome and patient care. Prasad.nagool@itshastra.com

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August 2014

TRADE & TRENDS

Hyzone Class II Microbiological Safety Cabinets from Thermolab These cabinets blend knowledge, experience and innovative design MICROBIOLOGICAL SAFETY Cabinets are used to give operator, environment and product protection when handling dangerous biological materials. Selection of a biological safety cabinet depends on the type of biologically hazardous materials handled inside the cabinet. Various international bodies recommend some biological risk classifications by taking into account the pathogenic nature of biological materials and minimum requirements for guaranteeing protection to personnel, environment and materials during their manipulations. The Dangerous Pathogens Advisory Group – Department of Health and Social Security – Great Britain (DPAG, DHSS-GB), Centre for Diseases Control, United States of America (CDC – US) World Health Organization (WHO), National Cancer Institute (NCI – US), National Institute of Health (NIH – US) etc., are some of the major contributors to development of parameters to classify different pathogens. Hyzone Class II Microbiological Safety Cabinets from Thermolab blend knowledge, experience and innovative design changes in creating state-of-theart equipment as part of its offerings. Hyzone is a Class II Microbiological Cabinet, designed and built to meet, if not exceed, performance requirements of the European Standard (EN) 12469:2000 Standard.

Classification of Microbiological Safety Cabinets Different countries have adopted various standards and specifications for this equip-

ment, but the following standards are generally accepted worldwide: ◗ NSF/ANSI 49 - 2002 (National Sanitation Foundation , US) ◗ EN 12469 - 2000 (European Standard) ◗ AS 2252 – 2004 (Australian Standard)

Types of biological hazards The Dangerous Pathogens Advisory Group - Department of Health and Social SecurityGreat Britain (DPAG, DHSS – GB) and Centre for Diseases Control, United States of America (CDC – US) have defined four groups of biologically hazardous organisms. Group 1 CDC (C-DPAG): Organisms are most unlikely to cause human disease. Group 2 CDC (B1- DPAG): Organisms may cause human disease, but are unlikely to spread to the community and effective treatment is usually available. Group 3 CDC (B1, B2 – DPAG): Organisms may cause severe human disease and may spread to the community, but effective treatment is usually available. Group 4 CDC (A-DPAG): Organisms cause severe human disease that may spread to the community, and no effective treatment is available.

Microbiological Safety Cabinet Class I It is an open-fronted safety cabinet with room air flowing in to provide containment and an HEPA filter on the exhaust. It gives operator and environmental protection but no product protection. Suitable for Group 1,2,3 organisms (CDC) or B1,B2,C (DPAG).

Microbiological Safety Cabinet Class II It is an open-fronted safety cabinet with drawn in air, a vertical laminar airflow over the work surface and an HEPA filter on the exhaust. It provides operator, environmental and product protection. Suitable for Group 1,2,3 organisms (CDC) or B1,B2,C (DPAG)

Microbiological Safety Cabinet Class III It is a totally enclosed gas-tight cabinet, where the operator will use glove ports to gain access. Air is drawn into the cabinet and exhausted through HEPA filters , while the whole unit is under negative pressure. It provides operator and environmental protection. Suitable for Group 1,2,3,4 organisms (CDC) or A,B1,B2,C (DPAG)

Hyzone Class II Cabinets are available in three types (Check table) In Hyzone Class II A2 Microbiological Safety Cabinet, 70 per cent air is re-circulated through the main H14 HEPA Filter within the cabinet, while the remaining 30 per cent is exhausted through two H14 HEPA filters in series.

Principle of operation Fresh air is drawn in from the slots at the front opening. This air passes under the work surface and joins the return air plenum. The main blower then pushes air into another plenum which also accommodates Supply HEPA filter, the Exhaust blower plenum and Exhaust HEPA filters. The inward air flow barrier prevents contaminants from exiting the work area. The innovative cabinet

design and positioning of supply and exhaust HEPA plenums in a negative envelope ensure that accidental air leakages are contained. As defined by the appropriate international standards, current health and safety guidelines and legislation aimed at safeguarding health and safety of operators at work, Hyzone cabinets are suitable for handling microorganisms and pathogens. 95 per cent of your requirements are met by Class II A2 Cabinets. However, Class I and Class III cabinets can be manufactured if your work so warrants.

Salient features of Hyzone Class II Microbiological Safety Cabinets ◗ Independent blowers for supply and exhaust air ◗ Double HEPA filtration of exhaust air. ◗ Negative pressure envelope (shroud) for HEPA filter plenums and return air path to prevent escape of contaminated air to atmosphere and work area. ◗ Simultaneous real time monitoring and display of supply and exhaust air velocities. ◗ Monitoring of work area temperature. ◗ Sliding front sash with counter weights for easy operation. ◗ Microprocessor controlled operations with Normal, Fast Start and Service modes and alarms. ◗ Ergonomic design like angled front sash, arm rest etc., for operator comfort. ◗ RS 232 connectivity. ◗ EN 12469:2000 compliant.

Soft touch keyboard Membrane touch keyboard and the rear-lit LCD display all required data keeping the operator constantly up to date of the cabinet conditions: ◗ Estimated life of HEPA filters ◗ Estimated life of UV lamp ◗ Cabinet temperature ◗ Laminar airflow (unidirectional down flow) velocity and frontal air barrier (in flow) velocity ◗ Front sash position

Audio visual alarms for: ◗ Out of range or incorrect laminar airflow velocity and frontal air barrier velocity. ◗ Incorrect position of front sash-window ◗ Clogging of HEPA filters ◗ End of life-cycle of UV Lamp ◗ Out of range temperature

Application areas ◗ Microbiology ◗ Medical Devices ◗ Virology ◗ Pharmaceuticals ◗ Haematology ◗ Pathology ◗ Cell Culture ◗ Blood Bank ◗ Recombinant – DNA ◗ Eye Bank ◗ Stem Cells Research ◗ Reconstitution of Parenteral drugs ◗ Biotechnology ◗ Genetics

Contact Pravin Mhapankar Thermolab Scientific Equipments Thermolab House, Plot No. 19, Vasai Municipal Ind. Area, Umela Road, Vasai (West) Phone: +91 – 250 – 2323156, 2324866 /7 Mob: 9820213893

MICROBIOLOGICALSAFETYCABINETS ARE DIVIDED INTO BASIC THREE CLASSES:

HYZONE CLASS II CABINETS ARE AVAILABLE IN THREE TYPES

Function

Class I

Class II

Class III

Class

Exhaust air %

Recirculated air %

Exhaust connection

Operator protection

Good

Excellent

II A2

Into room/Loose connected to exhaust duct

Environmental protection

Good

Excellent

II B1

Ducted out of Room

Product protection

None

Excellent

Poor

II B2

100

Ducted out of Room

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August 2014

TRADE & TRENDS

Osworld Scientific Equipments launches autoclaves Osworld Benchtop Autoclaves are widely used in various departments of hospitals and medicinal and pharmaceutical research like microbiology, medicine, veterinary science, mycology and dentistry loading- single handle type – Touch screen – Model no OAT-SHE

OSWORLD SCIENTIFIC Equipments is a manufacturer, supplier and exporter of laboratory and medical equipment for last four decades. Osworld is ISO 9001:2008 certified company and some products are having CE certification. Osworld is manufacturer of quality QC, R&D equipment like autoclave steam sterilizers, stability chamber, walk in stability chamber/cold rooms/freezers, photo stability chamber, BOD incubator, cooling incubator, bacteriological incubator, hot air oven, vacuum oven, deep freezer. Osworld has announced its latest development. The Osworld Benchtop Autoclaves are widely used in various departments of hospitals and medicinal and pharmaceutical research like microbiology, medicine, veterinary science, mycology, dentistry, etc. In pharma and medicinal industries, typical loads include laboratory glassware, surgical instruments, medical waste, etc.

Class B, Class N/S Sterilizers from 35 to 175 litres capacity, Temp range 121 to 134oC Osworld premium model autoclave are used in microbiology, QC & Research laboratories – pharma/medical industry. Osworld premium model autoclave is CE certified. It consists of microprocessorbased digital temperature controller indicator or touch screen model. The autoclave construction is double wall type design, however, has the inner chamber for steam, outer as cover. Only steam enters inner chambers for sterilisation. The chambers are made of stainless steel of LM 304/316 grade and the steel is exclusively provided by Jindal Steel. The equipment has all features required for Class B/S/N autoclaving.

Large Horizontal Model Autoclave- Front LoadingRadial Locking Type or Sliding Door – Model no OAT-HR

Front loading benchtop autoclave- Touch screen type – Model No OAT-FL Class B, Class N/S Sterilizers from 20 to 50 litres capacity, Temp range 121 to 134 o C Osworld front loading benchtop autoclave is CE certified. Microprocessorbased digital display, LCD back lit display. The inner chamber is 3mm thick and made of stainless steel. Outer cover is also made of mild steel/stainless steel; Lid is made of thick stainless steel. Initial auto water fill arrangement in external reservoir for steam generation, low water level alarm, automatic air exhaust cycle helps create partial

Class B, Class N/S Sterilizers from 100 to 1000 litres capacity, Temp range 121 to 134 oC Osworld Horizontal Model Autoclave is CE certified and mainly used for large requirements. Available in single door/double door model.

Contact vacuum in the chamber, vacuum pump for air removal with multiple pulsing, automatic door lock under pressure. A solenoid valve vents out air during the process of steam generation. At a preset temper-

ature the valve automatically shuts and thereafter steam pressure builds up. The sterilisation process should continue almost 15-20 minutes. Once sterile time period completes the steam is automatically ex-

hausted. Drying cycle provided optionally with print of entire cycle and PC interfacing software facility.

Premium model autoclave- Vertical type- top

Osworld Scientific Equipments B44, New Empire Industrial Premises, Kondivita, Andheri East, Mumbai – 400059. Tel: +91-22-28320880, 28390487 Email: info@osworldindia.com

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TRADE & TRENDS

Automation in ELISA- the preferred choice Saurabh Gupta, Sr Manager-Business Development, Transasia Bio-Medicals explains the benefits of automation in ELISA for validating the blood

SAURABH GUPTA Sr Manager-Business Development Transasia Bio-Medicals

Did you know that bloodthe most important fluid in the human body is also the most common carrier for infections? Blood donation is the noblest deed one can do, to help a person in need. However, it is utmost essential to ensure safe blood transfer, as patients run the risk of contracting an infection through blood transfusion. Validating that the blood is infection free is a basic mandate for blood banks and all healthcare setups. Advanced screening plays a major role in minimising horizontal transmission of diseases through blood donation. Nucleic Acid Testing (NAT), a technique used to detect the bacteria or virus in blood, is becoming a regular practice at reputed blood banks. Current trend in screening of blood bags include NAT+CLIA or NAT+ELISA of which the latter is more cost effective but has the disadvantage of being very tedious and requiring expert technical intervention. ELISA still remains the method of choice due to its reliability and quick results for blood screening. It also helps in improving the performance and maintaining the screening records, thus aiding in accreditation documentation as well. Serological screening of HIV, HBsAg and HCV is commonly done by ELISA. Even malaria and syphilis can be screened by ELISA. Better performing assay kits for serology are first introduced usually in ELISA technique. ELISA is easily adaptable, upgradable and the most affordable method for large screening of patients. Automation in ELISA + NAT is preferred for easy and complete

user friendly software helps to easily track the steps being performed during batch process. Mago 4 is another instrument manufactured by Delta Biologicals,Italy and distributed solely in India by Transasia. It is a fully automated 4 plate ELISA processor which can handle a high workload of upto 104 samples, perform 12 different tests in a plate and has the most easy to use software, making it the most ideal choice for fully automated ELISA system for high volume customers. The instrument delivers everything needed to ensure the rigorous, repeatable analysis required in critical applications including immunology, infectious disease, hormone, autoimmune and IFA. It eliminates errors that occur during manual processes, using advanced automation and precise liquid-handling capabilities. Mago 4 provides the flexibility of an open system; as a result, the users are not locked into a single reagent provider. It is ideal for blood banks in private and government sector in India.

EXPRESS HEALTHCARE

August 2014

Mago 4

screening. ELISA test typically has various steps (series of incubations, reagent additions and washing) for performing a test which is mostly done manually, with the help of semi-automated ELISA readers and washers. ELISA systems still have a major market share (30 per cent) of the total immunochemistry business in India. The immunoassay platform has, however, dramatically changed in recent years with the development of reduced assay step protocols and reduction in total testing time. New generation fully automated ELISA instrument, are designed to reduce the manual errors and steps for performing these tests. For blood banks, it is very important to source the instruments and reagents from manufacturers who can provide regular supplies and timely after sales support. Automated workflows for these assays offers a host of advantages such as reliable and effective results, shorter sample processing time, large sam-

Elan 30s

ple load capacity, multiple tests in a single batch, minimisation of human errors and cost effectiveness. ELISA is often used to screen a batch of samples of various origins, and adding automation is highly beneficial reducing the dependency on laboratory personnel. Moreover, automation assures accuracy since accurate volumes are dispensed and time is saved in transferring samples and reagents to designated micro-wells.

Automation in ELISA Transasia Bio-Medicals is a leading in-vitro diagnostic company. For the past 35 years of its existence, Transasia has been offering the highest quality products with excellent after sales services to meet the needs of healthcare professionals across the globe. Transasia offers complete range of instruments and reagents in the immunology segment for customers wanting to upgrade to automation. An extensive range of EIA automated analyzers supported by a robust team of experts,

ensure that we deliver excellence to our customers. Transasia's Elan 30s is a unique instrument indigenously designed and developed in India for small and medium workload labs offering assorted tests. It is a boon for blood banks where workload is always performed in batches. Elan 30s is a fully automated ELISA strip processor which can perform 6 tests in a single batch for a private laboratory setup where the workload is low. Earlier, many blood banks, weren't able to afford an automation for a medium workload laboratory owing to the high costs. Now, with the introduction of such system even a 300 â&#x20AC;&#x201C; 500 samples workload blood bank can offer ELISA automation. Elan 30s is an ideal automation platform since it has got a single arm for performing all the steps, automatically inbuilt incubators to control temperatures, washers, and readers to analyse results, with optional barcode reader to track samples, and data storage equipment for a complete automated workflow. The

TRADE & TRENDS

PRPTherapy: New avenue for regenerative medicine Dr Avinash Date, DHA, Consultant Orthopaedic Surgeon, SevenHills Hospital, Mumbai elaborates on the advantages of PRP Therapy PLATELET – RICH – Plasma (PRP) therapy was initially developed in 1970 by dental surgeons, which gathered momentum only recently after professional athletes like tennis legends Rafael Nadal and Maria Sharapova, basketball’s Kobe Bryant and Andrew Bynum, golfer Tiger Woods and numerous others hit headlines after undergoing this therapy for tendon inflammation. Since this therapy uses concentrated dose of autologous platelet from patients’ own whole blood and is injected at injury site, it is safe and doesn’t require FDA approval. This therapy had been regarded as better treatment alternative in orthopaedic and sports injuries, which is often used in combination with orthopaedic surgeries, moreover can sometimes eliminate the need for operative procedures. The crux of this therapy depends on harvesting optimum PRP, using patients’ blood that helps in healing process, since this reduces the risk of infection, allergy or any other side effects. Usually the physician extracts about twenty millilitres of blood from patients’ vein and spins it in REMI PRP Centrifuge to separate platelets from blood. Platelets are those components which secrete growth factors for stimulating clotting. These platelets are then injected back at the site of injury; enhancing and aggregating the platelet count in the micro-environment, thus stimulating immediate healing process. The comprehensive process takes place within 90 minutes. PRP Therapy principally supports to heal any ligament or tissue injury except acute or last stage injuries which might not provide anticipated results. This therapy is best suitable to

reduce the downtime of patient, while also decreases the chance of a more serious injury that will result in surgical intervention or permanent disability. PRP Therapy has been widely used to treat:

Tendon injury ◗ Elbow Tendinopathy - Lateral Epicondylitis (Tennis Elbow) : Lateral epicondylitis or tennis elbow a condition usually caused due to repetitive gripping or swinging action which leads to strain in muscles or partial tear in tendons of elbow. This condition takes time to heal and leads to pain when performing actions like gripping, picking or swinging. Earlier physicians alleviated the condition through physiotherapy and Corticosteroid injections, but with the advent of PRP therapy treatment, patients experienced enhance relief from inflammation with the use of autologous platelet-rich plasma, that is harvested through patients own blood. ◗ Achilles Tendinopathy: Achilles tendinopathy a condition which causes swelling, pain and weakness of Achilles Tendon. This condition is quite common in professional and amateur athletics, since it is one of the long tissue muscle connecting calf muscles to heel bone. Though it can be caused by multiple factors and the injury varies between early stage and acute inflammation. PRP therapy has shown promising results in management of this condition. ◗ Planter Fasciitis: Planter fascia is the most common cause of heel pain, involves tissue bands which runs across the bottom of heels and toe. Quite

common among athletes, this condition causes inflammation and pain of the tissue, often making it difficult for people to walk. This condition was been earlier treated with physiotherapy, stretching and physiotherapy aids, nevertheless it took time and lacked effectiveness. PRP therapy for plantar fasciitis involves injecting platelets in the area of the damaged tissue. ◗ Patellar tendinopathy: Patellar tendon also referred as jumper’s knee since it arises in athletes mostly involved in jumping sports like basketball, volleyball, etc. This condition results in wear and tear of the tendon that connects lower portion of kneecap and shin bone. However this condition is often neglected at premature stage, then again if the tissue repeatedly undergoes strain, the injury can exceed rate of repair. PRP Therapy has been postulated to have enhanced healing response for this condition, instead of the earlier treatments which included medication, physiotherapy and ice.

Ligament and muscle

PRP therapy uses patients’ own whole blood to harvest platelets which are injected at the injured site

injuries PRP Therapy has been gauged to heal ligament injuries which are quite common in professional and amateur athletic individuals due to frequent jumping, swinging and running activities. Formerly the treatment included physiotherapy and medication, but with the usage of PRP, the healing process has been enhanced.

How PRP therapy works? The muscle tissue healing typically begins with mechanisms that promote haemostasis or stoppage of bleeding. The process stimulates vasoconstriction, diminishing blood loss and exposed collagen from the damaged site draws the platelets to adhere. When platelets adhere at the micro-environment to the damaged vessel, they undergo degranulation and release cytoplasmic granules, which contain serotonin, a vasoconstrictor, ADP and Thromboxane A2. In most cases, formation of connective tissue fibres forms scar. Though in some conditions, such as fracture callus, this facilitate in the formation of new bone tissue. The following growth factors can be found at the micro environment site of blood clot: ◗ Transforming growth factor beta (TGF-b) ◗ Platelet-derived growth factor (PDGF) ◗ Insulin-like growth factor (IGF) ◗ Vascular endothelial growth factors (VEGF) ◗ Epidermal growth factor (EGF) ◗ Fibroblast growth factor-2 (FGF-2) All these above factors form the basis of healing mechanism which is used in the PRP process therapy. In this therapy Platelet –

DR AVINASH DATE DHA, Consultant Orthopaedic Surgeon, SevenHills Hospital

Rich – Plasma and that forms very small part of the whole blood component is separated by means of Remi PRP centrifuge process and injected at the site of injury which enhances and increases the platelet count multi-fold, thus speeding the healing process.

Benefits of PRP Therapy ◗ Safety: PRP Therapy is safe since it uses patients’ own whole blood to harvest platelets, which are injected at the injured site. So it is free from side effects, allergic reactions and is non – invasive. ◗ Easy recovery time: Patients typically experience discomfort post injection for less than a week. This occurs due to injecting large amount of platelet at the site of injury. Though medication is prescribed for pain management. ◗ Potential benefit: PRP therapy potentially speeds the recovery time and helps to decrease pain. As it is non– invasive it can be managed by physicians in day care centres. Physicians are gradually considering the role of PRP Therapy in healing inflammation of effected tissues by harnessing the power of patients own blood. Patients should understand that this process is a long term solution for their injury and might take two to three cycles. Previously physicians have often tried to reduce inflammation by using anti – inflammatory medication like steroids which provided immediate, but short term relief. This therapy has few drawbacks, the major one being pain. World is moving more and more towards finding biological solutions rather than mechanical solutions to solve such problems. This is one step towards it.

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August 2014

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