Express Healthcare September, 2014 by Indian Express

VOL.8 NO.9 PAGES 88

Cover story Tale of heart transplant in India: Alarming or Alluring? Strategy Reining in the NCD epidemic Life Diabetic teen from Pune scales Peru peak

www.expresshealthcare.com SEPTEMBER 2014, `50

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CONTENTS

Designing

Vol 8. No 9, SEPTEMBER 2014

Chairman of the Board Viveck Goenka

MARKET

FORTIS HOSPITAL NOIDA COLLABORATES WITH FORTIS ESCORTS HEART INSTITUTE

NANAVATI HOSPITAL OPENS RENOVATED CATH-LAB

IIT-DELHI, XRCVC AND SAKSHAM LAUNCH ASSISTIVE AIDS FOR VISUALLY IMPAIRED

POSITIVE BIOSCIENCE AND MEDANTA - THE MEDICITY LAUNCH PERSONAL GENOMICS CLINIC

SABRE PARTNERS LEADS $8 MILLION SERIES B INVESTMENT IN VYOME BIOSCIENCES

JIVA AYURVEDA CLINIC LAUNCHES ITS 28TH CLINIC IN AHMEDABAD

TRANSASIA LAUNCHES CUSTOMER CALL CENTRE

TRIVITRON HEALTHCARE JOINS HANDS UNIVERSITY OF TARTU, ESTONIA

SURAT HOSTS TRANSASIA SCIENTIFIC SEMINAR

for the family

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

With healthcare becoming more patient-centric, hospitals are also waking up to the benefits of providing value added services to the patients’ family as well and projecting them as a factor which sets them apart from their competitors. So, hospital design has also evolved to reflect these changes | P53

STRATEGY

MARKETING Regional Heads Prabhas Jha - North Dr Raghu Pillai - South Sanghamitra Kumar - East Harit Mohanty - West

REINING IN THE NCD EPIDEMIC

Marketing Team Kunal Gaurav G.M. Khaja Ali Ambuj Kumar E.Mujahid Yuvaraj Murali Ajanta Sengupta PRODUCTION General Manager B R Tipnis

LAYING A STRONG ECONOMIC FOUNDATION FOR NEW HOSPITALS

MEDICAL TECHNOLOGY: VISION 2025 ROADMAP FOR THE WAY FORWARD

Manager Bhadresh Valia Scheduling & Coordination Rohan Thakkar CIRCULATION Circulation Team Mohan Varadkar

RADIOLOGY

FROST & SULLIVAN HONOURS MOBIUS IMAGING FOR AIRO MOBILE INTRA OPERATIVE CT

LIFE

DIABETIC TEEN FROM PUNE SCALES PERU PEAK

WVU HEALTHCARE PERFORMS FIRST US COMMERCIAL NEURACEQ SCAN

SAMSUNG LAUNCHES ULTRASOUND SYSTEM, RS80A

P30: SPOTLIGHT

SICKKIDS DOCTORS DESTROY BONE TUMOUR USING INCISIONLESS SURGERY

P22: INTERVIEW: MILAN RAO

‘A PERSON WITH AN IMPLANTED EVERA ICD CAN GET AN MRI SCAN DONE FOR ANY PART OF THE BODY’

Dr Ramakant Panda, Asian Heart Institute

Chief Operating Officer – GE Healthcare, India & South Asia

P36: INTERVIEW: DR DHRUV KAZI Assistant Professor, UCSF School of Medicine, San Francisco

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.

EDITORâ&#x20AC;&#x2122;S NOTE

Taking stock after 100 days of NaMo

n average Mumbaikar is doomed to die eight years before the average Indian. Why? Blame non-communicable diseases or NCDs, of which cardiovascular diseases (CVD) account for the biggest chunk, (17.3 million annually), followed by cancers (7.6 million), respiratory diseases (4.2 million), and diabetes (1.3 million). These four groups of diseases, which account for around 80 per cent of all NCD deaths, share four risk factors: tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets. All risk factors are related to lifestyle choices and this probably explains why the World Heart Federation chose to focus on creating heart-healthy environments as the theme of this year's World Heart Day. Hopefully, this September 29 will see our government announce policies which will coax people to make heart-healthy choices. The extra tax on tobacco products is a good step, says diabetologist Dr Shashank Joshi , but can we go further and ban fast foods and colas? The Food Processing Industries Minister Harsimrat Kaur Badal recently asked Pepsi to cut down on sugar levels in Pepsi so the government does seem to be sticking to its line. Dr Joshi was part of an Idea Exchange hosted by Express Healthcare where the principal guest, Dr Kenneth Thorpe, Chairman of the Partnership to Fight Chronic Disease shared his experiences with drafting health policy in the US. The third guest, Dr Ratna Devi was the patient's voice at the meet. Each speaker gave their recommendations which I hope will guide policy makers and industry leaders. (See Express Healthcare September issue, pages 37-40: 'Reining in the NCD epidemic', for edited excerpts from the interaction) A major reason why CVDs, and for that matter any disease, take such a heavy toll in India is the fact that we live in denial mode. Heart disease does not make the headlines unless political bigwigs like

EXPRESS HEALTHCARE

September 2014

Are the politicos turned policymakers losing speed once the initial impetus has worn off? We hope that the issues will be addressed, implemented and taken beyond the announcements.We must not be in denial mode and deal with the challenges in order to tap the potential

Lalu Prasad Yadav get admitted for heart surgery. The fact that politicos now choose to have their surgery right here in India rather than fly to the west is proof that cardiac surgeons like Dr Ramakant Panda of Asian Heart Institute and his ilk have managed to inspire trust in the level of expertise they have nurtured over the years. (See pages 30-33 for the story of how Dr Panda built up AHI over the last decade and a sneak peek into his plans for the second decade.) But while cardiac care has improved by leaps and bounds in India, heart transplants are another story. We are still hampered by a serious lack of heart donors even while the art and science of heart transplants is something we have down to a pat. The lead story in the cover story section takes us through the highlights of heart transplant surgery in India. While the potential is alluring, the challenges are truly alarming; from availability of donor hearts to logistics to increasing costs. (See story, 'The tale of heart transplant in India: Alarming or alluring?' from pages 26-29) As the new government at the centre passes the 100 days milestone on September 2, it is a good time to take stock of NaMoâ&#x20AC;&#x2122;s performance. Have the political promises been kept? Or are the politicos turned policy makers losing speed once the initial impetus has worn off? Lov Verma, Secretary - Health & Family Welfare recently announced that the government is in the process of drafting a national health policy to meet the rising demand for sustainable healthcare across the country. We hope that these issues will be addressed, implemented and taken beyond the announcements. With the focus on better, efficient and cheaper options for accessible, affordable and quality healthcare in the country, we also hope to see industry leaders step up to the challenge more proactively. We must not be in denial mode and deal with the challenges in order to tap the potential. VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

QUOTE UNQUOTE LOV VERMA, Secretary - Health & Family Welfare

DR POONAM KHETRAPAL SINGH Regional Director-SEARO, WHO

The government is in the process of drafting a National Health Policy to meet the rising demand for sustainable healthcare across the country DR A DIDAR SINGH, Secretary General, FICCI

We propose to create a virtual pooling of industry CSR funds by creating Indian Industry in Solidarity for Health (IISH) Kosh to channelise funds into priority area in healthcare identified by the government SANGITA REDDY, Joint MD, Apollo Hospitals Group

There is hardcore need for innovations in developing new drugs, vaccines and diagnostics. Then there is a need for health systems innovations such as the use of technologies like mobile phones by health workers for patient referrals, event reporting and disease surveillance. Similarly, further innovation is needed in telehealth for tele-consultations

Our nation like most others across the world is standing at the precipice of crisis created by the burden of disease and woefully inadequate healthcare infrastructure

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EXPRESS HEALTHCARE

September 2014

MARKET NEWS

Fortis Hospital Noida collaborates with Fortis Escorts Heart Institute Launch comprehensive cardiac department, introduce cardiac helpline number to tackle growing cardiac emergency in the region FORTIS HOSPITAL, Noida has launched a Comprehensive Cardiac Sciences Department under the leadership of Fortis Escorts Heart Institute (FEHI). The hospital has also introduced a cardiac helpline number, 8800496677 that would be manned by qualified cardiac staff 24x7. The hospital will offer free ambulance services for emergency cardiac cases from Noida, Greater Noida and neighbourhood areas of Indirapuram, Ghaziabad and Vaishalli. The Cardiac Sciences Department at Fortis Hospital Noida is equipped with an advanced cardiac cath lab for both adult and paediatric care. The centre offers comprehensive care in all cardiology

The cardiac department would be led by a team of senior cardiologists including Dr Nishith Chandra, and Dr SN Khanna, Associate Director and HoD, Cardiac Surgery, FEHI procedures like percutaneous transluminal coronary angioplasty (PTCA), implantable cardioverter-defibrillator (ICD) pacemaker implantation and complex surgery procedures like coronary artery bypass grafting (CABG) and valve replacement. Dr Ashok Seth, Chairman, FEHI and Cardiology Council, Fortis Group of Hospitals said,

“We are delighted to bring our renowned experts and clinicians to transform the level of cardiac care to offer patients in Western UP and beyond to offer our understanding of heart disease, prevention and treatment options”. The cardiac department would be led by a team of senior cardiologists including Dr Nishith Chandra, and Dr SN

Khanna, Associate Director and HoD, Cardiac Surgery, FEHI. Dr Seth added, “Sedentary lifestyle, stressful work conditions and compromised diet are leading factors in precipitating heart disease risk. It is increasingly affecting younger people and women over the last 10-15 years, underscoring the need for continuous advances in cardiac treatment. The onus therefore

lies amongst each one of us to alleviate this potential burden by propagating the need for a healthy lifestyle and in creating a robust system across the full spectrum of cardiac care; from prevention to treatment, of cardiovascular diseases.” Dr Somesh Mittal, Zonal Director, Fortis Healthcare said, “After a decade of successful operations, we are introducing comprehensive cardiac care that will offer round-the-clock services at par with international care to improve treatment outcomes. We want to make cardiac care affordable and easily accessible for patients who entrust their lives with us.” EH News Bureau

Nanavati Hospital opens renovated cath-lab Chairman, Abhay Soi opened the cath-lab in the presence of other cardiologists at the hospital DR BALABHAI NANAVATI Hospital has opened its renovated new-look cath-lab, as part of revamping its operations. Radiant Life Care, which recently took over the operations and management of the hospital, has installed the lab on a priority basis to put Dr Balabhai Nanavati Hospital – Heart Institute (NHHI), on full

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September 2014

stream with comprehensive facilities. Chairman, Abhay Soi opened the new Cath-lab recently with all the leading cardiologists of the hospital and other top doctors of Dr Balabhai Nanavati Hospital. “We are introducing the global hospital management best practices and expanding the operations to transform

Nanavati into a world class facility. The cath-lab is just the first initiative in this direction,” Soi said. “The lab has state-of-the-art facilities to make it as one of the best in the country. Our lab is one of the busiest in the city and we perform, on an average, 3000 procedures every year,” said Dr Lekha Pathak. EH News Bureau

IIT-Delhi, XRCVC and Saksham launch assistive aids for visually impaired SmartCane and PlexTalk Vachak have been developed as affordable solutions, thus serving as exemplars of frugal innovation THE XAVIER’S Resource Centre for the Visually Challenged (XRCVC), St. Xavier’s College, Mumbai; in association with IIT-Delhi’s Assistech lab, Saksham Trust and the National Institute for the Visually Handicapped launched SmartCane and PlexTalk Vachak, two assistive aids for visually impaired

Both devices have been developed with the aim of keeping the cost to the end user low people under the Assistance to Disabled Persons Scheme (ADIP) scheme of the Department of Disability Affairs, Ministry of Social Justice & Empowerment. ADIP provides essential aids and appliances for social, economic and vocational rehabilitation for the differentlyabled. This launch was supported by actor, Vidya Balan, who distributed 50 of these devices to the beneficiaries of the ADIP scheme. Both these devices have reportedly been developed with the aim of keeping the cost to the end user low; with the SmartCane costing Rs 3000 (including delivery and training). With the mandatory CSR spending, many corporations with a healthcare citizenship programme are embracing the concept of supporting social and frugal innovation. EH News Bureau

EXPRESS HEALTHCARE

September 2014

CIN: U33110MH1997PTC111307

MARKET

Positive Bioscience and Medanta - The Medicity launch personal genomics clinic The services of the clinic will include pre-empting interventions for disease prevention, pre-test genetic counselling and DNA sequencing to post-test genetic counselling POSITIVE BIOSCIENCE and Medanta-The Medicity have to launched a personal genomics clinic, which reportedly offers state-of-the-art facilities and services in preventive healthcare and personalised medicine within the country. This partnership seeks to offer comprehensive personal genomics services to the customers along with advice from leading experts associated with the Medanta-The Medicity under one roof.

The services of the clinic will include pre-empting interventions for disease prevention, pre-test genetic counselling and DNA sequencing to post-test genetic counselling. The aim is to provide comprehensive genomic services for preventive medication so as to accelerate preventive healthcare work towards disease burden reduction and improve patient care in India. Pankaj Sahni, COO, Medanta – the Medicity said,

The clinic aims to provide comprehensive genomic services for preventive medication

“Personal genomics has huge potential and we are honored to be the first to open a clinic in this space.” He also added, “If one is not on board, they will not realise till the train leaves the station.” Samarth Jain, CEO, Positive Bioscience said, “The widespread appeal of personalised genomic will forever change the way we practice medicine today – from reactive to predictive. This clinic offers complete genomic services including

sample collection, interpretational analysis, genetic counselling for the patients. Additionally, Medanta - The Medicity also provides facilities and leading doctors who will provide individuals an option to consult specialists for preventive measures or screening test, thus ensuring that healthy individuals as well patient gets all solutions under one roof. This is reportedly the first facility of its kind in India.” EH News Bureau

Sabre Partners leads $8 million Series B investment in Vyome Biosciences Vyome is pioneering the development of a deep pipeline of molecules VYOME BIOSCIENCES, a dermatology company, has closed Series B financing of $8 million led by Sabre Partners, along with existing Series A investors Kalaari Capital and Aarin Capital. Vyome is pioneering the development of a deep pipeline of molecules, including ‘first in class’ Molecular Replacement Therapeutics (MRT) for killing

dandruff-causing fungus, new antibiotics using Dual Action Rational Therapeutics (DART) technology that kill resistant acne-causing bacteria. Vyome recently successfully completed clinical studies on VB001 and VB2421 for mild to moderate dandruff. Speaking on the occasion, N Venkat, Co-Founder and CEO of Vyome said, “This financing is a

major landmark in Vyome’s journey to translate cutting edge science into differentiated products and innovative commercialisation strategies, and gives the company substantial firepower to drive the completion of critical milestones of USFDA filings as well as Phase 1 and Phase 2 clinical research for some of its lead compounds and other development and commercialisa-

tion efforts of its Rx and OTC pipeline.” Sabre Partners has invested over $300 million in India. Sabre also has an infrastructure fund and a healthcare focused venture capital fund called ‘Spring Healthcare’, through which this investment in Vyome was made and through which Sabre has built a healthcare and life sciences portfolio over the

past four years. “We are delighted to partner with a world-class team that is applying science and critical understanding of unmet needs to develop unique platform technologies and products for the $20 billion global dermatology market” said Maliwal, Founder and Managing Partner, Sabre Partners. EH News Bureau

ABMH launches new speciality hospital at Mulshi It is a 50 bedded hospital spread across 15000 sq ft

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September 2014

ADITYA BIRLA Memorial Hospital (ABMH), Pune announced the acquisition of Mulshi Specialty Hospital at Lawale Road, Pirangut. Spread over an area of

15000 sq ft, Mulshi Specialty Hospital at Pirangut, is a 50 bedded hospital, with two operation theatres, laboratory, ICU, paediatric ICU facility, one delivery unit and 24 hours

ambulance services. The centre will also have a 24/7 pharmacy for the patients of Mulshi. “Strategically located at Pirangut, the hospital will en-

able easy access to quality treatment at affordable rate,” said Rekha Dubey, COO, Aditya Birla Memorial Hospital. EH News Bureau

MARKET

Jiva Ayurveda Clinic launches its 28 clinic in Ahmedabad

Jiva Ayurveda specialises in treating a variety of diseases like hypertension, diabetes, migraine, heart disease, asthma and obesity JIVA AYURVEDA, launched its new clinic in Ahmedabad, making it the 28th clinic in India. “Ayurveda, world’s oldest science of healing, is not just any other form of treatment available in the market. It is ‘a way of life’ that guides us on how to listen to our bodies and read the signals of distress to maintain good health and make our lives more balanced, productive and contented,” said Dr Partap Chauhan, Ayurvedacharya and Director Jiva Ayurveda. Jiva Ayurveda specialises in treating a variety of diseases like hypertension, diabetes, migraine, heart disease, asthma, obesity and more. The damage done by various chronic disorders can be mitigated to a certain extent through customised herbal medications and a correct diet and lifestyle regimen believes Dr Chauhan. With the addition of this new clinic, Jiva Ayurveda now operates 28 clinics spanning over ten states in India. Recently, the company has brought together a special team of doctors who will be dedicated to providing special diabetes consultation to patients at the Jiva Telemedicine Center in Faridabad. It is also the first company to introduce an Ayurvedic doctor on-call service in India for Airtel, Vodafone and Tata Docomo mobile subscribers. Dr Chauhan also informed the press that Jiva Ayurveda is providing Ayurveda support to patients suffering from chronic problems in collaboration with international institutions such as Autism Society in Poland and Dr Hagiwara in Japan, as well as in the US and Lithuania. EH News Bureau

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September 2014

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MARKET

Transasia launches customer call centre Dr Arvind Lal, Chairman and MD, Dr Lal Path Labs makes the inaugural call TRANSASIA BIO-MEDICALS recently launched its customer call centre at Transasia House, Mumbai. Dr Arvind Lal, Chairman and MD, Dr Lal Path Labs, inaugurated the call centre. Dr Lal unveiled the plaque through remote access and made the first inaugural call to the centre declaring the call centre open. This was followed by the lighting of the auspicious lamp by Mala Vazirani, Execu-

tive Director, Transasia BioMedical. Transasia is a leader in clinical diagnostics and provides solutions for clinical diagnosis in biochemistry, haematology, immunology, critical care, coagulation and urine analysis. The inauguration of the Transasia Call Centre is expected to add further value to their service delivery. the company feels that it will open new vistas in customer care. This

would facilitate a swifter response time, technical help; prompt handling of customer calls, improved coordination leading to better deliverables, reaching out even to the far-flung areas. Transasia’s call centre will extend its dedicated service to customers regularly between 8.45 am – 7.15 pm. on the toll free number: 1800 103 8226. EH News Bureau

Trivitron Healthcare joins hands University of Tartu, Estonia The cooperation will mainly be in areas of mass spectrometry, microchips, sequencing, molecular diagnostics and bio-banking TRIVITRON HEALTHCARE and University of Tartu, Estonia have signed a five-year memorandum of understanding (MoU) for broad scientific cooperation and furthering of medical education between India and Estonia. The cooperation will mainly be in areas of mass spectrometry, microchips, sequencing, molecular diagnostics and bio-banking. Dr G S K Velu, Founder and MD of Trivitron Healthcare said, “Trivitron is actively pursuing R&D in the new genera-

tion IVD techniques like next gen sequencing, micro array, mass spectrometry and molecular diagnostics. We found the scientists of University of Tartu had some clear insights in advancement of technologies in this area and hence we have formed an alliance to cooperate in R&D and commercialisation of products in this area. Apart from this, we have identified several areas of R&D collaboration and medical education collaboration with closer India/Finland and Estonia joint

Partners will explore opportunities to give medical education to University of Tartu in India, Dubai or Shanghai

initiatives to improve access and affordability for high end medical technology initiatives in selected areas of focus. We are sure this will lead to several break through innovations in the focus areas .” “The University of Tartu’s competence and means for innovative research and development activities are the reasons which motivated the major Indian enterprise Trivitron Healthcare to cooperate with the University of Tartu,” said Erik Puura, Vice-Rector for De-

velopment of the University of Tartu. “Our aim is to forge contacts between employees with similar interests to exchange the newest knowledge and develop solutions furthering people’s health,” commented Jane Luht, Head of Technology Transfer, University of Tartu. The partners will also explore the opportunities to give medical education to the University of Tartu in India, Dubai or Shanghai. EH News Bureau

M*Modal expands its medical transcription operations in Mysore Company charts aggressive hiring plans; to double the staff count to 600 by 2015 M*MODAL, PROVIDER of clinical documentation services and speech understanding solutions, announced the expansion of its existing facility in Mysore. The company has set aggressive hiring plans to ramp-up the centre’s headcount to 600 staff by 2015. Shaw Rietkerk, Sr VP, Worldwide HDS Operations M*Modal, US, inaugurated the

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September 2014

new facility. M*Modal has over 300 staff providing clinical documentation services to its healthcare provider customers in the US. Located at Udaya Ravi Road in Kuvempunagar, M*Modal’s Mysore is a new 170-seat facility spread across 5,400 sq ft, complementing M*Modal’s existing 110-seat, 5,400 sq.ft office at the lower floor. Now with a

combined office space of 10,800 sq. ft, the Mysore facility will be able to accommodate additional production and training seats for round-the-clock clinical documentation services. Rietkerk said, “India’s role in M*Modal’s global strategy is crucial. Mysore has contributed significantly to our success and I am happy to state that we have delivered on our

commitment to expand our Mysore operations when this centre was launched in 2012. This expansion has also allowed us to further tap into the skilled local talent pool, while also strengthening our brand presence in Mysore. I congratulate the Mysore team for its operational efficiencies and commitment to M*Modal’s growth.”

Biju Thomas, VP-Operations, India East said, “With a large talent pool, Mysore has grown to become an important location for M*Modal. Our rapid growth is testimony to the quality of work being done from here.”M*Modal's global centres are located in the US, Canada, U.K., Belgium, Philippines and India. EH News Bureau

MARKET POST EVENTS

13,715 school students take anti-tobacco pledge across India Two anti-cancer NGOs – Nanhey Farishtey from Indore and Indian Cancer Society organised this campaign AS PART of a nationwide campaign, more than 13,715 school students recently took a pledge against tobacco. This was initiated by two anti cancer NGOs – Nanhey Farishtey from Indore and Indian Cancer Society, which has its national headquarters in Mumbai. The pledge said, “In India, tobacco products are responsible for causing one million deaths every year. The Global Adult Tobacco Survey (GATS 2009-10) by Ministry of Health and Family Welfare, Govt of India shows that 35 per cent of the adult Indian population is consuming tobacco. In India, 5500 children fall prey to and start using tobacco every day. I pledge my support to fight this growing menace with all my strength and conviction. I will raise my voice against tobacco and help prevent cancer. I will not allow ‘Chewing and/or Smoking Tobacco’ in my life, family, community or country. I will help save millions of Indian lives.” The largest group was in Indore, where 44 schools participated in a massive public anti-tobacco pledge in the presence of Health Minister of Madhya Pradesh. Schools students from cities of Mumbai, Hyderabad, Kolkata, Satna, Darjeeling, Bhubaneswar, Matigara and several districts of Bihar also participated in the campaign.

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September 2014

MARKET

Surat hosts Transasia Scientific Seminar Ober 80 top pathologists from Surat and nearby areas attended the seminar THROUGHOUT THE year, Transasia organises a series of Transasia Scientific Seminar (TSS) to encourage knowledge sharing and exchange of scientific updates in tier II and tier III cities. The platform aims to bring together the doctors and technicians from the nearby areas for exchange of technical know-how and hands-on experience on the instruments. The latest TSS was held in Surat recently at Hotel Gateway. Dr Anil Handoo, Sr Consultant Haematology and Director-Laboratory Services, BLK Super Speciality Hospital, New Delhi delivered a lecture on ‘From workhorse to a thoroughbred-Journey of the hematology analyser.’ The session was chaired by Dr KG Naik and Dr RM Khandwala, senior pathologists from Surat. Senior Haematologist, Dr Kiran Shah moderated the session. The seminar reportedly received an overwhelming response with more than 80 top pathologists attending the session not only from Surat but other towns such as Bharuch, Ankleshwar, Navsari, Valsad, Vapi, Bardoli and Vyara. The event was well by supported South Gujarat Practicing Pathologists Association, Surat. The attending doctors also

Participants at the event

got a chance for a hands-on training on 6-Part Differential Haematology Analyzer XN1000, 5-Part Differential Hematology Analyzer XS-800i and 3Part Differential Hematology Analyzer XP-100. The participants appreciated the session and demanding more such seminars to be held in the future as well.

The seminar was attended by more than 80 top pathologists from Surat and adjoining areas

Dr Anil Handoo, Sr Consultant Haematology and Director-Laboratory Services, BLK Super Speciality Hospital, New Delhi and Anil Jotwani, Senior VP, Sales and Marketing, Transasia Bio-medicals

Symbiosis organises blood donation camp It was conducted as part of International Students Day activities SYMBIOSIS CELEBRATED International Students Day with multiple social and cultural events including a blood donation camp. The camp was arranged simultaneously by Symbiosis Centre of Health Care (SCHC) at seven campuses of Symbiosis in Pune and three campuses at Noida, Nashik and Bangalore, in association with seven blood banks. The campaign to maximise

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Awareness was created amongst the staff and student community, through motivation campaigns comprising present ation, skits and street plays enacted by the MBA students on all campuses the turnout for the blood donation camp was done by MBA (Hospital & Healthcare Management) students of Symbio-

sis Institute of Health Sciences under the supervision of healthcare professionals of SCHC. The universal slogan

delivered by the campaigning students was, ‘Give mankind the greatest gift. Donate blood when blood bank comes to

your place.’ Awareness was created amongst the staff and student community, through motivation campaigns comprising presentation, skits and street plays enacted by the MBA students on all campuses. Posters and banners were erected to create awareness for the camp. A special motivation film made by Symbiosis Studios was shown to students at various campuses.

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ASSI conducts instructional course on geriatric spinal problems Early detection of symptoms crucial to better management and health outcomes ASSOCIATION OF Spine Surgeons of India (ASSI) recently organised an Instructional Course in Spine (ICS 2014) -“The Ageing Spine” in collaboration with AO Spine International in Udaipur, Rajasthan. The Spine Society Delhi Chapter organised the course on behalf of ASSI. “Spinal problems are quite common in geriatric patients because of degenerative and other ageing changes. The good news is that such problems can be managed conservatively without any surgery,” said Dr Sajan Hegde, President-ASSI, Consultant Spine Surgeon and Head, Department of Orthopaedics, Apollo Hospitals, Chennai. “Surgical management for geriatric population, where required, becomes challenging, not only due to the co-morbid factors which increase the incidence of complications of anaesthesia and immobilisation, but also due to osteoporosis which makes the fixation challenging,” said Dr HS Chhabra, Secretary, ASSI and Medical Director, Indian Spinal Injuries Centre. ASSI feels that most of these age related spinal problems can be managed with proper care if the geriatric community is well aware of the early symptoms which could alert them to seek timely medical attention. “The geriatric community should be aware of the early signs and symptoms of geriatric spinal ailments so that they could seek medical attention well in time. They should especially understand the red-flags which include night pain, difficulty in bowel and bladder control, progressive weight loss/ weekness in legs and arms should alert them to seek immediate medical attention,” said Dr Saumyajit Basu, Jt Secretary ASSI and Sr Consultant Spine Surgery, Park Clinic, Kolkata.

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MARKET I N T E R V I E W

‘The opportunity for growth is tremendous with the huge demand for quality healthcare’ Milan Rao, COO – GE Healthcare, India & South Asia, in his earlier role as CEO for Enterprise Business at Bharti Airtel, was responsible for driving growth and profitability of the $750 million business from corporate and government institutions in India and globally. M Neelam Kachhap speakes to him to know more about strategic direction he will conceive in his new role

What are you excited about most at GE Healthcare? I am very excited to work with the leader in healthcare technology in India and be a part of GE Healthcare’s vision, “At work for a healthier India”. GE is one of the most respected companies in the world - a global leader in a variety of industries including healthcare. GE is known for its pioneering technology that has successfully overcome the toughest of challenges for well over 130 years - starting with a light bulb in the 18th century, to the most sophisticated aircraft engines and molecular medicine of today. GE’s innovations touch millions of lives every day and GE Healthcare’s solutions help save thousands of lives every day. GE also has a great reputation for its unyielding integrity and leadership development – now, that’s a great company to work for! What is your view of the medical device market in India? The market has been growing at a double digit rate for several years. However, the growth rate has been steady and the industry has not seen a boom like some of the other industries, say IT or

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telecom. The opportunity for growth is tremendous with the huge demand for quality healthcare. I believe this industry would boom if there was more emphasis on local manufacturing and less reliance on imported technologies. We would like to work with the government and other industry players to develop localised solutions that will lower costs and improve affordability. How is this industry different from the Industries you have worked in before? I have had an opportunity to study the industry over the last 10 months and meet most of the luminaries in healthcare in India. There are several unique characteristics to healthcare industry...firstly, there is tremendous domain expertise in the industry in India. Medical professionals in India are comparable to the best in the world. At the same time, there is a huge shortage of talent, especially in tier II/III cities and beyond. The infrastructure is also weak beyond the top cities, which presents a huge opportunity. Some of the sectors I have worked before – such as FMCG, banking and telecom

The three key challenges I see for this industry are improving distribution, developing funding solutions and reducing the cost to serve

have seen tremendous influx of investments and global best practices. And it has helped them grow rapidly. Healthcare has not seen an influx of funds that will allow it to catapult into a large industry. However, healthcare sector is still not as organised as other industries. I think healthcare is truly at a ‘launching point’. With government’s renewed commitment to healthcare, ‘Make in India’ policy and investment by companies such as GE Healthcare in local research, technology innovation and manufacturing, I am sure t his sector will also see similar advancement over the next decade. What are the challenges faced by the Indian healthcare industry today and how will GE Healthcare under your leadership help address these challenges? The three key challenges I see for this industry are improving distribution, developing funding solutions and reducing the cost to serve. Having worked in industries such as FMCG, financial services and telecom that faced such challenges, I am sure I will be in a position to help GE Healthcare

overcome these challenges and continue to lead the healthcare market. What are your plans for GE in the future? As the leader of the healthcare imaging industry, we believe we have a bigger role than just selling and servicing medical equipment. While we continue to consolidate our leadership position by focusing on customer centricity, superior distribution, financing and servicing capabilities, we are also committed to our vision, ‘At work for a healthier India’. We are in the process of accelerating our efforts to solve some of the biggest challenges outlined above like skill development, improving affordable access etc. We are trying to change healthcare outcomes by understanding diseases better and developing advanced therapies. Our mission is to work towards early detection of cancer, lowering heart disease burden as well as reducing maternal and infant mortality– through innovating affordable solutions in India and partnering with government and healthcare providers. mneelam.kachhap@expressindia.com

EVENT BRIEF SEPT-NOV-2014 25

6th edition VCCircle Healthcare Investment Summit 2014

MEDICA 2014, COMPAMED 2014

6TH EDITION VCCIRCLE HEALTHCARE INVESTMENT SUMMIT2014 Date: 25 September, 2014 Venue: Taj Mahal Palace, Mumbai Summary: It is a reputed and well-attended healthcare summit in India. It will gather 250+ CEOs representing India's top and emerging healthcare companies and leading institutional and private equity investors betting on the sector. This year the summit will focus on: ◗ Emerging trends in the healthcare segment ◗ Deepening demand in super-speciality sector, single speciality, retail clinics, diagnostic and medical devices segment ◗ Creating world class healthcare infrastructure for India ◗ Pain and relief from the private equity point of view Contact AVP - Conferences VCCircle, Mosaic Media Ventures C-125A, Second Floor Sector – 2, Noida, UP - 201301 Phone: 0120-4171111 Mob: +91-99107 25411

MEDICA 2014, COMPAMED 2014 Date: November 12-15, 2014 Venue: Düsseldorf Trade Show Complex, Düsseldorf, Germany Summary: More than 4,500 exhibitors from around 65 nations are expected at MEDICA 2014 to present the entire spectrum of new products, services and procedures to raise efficiency and quality in outpatient and in-patient care. The MEDICA trade show’s focus would be on electromedicine medical

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technology, laboratory technology/ diagnostics, physiotherapy/orthopaedi c technology, commodities and consumables, information and communication technology, medical furniture and specialist

furnishings, and building technology for hospitals and doctors’ offices. COMPAMED 2014 is an international platform for suppliers. Around 700 exhibitors would present their technological and service solutions for use

within the medical technological industry – from new materials, components, primary products, packaging and services. Contact Messe Duesseldorf India Centre Point Building,

7th floor Santacruz West Mumbai 400 054 Phone: +91 (0)22 6678 9933 Fax: +91 (0)22 6678 9911 E-mail: messeduesseldorf@mdindia.com Website: www.md-india.com

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A Even though there is now a fairly active transplant programme, we still have a situation where organs are wasted Dr KR Balakrishnan Director-Cardiac Sciences, Fortis Malar Hospital

kanksha Singh (name changed) sits quietly on the stage while her doctor addresses the press conference. He is narrating her story; how a joyful picnic on the hills turned into nightmare for Akanksha (34) and her family when she became breathless and was diagnosed with end-stage heart failure. How within weeks her organs started to fail awaiting a donor heart and how she was saved by a pump till she finally received a heart transplant. An extraordinary feat for her doctor Dr KR Balakrishnan, Director Cardiac Sciences, Fortis Malar Hospital who used the Extra Corporeal Membrane Oxygenation device (ECMO) to buy time for Akanksha who recovered wonderfully and is event free two years down the line. Having heard Akanksha's story, one would think heart transplant has come of age in India but the real truth is far more worrying. Only a handful of hospitals in India perform heart transplants even though there are a number of cardio-thoracic and transplant surgeons experienced and capable of performing the surgery and a huge number of patients needing it.

Alarming gap

Success of heart transplantation is related to the discovery of effective immunosuppressive regiments and the methods for managing acute rejection Dr KM Cherian CEO and Chairman, Frontier Lifeline, Chennai

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Heart failure is a major health concern worldwide including India. Twenty million people worldwide suffer from heart failure, of which India witnesses two million new cases every year with at least a third of them requiring advanced therapy to survive. “The incidence of end stage heart failure is increasing steadily, the approximate number is difficult to comprehend. In India, it has been estimated that there are about 19 million (1.9 crores) patients with heart failure (HF) with 1.5 million new cases per year,” says Dr KM Cherian, CEO and Chairman, Frontier Life-

line, Chennai and the pioneer of heart transplant in the private sector. It is also important to note that the mortality in heart failure patients is as high as 30-40 per cent, within a year of diagnosis. In India, the treatment for heart failure is restricted to medical therapy, revascularisation therapy (restoration/augmentation of blood supply to the heart), valvular surgeries and cardiac resynchronisation (heart pacing) therapy. Worldwide, a total of 4,096

heart transplants (including 3,529 adult) from 249 centres were performed in 2011 and reported to the International Registry for Heart and Lung Transplantation. According to the 30th adult heart transplant report, over 110,486 heart transplants were conducted in over 407 centres since 1982 through June 30, 2012.

Challenges Heart transplant in India faces many challenges, but the most glaring of them concerns organ donation. “All over developed

countries, the main problem is the availability of donors as there are always a huge number of patients waiting for transplantation and many of them die while waiting for donor heart,” explains Dr Alla Gopala Krishna Gokhale, Heart & Lung Transplant Surgeon, Yashoda Hospitals, Secunderabad. Although the Zonal Transplant Coordination Committees across India are making dedicated efforts to spread the word on organ donation not many states have been able to coordinate

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dedicated efforts for the same. “Donation is happening to some extent only in Tamil Nadu and Hyderabad. For e.g. in the last one and a half years, in Hyderabad, Jeevan Dan mobilised 60 organ donors. Of these 55 livers and 115 klidneys were used and only two hearts were used. In these cities, the main problem is availability of recipients,” says Dr Gokhale. “It is mainly because of lack of awareness among public and medical fraternity and especially cardiology faculty is showing apathy to this group of patients and not directing them properly,” he adds.

Heart transplant in India faces many challenges, but the most glaring of them is about organ donation Logistics Sometimes the donated organ gets wasted as it is not able to get to the patient on time. “Even though there is now a fairly active transplant programme, we still have a situation where organs are wasted,” laments Dr KR Balakrishnan, Director, Heart Transplantation and Mechan-

ical Circulatory Support, Fortis Malar hospital, Chennai. “When you have a sick patient needing an urgent transplant, an organ may not be available, or the best recipient for that organ may be in another location, and transporting the organ is not often possible over longer times and distances as we are also faced

with a time limit of around four hours of ischemia for the heart, after which the heart is not usable,” he explains. Orchestrated efforts from surgeons, traffic personnel and public have in the past proved life-saving for some patients. 'Green corridor' or ‘Corridor of Life’ are red-light free road access to transport donated organ to the suffering patient.

Rising costs Cost of surgery is one of the main deterrents to heart transplant. “The main challenges with heart transplant in India are the cost of

Main problem is availability of donors as there is always a huge number of patients waiting for transplantation and many die while waiting for donor heart Dr Alla Gopala Krishna Gokhale Heart & Lung Transplant Surgeon, Yashoda Hospitals, Secunderabad

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cover ) SURVIVING STARS transplant and the cost of immunosuppressant medicines post transplant which is approximately Rs 30,000 per month as per rates now,” says Dr Cherian. Besides there are no option for heart transplant in medical insurance. “It costs about Rs 15 lakhs for surgery and about Rs 30000 for monthly maintenance. In developed countries, 85 per cent people have insurance whereas in our country 85 per cent pay from pocket. Insurance companies and government have not taken the initiative to promote this treatment option,” says Dr Gokhale.

Evolution of heart transplant in India Despite the rising challenges India has managed to keep the option of heart transplant open for patients. Collectively, 129 heart transplants have been performed in India since 1994 with 82 in Chennai, 33 at AIIMS and 14 at other centres in India. At KEM Hospital, Mumbai, Dr PK Sen and his team performed the first heart transplant in India in February 1968, months after the first attempt at heart transplant was made by Christiaan N. Barnard in December 1967 at SouthAfrica. Barnards's patient lived for 18 days while Sen's patient died within 24 hours, this was before immuno-supressing drugs were made. After 1968, Dr Sen and his team did perform other heart transplants but the surgery did not yield positive results. By the time organ rejection suppressing drugs became available, many other problems cropped up in India. Primarily, the unclear law relating to organ transplant. By early 1980s the surgeons began to lobby for a clearer law. “In 1983, Former Secretary of Health, Govt of India, Dr Srinivasan called for a meeting of representatives from various groups of society,” recalls Dr Cherian. “This meeting was conducted at Vijay Hospital and attended by priests of different religions, judges, advocates etc and there were more than 500 people

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that participated and unanimously approved that the brain dead should be legalised. This was the first meeting ever conducted in India and later followed by Delhi, Kolkata and Mumbai,” he adds. In the meantime, Dr P Venugopal and his team at the department of cardiothoracic and vascular surgery, AIIMS Delhi, were fine-tuning heart transplant surgery techniques by experimenting on animals. The Organ Transplant Bill 1994 was passed in the Indian Parliament in May 1994 which cleared the way for organ harvest from brain-dead patients. Successively, Dr P Venugopal and his team performed the first successful heart transplant on August 3, 1994. However, the full extent of the law and notification happened in 1995 after which other centres in India performed the surgery successfully. “The brain dead legalisation was brought about in June 1995 and it was passed in the Upper and Lower House. After legalisation of brain dead, I believe we performed the first successful transplant in Vijaya Hospital, Chennai,” recalls Dr Cherian. Since then there has been no looking back. “India’s first heart transplant was performed at AIIMS on August 3, 1994. From a few sporadic transplants at that point in time, we now have a fairly well organised programme in place,” says Dr Bagirath Raghuraman, Senior Consultant Interventional Cardiologist & Heart Failure Specialist, Narayana Health City, Bangalore. Vital statistics on heart transplant and knowledge sharing has suffered due to the lack of a registry. A registry has been launched recently which will start providing data soon. “We do not have statistics and actual numbers of patients needing heart transplant in India,” informs Dr Raghuraman. “We have recently formed the

LOUIS WASHKANSKY was the first recipient of heart transplant in South Africa by Dr Christian Barnard. He survived the operation and lived for 18 days TONY HUESMAN is the world's longest living heart transplant recipient who survived 31 years. He received a heart in 1978 at the age of 20 after viral pneumonia severely weakened his heart. Huesman died on August 10, 2009 of cancer. He was operated at Stanford University under heart transplant pioneer Dr Norman Shumway ELIZABETH CRAZE, now 32 years old, an IT employee working for Facebook in Palo Alto is one of the youngest successful heart transplant recipients in the world who received transplant at the age of two years and 10 months KELLY PERKINS climbs mountains around the world to promote positive awareness of organ donation. Perkins was the first recipient to climb the peaks of Mt. Fuji, Mt. Kilimanjaro, the Matterhorn, Mt. Whitney, and Cajon de Arenales in Argentina in 2007, 12 years after her surgery Twenty-two years after DWIGHT KROENING had a heart transplant, he was the first recipient to finish an Ironman competition FIONA COOTE was the second Australian to receive a heart transplant in 1984 (at age 14) and the youngest Australian. In the 24 years after her transplant, she became involved in publicity and charity work for the Red Cross, and promoted organ donation in Australia A 71 year old in Australia is the oldest person in the world to undergo heart transplant

'Heart Failure Association of India' which has embarked on the task of collecting heart failure data from all over the country. We will have meaningful figures by the end of the year,” he adds.

Advances in heart transplantation Heart transplantation is evolving and now has excellent outcomes. “The success of heart transplantation is closely related to the discovery of effective immunosuppressive regiments and the methods for managing acute rejection,” says Dr Cherian. Agreeing Dr Balakrishnan says, “The advances in heart transplant in recent years has been in the use of more sophisticated and gentle immunosuppressive drug therapy so that the harmful effects of these drugs are minimised and patients live much longer.” Another promising advancement has been in normothermic organ preservation, which provides warm blood perfusion of the donor organ, potentially decreasing reperfusion injury and graft dysfunction. Experts believe that if proven effective, this technology may decrease early graft failure and allow increased utilisation of available organs. Its potential to decrease ischemic time may also give greater opportunity for prospective cross-matching in heart transplantation. Talking about the organ care system developed by a US-based company, Dr Raghuraman says, “After a heart is removed from a donor's body, it is placed in a high-tech organ care system box and is immediately revived to a beating state, perfused with oxygen and nutrient-rich blood, and maintained at an appropriate temperature. The device also features monitors that display how the heart is functioning during transport.” The box is not widely available in India. “If this box is made available in India, it

may be possible to keep donor hearts viable for longer periods given our country’s infrastructural limitations,” says Dr Raghuraman.

Better outcomes with Ventricular Assist Devices (VADs) Ventricular Assist Devices (VADs) are implantable mechanical heart pumps. They have been used in recent times to sustain patients who are candidates for heart transplant as they await a donor heart and are increasingly being used as a substitute for transplantation. “Emerging research shows that VAD patients find that their hearts actually improve with help from these mechanical pumps,” says Dr Balakrishnan. VADs have also evolved with time. “In the beginning left VADs (LVADs) were not very sophisticated and had moving parts, which created noise,” explains Dr Balakrishnan. “The current breed of LVADs are magnetic levitation devices that are much smaller and advanced,” explains Dr Balakrishnan. “With a fourth generation LVAD, we don’t need to cut open the abdomen, or even the diaphragm, to fit the machine. It’s intrapericardial and doesn’t even encroach upon the lung space. The latest circulite LVAD can be placed in the muscles of the right side chest wall and is a little bigger than a pacemaker in size,” says Dr Raghuraman. Speaking about his experience Dr Cherian says, “There are two methods of supporting the failing heart. Firstly, a bridge to the transplant and secondly a destination therapy.” “The bridge to transplant has been done by us couple of times and one patient had the heart transplant after being given artificial support heart for 39 days,” he informs. “The cost of this device will be around Rs 25 lakhs. This involves the cost of machine and other expenses etc. For the first time in Asia officially an artificial heart transplant

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Despite rising challenges India has managed to keep the option of heart transplant open for patients. Collectively, 129 heart transplants have been performed in India since 1994 with 82 in Chennai, 33 at AIIMS and 14 at other centres in India (HeartWare) was done at our Frontier Mediville on July 15, 2014,” he says. The cardiac transplant team at Fortis Malar has so far performed 16 heart-transplants, five VADs and is credited with India’s first successful implantation of Heartmate II LVAD and HVAD, a mechanical artificial heart pump. Narayana Hrudayalaya, one of Asia’s first hospitals to implant total artificial hearts from an Australian company, Ventracor in 2008, has reported success of artificial heart implants in their patients.

The road ahead India can emerge as a major player in the heart transplantation scene in the future. “We have the facilities, trained specialists and infrastructure to go the distance. Improving the existing facilities to world class standards holds the key,” says Dr Raghuraman. Surgeons are hopeful of increase in the number of organ donations in future. “It is going to go only one way. Donation rates are going to go up and heart transplantation will become a common surgery. How long it will take I do not know but I am hoping that by the end of coming 10 years, it will be available to many and many will utilise it,” opines Dr Gokhale. “Already there is a lot of interest in several states to start cadaveric transplant programmes modelled on what is being done in Tamil Nadu. I expect in the next few years, the numbers will grow substantially

once awareness about organ donation is created across the country,” says Dr Balakrishnan. Bringing down the cost of surgery will be a sure mantra for success. “The future of heart transplant in India is dependent on the involvement of the private and government sector in bringing down the cost of medicines and immunosuppressants. It depends on the knowledge among the layman for donation. Organ donation awareness is a must,” shares Dr Cherian. Focus on innovation in VADs is also expected. “We need a reliable and affordable LVAD to keep critically ill patients alive till a suitable donor organ is found,” says Dr Balakrishnan. The consensus and involvement of insurance for hearttransplants is a must to uplift the intervention. “We need to bring heart transplantation and organ transplantation in general under the gambit of health insurance and the national health programme. Funding such programs will immensely benefit these patients. Availability of costly immunosuppressive medications at subsidised rates will ensure better compliance with medications and lesser drop out rates. Educating the general public, awareness programmes and public participation can immensely change the scenario. It is a question of time before the bits of the jigsaw puzzle fall in place. We look forward to a change in the fortunes of these unfortunate people and be the hope for the hopeless,” concludes Dr Raghuraman. mneelam.kachhap@expressindia.com

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cover ) SPOTLIGHT

DR RAMAKANT PANDA

ASIAN HEARTINSTITUTE

PRESERVING INDIA'S HEART Asian Heart Institute, after tracing a phenomenal journey to become one of the top cardiac care institutions in the country, is set to conquer new pinnacles in the current decade, spearheaded by its illustrious leader, Dr Ramakant Panda BY LAKSHMIPRIYA NAIR

r Ramakant Panda, the man who held ex-PM Dr Manmohan Singh’s heart in his hands, needs no other introduction. He has given a new lease of life to countless people suffering from heart ailments, including RJD supremo Lalu Prasad Yadav, who recently got operated by Dr Panda. At the same time, he has also been the kingpin behind the rise of Asian Heart Institute (AHI) as a premier

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heart care hospital, not only in the country but across the globe, in a matter of mere ten years.

A decade of ascent Set up in 2002 under the aegis of Asian Hospitals, with Dr Panda at the helm as its Vice Chairman, AHI has achieved considerable success and a great reputation in just over a decade’s time. Talking about AHI’s growth, Dr Panda, beaming like a proud father, informs, “In the last ten years, AHI has

put a benchmark in cardiac care in the country, whether it’s in terms of design, clinical results and patient outcomes, less complications or low infection rates. That is our biggest contribution.” Today, the hospital has reportedly completed over 30000 angioplasties and 18000 heart surgeries since its inception. Aided by its talented and dedicated team as well as avantgarde technological advancements, it boasts of a staggering success rate of 99.6 per cent in

cardiac surgery. The hospital also lays claim to handling the highest volume of cardiac surgical procedures in Mumbai, in the present day.

Stairways to success A strong proponent of standardisation of medical care in the country, Dr Panda has ensured that AHI has several accreditations given by top notch global organisations such as Joint Commission International (JCI), National Integrated Accreditation for

Healthcare Organizations (NIAHO), and International Organization for Standardization (ISO), to its credit. One of the top accreditating agencies in the world also ranked AHI as No.1 in results among its participating hospitals. These accreditations stand testimony to the AHI’s endeavours to offer top quality care through strong adherence to patient safety and treatment protocols as well as infection control practices which was greatly aided by a patient-cen-

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tric hospital design. Dr Panda highlights some of the measures taken in this area, “No hospital had a lounge or counselling room for those who accompanied ICU patients. We created a huge lounge with beds and shower facility for ICU relatives and when the treatment was in progress, the patients’ relatives are counselled about the procedure. Similarly, many hospitals had cafeterias but not of the quality and level that we put up."

These measures paid off and played their role in building AHI’s reputation and credibility. Reiterating this, Dr Panda informs, “We are the highest accreditated hospital in the country. Our results are among the best in the world, not just in the country. Moreover, our infection rates are among the lowest in the country. A major worldwide accreditation agency conducted a two year survey from 2009 to 2011, of fifteen top most hos-

pitals in the world. We were at the top in terms of results. So, when we are looking at quality of patient care, we have put a lot of benchmarks.” Dr Panda also highlights that AHI has been in the forefront when it comes to adopting technology to spur better health outcomes. They are said to be the pioneers in robotic surgery in Mumbai and Western India. The da Vinci Si Robotic Surgical system in use at the hospital is reportedly

one of the very first in the Asia-Pacific region to use a simulator for robotic training. Comfort and quality, two of AHI’s most distinguishing features have also made it a ‘Mecca’ for medical tourists. Elaborating on the reasons that make AHI a preferred destination for medical tourists, Dr Panda says, “People come to AHI for the best results in the world. At 1/4 or 1/5 of the cost that is needed to go to the US, they can get it

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cover ) done at AHI.” The hospital has been ranked amongst the TOP 10 World’s Best Hospitals for Medical Tourists by Medical Travel Quality Alliance (MTQUA) in 2013.

of cost at the AHI Pediatric Cardiac Centre, which is equipped with facilities at par with global standards.

Grit and the glory

Ten years of AHI’s existence comprises phenomenal growth and countless triumphs. Yet, if the journey to the top is hard then retaining the top slot is harder. Now, AHI has entered into its second decade and embarked on its next phase of growth. So, at a time when competition and opportunities both are in plenty, how would the hospital continue to deliver the best? And how would Dr Panda continue his strides towards his goal of providing world-class cardiac care in the country? What are his plans to take AHI to the next level? A visionary by nature, Dr Panda has already charted out his strategies for the next phase of AHI’s development. Gung ho on growth, he believes that cardiac care has evolved significantly in the last three decades and would continue to do so. He narrates an incident where the dean of his medical college had to go to the US to get an angiogram done and says that today, au contraire; a patient can get an angiogram done at a centre within 100 metres from where he is located. He says, “When I was doing my post graduation, only four or five hospitals in the country had angiogram facilities. Today, only Mumbai has 50 centres for angiogram. Every tier-II or tier-III city has cardiac care facilities. Thus it has evolved in terms of reach as well as technological advances". Giving an insight on the changing standards of cardiac care, he says, “The type of treatment that was given 30 years ago and the current treatment methods are very different. When I got trained, bypass surgeries used to carry 50 per cent risk, 50 per cent people used to die. Now it is less than one per cent. In AHI, less than 0.5 per cent die. So there has been a quantum leap in the safety and standards of cardiac care treatment.” He informs that treatment methods like angioplasty, drug eluting

The interesting journey traversed by the hospital on a path strewn with several milestones, bears similarity to the successes achieved by its leader, Dr Panda. Vincent Lombardi, celebrated American football player and coach had once quoted, “Leaders aren’t born they are made. And they are made just like anything else, through hard work.” These words have proven prophetic in Dr Panda’s case. His accomplishments reflects hard work, dedication, determination and of course talent. Good at academics right from childhood, from small town beginnings he went on to learn cardiac surgery at AIIMS and complete his fellowship training from Cleveland Clinic, US (the Mecca of cardiac surgery) where he could learn from Dr Floyd D Loop, credited with being the pioneer in bypass surgery. A year of working as the Senior Registrar at the Harefield Hospital in the UK, gave him the opportunity to train under Professor Magdi Yocoub, one of the best cardiac surgeons in the world. Thus, a boy from a small village in Odisha, inspired by an article in the LIFE magazine on Dr Denton A Cooley (President and Surgeon-in-Chief, who founded the Texas Heart Institute), and one of the all-time great heart surgeons, traced a journey which has made him a name to be reckoned with in the field of cardiac surgery. He is one of the most revered heart surgeons in India today; with over 18000 cardiac surgeries including bypass, complex aneurysms, valve repairs and replacements as well as over 1200 redo bypass surgeries to his credit. A pioneer of several cardiac surgery techniques such as ‘off-pump bypass’, ‘total arterial revascularisation’, and redo bypass surgery he has the distinction of handling over 3000 high-risk surgeries, of which many were

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Embarking on the next growth phase

A pioneer of several cardiac surgery techniques such as ‘off-pump bypass’, ‘total arterial revascularisation’, and redo bypass surgery, Dr Panda has the distinction of handling over 3000 high-risk surgeries considered ‘inoperable.’ His success in handling high profile cases like ex-PM Dr Manmohan Singh’s redo bypass surgery, Assam CM Tarun Gogoi’s bypass and valve replacement surgeries, and more recently, RJD chief Lalu Prasad Yadav’s aortic valve repair and replacement surgeries have cemented his reputation as one of the safest cardiac surgeons in the world and earned him several notable awards and accolades including the Padma Bushan, the third highest civilian award by the Government of India.

Excellence with integrity Dr Panda’s expertise is celebrated, but so are his ethics

and integrity. He was given the prestigious Rashtriya Samman by the Income Tax department for being one of the highest taxpayers between 1994-95 and 1998-99. He refuses to be paid in cash and abhors the system of cut-practice, though it is widely prevalent nowadays. The same zeal and ethics are the pillars of AHI's foundation as well. Giving us an insight into the hospital’s working, Dr Panda informs, “We are also proud to say that in the last eleven years, we have been one of the very few hospitals which don’t believe in cut practice. We don’t pay any cut to anybody. I think these are some of the major

milestones and contributions in the last ten years.” Realising the serious concerns that accessibility and affordability of healthcare pose in our country, AHI has a motto to serve quality care through ethical practice at reasonable costs. It also undertakes several initiatives and campaigns for the benefit of the masses. One such pro bono venture is that AHI, alongwith with the KEM Hospital, would carry out cardiac surgeries for infants and children suffering from complicated heart ailments and cannot afford treatment. Dr Panda has pledge to operate 1000 such children, completely free

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stents, specialised pacemakers, using a catheter to resolve children’s heart problems were not imaginable thirty years back but they have wrought wonders today. In his opinion, in terms CVD treatment innovation and standards, India has a lot to offer. “I am proud to say that India is at par with global standards in terms of cardiac care, otherwise the PM would not have chosen to get himself treated at the hands of Indian surgeons,” he avers. The current challenges plaguing Indian healthcare themselves would pave the way for AHI’s growth, believes Dr Panda. Hence, he has already laid the foundations to ensure that the hospital is ready to face the challenges and optimise the opportunities that would come its way in the times to come. Sharing some of his plans in the offing he informs, “We are looking at expansion of our current facility. Unfortunately we are stuck because of the new fire regulations which decree that a hospital’s height should not be more than 30 me-

tres. Otherwise three years back we had already purchased 2,50,000 lakh sq ft land from the government. The plan was already in place.” He further informs, “At the same time we are also looking at other expansion such as on the Mumbai-Delhi corridor side. Reiterating his plans for medical training centre in Odisha, he says, “I am also committed to developing a centre in Bhubaneshwar. We had acquired 10 acres of land from the government but it is stuck in litigation. We are hoping that the verdict comes in our favour, so that we can go ahead

with the project." Thus, he has charted out his path for the future but believes, “there are miles to go” as poet Robert Frost would say. He feels that the government's timely intervention and support would provide a much needed impetus for further progress in CVD treatment.

Pointers for progress Informing that non communicable diseases (NCDS), especially cardiovascular diseases are one the biggest healthcare

India is at par with global standards in terms of cardiac care, otherwise the PM would not have chosen to get himself treated at the hands of Indian surgeons

problems in the country, he says that WHO has predicted productivity loss of $243 billion from cardiovascular diseases between 2005 to 2016. “That is the magnitude of the problem we are facing. So I think that the government needs to focus quite a bit in this area. However, it needs a holistic approach for tackling the threat of CVDs.” He also endorses the need for an effective system which would help achieve our healthcare goals by ◗ educating and encouraging people to stay healthy and prevent illness; ◗ detecting health conditions early; ◗ universal healthcare insurance; and ◗ building the infrastructure and manpower to treat disease He recommends educating the public to improve hygiene, sanitation practices and adopt healthier lifestyles, encouraging indigenous production of medical equip-

ment, increasing healthcare resources be it nurses, doctors or paramedical staff, shoring up the number of post graduates by allowing private healthcare institutions to offer PG courses, improving Universal Health Coverage, especially for the needy populace; and creating more infrastructure for primary and secondary healthcare as measures that are crucial to better healthcare standards in the country. His message to doctors in the country is the maxim he himself lives by. “Work hard and focus on the patient, not money. Money will follow automatically. Make sure that you give the best result and care to your patients, don’t compromise on that.” Thus, Dr Panda is optimistic about growth in Indian healthcare and is all set to accelerate the revolution with AHI in the forefront. His zeal and enthusiasm offers new hope that healthcare in India is set for a renaissance. lakshmipriya.nair@expressindia.co

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cover ) INSIGHT

Heart transplant through the years

DR PAUL RAMESH THANGARAJ Sr Consultant Cardiothoracic, Heart and Lung Transplant Surgeon, Apollo Hospitals, Chennai Adjunct Faculty, Department of Physics, IIT-Madras

Dr Paul Ramesh Thangaraj, Senior Consultant Cardiothoracic, Heart and Lung Transplant Surgeon, Apollo Hospitals, Chennai; and Adjunct Faculty, Department of Physics, IIT-Madras gives an overview on heart transplant in India and its advancement over the years

ur hearts perform the vital function of moving blood, laden with oxygen obtained by our lungs (that is needed by our cells to breakdown food and use the energy to function and keep us alive) to our cells and bring back carbon dioxide formed to be exhaled out by the lungs. It achieves this by generating mechanical power in its heart cells (cardiomyocytes) by converting chemical energy into mechanical energy. The unidirectional flow of blood from the left side of the heart to the body and its return to the right side of the heart, its subsequent journey through the lungs to exchange oxygen and expel carbon dioxide is made possible by the work of four valves - two on the right and two on the left side of the heart. The heart itself is powered by blood that flows through arteries called the coronary arteries. If our heart stops working and no treatment is available we would die in a matter of minutes. Our heart could, for a variety of reasons, stop suddenly (the commonest reason is a massive heart attack). This is called acute heart failure. More commonly, it loses its function slowly over a period of time. This can happen as a re-

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The advances made in the field of transplantation in general and heart transplant in specific have been due to better management of donors, surveillance, prevention and early management of both rejection and infection

sult of a single heart attack, or repeated mild heart attacks, valves not working well and leaking blood back into the wrong chamber (regurgitation) or becoming tight (stenosis) and not allowing blood to enter a chamber or a combination of both (mixed valve disease), an inability of the heart cell to generate enough power (cardiomyopathy). The latter condition can be the result of infections (especially viral), genetic or medicines (e.g. some cancer drugs). When the heart starts to lose its power, the circulation slows down. the result is that fluid backs up in the tissues. When there is a build up of fluid in the lungs it can lead to breathlessness. The fluid can also build up in the abdomen and around the ankles - these are signs of heart failure. The rising incidence of coronary artery disease in young patients will reflect in time as an increase in the number of patients with ischemic cardiomyopathy.

Difference between heart attack and heart failure The reduction of blood flow in the blood vessels of the heart (coronary artery) can deprive the heart cells of oxygen (ischemia) and cause damage

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to the heart muscle - this is termed as a heart attack. The damage can announce itself as chest pain (angina) or may be silent. The damage can sometimes (not always) result in death to part of the heart muscle (myocardial infarction). When a lot of muscle is damaged the pump function of the heart suffers - this is heart failure. Heart failure is the inability of the heart to maintain the circulation of the blood in step with the needs of the body. Initially, its symptoms may be present only during strenuous work or exercise, later even during rest. Our body has a huge reserve and the ability to adapt and compensate for loss of heart function. This implies that when symptoms appear these reserves are overcome. When symptoms appear at rest it indicates advanced heart failure. Heart failure can be treated initially with medicines, sometimes with conventional management techniques like valve and coronary bypass surgery or stents. If the heart failure is being worsened by a rhythm problem, specialised pacemakers can help. However, when these options are exhausted then heart transplant remains the best option. Heart transplants are the gold standard for the treatment of end stage heart failure. It has come a long way since its introduction in December 1967 and is currently associated with excellent results. The advances made in the field of transplantation in general and heart transplant in specific have been due to better management of donors, surveillance, prevention and early management of both rejection and infection. One of the most important principles that underpin any transplant programme is ensuring that the right person gets the organ at the right time. In the course of their disease, patients transit from a point where their own organ although damaged, can support them (too well to transplant) to a point where the dis-

Heart transplants are the gold standard for the treatment of end stage heart failure. It has come a long way since its introduction and is currently associated with excellent results ease has rendered other organ systems dysfunctional and has resulted in the patient becoming exceptionally high risk for a transplant (too sick to transplant). The time interval between these two points is sometimes referred to as the ‘transplant window.’ Unfortunately, heart and lung failure patients in India are referred very late for consideration of transplants. The potential recipient undergoes a variety of tests to determine their suitability for transplant. The data are summarised in risk scores (eg. Seattle Heart Failure Score) and objective assessment rather than a guess at whether the patient has a better chance with a transplant or not. These scores can be validated in Indian populations only if an effort is made to streamline patients with heart failure into dedicated heart failure clinics with an interdisciplinary mindset. They should

consist of general physician, cardiologist and cardiac surgeons with nurses and rehabilitation personnel to assess, and quantify quality of life issues at all stages of heart failure. Few hospitals in India have such dedicated teams. Heart transplant is associated with excellent outcomes. Our programme has a one year survival of 86 per cent. In terms of quality of life, I can illustrate it with examples of two of my own patients. One of them was 65 years old, breathless on mild exertion, previous coronary bypass, stents placed in the coronary arteries and with cardiac resynchronisation therapy done. None of the above had helped and he had progressive heart failure. He is now four years post transplant and lives life to the fullest, working at his business and runs 10-15 km a day. The second is a young boy, 19 years of age, with restrictive cardiomyopathy. He was bed bound with breathlessness and

DIFFERENCE BETWEEN HEARTATTACK AND HEART FAILURE The reduction of blood flow in the blood vessels of the heart can deprive the heart cells of oxygen and causes damage to the heart muscle - this is termed a heart attack When a lot of muscle is damaged, pump function of the heart suffers this is heart failure. It is the inability of the heart to maintain the circulation of the blood in step with the needs of the body

advanced heart failure. Today, three years post transplant, he has passed his CA exams and leads a normal life.

Heart transplant in India Prof PK Sen is said to have done a heart transplant in India in 1968, soon after Christian Barnard’s maiden attempt in December 1967. The first recorded heart transplant was done in AIIMS in August 1994 soon after the Organ Transplant Act was passed in the parliament. After an initial flurry of activity, enthusiasm waned. A second wave in mid2000s, especially in Tamil Nadu, led to a resurgence of activity. Tamil Nadu in particular has had empathic state support in the form of Tamil Nadu Organ Sharing (TNOS), an initiative by the state government to streamline organ sharing in the entire state. Although in Tamil Nadu the government sector has recorded heart transplants, the majority of heart trans-

plants are still performed in the private sector. No specific registry exists to collate information. A combination of published material, media reports and web-based data indicate that less than 150 heart transplants have been done to date. AIIMS has done 33, TNOS data shows that 88 heart transplants have been performed in Tamil Nadu. Occasional cases have been reported mainly in the media from Kerala, Andhra Pradesh and Chandigarh as well. The reluctance to refer early (in the transplant window), hesitation on the part of patients to see it as valid therapy, cost and logistics have all been factors that have hindered widespread application of heart transplant in the management of heart failure in India. Early referral does not mean early transplant, it will ensure that the patient is optimised and the transplant window is ascertained. It also means that the transplant is not done as an emergency or salvage procedure which in turn limits outcomes.

Future of heart transplant Current medical management, advanced pacemaker options and mechanical hearts have all helped to palliate this difficult clinical problem. Their overall impact has however been variable. Left ventricular assists devices are useful as bridge to transplants and also as an alternative in patients who are not eligible for transplants. When both ventricles are supported it is termed a ‘Total Artificial Heart’. The problems are development of thrombus, strokes, infection and the high costs involved. Increasing miniaturisation of mechanical devices and stem cell therapy are potential therapies that hold promise for the future. They will have to show an equivalence in achieving similar outcomes to heart transplant. Until that happens heart transplantation will remain an important mode of treatment for patients with end stage heart failure.

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cover ) I N T E R V I E W

‘Much of CVD management is amenable to being managed by an app or software’ A cardiovascular health economist interested in understanding and improving long-term clinical outcomes among patients with cardiovascular disease; he co-founded heartMAP – a low-cost, data-driven programme focused on improving medication adherence among lowliteracy patients with advanced cardiovascular disease. M Neelam Kachhap finds out more about the technology, in conversation with Dr Dhruv Kazi, Assistant Professor, UCSF School of Medicine, San Francisco Could you give us a sense of CVD in India? CVD is a threat to the Indian economy as it affects men and women in their 50s, who are at the peak of their economic productivity. This is almost a decade younger than in Western countries, so our ageadjusted rates of CVD are among the highest in the world. As a society, we’ve gotten more overweight and less physically active, and have some of the highest rates of diabetes and high blood pressure in the world. So, we are seeing an epidemic of CVDs of unprecedented proportions. How does CVD in India compare to a similar nation, China? China faces similar challenges with CVDs and tobacco use, with some key differences. They have higher rates of strokes than we do – and we have higher rates of heart attacks. It’s not clear why this difference exists. However, China has invested heavily in its public healthcare system over the past decade, so they now are better equipped to handle cardiac emergencies. They are also investing heavily in research, to understand the local needs and opportunities. Why should we use m-Health for managing diseases? India has seven doctors per 10,000 population – one fourth of those in Western countries. As you know, this number is

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only a half-truth – disparities are even more severe in rural areas, where one may not find a trained experienced practitioner for miles. We clearly do not have the resources needed to rely on doctors to manage the national burden of CVDs – we don’t have enough physicians and it would simply be too expensive. We need to find alternative, costeffective solutions, so that doctors can focus on the most complex cases, while the everyday management of hypertension or uncomplicated CVD can be done by trained healthcare workers empowered by technology. And this is achievable – much of CVD management is algorithmic and therefore amenable to being managed by an app or software. Latest figures suggest we have 900 million mobile subscriptions in a country of 1.2 billion people – practically every adult has one. Over the next decade, we will see increased penetration of low cost smart phones – so every Indian will have the power of a small computer in their pockets, and communication costs will be low. This is a fantastic opportunity to leverage welldesigned, well-studied technological solutions to help address the gap in healthcare services and boost the health of our entire population. Tell us about the study you undertook at Bangalore for

Developing technologies for healthcare requires a nuanced understanding of the providers and patients managing CVD patients? The project in Bangalore, with Narayana Hospitals, is an ongoing project. We are currently in pilot stages and are examining whether a welldesigned app can help nurses and technicians manage relatively complex patients who need to be on blood thinners after heart surgery. This

particular app is designed for use by nurses and technicians rather than the patients themselves, but eventually the goal will be to have the patients enter their own data into the app. It uses a simple algorithm at the back end to make recommendations about how to adjust the dose of the blood thinner and when the patient needs to get checked. In order to teach people about blood thinners, we developed a soap opera (in Kannada) with local TV celebrities. The Center for Chronic Disease Control in New Delhi are also partners in the project and, along with Narayana Hospitals, have been incredibly supportive. What are the learnings from the pilot project? Our early field tests have shown some interesting results. Nurses and technicians are excited about the technology, and find it very simple to use. It helps them make better decisions but also improves efficiency – so it’s a win-win for all concerned. We did learn that in this particular patient population, literacy is a real challenge, so patients prefer using phone calls to SMS. How did the study help in understanding the use of mobile apps for disease management? Developing technologies for healthcare requires a nuanced understanding of the providers and patients. There is great

value to partner with patients, families, and their providers early in the design process – which helps make the product more user friendly and practical. There are many opportunities in our health care system for well-designed and validated applications to address the health needs of our population. What is the next step ? Our project is ongoing as we continue to refine and deploy the product. We have received an overwhelming response from cardiologists and patients and are looking for technology partners in India to help with the growth. In the long-run, I would like to see dedicated incubators or training programmes that help young software developers or entrepreneurs understand the special needs of developing robust healthcare applications. Your parting remarks The epidemic of CVDs in India is a real threat to our future and we will pay an enormous price - in lives and money - if we continue to ignore it. But we have an amazing opportunity to fix this problem in a cost–effective manner. We need to inspire the next generation of young techies and entrepreneurs to partner with doctors and population scientists to tackle this challenge head–on. We can fix this, but the time to act is now. mneelam.kachhap@expressindia.com

STRATEGY IDEA EXCHANGE

Reining in the NCD epidemic India has some of the worst disease indicators when it comes to Non-Communicable Diseases (NCDs). Express Healthcare recently organised an Idea Exchange with key stakeholders to understand what could be the first steps toward formulating a policy framework to aggressively tackle the problem. Excerpts from the interaction ... Viveka Roychowdhury, Editor, Express Healthcare: We welcome our guests on the panel: Dr Kenneth Thorpe who is the Chairman of the Partnership to Fight Chronic Disease (PFCD), Dr Shashank Joshi, a renowned diabetologist and Dr Ratna Devi, CEO and Co-founder of DakshamA Health and Education. Between them, we have three important stakeholders in the fight against NCDs: a policy expert, a clinician and a health management professional who has worked in private and government health facilities and now bridges the gap between the two and patients. Let me start by asking Dr Thorpe to share his experiences while engaging with policy makers in India on the topic of NCDs. I will ask him to juxtapose this with his experience in the US where he has been associated formulating healthcare policy. Are we on the right path in India? Dr Thorpe: We've seen a number of interesting things during our trip to India. One is that there is obviously a consensus that the magnitude of the problem of chronic diseases (NCDs) in India is substantial and is growing. There are currently around 65 million diabetics and going by current trends this is going to increase to well over 100 million diabetics pretty soon. The magnitude of the problem is substantial. I think people have a common understanding that there is a substantial problem. Second, I think that there is a common understanding that the capacity of the prevention and delivery system that is currently in place is not well equipped

(L-R) Dr Ratna Devi, CEO, DakshamA Health and Education, Dr Kenneth Thorpe, Chairman of the Partnership to Fight Chronic Disease (PFCD) and Dr Shashank Joshi, President, Indian Diabetic Association

to deal with that problem. Third, if you look at the gap between what's needed in terms of system delivery and patient treatment, I think there is growing interest in coming up with a blueprint and broad thinking nationally about a comprehensive healthcare reform framework that really focuses on three issues: How do we do a better job of preventing the growth in chronic disease? How do we increase disease detection rates so that we can clinically intervene earlier? And thirdly, building a primary care team-based care management system that really deals with patients that

have not just one but multiple chronic conditions. The other realisation is that most times, we tend to categorise and look at silos whether its diabetes, hypertension and so on. The reality is that most patients having chronic disease have several chronic diseases ranging from mental disorders, diabetes, other cardiovascular risk factors and so on. So having a system in place that really effectively engages patients to keep them healthy is the third part which I think still needs to happen. Roychowdhury: Dr Shashank Joshi, Dr Thorpe mentioned that patients

have multiple diseases. What is your perspective coming from your clinical experience? You have published many papers based on your research on the Indian population on this aspect and your conclusions are that early detection and early diagnosis is part of it. How do you actually implement those kind of things here in India? Dr Shashank Joshi: There is no simple answer. We as Asian Indians are based out of India but we have this huge change happening in the last 200 years. To be more specific, in the last 30 to 40 years which is development and growth.

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STRATEGY

IF YOU LOOK AT THE GAP BETWEEN WHAT'S NEEDED IN TERMS OF SYSTEM DELIVERY AND PATIENT TREATMENT, I THINK THERE IS GROWING INTEREST IN COMING UP WITH A BLUEPRINT AND BROAD THINKING NATIONALLY ABOUT A COMPREHENSIVE HEALTHCARE -DR KENNETH THORPE REFORM FRAMEWORK We have abandoned our ancestral habits. We have moved from tribes to villages to small towns, from small towns to big towns to big cities within India. Asian Indians are also one of the the largest migrant communities across the world. Whenever you migrate and improve your socio-economic status, you become affluent and sedentary and that is giving rise to a whole cluster of NCDs, whether it mental health which leads to stress leading to depression, anxiety or disease like blood pressure or diabetes or coronary artery disease. They all have a common thread, which is clustering of these metabolic risk factors. They are all fundamentally due to sedentary work habits, probably improper diet and probably some genetic transformation. We were a famine ridden economically deprived country and physically very active. So obviously, over the last few hundred years we have conserved the fuel storage needs in our stomach. And that abdominal fat has led to the metabolic syndrome. So we cannot have disease specific options. I think you have to have NCDs as a common goal, common theme and deliverables which can be done (at the level of) healthcare workers, lay persons. On the other hand, we are one of the largest exporters of healthcare workers, whether it is doctors or nurses, across the world. Our best graduates are migrating to different parts of the world, whether it is to the Middle East, Europe and North America. So our healthcare system is grossly understaffed. We have one of the worst doctor:patient ratios. But the bigger challenge in prevention is looking at pre-disease, into hidden disease. That burden of disease is very large and that needs political will as well as individual will to make a change. And we have not yet empowered either our policy makers or our individuals to make the change. It has to be a movement. Unless and until we are able to crystallised it into a movement, we will not be able to make a dent on the numbers. For example, in diabetes, we are committed that we want to change our diabetes numbers. So when I was president of RSSDI, we

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had only a prevention mantra but that time we were the number one country in the world in the diabetes. Now we are happy that we are number two! We would be happy to be in last in this list! But we are not stopping there. As healthcare providers, our theme is very clear: we want to be the diabetes care capital of the world. We want to give the best care, we want to get the best prevention strategy in place. And we have to do capacity building for our own healthcare providers. Our capacity building is very woefully lacking. Also remember, compared to Western populations, we are a completely non-reimbursed market. Health is number 22 (on the priority list) so we cannot expect the government to do any change. Everybody in India pays for healthcare out-of-pocket. Our public health infrastructure is not commensurate with our general population. 92 per cent of our healthcare delivery, even today in urban India, is through the private sector. More than 82 per cent of our healthcare delivery even in rural areas, occurs though the private sector, which speaks a lot for our public health infrastructure. Obviously there are gaps. We need to change that. Roychowdhury: Dr Ratna Devi, you could be in some way part of the change because you been bridge between political will and the patient will and other stakeholders as part of it so you've been the unifying structure there to implement what the government wants to do with the help of other stakeholders. So can you share with us your experience, what kind of projects are being done in India and what more needs to be done. Dr Ratna Devi: Unfortunately in India, culturally, we do not consider healthcare as a priority. Even when we are healthy and there is an incident, we try to postpone a visit to the doctor or to manage our healthcare on our own till it becomes a crisis situation where we can no longer postpone it. That's one of the reasons for the high costs of healthcare which could have been prevented had some intervention taken place at the primary level itself.

There are several reasons for that. I think traditionally we are stoic population who like to put off things, saying it will correct itself over a period of time. There have been traditional ways of managing small incidences and when those things do not work, then we seek care at a hospital or healthcare facility. As Dr Joshi mentioned, there has been lot of migration. People moving from rural to urban areas bringing massive changes in lifestyles and consequently no time to seek healthcare. Even if a person wanted to, daily life is so grueling that it is impossible to seek healthcare without losing your daily wages or without losing your job opportunities. So the whole concept of managing your own health, that 'I'm the person responsible for my own good health' does not exist. Also, there is low health literacy. Whether it is the so-called rural population or the urban educated population, you donâ&#x20AC;&#x2122;t see behaviour change happening in spite of good messaging, in spite of reading the right stuff, in spite of people being told by their physicians. Or even inspite of people having other members in the family suffering from the same disease. Prevention just does not happen. I think that is because people live in denial. Most often people think, 'Itâ&#x20AC;&#x2122;s not going to happen to me'. And one of the reasons could be the cost of healthcare. The general understanding of people is that if you go to a hospital, you end up with something that you did not know existed and that could result in a lot more spending that you had not expected. For good examples (of existing healthcare delivery projects), the best one that I can relate to is the HIV movement, where the patients themselves formed peer groups and the stigma that was associated with the diseases was removed. There was lot of awareness generation because people talked among themselves. The movement was successful because people came out from their homes, got themselves tested and those who were positive, were then directed towards healthcare facilities. In the NCD segment, that kind of moment is yet to start. There are a few organisations working in that particu-

lar area, specially the cancer groups, where there has been a lot of advocacy and awareness generation. Enrollment has happened so people are coming forward to seek treatment. It is still in a very very nascent stage and lot of work needs to be done to get people mobilised to work together, to become aware that what we are talking about, actually affects everybody and then start working towards prevention so that they are the managers of their own health. Lakshmipriya Nair: Dr Thorpe, can you give us some examples of successful programmes that have been implemented in other countries and can be implemented in India so that NCDs can be controlled. Dr Thorpe: On the prevention side, I can think of two things that happened in US. One, is that smoking rates declined from about 50-55 per cent of the population in the 1960ties to 20-21 per cent of the population today. So if you look at that big decline in smoking, combined with the more extensive use of statins, and other types of cholesterol-lowering drugs, anti-hypertensives etc, cardiovascular mortality rates in deaths due to strokes have dropped dramatically. There's been some important successes there. There are lot of reasons why smoking rates went down. A part of it is the high taxes we imposed, both at the state and federal level, on buying of tobacco products. But there is also a shift in social perception of smoking that happened over a long period of time. On the obesity side, we have lot of good data now from a intense lifestyle intervention programme called the diabetes prevention programme. Very similar programmes like that have been operated in very diverse countries: Finland, China, the US. We have 10 years of data from the US randomised trial that shows that that programme targeting overweight pre-diabetic adults has resulted in cumulative reduction in the incidence of diabetes. There are elements of that programme (diet, exercise, nutrition, physical activity and exercise goals) that could be and have been adapted in a variety of different settings.

STRATEGY

ABOUTTHE PANELISTS

DR KENNETH THORPE

DR SHASHANK JOSHI

DR RATNA DEVI

is the Chairman of the Partnership to Fight Chronic Disease; He was the Deputy Assistant Secretary for Health Policy in the US and has given a lot of inputs to President Clinton's healthcare reform proposals for the White House. He has continued to advise health policy experts in the US and in particualr to evaluate alternative approaches for providing health insurance to the uninsured.

is the President, Association of Physicians of India (API), President of Indian Academy of Diabetes and Past President of Research Society for Study of Diabetes in India (RSSDI). His prevention mantra, launched at RSSDI in 2011 is, "Eat less, Eat on time, Eat Right, Walk More, Sleep well & on time and smile" and I think that sums up very nicely a mantra for all of us to follow but obviously there is a gap in patent behavioral patterns. He has also spoken extensively on the potential to make India not the diabetes capital but the diabetes care capital of the world.

is the CEO and Co-founder of DakshamA Health and Education, an organisation that is dedicated to working for access to health, patient education and advocacy. DakshamA aims to create a network of caregivers and patient groups, and work with them on knowledge sharing as well as providing essential feedback for managing long term and chronic diseases. Dr. Devi works towards achieving these objectives by collaborating with the government and other vital

On the treatment side, where all the money is, in terms of expenditure associated with chronic disease, one of the things I think we've learnt from looking at data over the last decades, is that we will need to use interdisciplinary health teams. And they don't have to all be primary healthcare physicians. Managing and working with patients and engaging with patients to be compliant in terms of taking their medication, having the right combinations of medicines and dosage of them, can be done with community health workers, home health aides, nurses, nurse practitioners working with primary care physicians that are doing the basic and fundamental diagnosis of the disease. Going by the data we have, those health teams have resulted in the dramatic reductions in rate of hospitalisations, the rate of re-admissions to hospitals, the number of emergency room and clinic visits. So that is one of the very good success stories we could look at in a variety of different countries to find ways to scale those teams and replicate their success. A lot of what we are talking about here is not necessarily health insurance benefit designed but is related to population and public health interventions that need to be more widely diffused in countries like India as well as in the US, in order to combat these problems. Usha Sharma: Dr Joshi, as a doctor, how are you increasing awareness about NCDs as well as creating better platforms to access medication?

WE ALSO HAVE A DOUBLE BURDEN OF A LARGE PAEDIATRIC POPULATION AS WELL AS A VERY LARGE GERIATRIC POPULATION. ONE FOURTH OF THE GERIATRIC POPULATION OF THE WORLD LIVES IN INDIA. SO WE NEED TO HAVE THINGS IN PLACE AND NOT BE IN NCD DENIAL MODE. OUR HEALTHCARE PROFESSIONALS, PARTICULARLY FROM THE HEALTH MINISTRY, NEED TO RECOGNISE THAT -DR SHASHANK JOSHI

Dr Joshi: The situation is extremely critical in India. I would say that it is a danger zone because NCDs are driving two things. One is they are killing people. The average life span of a Mumbaikar is eight years less than an average Indian. And why does he die early compared to rest of the population in India? Because seven out of 10 causes

of death are NCDs. I.e diabetes, chronic heart disease, respiratory disease, hypertension, COPD, pollution related asthma etc. We all are living here but we all are going to die eight years before rest of the people in India. This is hardcore data from our own city. Let us look at causes of death at a national level. Just 10-20 years back, (the highest deaths) were from diseases like tuberculosis and communicable diseases. HIV gets more media publicity but its intervention programme is in place. Today it is NCDs that are killing (patients). Even mortality indicators are clearly showing that these diseases kill. But the bigger problem than mortality is that these diseases are affecting the productive years of people's lives, which are the years between 25 to 55 years. We know that all the NCDs in India occur a decade or so earlier than in the Causacian population. We have lower BMI, our body structure is smaller but our body composition has more fat and therefore we are 'thin fat Indians'. We are actually abdominally obese, with high insulin resistance which is driving the epidemic. When somebody (is diagnosed with) diabetes or blood pressure, it is not the disease that kills, it is the burden of the disease which comes due to the complications of the disease. The disease is diagnosed almost a decade late, it comes almost a decade earlier and as Dr Ratna Devi rightly said, people in India get diagnosed late and only go to a doctor in a crisis. Indian diabetic patients do not

take their diabetes as seriously as this: they will exercise a bit, change some dietary habits, take alternative medicines and then dismiss it as a 'mild sugar problem'. Till he has a heart attack, or his kidneys fail or he becomes blind or his legs are amputated. Whereas in the US, in 2003, the American Diabetic Association and American Heart Association had said, that if you have a simple diagnosis of diabetes, it is equivalent to a heart attack. Here, the rates of deadly retinopathies, renal failures, amputations and heart problems have reduced because their prevention programmes are in place. Of course, they have a reimbursement system in place as well ... of course there are problems with Obamacare, but they do have some systems in place. So firstly, NCDs kill. Secondly, they cripple and maim. And the economic costs of complications arising due to NCDs is very very large. These complications put fear into patients and they go into denial mode. So we have got into a vicious cycle which needs to be broken. We need to recognise that NCDs are epidemical in India, they are killing Indians and we are clearly in a danger zone. The average life of any Indian or an urbanite Indian residing in any city of the country is lesser than that of an average person living in the world. We also have a double burden of a large paediatric population as well as a very large geriatric population. One fourth of the geriatric population of the world lives in India. So we need to have

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STRATEGY things in place and not be in NCD denial mode. Our healthcare professionals, particularly from the Health Ministry, need to recognise that. Our tobacco control and smoking cessation programmes have just come into place via some legislations and taxations. Also, fast foods are breaking our ancestral food habits and diets. Our Government should ban or tax these products heavily so that they are unsustainable in India because they are damaging our health and economy. So we should not deny that we have an NCD problem; we need to tackle it aggressively at every stage, be it pre disease or end stage and we need to ensure that we empower our patients. Currently our healthcare infrastructure is over burdened so healthcare providers do not have the time. So therefore we need to have more nutritionists, counselors and patient support systems in place. We need to have peer groups, as Dr Ratna Devi was saying, Unless you take drastic steps there will be no change. Otherwise it will be too late to manage it. NCDs have clearly overtaken the communicable diseases. Sanjiv Das: Do certain dietary habits predipose us to diabetes? For instance, I am from the state of West Bengal and all Bengalis love their sweets. Rice is also a staple of our diet. And many of our relatives have been diagnosed with diabetes. What advice can you give for such populations? Dr Joshi: Eating sweets and rice does not mean that you will develop diabetes as long as you are physically active. Physical activities can reduce the chances of having diabetes. If there's a family history of diabetes then this can increase the chances of diabetes. There are two major risk factors for diabetics in India. One is family history and the other is abdominal circumference. Men with an abdominal circumference of more than 90 cm and women with more than 80 cm are at a greater risk to develop any of the NCDs or metabolic syndrome cluster of disease conditions like increased blood pressure, a high blood sugar level, and abnormal cholesterol levels. My advice is very simple: eat moderately and exercise. Prevention is all about motivation and empowerment. Walk at least 1000 steps a day, and you can walk away from diabetes and other NCDs. A community movement is necessary for general awareness and I don't think it is impossible. Roychowdhury: Dr Ratna Devi, what are your key recommendations for the government?

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Dr Ratna Devi: My first recommendation is to recognise patients as a very strong voice that can contribute very positively at different levels, whether it is at the prevention, management or a service delivery platform. In all these platforms they (the patients) have a definite role. If it is a large enough group, they can be a very strong voice to bring about changes at the policy level as to what is the most conducive way to reach out to populations that need those kind of services. For prevention strategies, since we are such a diverse country, it is very important that patients are involved in message dissemination, message construction, as well as converting those messages into behaviour change. In terms of service delivery, there have been excellent examples where people who have come out of a situation have been able to convince other people to adopt healthy means and these could be expert patients who are then trained so that they can manage situations at the community level or at the home level. This is the first recommendation I have, to be able to recognise them as a very strong voice that can contribute very positively at different levels. The second one is to empower them with the right amount of knowledge and the tools. There is a lot of information available but how to understand that at an individual level to be able to connect or correlate to the disease condition or the disease syndrome that the patient has, is very difficult. That is the reason why we hear a lot of stuff but we do not really imbibe or understand what exactly it is trying to convey to us. So, empower them with the right knowledge and the right tools. When we say tools, there are lot of diagnostic kits and home made kits available in the market but how easy are they to use, how comfortable are people really with these kits? Patients may buy an instrument but the paraphernalia that goes with it is sometimes not available. So empower the patients so that they are able to use the tools with the right knowledge and the right information. Thirdly, make the patients responsible for their own disease outcomes, manage their own disease in a way that they feel happy at the end of a certain period that they have achieved the targets they set for themselves. It is very difficult in the current situation because as we said, our health system is so over burdened so that kind of space just does not exist. But what we can do is have counselors from amongst the patients or caregivers who can then come forward and do this work for them.

FOR PREVENTION STRATEGIES, SINCE WE ARE SUCH A DIVERSE COUNTRY, IT IS VERY IMPORTANT THAT PATIENTS ARE INVOLVED IN MESSAGE DISSEMINATION, MESSAGE CONSTRUCTION, AS WELL AS CONVERTING THOSE MESSAGES INTO BEHAVIOUR CHANGE - DR RATNA DEVI

Roychowdhury: Dr Thorpe, we do see certain policy initiatives with a health focus like the recent increased tax on tobacco products. What would be your recommendations? Dr Thorpe: I will start in a couple of places. One of the things that I have mentioned in the beginning is to develop a national framework, a national roadmap for driving the reforms we've been talking about, that will prevent the growth in NCDs, do a better job of early detection and then manage and work with patients to do that. If you have to be successful then a couple of things have to happen with the blueprint. One recommendation is to recognise the power of partnerships. The magnitude of this problem, be it any country, be it India, Indonesia, US, etc is quite substantial. The government is not going to be able solve this by itself. So, patients, providers, employers and those whom they employ, should work collaboratively so that it is part of a process. Secondly, we have to find new ways to unleash the extraordinary amount of entrepreneurship and innovation, which is already here in India. In so many sectors of the Indian economy there has been a lot of innovation in international leadership going on, innovation in entrepreneurship. We have to harness that in some way in order to make it a part of the reform process, for coming up with innovative ways for preventing disease or doing delivery system reforms. For instance, take the role of electronics, the role of some of the new monitoring devices that are available and are being developed. We can look at more innovative and effective ways of preventing and managing these diseases, Finally, to lay this blueprint down,

you must see what the requirements are and have a discussion on how are you going to get to pay for it, to decide what is fair and what makes sense. I was really struck by how low India's spend on healthcare is as a percentage of its GDP. The bulk of it, over 60 per cent, is paidout-of-pocket. So I think as part of the framework discussion, they should have a debate, a discussion on what role is expanding private insurance going to play. Does the type of private insurance that currently exists in the market make any sense in terms of treatment needs of chronically ill patients? I think that probably there is a big gap between what the insurance covers and what you really need to provide healthcare services that are clinically effective to chronically ill patients. If you can get more money from the private sector to do this then is there an opportunity for the government sector, over a period of time, to increase their commitment towards those at the lower end of income distribution, for those who are living in poverty, and for coming up with a national framework for public health infrastructure that would be adopted obviously at the state-level? So that would be a starting point. If we have a road-map that engages a wide variety of stakeholders and takes the best of the best - there is a lot of good thinking out there in terms of provider groups, insurance groups, patient advocacy groups, employers and so on - then we will have all of these people sitting at the table trying to solve the problem. Roychowdhury: What will be the role of PFCD in this scenario? Dr Thorpe: We'd love to serve as a resource to work with different groups that are interested in putting this framework together. We have found, at least in the US, that is increasingly working in a variety of different countries, that having a stakeholder approach, that 'we pull together', we have around 100 different organisations working together collaboratively, with policy makers, who are putting together policies to solve the NCD problem. We started out by highlighting the problem, (like we did here today), in recognising the problem. We need to make a quick transition into implementing a best practice solution to solving these problems. A starting point in terms of the framework is cataloging what are the effective interventions out there that we've seen internationally or in India through existing pilot projects that work. How can we scale and replicate those successful models so that they are available throughout India and not in some limited pilots?

STRATEGY INSIGHT

Laying a strong economic foundation for new hospitals The market for healthcare services in India is growing, yet many examples of empty or unprofitable hospitals indicate that despite the opportunity, success is not guaranteed. To lay a strong economic foundation for new hospitals, promoters can articulate their vision and then put it to the test, say Ravindra Beleyur and Vlad Flamind from Kanvic Consulting

RAVINDRA BELEYUR Co-Founder and Director, Kanvic Consulting

VLAD FLAMIND Associate Consultant, Kanvic Consulting

he Indian healthcare market is characterised by a vast and persistent gap between supply and demand. Over the last decade a tremendous number of hospitals have been opened across the country in an attempt to bridge this gap. Many of these ventures have been successful in addressing the needs of the patients and in rewarding investors with healthy returns. However, failures have also been plentiful. Numerous hospitals have failed to achieve profitability, showing that despite the enormous opportunity, success in not guaranteed in the Indian healthcare sector. If healthcare leaders are to invest in new hospital ventures with confidence, it is important that they are aware of the common pitfalls related to setting-up new hospitals. Furthermore, by conducting thorough strategic and financial assessments, they can lay a strong economic foundation which increases the future returns and mitigates the potential risks. ■ Tremendous opportunity for growth in Indian healthcare There is an immense need for additional hospitals in India to improve coverage and relieve overcrowding in existing facilities. Today, there are about 1.6 million hospital beds available across the country. To meet the most basic international standards, India should be equipped with at least three million more. In this context, the opportunity for Indian and international hospital promoters is substantial. Demand is vast, largely untapped, and continually expanding (Exhibit 01). The rapid growth of the Indian population is itself contributing to the increased demand for healthcare, but the rise in consultations and hospitalisations is also driven by increasing affordability, patients’ changing lifestyles and their evolving perceptions of healthcare. Patients are able to spend an increasing amount of time and money on healthcare thanks to improving income levels, better availability of insurance, and schemes supported by the government. At the same time, the clinical profile of patients is changing with increasing morbidity from noncommunicable diseases such as diabetes, hypertension, or injuries caused by traffic accidents. Demand is also driven by changes in patients’

perception of health and healthcare. Indian patients now have a better awareness of the risks associated with their condition, and of the capacity of allopathic medicine to treat them. They are becoming less inclined to restrict their hospital visits for extreme cases, or to postpone them until pain becomes unbearable. The net effect of all these changes is that more patients are seeking medical care, and tend to visit hospitals more often. ■ New hospital promoters need to clarify and test their vision before making any investment Doctors and hospital leaders are well aware of the opportunity and do not lack the ambition to seize it. Most of the time, they also have a solid set of strengths they can rely on to set-up successful hospitals. After

many years in the market, they benefit from a base of loyal patients, an established reputation, as well as a network of doctors and potential financiers that could play key roles in their expansion plans. However, confidence in one’s capabilities and in the market opportunity tends to generate a bias for hasty action. As a result, the focus of many healthcare leaders often jumps to acquiring land and premises, building a team of medical specialists, and securing finance for their project. All of this is necessary, but two fundamental questions should be addressed beforehand: ◗ What type of hospital could be successful in this location? ◗ What returns can be expected from such a project? Leaving these questions unanswered can result in

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STRATEGY To make the right strategic and financial decisions, healthcare leaders can follow an iterative process based on defining, testing and refining their project leaders and promoters making critical decisions in the dark. To make the right strategic and financial decisions, healthcare leaders can follow an iterative process based on defining, testing and refining their project. They should start by translating their vision of the new hospital into a well defined concept. This concept should be shaped around a set of critical elements impacting investment, revenue generation and cost structure, and which will be used to draw-up a business model. Once the business model is built, it should be subjected to a series of tests to ensure its economic viability and financial attractiveness. Investment and set-up should only start when the tests show the green light. If the tests are negative, the concept must be revised and assessed again (Exhibit 02). ■ Healthcare providers need to look at five major elements to define a hospital concept A hospital concept can be articulated around five major elements (Exhibit 03): ◗ Location: Expressed in terms of city, district or precise location - if already available - the location is an essential component of the concept. It frames the strategic playing field - or catchment area - by narrowing down the patient population, as well as the hospitals to be considered as competitors. It also has a direct impact on the investment or rental costs the hospital will absorb. ◗ Patient profile: Within the considered catchment area, specific groups of patients should be identified as targets. This can be done by analysing the clinical and non-clinical profiles of the population. Potential patients can be grouped into categories based on their place of residence, age, socio-economic class and insurance coverage or by estimating disease incidence and hospitalisation rates. At this stage, the analysis aims to provide an indication of the local demand for specific healthcare services. ◗ Scope of services: With an understanding of the local market context, the services to be provided by the planned hospital can be better defined. The scope relates to the medical specialities covered and the depth at which care will be provided. These elements will in turn drive the type of beds, equipment, and medical staff required in the hospital. ◗ Scale: Scale is determined by the number of beds installed and by the size of the facilities. It is a critical part of the concept because it has a major impact on the initial investment and cost structure. This is

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mainly through the equipment, land and building, and human resource the planned hospital will require. ◗ Level of amenities: A hospital’s level of amenities contribute to creating a unique experience for the patients as well as their visiting relatives. Their experience is shaped by a number of elements ranging from the layout and appearance of the premises to the type of non-medical services available. Indian patients are increasingly seeking value outside the purely clinical side of healthcare; convenience,

prestige, and comfort now play an important role in their decision making process. But seeking differentiation in these areas also generates additional costs, making amenities a central part of a hospital’s concept. Once the five elements of the concept are defined, their coherence must be verified. For example, the pricing levels and the scope of services should match the clinical and socio-economic profile of the population in the desired location. Both of them should also be calibrated with regards to the existing competition

STRATEGY To estimate profitability the cost structure required to run the particular hospital concept and the potential revenue generation should be understood in the area. Similarly, the scale must be large enough to offer the desired scope of services, but not so large that it prevents achieving a high bed occupancy rate. In this way all the elements of the concept must be analysed in relation to each other. This assessment for coherence must be thorough and should be used to refine the initial concept. ■ The hospital concept must be translated into a business model When the concept reaches a coherent shape it can be translated into a business model expressed around three metrics: investment, profitability and value. This step is critical because a coherent concept may not necessarily be viable from an economic and financial standpoint. ◗ Investment: Investment requirements for a hospital can vary depending on two alternative options (Exhibit 04). The first is the asset heavy option, in which substantial investment is directed to the acquisition of land, premises and equipment. The second is the asset light option, in which these investments are made by other partners. Instead of owning land, building and equipment, the main promoters choose to rent or lease them, effectively treating them as costs. Going for the asset light option can easily enable over 50 per cent reduction in the initial investment required, shortening the payback period substantially. However, renting or leasing also comes with certain disadvantages including: the inability to benefit from accruals in land value, or the potential need to share equity in compensation for the contribution from the real estate investor or other partners. ◗ Profitability: To estimate profitability the cost structure required to run the particular hospital concept and the potential revenue generation should be understood. Estimating profits is a delicate step that should always be anchored in reality. To avoid the trap of wishful thinking it is necessary to study how hospitals located in the same region, as well as hospitals sharing comparable concepts have performed historically. A critical variable that ought to be approached conservatively is bed occupancy. Generally, after a hospital is set-up, it takes three to five years to reach a healthy and stable occupancy rate. ◗ Value: The last element to include in the business model is valuation. Based on investment and profitability estimates, the value of the planned

hospital can be derived. This measurement is necessary to determine how much each promoter should contribute to own a given stake in the project, as well as to establish the optimal distribution of equity between partners. The business model needs to be tested to determine project attractiveness Once the model is built, the viability of the concept can be tested both financially and strategically.

If the tests are negative, the concept must be refined. If positive, investment can be considered. ◗ Financial test: The financial test revolves around a set of questions aimed at assessing the attractiveness of the investment (Exhibit 05). The investors must first decide if they are willing to commit the funds required for the hospital set-up. They must then determine whether the project can be financed with an acceptable amount of debt and

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STRATEGY Before investing in a new hospital, a leadership team has to be formed, information must be shared, decisions delegated and power distributed external equity, and whether the distribution of shares is in line with their expectations. Finally, they must establish whether the expected returns are satisfactory. If the required investment seems too daunting a prospect, unfavourable to their long-term interests, or insufficiently attractive, the concept must be revised. ◗ Strategic test: If the financial test is positive, the concept can be submitted to a final strategic test (Exhibit 06). This last stage will determine whether the concept is fit for the realities of the market by answering two questions: 1) Is the concept what the market needs? 2) Is the leadership team capable of successfully running the hospital? Answering the first question requires a deeper understanding of the supply and demand situation in the catchment area. This understanding should be both quantitative and qualitative to best evaluate the assumptions made when projecting the revenues of the business model. On the quantitative side, the disease incidence and hospitalisation rates of the target population should be compared with the existing supply of beds, medical specialists and services in the area. This is required to ensure that the new hospital has the scale and scope to fill the right gaps in demand. On the qualitative side, existing hospitals in the region should be visited and their patients observed and interviewed. Key areas to investigate include the target patients’ inclination and capacity to pay for healthcare, their preference for certain hospitals, and the key elements that influence their decision making. This on-the-ground knowledge is critical to understanding whether the new concept would be appealing to local patients. If the concept is indeed aligned with the market needs, the very last question to address is the one of leadership. When setting-up a new hospital, entrepreneurs often go for bigger facilities than the ones they have been running in the past. What is important to realise is that the challenges of leading a 200 beds hospital are quite different from those of a 50 beds facility. The transition requires a shift in the way leadership is exercised, and in the type of people needed to take-on key positions. Managing the entire operation single-handedly is no longer possible when the hospital scales-up. A leadership team has to be formed, information must be shared, decisions delegated and power distributed. Before investing in a new hospital, this team must be identified and aligned with the project’s objectives.

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■ If the lights turn green, investment can be considered with confidence If the tests are positive, investors can proceed with confidence. The hospital concept has an economically sound business model, and the prospects for success in the market are high. Action can be taken to plan the hospital construction, approach external lenders and investors, and bring doctors and other key stakeholders on-board. Also, the knowl-

edge gained while building and testing the concept will promote unity around the vision and clarity in execution. About the authors: Ravindra Beleyur is a Co Founder and Director at Kanvic where he leads Corporate Finance practice. Vlad Flamind is an Associate Consultant working in Kanvic’s strategy practice between India and Europe

STRATEGY INSIGHT

Medical Technology: Vision 2025 roadmap for the way forward Boston Consulting Group and Confederation of Indian Industry’s white paper, Medical Technology: Vision 2025, highlights the opportunity for the medical technology industry in India. Excerpts from the report

oston Consulting Group (BCG) and Confederation of Indian Industry (CII) after several months of deliberation has created a roadmap to create a $50 billion opportunity in the medical technology space in India. Collectively, they have identified six areas to work on creating the right supporting ecosystem. BCG and CII have highlighted four ‘quick wins’ and two longer–term initiatives which will help develop this ecosystem. Quick wins are initiatives which should be implemented within the next 12 months as these are crucial for the further growth of the medical technology industry.

ROADMAP FOR A VIBRANT MEDICAL TECHNOLOGY INDUSTRY IN INDIA

◗ Reward local and market relevant innovation

QUICK WINS ◗ Medical technology relevant regulation

Regulations should be in place that are dedicated, predictable, transparent, globally harmonised and appropriate for medical devices. It could preferably be based on a separate medical device regulatory act and governed by an independent regulatory body with specialised regulators. If that is not achievable in the short term, at the very least, it is recommended that the government should include industry inputs and pass the Drugs & Cosmetics Amendment Bill 2013, which can then provide a starting point to separate medical devices from drugs and pharmaceuticals. A ‘one–window’ institution needs to be created to ease the regulatory burden for the

training and accreditation, particularly when it comes to healthcare workers.

Source: Vision 2025 — CII brainstorming sessions held on December 2013 and April 2014 industry and reduce the bureaucracy associated with approval for development, technology transfer and manufacturing. The government has to promote transparent and evidence-based pricing and reimbursement policies. It needs to develop a dynamic procurement mechanism

Government should promote transparent and evidencebased pricing policies

for assessing the clinical outcomes and cost effectiveness of a medical technology to determine its merit for inclusion in public insurance schemes. The government should also table discussions on a PPP framework for operationalisation of partnerships as well as discussions around

A national innovation policy linked to the disease profile is required and should be organised in a way that innovation which are locally relevant in India can be rewarded. Initiatives like BIRAC to medical technology should be expanded; these initiatives should be broadened to cover more research and support more local innovation. These schemes should provide seed capital, viability gap funding, co-fund start-up projects and support the commercialisation of innovations. The government should create strong incentives for commercialisation of ideas by creating access to reimbursement in the governmentfunded schemes using a value based approach. A longer-term view (10 years window) for 200 per cent weighted tax deduction on approved expenditure on R&D activities should be provided as the gestation period is high in this industry. ◗ Build manufacturing infrastructure

Streamline the process of setting up manufacturing facilities in India by designating medical technology hubs with the right infrastructure in place to support complex medical technology manufacturing.

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STRATEGY Create training hubs around these manufacturing hubs to ensure a ready supply of trained talent to support these hubs. Industry to assure recruitment from these hubs. Manufacturing incentives for example, tax support, low cost funding should be provided to spur investments and to make the busi-ness case attractive. ◗ Collaborative partnerships

Close coordinated working with academic institutes to build global partnerships with medical technology companies who don’t have access to India. Need to select three institutes which will drive this collaboration with industry. Create industry sponsored programmes between local and global industry on joint collaboration projects using relationships with specific trade bodies

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Initiatives like BIRAC to medical technology should be expanded. These initiatives should be broadened to cover more research and support more local innovation. These schemes should provide seed capital, viability gap funding, co-fund start-up projects and support the commercialisation of innovations and industry fora. Address the capability shortfall in crucial areas holistically by building select partnerships in procurement, testing, calibration and clinical trials which limits the extent of investment in innovation in India.

INITIATIVES ◗

Capability development

and training Industry and academia should jointly define the expectations from new graduates. Based on these requirements, the academia must put together a curriculum designed at developing the desired skill sets. Academia should cultivate a culture of collaboration on

campus by providing the necessary platforms for interaction with industry. Universities must facilitate interaction between the students of medical technology and business management to ensure cross–pollination of knowledge. Healthcare sector skill council to take as a priority the development of the

medical technology skill set. This should form part of their mandate and drive the right talent development initiatives. Allocate funds to set up centres of excellence for medical technology training. ◗ Integrated stakeholder forum for meaningful engagement

Coordinated awareness effort of multiple stakeholders led by an industry body to ensure that the benefits of medical technology innovation in the country are well understood by all. Global task force to promote India as a manufacturing and R&D hub globally through targeted specific fora to build bi-lateral dialogue. CII will further need to coordinate between all stakeholders to take the Vision 2025 forward, and it is vital that this effort starts soon.

RADIOLOGY HIGHLIGHTS

Frost & Sullivan honours Mobius Imaging for its Airo Mobile Intraoperative CT The mobile 32-slice CT scanner reportedly has the largest gantry opening and is being touted as a breakthrough technology in healthcare imaging FROST & SULLIVAN recognised Mobius Imaging with the 2014 North America Frost & Sullivan Award for New Product Innovation Leadership. Mobius Imaging's mobile 32-slice CT scanner, Airo Mobile Intraoperative CT with reportedly the industry's largest gantry opening, is being touted as a breakthrough technology in the healthcare imaging industry. A gantry opening of 107 cm allows the system to scan the patient in the treatment position. Its design combines a highly flexible detector with an extra-slim patented gantry (30.5 x 38 cm) that leads to a significantly smaller product

footprint (1.5 m2). The fully integrated high-end Trumpf TruSystem 7500 surgical OR table column offers fixed correlation between patient and scanner, resulting in reproducible imaging. "Although the size of the product has been reduced vastly, it still provides the same resolution as that of other large CT systems and performs the same tasks in a reduced time," said Swathi Allada, Research Analyst, Frost & Sullivan. "This system has been designed by compressing the power supply and cooling system so that it would require smaller tubes for emitting X-rays."

Airo's compactness makes it ideal for use in ORs, ICUs, and emergency care suites The Airo system operates on a standard power connection at one-phase 100-240V. It has a front-view camera which helps in portability. The Airo handheld system pendant

offers hassle-free movement and system maintenance, including room-to-room transport, daily calibration, and laser alignment during surgical procedures. The communication between Airo and Curve allows automatic image transfer to Brainlab imageguided surgery (IGS) systems along with synchronisation of picture archiving and communication systems (PACS). Airo's compactness makes it ideal for use in operating rooms (ORs), intensive care units (ICUs), and emergency care suites. It has found application in cranial, spine, trauma, and other surgical procedures. It also supports

advanced minimally invasive surgery and is digital imaging and communications in medicine (DICOM)-compatible with most hospital PACS. "The company uses intelligent imaging technologies to develop novel products that are engineered to acclimatise to different care environments," noted Allada. "Mobius Imaging is aiming to establish a place in the advanced medical imaging market by improving the workflow and clinical decision-making, which will be beneficial to both patients and surgical teams," she added EH News Bureau

WVU Healthcare performs first US commercial Neuraceq scan Neuraceq is a radiopharmaceutical from Piramal Imaging for Beta-Amyloid Plaque Imaging WVU HEALTHCARE in West Virginia, is the first centre in the US to perform commercial scans using Neuraceq. It became available for commercial use in August, marking the first time patients are able to receive Neuraceq scans in the US outside of research studies. Neuraceq, which received marketing authorisation in the European Union and in the US earlier this year, is a radiopharmaceutical indicated for Positron Emission

Tomography (PET) imaging of the brain to estimate betaamyloid neuritic plaque density in adult patients with cognitive impairment who are being evaluated for Alzheimer’s disease (AD) and other causes of cognitive decline. A negative beta-amyloid scan may help rule out AD as a cause of a patient’s cognitive decline. A positive Neuraceq scan indicates moderate to frequent amyloid neuritic plaques; neuropathological examination

has shown this amount of amyloid neuritic plaque is present in patients with AD, but may also be present in patients with other types of neurologic conditions as well as older people with normal cognition. Prior to the availability of this technology a confirmation of the clinical diagnosis of AD could only be accomplished through autopsy. Neuraceq was approved by the FDA earlier this year. ”At WVU Healthcare, we

are making history as the first centre in the US to offer patients access to beta-amyloid imaging with florbetaben without enrolling in a research trial.” said Dr Gary D Marano, Medical Director of Nuclear Medicine and PET/CT. “For us as clinicians, it’s a new diagnostic option to offer patients and referring physicians in cases of cognitive decline and concerns for Alzheimer’s disease.” “As a company dedicated to

innovation in molecular imaging, it was important to deliver Neuraceq into hands of trained dementia experts as soon as possible to start advancing treatment options and improving patient outcomes,” said Friedrich Gause, COO, Piramal Imaging “We view this as an important milestone but just the beginning of our work to bring beta-amyloid imaging to the US patient population.” EH News Bureau

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RADIOLOGY

Samsung launches premium ultrasound system,RS80A It reportedly offers exceptional image quality, ergonomic design and functional efficiency

L-R: SI Cho, President, Samsung Health & Medical Equipment business; Dinesh Lodha, VP, Health & Medical Equipment business, Samsung India; Dr Harsh Mahajan, Founder, Mahajan Imaging); Dr Naresh Trehan, Chairman & MD, Medanta; and BD Park, President & CEO, Samsung South West Asia

SAMSUNG ELECTRONICS, announced the launch of ‘RS80A’, a premium ultrasound system designed for exceptional image quality and functions for increased diagnostic performance. The RS80A is Samsung Medison’s first product to target the radiology segment which is the largest portion in diagnostic imaging market. Dinesh Lodha, VP – Health and Medical Equipment vertical, Samsung India Electronics said, “Samsung has forayed into the radiology market with the launch of our new ultrasound system RS80A in India. The introduction of this premium system with significant new features and technological advancements will enable users to experience a new level of diagnostic quality and convenience.” Samsung RS80A reportedly provides clinicians with superior ultrasound performance and features ideal solu-

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tions for general imaging. The new machine is equipped with a 23 inch HD LED Screen, 13.3 inch full function touch screen with tilt facility, five probe port and electronic console movement (up-down and sidewise). It also supports 10 ports Digital TGC which provides easy control with the help of reference image on the touch panel. The RS80A’s S-Vision Architecture provides outstanding images through newly developed S-Vision Beamformer and Imaging Engine while the 23 inch LED monitor provides clearer and brighter display. These technologies ensure detailed resolution and tissue uniformity for all types of applications in radiology and general imaging. S-Vue Transducer gives broader bandwidth and higher sensitivity to enable good image quality at depth. S-Detect uses the standardised Breast ImagingReporting and Data System

(BI-RADS) score for analysis and classification of targeted regions. S-Detect results in more effective diagnosis and saving time through simplified procedures. E-Breast and EThyroid are the latest breast and thyroid ElastoScan (Elastography) that makes it easier for users to distinguish benign from malignant masses through acquiring the strain ratio between the target and reference area faster. Advanced QuickScan allows automatic adjustments of imaging parameters, such as colour gain, location of the colour box and angle correction. It is equipped with 3D navigator and fewer keys on the control panel for ease of use and greater examination throughput. The keyboard is embedded into the touch screen. The device can remember user’s position and height of the control panel each time they run the system. EH News Bureau

SickKids doctors destroybone tumour using incisionless surgery Doctors used an MRI to guide high-intensity ultrasound waves to destroy the benign tumour A PATIENT at The Hospital for Sick Children (SickKids) is the first child in North America to have undergone a specialised procedure that uses ultrasound and magnetic resonance imaging (MRI) to destroy a tumour in his leg without piercing the skin. Doctors used an MRI to guide high-intensity ultrasound waves to destroy a benign bone tumour called osteoid osteoma. The lesion had caused 16-year-old Jack Campanile excruciating pain for a year. By the time he went to bed that night, the athletic teen experienced complete pain relief. “With high-intensity focused ultrasound, we are moving from minimally-invasive to non-invasive therapy, significantly reducing risk to the patient and fast-tracking recovery,” said SickKids interventional radiologist, Dr Michael Temple, who led the team that performed the surgery. “The osteoid osteoma tumour was chosen as our pilot study because the lesion is easily accessible and while the procedure is sophisticated, it is relatively straightforward. The success of this first case is great news for Jack, and exciting for our team as we look at developing more complex incisionless treatments in the future.” The procedure was performed by SickKids staff using a specialised MRI table at Sunnybrook Health Sciences Centre, with support from Sunnybrook’s MRI and Radiation Oncology

staff. The team used the MRI to determine the exact location of the tumour and to help target the ultrasound waves to burn the whole tumour, one focal spot at a time at a high energy. The MRI also enabled them to monitor the temperature induced by the ultrasound to ensure that there was no unexpected increase in heat in surrounding tissues. Accurate positioning and monitoring are critical, as the ultrasound waves could damage surrounding tissues, nerves or skin. A few hours after the procedure, Jack was discharged home, where his recovery has been reportedly smooth and quick, with no complications to date. Before the surgery, Jack’s pain was so debilitating that he needed to take pain medication up to four times daily. “The idea of being the first to undergo this new treatment was intriguing. I wanted to see what it would be like. If it did work, it would be a whole new world for medical procedures and treating osteoid osteoma,” Jack explains. This breakthrough is the latest from SickKids’ Centre for Image-Guided Innovation and Therapeutic Intervention (CIGITI), a research programme that brings together surgeons, radiologists, software developers and engineers to develop innovative technologies in robotic and minimally-invasive surgery. EH News Bureau

RADIOLOGY I N T E R V I E W

‘A person with an implanted Evera ICD can get an MRI scan done for any part of the body’ Recently launched, Evera MRI SureScan is reportedly the first ICD system approved for MRI scans positioned on any region of the body. Medanta, The Medicity is the first hospital to implant the system. Dr Mauro Biffi, a Senior Electrophysiologist at the Institute of Cardiovascular Diseases of the University of Bologna, Italy and a strong advocate of device automaticity and Remote Support by Technical Advisors for the management of Cardiovascular Implantable Electronic Devices (CIED) recipients, gives an insight on the features and benefits of Evera MRI SureScan, in an interaction with Lakshmipriya Nair Tell us more about Evera MRI SureScan. Evera MRI SureScan implantable cardioverterdefibrillator (ICD) system is the first ICD system approved for magnetic resonance imaging (MRI) scans positioned on any region of the body. It features a contoured shape with thin, smooth edges that better fits inside the body, increasing patient comfort by reducing skin pressure by 30 per cent. In addition, Evera MRI is paired with the Sprint Quattro Secure family of ICD leads, which has 10 years of proven performance with active monitoring and is safe for use in an MRI environment. Evera MRI includes SmartShock 2.0 – an exclusive shock reduction algorithm that enables the device to better differentiate between dangerous and harmless heart rhythms and deliver shock only in response to a genuine arrhythmia event. SmartShock technology delivers a 98-per cent inappropriate shock free rate at one year. Also included in the Evera MRI is OptiVol 2.0 Fluid Status Monitoring and complete diagnostics, which helps to identify patients at risk of worsening heart failure and atrial fibrillation.

What are its major advantages? Evera MRI SureScan comes with several advantages. There are no regional restrictions and a person with an implanted Evera ICD can get an MRI scan done for any part of the body. It is estimated that 50 – 75 per cent of patients with an implantable cardiac device will need an MRI scan over the lifetime of their device. And the launch of these devices will be a boon for all such patients. Secondly, its SmartShock 2.0 technology which is an exclusive shock reduction algorithm that enables the device to better differentiate between dangerous and harmless heart rhythms and deliver shock only in response to a genuine arrhythmia event. While the majority of shocks delivered are necessary to treat potentially fatal arrhythmias, studies estimate that approximately 20 per cent of patients with implantable defibrillators may experience inappropriate shocks in response to a benign arrhythmia or electrical noise sensed by the device. SmartShock technology helps to eliminate these inappropriate shocks, and delivers a 98-per cent

inappropriate shock free rate at one year.

With this technology, imaging will be accessible to more and more people who need to undergo this very critical test of diagnosis

What are the characteristics that make it safe for MRI? The Surescan technology used in these devices makes it safe for MRI scans. This trademarked technology from Medtronic has advanced circuit designs, software as well as device programming making it safer for MRI. Apart from this, the material of the device has also been modified in order to reduce the amount of ferro-magnetic substances, thereby reducing the interference with the powerful magnetic fields and radio waves which are a part of MRI scans. How will this technology help imaging evolve? It is estimated that as many as 63 per cent of ICD patients will need an MRI within 10 years of receiving a device. Until the availability of MR-conditional ICD systems, patients with devices have been contraindicated from receiving MRI scans because of potential interactions between the MRI and device function. With this technology, imaging will be accessible to more and more people who need to undergo this very

critical test of diagnosis. Tell us about how the product has been adopted by healthcare industry? Medtronic was the first to launch the MRI conditional pacemaker in 2008. In the past few years, it has been witnessed that the adoption of this device has increased rapidly. Today, more than 25 per cent of the Medtronic dual chamber pacemakers implanted in India is MRI conditional. And a similar response is expected for the new products as well. How cost-effective is it? How do you plan to market it in India? The new products are priced at a nominal 10 per cent premium over the existing models – in order to make it more affordable and accessible to everybody. As mentioned earlier, there are as many as 63 per cent of ICD patients who will need an MRI scan within the next 10 years. The product would be marketed to these set of patients and answer their unmet need of not being able to undergo this critical test of diagnosis for accurate analysis of disease condition. lakshmipriya.nair@expresshealthcare.com

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IT@HEALTHCARE INSIGHT

Transforming healthcare with technology

SUNIL PAIKATTIL Head – Solutions and Centre of Excellence, Healthcare Practice, Xchanging

PRABHU RANGASWAMY Senior Manager – Operations, Healthcare Practice, Xchanging

Sunil Paikattil, Head – Solutions and Centre of Excellence, Healthcare Practice, Xchanging and Prabhu Rangaswamy, Senior Manager – Operations, Healthcare Practice, Xchanging giving insights on how technology is changing the way healthcare is delivered

he healthcare industry has been undergoing a significant transformation since the start of the new millennium and the pace of innovation and technology adoption has gained real momentum in the last few years. One of the major transformations in the healthcare industry has been the change in the approach towards improving population health by shifting the focus from reactive measures such as disease management to preventive measures for treating chronic diseases and other life threatening ailments. As a result, we are now witnessing increasing investments in R&D from pharma companies and surging investment in technology upgrades by medical care providers, in order to deliver superior patient experience. In addition to providing the best possible treatment to the patient, healthcare providers also need to focus on reducing inefficiencies in drug spending, surgeries and hospital admissions; while at the

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Hospitals are increasingly relying on data from a multitude of sources—from Electronic Medical Records (EMR) and Health Information Exchanges (HIEs) to wearable devices that transmit real time patient health data same time optimising the delivery of healthcare services through cutting-edge technology and best-in-class business processes. The Affordable Care Act or Obamacare as it is popularly known in the US has quickened this process, as newer and more disruptive technology solutions are changing the landscape of patient care. Doctors now have the necessary wherewithal, in terms of equipment and test methods, and therefore the ability to diagnose patient problems more accurately and treat them more effectively than they could in the past. Guesswork and relying on previous experience, has been replaced by precise and targeted treatment methodolo-

gies that have been honed by increasingly sophisticated R&D.

Increasing reliance on technology-enabled processes Hospitals are increasingly relying on data from a multitude of sources—from Electronic Medical Records (EMR) and Health Information Exchanges (HIEs) to wearable devices that transmit real time patient health data. The objective of sourcing data from multiple sources is to build a complete and holistic picture of the patient’s health and track record; which in turn leads to targeted and effective treatments, both before and after a hospital visit. The latest trends are ‘smart cap’

for those patients who have been prescribed specific injections (e.g. insulin) that inform patients the time from their last injection and ‘smart bottles’ which provides escalating reminders to the patients, pharmacy, physicians on the usage of the drug. Whilst these new and disruptive technologies are transforming the healthcare provider space, they are also bringing changes in the larger ecosystem. Growing transparency in the way healthcare providers now function and the extensively available information on the internet are empowering patients to make more informed decisions about their own healthcare and seek best possible treatment within their

own resources and constraints. At the same time, payers are also questioning expensive and prolonged treatments and persuading healthcare providers to look for cheaper yet more effective solutions such as telemedicine to reduce the overall cost of delivering healthcare services to patients. They are also adapting to this tectonic shift by relooking at the way they underwrite policies and administer claims. This is where healthcare-focused business process services (BPS) companies can help by taking away some of the routine administrative tasks and bringing in technology to make transactions faster as well as simpler to execute and complete.

Analytics: The next big thing in healthcare India has seen a lot of changes since the time BPS providers started with basic offerings such as medical transcription and data entry services for the healthcare industry. The offerings today have moved up the value chain and involve significant judgement, analysis

and decision making. For e.g, in the US Workers’ Compensation domain, the services provided are very complex and businesscritical which range from claims adjustment to adjudication and final settlement. An example of a disruptor which will revolutionise the US healthcare treatment delivery is by way of extensively using analytics. Analytics will help in creating a three way link between the data available with the hospitals, doctors who are actually patients and finance teams who are focusing on revenue and profitability. A recent research report showed that approximately five per cent of the patients visiting a hospital in the US on an average accounted for 50 per cent of healthcare spend on treatment. The focus in the US now is to ensure that special care is given to the ‘very sick’ through a joint collaboration between the treating doctors, finance leadership at hospitals and the payers (insurance companies); and to drive cost effective treatment plans. India’s capability in technology enabled business services and advanced data analytics will help the Indian healthcare market through similar analysis, to reduce overall healthcare spend and improve the quality of healthcare provided within the country. BPS providers, who want to remain relevant to their clients, have to develop comprehensive domain knowledge of the healthcare industry. Most importantly, they need to have the ability to advise their clients, be it providers, payers or other intermediaries, on the most efficient and optimal way to deliver healthcare services. They have to tailor their service offerings to the changing industry needs and integrate technology seamlessly. Smart BPS providers are actively exploring technology innovation, automation, data analytics and commercial models such as Business Process as a Service (BPaaS) in order to help their customers achieve better “value for money.” With the customer-base varying from insurance companies (payer) or a third party administrator (TPA) to hospitals, billing companies and

REVOLUTIONISE INDIAN MEDICAL SYSTEM

intermediaries such as pharmacy and ancillary service providers; the role of BPS companies is becoming significantly larger and more complex. BPS companies are supporting customers on several activities such as vendor credentialing, complex claims intake, calling out to injured workers and providing analytical services. In addition, BPS companies are also playing a critical role in supporting customers in calling out to injured workers, doctors, making compensation decision, and suggesting changes to revenue cycle management process to improve Days Sales Outstanding (DSO) of a provider. With access to the best technical capabilities and skilled talent pool of business analysts, Indian BPS companies are actively leveraging this to transform healthcare service delivery.

Challenges and solutions in the Indian context The expertise that has been built over the years in India through servicing payers, providers, and billing companies in the US and Europe should now be used to revolutionise the Indian healthcare sector. However, some of the current challenges in India are lack of standard diagnostic protocols, lack of standardised billing from hospitals, presence of various unorganised service providers (aiming at profit rather than service), and paucity

of public information available freely to patients. This is compounded by the lack of a good regulatory framework that puts punitive measures in place to penalise those providers who provide poor healthcare services, spurious medicines or dubious treatments to patients. The effort to form General Insurer Public Sector Association of India (GIPSA) by the four largest nationalised insurance companies in India to bring about standardised claims management process is a commendable story. Standardised billing using current procedural

Indian healthcare industry should adopt methodologies that have been successfully implemented and have delivered efficiencies in the Western countries

terminology (CPT) codes, and advising on common protocols in treatment, are areas where BPS providers can really contribute. Indian healthcare industry should learn from the development cycle that the Western countries have gone through and adopt methodologies that have been successfully implemented and have delivered efficiencies. There is a huge effort needed to link in-patient, laboratory, outpatient, claims, pharmacy and diagnostics. Technology plays a very pivotal role here in the seamless transmission of information across the value chain, thereby creating transparency and efficiency. The vast pool of knowledge base available in the BPS and IT industries can be effectively utilised to leapfrog the intermediate development stages in the Indian context. Indian healthcare landscape should align the way payers, providers and ancillary service providers provide service to the patient and ultimately, the patient should benefit through improved treatment and better healthcare outcomes.

Disruptive technologies – Making cutting-edge medical services a reality The edge for India based BPS service providers reside in the fact that we are taking up more complex tasks and solving them within a defined timeframe. India’s most important asset is

its ability to take on and solve big problems, which has resulted in an increased confidence in the talent of the Indian BPS industry. The healthcare industry in India has moved beyond just cost savings to innovation as the primary value creator. An example of this is the way technology is used to automate repetitive and low value business processes through the use of robotics. Our real test lies in our entrepreneurial ability to solve the next set of challenges that the global healthcare industry is facing and find innovative ways to address some of the most ‘wicked’ healthcare problems, within the Indian context. Healthcare services in India can be developed on the lines of the booming E-commerce industry. With the potential of technologyenabled BPS offerings, we can make concierge medical services a reality. Wearable devices are touted to bring in an unprecedented change in healthcare and we are going to witness many such disruptors in this space. By strengthening our BPS offerings, Indian companies can uniquely position themselves in a competitive global market; and at the same time leverage the knowledge gleaned from other markets to meet the domestic healthcare needs. If you ever wondered where the next big disruptor is lurking, it is in healthcare, and the time is now!

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IT@HEALTHCARE HIGHLIGHTS

Accenture and Philips develop proof of concept app The software shows how ALS patients could gain greater control of their lives through brain, voice and eye commands ROYAL PHILIPS and Accenture have developed proof of concept software connecting a wearable display to Emotiv Insight Brainware that could ultimately give more independence to patients with amyotrophic lateral sclerosis (ALS) and other neurodegenerative diseases. “This proof of concept exemplifies how people, devices, data and technology could be brought together quickly to connect beyond the hospital walls in a way that can potentially help improve the quality of life for patients, wherever they are in their journey," said Jeroen Tas, CEO, Healthcare Informatics

Solutions and Services for Philips. “Philips will continue to collaborate with innovative technology companies such as Accenture to explore new wearable and sensor solutions that change peoples' lives and create a healthier future.” When a wearable display and the Emotiv Insight Brainware, which scans EEG brainwaves, are connected to a tablet, users can issue brain commands to control Philips products including Philips Lifeline Medical Alert Service, Philips SmartTV (with TP Vision), and Philips Hue personal wireless lighting. The tablet also allows

control of these products using eye and voice commands. In both cases, a person could communicate pre-configured messages, request medical assistance, and control TVs and lights. Accenture and Philips developed the software that enables the integration and interaction between these multiple technologies. The proof of concept application demonstrates how existing technology could be used to transform the quality of life for ALS patients. When patients lose muscle control and eye tracking ability, they can still potentially operate the Philips

suite of connected products in their home environment through brain commands. The Emotiv technology uses sensors to tune in to electric signals produced by the wearer's brain to detect, in real-time, their thoughts, feelings and expressions. The wearable display provides visual feedback that allows the wearer to navigate through the application menu. The Accenture Technology Labs in San Jose, California collaborated with the Philips Digital Accelerator Lab in the Netherlands to create the software to interact with the Emotiv Insight Brainware and the

wearable display. Fjord, a design consultancy owned by Accenture Interactive, designed the display's user interface. "Empowering people with Lou Gehrig's disease to live fuller lives is at the heart of the ALS Association's mission," said Ineke Zaal, spokesperson for Stichting ALS in The Netherlands. "We are tremendously excited about the potential for this proof of concept to give people with ALS greater independence and quality of life as we continue to actively search for a cure." Source: International Alliance of ALS/MND Associations

IBM Cloud to power Narayana Health email system IBM iNotes via Cloud will help reduce IT cost and complexity IBM HAS partnered with Narayana Health for implementing an efficient email and collaboration tool that will reportedly keep all the employees, associated professionals and other stakeholders completely connected. This partnership aims to help Narayana Health administrators and employees to more easily collaborate while keeping IT expenditure for the solution at a minimum. The hospital now has access to business class email, a collaborative calendar and contact management that can be virtually accessed anywhere in a security rich cloud environment, lowering operational costs by at least 15 per cent, while improving reliability and manageability. Harnessing the power of the

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cloud helps simplify email administration, while providing robust, flexible services that enable both administrators and end users to configure the service to meet their needs. IBM iNotes via Cloud is expected to not only benefit the hospital administration, but also its caregivers who can now collaborate more quickly, share files and manage projects seamlessly through cloud. This in turn is expected to aid physicians, nurses and other employees to contribute easily across projects, create communities quickly and effortlessly and work as a cohesive team with better communication. Using IBM iNotes’ via Cloud, email, calendar and contact management tools, Narayana Health is able to improve pro-

ductivity, deepen customer relationships, generate new ideas faster and enable a more effective workforce. With IBM’s Cloud implementation, the hospital has apparently streamlined the process of keeping record of salary slips for over

13,000 employees instead of providing pay slips manually. “We are pleased to work with IBM in helping upgrade our IT Infrastructure and addressing our business needs,” said Srikanth Raman, Group Head - Information Technology, at Narayana Health. “We were looking for a partner with an unimpeachable track record and strong industry expertise – both from the knowledge and from customer experience perspective – and the IBM team demonstrated expertise, passion and zeal in understanding our business priorities. We are looking forward to further deepen and leverage this relationship in future.” “Cloud computing has redefined the way businesses

function today. Our cloud solutions are highly customised depending on an organisation’s business needs and can address all key business imperatives,” said Anmol Nautiyal, Director, IBM Social Business & IBM Smarter Workforce. IBM iNotes via Cloud is being touted as an enterprise solution for organisations looking to reduce IT cost and complexity. The solution reportedly provides ease of use, simple administration and delivers business ready services through a security-rich cloud environment. It is virtually accessible from anywhere and across platforms, iNotes allows ease of use for administrators, end users and available in 22 languages. EH News Bureau

HOSPITAL INFRA TREND

Designing for the family

Library patients and their relatives at Asian Heart Institute

With healthcare becoming more patient-centric, hospitals are waking up to the benefits of providing value-added services to the patientsâ&#x20AC;&#x2122; family as well. In fact, this attention to detail is being projected as a factor which sets them apart from their competitors. Hospital design has also evolved to reflect these changes By Lakshmipriya Nair

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HOSPITAL INFRA

We have been taught to address patient care all the time, but patient support/family care has become equally important

emographic and economic factors such as changes in the disease pattern, growth of disposable income, rise in awareness levels among the masses, growing competition among private healthcare providers, huge geriatric and paediatric population, medical tourism etc. have ushered a sea change in Indian healthcare over the last decade. The emphasis today is on the need for an integrated healthcare delivery system which would pre-dominantly revolve around patientcentric care.

Ajay Gupta, Executive Director, KGD

Modern hospitals are well designed buildings with areas defined to cater to specific needs of the growing population Dr Niraj Uttamani Chief Executive Officer Cumballa Hill Hospital

Nowadays more importance is given to hospitality, patient safety and other value added services Tarun Katiyar Principal Consultant, Hospaccx India

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Revolution in hospital design Hospital design has also changed drastically to suit the changing needs of an industry which is at an inflection point. Dr Rajeev Boudhankar, VP, Kohinoor Hospital explains, “Earlier hospitals were designed sprawling horizontally with different departments located in different areas. However, with changing times, convenience, operational efficiency, cost control, optimal utilisation of common resources like OT, CSSD, radiology, pathology, blood bank, etc were incorporated into the design. Vertical designs later became a norm given the space constraints in bigger cities. The designs of wards were changed accordingly to bring about more patient privacy and introduce hospital private rooms in ‘patient housing’ area. Other areas of the hospital also kept pace with times and technology upgradation.” Adding his insights to this view, Dr Niraj Uttamani, CEO, Cumballa Hill Hospital avers, “Earlier, many hospitals were started as part of a church/dharamshala and used to house patients in a dormitory like area with common toilets/bathrooms and separate areas for males and females. There was no concept of special rooms and special designs. The idea was to manage more number of patients with common facilities and staff. Modern hospitals are well designed buildings with ample parking space and areas defined to cater to specific needs of the growing population.”

Creating healing centres Similarly, gone are the days when a hospital evoked images of a chaotic, sterile, impersonal space without much warmth. Today, they aim to be centres of healing where the patient and his family are permeated with a sense of trust that health would be restored. As Ajay Gupta, Executive Director, KGD says, “A healing environment and wellness approach have started showing in hospital design which has helped us part from a sterile clinical design and embrace warm design philosophies. In today’s day and age, hospitals are hotels with medical gases and clinical support.” KGD is an architectural, engineering and interior design firm which has been involved in several healthcare projects like Apollo Mega Health City in Chitoor, Andhra Pradesh, Columbia Asia Hospital and Manipal Hospital in Bengaluru, Karnataka; Max Healthcare in New Delhi, to name a few. Dr Ramakant Panda, Vice Chairman and MD, Asian Heart Institute, says, “Hospital design has changed from providing only medical treatment to a holistic approach which includes patient safety and comfort, as well as service and comfort to relatives.” Elaborating further, Subham Bardhan, CEO of the soon to be launched, Sunrise Hospital in the suburbs of Mumbai, says, “Hospitals of today have now stated incorporating additional features. They include high-end relative waiting areas, Wi-Fi facilities, personal nursing, custom food, ambience, hospi-

tals – without the typical hospital smell, multi-faith prayer rooms, etc.

Precedence for value added services Factors like patient-safety have also gained precedence in hospital design. As Dr Hilal Ahmed, Medical Superintendent, Asian Institute of Medical Sciences, Faridabad says, “Our hospital design has changed over the years to improve patient safety and patient satisfaction. The hospital is designed to switch from being provider-centred to patient-centred. We have included quality assurance procedures and principles.” Tarun Katiyar, Principal Consultant of a healthcare consulting firm, Hospaccx India also informs, “The present scenario of hospitals have changed a lot. Apart from infrastructure and good medical and non-medical staff, nowadays more importance is given to hospitality, patient safety and other value added services.”

Seeking the new differentiator Now, every major healthcare provider has incorporated these details while designing their set ups. However, this has also bought in a certain amount of homogeneity. Most hospitals offer good medical support, boast of renowned specialists, have hi-tech equipment, and provide several value added services. So, what is the new differentiator among these hospitals? Many feel that apart from the facilities given to the patients, benefits provided to the families or relatives of these

Deluxe room at Cumballa Hill Hospital

patients could be a major lure and tilt the scales in favour a certain hospital. The rise of medical tourism in this country has also drawn more attention to this aspect as patients coming from different parts of the world are generally accompanied by someone. Thus it has now become imperative to please not only the patients but also the patients’ attendants. In Dr Panda’s opinion offering support to patients’ attendants is a part of the service that should be offered by the hospital. He says, “Unlike Western countries, in India, whenever a family member is sick all relatives prefer to visit and spend time in the hospital, giving the much required emotional support to patient. So it is very important for the hospital to provide comfort to relatives.” Dr Ahmed believes that catering to the relatives’ comfort would be beneficial for the patient’s recovery since his family and friends would offer the much needed emotional support at such a time. He opines, “Customising and personalising the patient experience is a key strategy for overcoming the fear, anxiety and stress associated with being at the hospital. The family members can help to reassure patients in times of uncertainty, anxiety or vulnerability.” Gupta also endorses the same view and states, “We as hospital designers and operators have been taught to address patient care all the time, but in addition to that, patient support/family care has become equally important. I truly believe that after clinical and medical support, the patient benefits from have the family and friends’ positive

HOSPITAL INFRA energy around him which can only be achieved if the family members are comforted and taken care too. On a more pragmatic note, the brand and goodwill of a healthcare provider is a direct result of the experience of patients’ family members during the stay in the hospital.” In Katiyar’s view, relatives or friends could be instrumental in creating a good or bad impression about a hospital in the minds of patients. “Nowadays, it is more important to provide comfort to the patient’s relative than to the patient, because generally patients’ relatives have more complaints. So, hospitals are also designing and giving more importance to value added facilities for relatives of the patient.” Katiyar is also the MD of Vasudev Hospitals (VHPL) group which recently inaugurated their first hospital in Bijapur, Karnataka. Dr Boudhankar puts it very concisely, “It is an important factor and plays a big role in the patient satisfaction index.”

Attending to patients’ attendants So, what are the measures that these hospitals have taken to ensure the comfort and convenience of the patients’ attendants? Asian Heart Institute, which was ranked amongst the Top 10 World's Best Hospitals for Medical Tourists by Medical Travel Quality Alliance (MTQUA), claims to have introduced several firsts in terms of benefits for patients and their attendants. Dr Panda informs, “We were the first one to provide a separate resting lounge with bed, Internet facilities to ICU patients’ relatives, counselling area to patients’ relatives while procedure is going on.” He also informs that other facilities such as separate lounge in each patient floor area for relatives to relax, travel assistance to patient and relatives, free airport pick up and drop service for all foreign patients, cafeteria 24x7, library, prayer room, Wi-Fi facility, ATM facility are part of AHI’s services. He further states, “In India, relatives play a significant role in the patient’s decision making about the hospital and the doctor. So, though directly they may not be

Playing space for kids in the OPD waiting area at Sunrise Hospital

the major differentiating factor, indirectly it plays a role in decision making because of good experience of the relatives.” Dr Boudhankar informs that Kohinoor hospital has adopted ‘patient affection’ as one of its main goals; and has introduced innovative measures such as air-conditioned waiting areas for ICU patients’ relatives, counselling for ICU patients’ relatives, two times a day by the chief intensivist; financial counselling before admissions for billing so that patients’ relatives are well aware about the expected hospital bill for the treatment; TPA cell to facilitate pre-authorisation of hospital expenses before admission; separate room for breast feeding for mothers whose babies are in NICU/PICU; fathers to be allowed to be by the side of their spouses when they are admitted for deliveries; free collection of pathology samples and delivery of medicines for patients who require long-term medications, free pickup and drop of patient/relatives at airport and assistance for clearance from Mumbai Police for foreign nationals. Dr Ahmed also assures that several facilities are accorded to patients’ relatives at his hospital. He says, “We have tie-ups with various insurance companies for easy payments and with leading travel companies to facilitate smooth travel of international patients and their family members. We also assist patients in making the appropriate arrangements for their travel and stay within India. We assist the patient/ family to take an informed decision in finding an accommodation near the hospital.

“Apart from the medical and nursing team, managers in our hospital take care of all the needs of patient and family. The devoted managers facilitate the international patient and families and provide all the necessary assistance required for hospital registration, payments, appointments, admissions, billing, language interpreters and translators, foreign exchange, etc. Multi-cuisine customised menu, ATM and Wi-Fi Internet facility is available inside the hospital premises,” he further elaborates. Thus, hospitals are going all out to ensure that they adapt themselves to the changing times. In fact, many of them have even start offering services like Jain food, multi cuisine for international visitors, local tours such as ‘Mumbai Darshan’ for international patients, crèches and play areas for children, gift shops and so on.

Time for untried concepts In fact, untried concepts like establishing a hospital in a mall are also being implemented. The soon-to-belaunched Sunrise Hospital’s CEO, Bardhan informs, “When it comes to Sunrise Hospital, Mumbai, we are trendsetters, making the hospital inside a mall, an innovative thought process of our promoters. A lot of brain storming went through to break the monotony of old conventional hospital offerings. So this idea of giving expert care with a certain amount of pampering to the patients’ attendants came into play. Our hospital includes all the facilities that any other tertiary care hospital offers; and yet is aesthetically

designed to make you not feel as if you are either in a mall or in a hospital.” Explaining further, he says, “Sunrise Hospital has attendant staying facilities from twin sharing beds upwards till suite level. We also have well placed dormitories facility for ICU patients. To add on, we have been thinking differently for the attendants, offering them all the facilities which are available inside the mall. The second floor, which is part of the mall, has got a food court, a resto bar, game zone, bowling zone, a six-screen multiplex and different shopping locations. One single floor has everything. Attendants can spend their time qualitatively on multiple activities inside the mall; yet be close to their loved ones.”

Hospital design has changed to a holistic approach which includes patient safety and comfort, as well as service and comfort to relatives Dr Ramakant Panda Vice Chairman & MD Asian Heart Institute

More than a trend With rapid growth of medical tourism in India, healthcare players are increasingly becoming convinced that offering these services to their patients and their families would be beneficial to them in the long run. Gupta advises, “A hospital is a place where the patient and the family are the most vulnerable, some of these services help them approach the healthcare provider with little more ease, and bring out the best environment around the patient. Agreeing, Dr Boudhankar says, “These added benefits give psychological and emotional support to the relatives and thereby even to their patients. It forms a bond between the hospital and patients on levels of loyalty and care.” Dr Uttamani feels, “Not only the patient’s experience but his entire family’s experience is part of his recovery. It can be proactively utilised, especially for positive health information.” Dr Ahmed also informs, “These services have improved the level of patient satisfaction and trust in our hospital.” Thus, this growing practice of offering utmost hospitality in a hospital is set to become the norm than a trend. lakshmipriya.nair@expressindia.com

These added benefits forms a bond between the hospital and patients on levels of loyalty and care Dr Rajeev Boudhankar Vice President, Kohinoor Hospital

We are trendsetters, making the hospital inside a mall to break the monotony of conventional hospital offerings Subham Bardhan Chief Executive Officer Sunrise Hospitals

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ASK A QUESTION What is the importance of rural market penetration through telemedicine? DR AJAY LULLA, Udaipur

The advances in medical science and bio-medical engineering on one hand and telecommunication and information technology on the other are offering wide opportunities for improved health care in India. The factors that are likely to drive the growth of telemedicine in India are the following: ◗ Inaccessibility of care for majority of the population ◗ A severe shortage of skilled and qualified doctors in the rural areas ◗ High cost of healthcare, particularly for secondary and tertiary care ◗ Very high patient volume in the rural areas compared to the number of doctors, hospital beds and trained medical staff

◗ Problem of retaining doctors in the rural areas ◗ Specialist doctors cannot be retained at rural areas as they will be professionally isolated and become obsolete ◗ Widespread availability of mobile network What are the streams of hospital operations? DR MALAY BABU, Bengaluru

The main streams of hospital operations which need to be streamlined for smooth working, are: ◗ Patients stream ◗ Staff stream ◗ Patients’ sample stream ◗ Drug stream ◗ Material stream ◗ Visitors stream ◗ Information stream Why should we rethink on our healthcare system?

SRIVIDYA, Chennai

Factors leading to rethink on the healthcare system are: ◗ Prevention is still not enough ◗ Unequal provisions still exist ◗ Too labour intensive ◗ Costly medical facilities ◗ Fragmented market What are the main challenges in setting up a healthcare facility in a rural area? MANISH JHA, Ranchi

Main challenges that we face while setting up a hospital in a rural are: ◗ Funding of healthcare projects ◗ Day-to-day operation facilities ◗ Affordability of care ◗ Availability of healthcare staff ◗ Access to essential drugs and medicine What are the barriers in infrastructure development in rural areas? DHANI MALHOTRA, Punjab

Infrastructure has always been a barrier to the growth of the Indian healthcare industry. Poor energy and transport infrastructure has traditionally posed a problem for companies. Some areas lack basic hotel facilities, preventing reach and penetration. With the government gradually increasing investment in infrastructure, the situation is improving, but it is still seen as an investment opportunity in the country. Lack of education and knowledge leads to misunderstanding among the local public towards infrastructure development in the rural area.

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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

BUSINESS AVENUES

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ACCESSORIES . ..for Artificial Respiration AIR COMPRESSORS RESPIRATORY HUMIDIFIERS HUMIDIFICATION CHAMBERS PEDESTAL ASSEMBLIES

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Capturing physical assessment and vital signs data is routine.

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LIFE LINE COMPACT & MK - IV MAJOR PLUS

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LIFE PEOPLE

Diabetic teen from Pune scales Peru peak He was the youngest member of a 13-member international team who trekked to reach the legendary ancient Inca settlement SANOFI INDIA along with Pune-based Diabetes Care and Research Foundation, joined hands to felicitate Eshaan Shevate, a type 1 diabetic teen from Pune, on his successful completion of Sanofi and World Diabetes Tour’s ‘Type 1 Challenge to Machu Picchu (Peru)’. An engineering student from Pune, 19-year old Shevate was diagnosed with Type 1 diabetes when he was 12. Identifying his potential, Dr Mutha’s Diabetes Care and Research Foundation’ supported his complete care - insulin, insulin pump, education, hospitalisation and all investigations. He was the youngest member of a 13-member international team (10 of whom have Type 1 diabetes) who trekked to reach the legendary ancient Inca settlement Machu Picchu, one of the seven wonders of the world. Representing eight countries across four continents, together, they demonstrated a positive attitude towards type 1 diabetes, sending out a message to the global Type 1 diabetes community that by striving for control of their diabetes, they can dare to dream. Dr Abhay A Mutha, Consultant Diabetologist and President - Diabetes Care and Research Foundation, Pune said, “Shevate is one of the many promising type 1 diabetics supported by our foundation ‘Diabetes Care and Research Foundation’, which has since 2004 been dedicated to empowering diabetic children

and their families with adequate knowledge, care and assistance to help them lead a normal life. A large number of juvenile diabetics that come to us, are from poor families; they are required to spend

almost 25 per cent of their income on the treatment of one child. In order to help such patients, the Foundation has started the ‘Childhood Diabetes Welfare Program’ that has so far adopted more

than 400 kids all over Maharashtra. Till the age of 18, all their expenses for investigations, insulin injections, hospitalisation, education and other requirements, are taken care of by the Foundation.

Even today, this is the only foundation of its kind in the country for the welfare of diabetic children.” While sharing anecdotes from his inspiring journey, Shevate stated, “I am very proud to share that together we have conveyed a message of hope, and demonstrated that it is possible to go beyond diabetes with the right preparation and good knowledge of one’s dietary and physical needs.” Speaking at the felicitation event, Ramprasad Bhat, Senior Director - Diabetes Business Unit, Sanofi India said, “We are very proud that a patient from India participated and successfully completed Sanofi and World Diabetes Tour’s Type 1 Challenge to Machu Picchu. We believe Shevate’s story will help spread the powerful message that diabetic patients can take on all life challenges if they receive timely support, abide by the advice of their doctor and diligently following their treatment plan.” Committed to the cause of Type 1 diabetes, Dr Mutha added, “We need government support in our endeavour to reach out to larger number of young diabetic patients and expand our network to other states. By giving scholarships, removing taxes for insulin, reducing excise duty for pumps, improving infrastructure and delivery chain, and creating public private partnerships, the government can immensely help in improving the lives of Type 1 diabetes patients in our country.”

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September 2014

TRADE & TRENDS

Medisystems launches bed-head panels These wide range of bed-head panels can be used for any application within the hospital MEDISYSTEMS bed-head panels are specially fabricated units for hospital use, designed to converge all the essential utilities around the patient's bed. These bed-head panels are configured to carry user terminals for electrical power, illumination, communications, biosignals, data, medical gas and carry a medical rail with a range of mountable accessories like examination lamps, BP instrument holder, case sheet holders, IV and infusion pump stands, bowl holders and the like. Medisystemsâ&#x20AC;&#x2122; circuit protected bed-head panels have now become part of ICU and patient room infrastructure in every hospital. Standard configuration panels are available for ICU, wards, private rooms /suites. Custom configurations to closely meet user requirements are also available. Medisystems bed-head panels are constructed from light weight extruded aluminium sheets and sections and from stainless steel. The aluminium is surface treated with epoxy-polyester powder coats in a seven stage process which ensures life time protection to the metal surface with ease of cleaning and ability to withstand damage from common hospital fluids like saline, drugs, blood etc. These light weight panels can also be mounted on non-brick walls made of siporex or gypsum board. All panels have safety metal partitions between high voltage, low voltage and medical gas outlets. Medisystems manufactures a very wide range of such panels to meet practically every kind of need. Such panels are available in standardised as well as custom configurations which include horizontal, vertical, running length or wall angular orientation, in colours and finish of choice.

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3 Element patient-bed lamp

ICU panel in horizontal orientation

Horizontal panel for a private room

Horizontal room panel in wood finish

Vertical panel for a private room in wood finish Vertical corner panel for ICU in wood finish

Customised panel in wood finish

Medisystems patient bed lamps Patient-bed lamps are designed to accompany Medisystems bed-head panels or can be purchased individually. Medisystems patient-bed lamps have carefully profiled mirror optic reflectors, to throw uniform light towards the bed areas for examination or reading purposes. They are available in two feet and three feet lengths and mounted at a height of 1.85 metres on the wall behind the patient’s bed. Patient bed lamps are made in light-weight powder-coated aluminium with glass diffusers and mirror optic reflectors. They are pre-fitted with uplighter, downlighter and LED nightlamps. All lamps can operate independently. Made with energy efficient T5 FTL’s or LED tubes and electronic ballasts, they have long lamp life, low electricity consumption and are quick and easy to replace by staff. Each lamp has a colour temperature of 6500 K cool daylight and is designed to give over 1150 lumens of uniform lighting adequate for bedside areas.

Medisystems medical rail and accessories Medisystems also offers a range of medical rail mountable accessories. Each of these accessories is fixed on one or more sliders which can be smoothly moved on the rail and fixed at any desired location along the length of the rail. Medical rail accessories include case sheet holders, SS bowl for medicines, utility baskets, blood pressure instruments, IV poles, infusion pump stands, suction bottles, examination lamps and rail slider clamps for just about any mountable item. With more than 75 installations in hospitals and nursing homes all over the India and overseas, Medisystems undertakes the design, assembly, factory test, supply, delivery, field testing and commissioning of bed-head panels in standardised as well as almost any type of custom configuration or finish to meet the requirement of every type of hospital. Contact medisystems@gmail.com

Medisystems’electronic nurse-call systems The ideal patient care solution for modern hospitals MEDISYSTEMS electronic nurse-call systems are modern microcontroller-based digital systems. Each system comprises a central display unit placed at the nurse-station countertop which is cable linked to its associated set of bed units, mounted at each bed side, along with door units, mounted at the patient’s room entrance, and emergency alert units mounted within the patient room toilets. Since these systems are installed all over the country, their components, spares and parts have been carefully selected for easy indigenous availability. The systems are also modular. This allows the user to select the correct system size initially, followed by a convenient future upgradation, whenever needed. For example, if the ward strength is increased after two years from 16 to 20 beds, all that is needed is the addition of the bed unit modules and upgrading of the central unit software. The systems’ features have been designed to cater for hospital practices prevailing in India. Hence, the basic audio-visual arrangement has been designed as a simple red-yellow-green lamp code with easily recognisable audio chimes. The reset button has been placed only at the patient’s bed site, to ensure that no call goes unattended. To avoid confusion during multiple calls, the calling bed number is not merely indicated on the panel but it is clearly ennunciated in numerics or through ward graphics.

Added features include Toilet emergency alert: Available to the patient in the event of distress while locked within the toilet. Nurse presence registration: Implemented by the

nurse as she enters the patient’s room and indicated on the central display as well as in the corridor so that the nurse can be easily located. Nurse help request: Can be requested by the attending nurse from the patient’s bed side, if the situation should require. Additional call signals: Allows patient to call a ward attendant or room service from the hospital’s cafeteria or canteen either through the nurse display or directly. Instrument alarm relay: A useful feature especially in the ICU/post-op area where a number of monitors and syringe/infusion pumps are at the bed side. I-V drip sensor: It monitors drip flow and alerts the nurse to halt and replenish with a fresh drip, avoiding ingress of air bubbles in the I-V line. Code-Blue alert: A hospital wide alert, for cardiac and other emergencies when help must be secured from wherever available, within the hospital’s premises. Patient-nurse intercom:

It enables the nurse to talk to the patient and go suitably prepared to the bed side, reducing to and fro trips. Nurse-call response monitoring: A monitoring system to capture and data log all nurse call activity. Reports highlight delayed response to calls, level of call traffic on a given floor or ward, and intra-day call load on the nurse-station. This feature is implemented on a single PC terminal at the Matron’s or Medical Director’s desk and may, optionally, be linked through the hospital’s main server to the rest of the hospital information system. SMS alerts: Specific alert calls can be relayed to selected cell-phones including the concerned physician and key hospital staff. Corridor display modules: Enhance call capture for hospitals having long corridors with one or more bends. Multi-function handsets: In addition to the nurse-call function, these enable the patient to also

conveniently switch lamps, fans, audio and TV from the same handset; and to change the TV channels and sound volume (when integrated with a suitably selected institutional model TV set). Call transfer facility: Allows night shift duty transfer of calls from any nurse-station to another nurse-station on the same floor. This enables optimal deployment of night shift duty nursing staff. After commissioning, these systems require virtually no maintenance except to replace any physically damaged module or to upgrade the software/hardware elements, whenever needed. Nurse-call system installations are directly implemented by Medisystems engineers and technicians, or by their authorised representatives, working in close co-ordination with the hospital’s electrical consultants and contractors. Customer support is prompt and monitored through the company’s service centre and its local service representatives.

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September 2014

TRADE & TRENDS INSIGHT

Blood management systems and policies for hospitals

DR LINCY JACOB Consultant & Dept. Coordinator, Department of Transfusion Medicine, Dr L H Hiranandani Hospital, Mumbai

A blood transfusion service is incomplete without a well defined quality management system that ensures implementation and effectiveness of essential policies and best practices, says Dr Lincy Jacob, Consultant & Department Coordinator, Department of Transfusion Medicine, Dr L H Hiranandani Hospital, Mumbai. She also details the steps needed to implement good blood bank practices and the policies that would help in this endeavour A QUALITY conscious hospital comprehends the need for an efficient blood transfusion service and strives to support, maintain and strengthen it within the boundaries of its health facility. Unlike most services within a hospital, the blood transfusion service is governed by stringent guidelines and policies, is licensed by the local regulatory body and functions in accordance with current national or international standards. The blood management system aims to ensure donor and patient satisfaction and promote blood safety, through outcomes that are consistent, traceable and effective. A blood transfusion service is incomplete without a well defined quality management system (QMS) that ensures implementation and effectiveness of essential policies and best practices. The blood bank QMS improves current practices with planning, periodic review and monitoring for continuous improvement

Code of Ethics They play a critical role in the blood transfusion service. Blood banks should bypass unethical practices and substandard testing or processing techniques that ultimately compromise blood safety. It is the responsibility of the blood bank management to define, document and ensure compliance to the code of ethics. Every effort must be taken to provide safe blood from 100 per cent voluntary,

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low risk, non-remunerated donors and pursue effective testing and processing strategies in accordance with National Blood Policy. Regular training of staff is essential to identify and prevent professional donors from jeopardising the national blood supply.

Confidentiality To safeguard donor and

patient identity and secure confidential records, access to blood bank documentation system is restricted to authorised personnel. Every hospital transfusion service is encouraged to establish a Confidentiality policy which is considered to be the foundation of all blood bank processes. Newly recruited staff is encouraged to read, understand and implement

the confidentiality policy on a day to day basis.

Counselling and informed consent This has become an extremely vital part of a hospital-based blood service. Every donor and recipient has the right to be informed in an understandable language, about the advantages and risks associated with blood donation or trans-

fusion and allowed to make an informed decision regarding the same. Information is disseminated through pamphlets, emails, posters, counselling sessions, awareness talks during blood donation camps and World Blood Donor Day programmes. In addition, a deferred donor or donors found reactive for transfusion transmitted infections, is provided referral and

TRADE & TRENDS follow up services. Eligible donors are encouraged to register with Voluntary Blood and Apheresis programmes. Identity of donors and recipients are kept anonymous and related or directed donations are avoided, as the negative impact far outweighs the positive.

Consistent quality and safety in the provision, prescription and administration of blood and blood components can only be achieved through inter-departmental coordination and cooperation

Process control Provision of safe blood and components requires appropriate infrastructure and an adequate and reliable supply of kits and reagents. Standard operating procedures, work instructions, periodic staff training and professional development are prerequisites to ensure smooth workflow. The use of reliable, specialised and calibrated equipment for blood collection, storage, transport, testing and processing provides the assurance of quality, safety and efficacy. Fully automated analyzers for testing have minimised technical errors, reduced turnaround time and infectious disease window period, thus bringing the transfusion services one step closer to providing near zero-risk blood. Continuous 24-hour wireless temperature monitors are recommended to monitor temperature and maintain viability of blood and components during storage and transport. Apheresis machines have provided the alternative to prepare the component of choice in a safe and reliable manner. Quality assurance indicators monitor blood utilisation rates and provide opportunity to reduce transfusion adverse reactions, control wastage, reduce turnaround time from receipt of blood order to bedside transfusion and help predict the overall performance of the hospital blood bank services.

Policy for procurement and utilisation of blood In the event of an emergency, massive blood loss or natural or man-made disasters, the blood centre shall have a well documented protocol for procurement of blood and blood components. Monitoring the blood stock on a daily basis can avert stock-out situations.

as per legal requirements. A well-organised documentation system enables traceability of a blood unit from collection to final disposal in a timely manner. As a part of quality improvement process, process deviations, near miss incidents, complaints and incidents are reported, documented and discussed in management quality review meetings. Corrective and preventive action discussed is initiated and implemented at the earliest. Where change of process is evident, the concerned departments and clinicians are informed for immediate compliance

Infection control policy

A Maximum Surgical Blood Order Schedule (MSBOS) formulated by hospital transfusion committee is made available to all clinicians to encourage appropriate and judicial use of blood. Exchange of blood between FDAapproved blood banks in the city, can help meet emergency situations and prevent wastage and expiry. Blood banks can efficiently reduce turnaround time for procurement of blood by immediate access to online blood bank stock inventory available under State Blood Transfusion Centre (SBTC) website.

staff communication and dissemination of information throughout the hospital. Feedback forms from patients, clinicians, camp organisers and donors provide the opportunity for improvement of services. Use of inter-departmental circulars and email facility is encouraged to enable exchange of relevant information or advancements in the field, indicate process changes or convey decisions taken by the hospital transfusion committee

Efficient communication system

It is necessary to identify and define crisis situations that may arise in a transfusion service that require immediate action and review. It is recommended to include a policy for prevention and management of critical situations,

An effective internal communication system is essential for safe, appropriate and timely provision of blood. A clear and effective mechanism is identified for inter-

Policy for crisis management

such as equipment breakdown, fire, power failure, floods and other sentinel events into the standard operating procedures. Coordination between concerned hospital departments is essential to ensure backup of standby equipments, generator or UPS supply. Staff training exercise includes mock drills and periodic assessment to provide assurance of unhindered blood services at all times. Mandatory user training on technical and safety standards, maintenance and calibration of equipment installed, adds to the confidence of end user during emergencies

Documentation and reporting Blood Bank Records is retained manually, electronically or as a combination of both for the specified period

Blood bank personnel are at a constant risk of acquiring infection or needle stick injuries. Staff members are trained to strictly adhere to hospital infection control policy and report incidents of needle stick injuries or splashes. The immunisation policy for hospital employees will be applicable to the blood bank staff as well. Personnel are encouraged to practice universal precautions in the laboratory, during blood collection, testing and processing. Waste disposal, handling blood spills and disinfection policy of blood bank remains common to that of hospital. However, the hospital infection control nurse and blood bank management share responsibility of conducting regular training and surprise audits to verify compliance to infection control practices.

Conclusion Consistent quality and safety in the provision, prescription and administration of blood and blood components can only be achieved through inter-departmental coordination and cooperation. Be it the Blood Bank Management who supervise and take active decisions on a day to day basis, or qualified staff who perform the individual tasks; every hospital requires committed, dedicated, quality conscious and trained personnel to ensure uniform standards at all levels.

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September 2014

TRADE & TRENDS I N T E R V I E W

‘There is immense scope for enhancing healthcare services penetration in India’ Prasad Nagool, CEO, ITShastra India tell us about his company's offerings and its future plans, in an interaction with Express Healthcare When and how did ITShastra foray into the healthcare domain? Healthcare has always been a focus area of ITShastra. There is immense scope for enhancing healthcare services penetration in India and aboard, this presents ample opportunity for development of the healthcare industry. ITShastra started its operation in 2001, looking at the current healthcare scenario; the team always felt the requirement of sophisticated Information Technology (IT) in the hospitals. IT has the potential to improve the quality and efficiency of hospitals or healthcare centres. With a team of doctors and IT professionals, ITShastra started its work on software development. Since the last ten years, with the feedback from clients and doctors the products were improved and upgraded to suit every

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September 2014

hospital’s requirement. What are the healthcare product range that ITShastra offers? ITShastra wanted to have a separate dedicated team who would only focus on healthcare vertical, thus “ITShastra” was born to cater towards the healthcare sector. The company provides both client-server (Desktop) and web-based solutions. We take pride in our path breaking products like: ◗ RxOffice HMS ◗ RxOffice Radiology ◗ RxOffice Pathology ◗ RxOffice Pharmacy ◗ RxOffice EMR ◗ RxOffice Lab Information Management System ◗ RxOffice Wipeout What is the USP of HMS products? Various solutions offered to specific customer problems in last 10 years have become essential features of HMS.

IT has the potential to improve the quality and efficiency of hospitals or healthcare centres

◗ Easy to use: Any person with basic knowledge of English language can operate this ◗ Day summary report: If you are a hospital administrator or owner you need the entire overview of your hospital in one or two pages. Our daily summary report provides summary of all major items in a single page. To name a few, today’s admissions, discharge, bed occupancy, OPD/ IPD collection, total pathology/radiology tests collection, stock status, equipment warranty renewal data, AMC date etc. Why should hospitals choose ITShastra above other medical software companies? ITShastra is the winner of “National Quality Award on Economics of Quality” by Quality Council of India. ITShastra has the experience of more than 200 hospitals

behind it. Multiple workflows are available for hospitals to select depending on their current flow or select from the “Best Practices” followed by the leaders. ITShastra has products certified for US practice as well as small Indian hospitals that give a wide range of experience. What are your company’s future plans? ITShastra has more than 200 clients in the private sector and each client is equally important to us. Our future plan holds working closely with government hospitals and healthcare centres to provide swift and stressfree service for administration. We are also planning to expand our operations abroad as we have some potential customers in Gulf countries and Africa. We are taking slow and steady steps as we believe in quality and not the quantity of service.

TRADE & TRENDS I N T E R V I E W

‘A reverse shoulder replacement can significantly decrease pain and improve function for patients’ Shoulder pain and shoulder arthritis are common complaints with growing incidence. With age, alongwith wear and tear of shoulder joint, the rotator cuff muscles also undergo degeneration leading to large irreparable muscle tears along with a condition known as cuff tear arthropathy. Earlier treatment options like hemiarthroplasty, total shoulder replacement or debridement had limited success. Reverse shoulder replacement is a method of surgery that has shown excellent results in patients with cuff tear arthropathy. Dr Harpreet Singh, Associate Consultant – Orthopaedics, Shoulder and Elbow Surgeon, Indian Spinal Injuries Center, explains the details of the procedure, in an interaction with Express Healthcare What is a reverse shoulder replacement? It is a type of shoulder replacement done for patients who have been diagnosed with rotator cuff tear arthropathy. This is a unique form of arthritis affecting only the shoulder joint which develops because of a massive rotator cuff tear that is no longer repairable. These patients have severe pain and are unable to lift their arms even up to the shoulder level (known as pseudo-paralysis). Reverse shoulder replacement allows restoration of overhead function, alleviates pain and gives the patient a pain-free functional shoulder. Is it a new type of surgical procedure? Are its long term results known? No it’s not a new type of replacement. It has been used extensively in Europe since 1980s when Paul Grammont introduced the concept of reverse shoulder prosthesis. Many long term studies have proven its efficacy and it has become the standard treatment for cuff tear arthropathy. It got its FDA approval in 2004 and has been used extensively in the US ever since. It was introduced in India in 2011-12. What are the indications for a reverse shoulder

replacement? Patients with cuff tear arthropathy often have severe pain and disability. Pain is severe at night and often disturbs sleep. Patient are unable to perform activities of daily living like eating, combing, getting dressed because of the severe pain, restriction of motion and diminished strength. Pseudo-paralysis and rotator cuff arthropathy can be seen in older patients with a degenerative massive rotator cuff tear. Other causes of cuff arthropathy include prior failed rotator cuff repairs, or individuals with prior failed shoulder replacement surgery. A reverse shoulder replacement can also be useful in the cases of severe fractures of the proximal humerus (shoulder joint) in older individuals. In patients with cuff tear arthropathy, an initial trial of physical therapy may be given to try and restore function to acceptable levels. If however significant functional loss and associated pain persist, reverse arthroplasty is the only surgical option. Why is it called a "reverse" shoulder replacement? The position of the ball and socket is changed so that the ball is on the socket side of the joint and the socket is on the

ball side. In the normal shoulder, the rotator cuff helps the large deltoid muscle to elevate the arm. When the rotator cuff is completely torn and non-functional the humeral head “escapes” superiorly, and the deltoid is then unable to lift the arm by itself. By reversing the position of the ball and socket the loss of the normal rotator cuff is compensated for and the deltoid muscle can then once again raise the arm.

Reverse shoulder replacement allows restoration of overhead function, alleviates pain and gives the patient a pain-free functional shoulder

How is the surgery done? The surgery is done as an in-patient procedure and usually involves a hospital stay of three to four nights. An interscalene nerve block is done to numb the shoulder and arm, and general anesthesia may also be used. An incision is made over the front of the shoulder and all arthritic bone, and any bone spurs, as well as tight scar tissue is removed and a reverse shoulder replacement is implanted. What is the recovery like? Physical therapy is initiated during the hospital stay. The patient is taught a simple set of exercises that they can do on their own at home. Typically full recovery is achieved by three to four months postoperatively. A reverse shoulder replacement can significantly decrease pain and

improve function for patients and contribute significantly to an improved quality of life. Why choose Indian Spinal Injuries Center? The Indian Spinal Injuries Center is a tertiary referral center for complex orthopaedic and joint problems and as such, we are specifically equipped to handle this type of complex operation. Our centre has the distinction of performing the most number of reverse shoulder replacement of any private institute in north India. Our institute has an experienced team of orthopedic surgeons including Dr Deepak Raina, Dr Sumit Khurana and Dr Jayant Kumar, who have been trained in India and abroad in performing this complex surgical procedure. Patients benefit from our multidisciplinary approach to the treatment of shoulder disorders and have access to a full range of care. Our experienced team of physicians, certified physical therapists, and support staff all work together to help patients achieve success. In addition, our affiliated occupational and physical therapists are specially trained in rehabilitation of the shoulder and elbow prior to and after surgical reconstruction.

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TRADE & TRENDS

Dräger Design Center in India The Dräger Design Center replicates a hospital’s environment and is a functional space where medical users, planners and architects can experience a range of equipment arranged in a solutions format Experience cutting-edge Dräger medical technology in real life setting The Dräger Design Center marks an open invitation for the customers to come and experience this functional space where the company have recreated acute care areas. Visitors of the “hospital area” can experience their workplace before it is actually setup.

Comprehensive Solutions The visitors of the Design Center can trace a patient’s progress through the stages of transport ventilation, resuscitation, induction, surgery, post-operative, recovery and intensive care. This gives visitors first-hand experience with various Dräger devices in action, such as Central gas supply Systems, Ceiling supply units, Modular OR, Anaesthesia workstations, ICU ventilation, Patient Monitoring and information Management and Neonatal Care Systems with accessories/consumables for all these devices.

Modular Operation Room In addition to the devices, the company also showcases other

solutions along the clinical pathway, such as a modular operation room. Upon request, a room can be set up according to the exact specifications desired by customers for their own hospital. This enables them to sample, test and see if it fits in with their established working practices, or if any changes are necessary.

Customisation Using a 3D computer application, the desired configuration can then be created as a virtual working environment and documented. This results in a customised solution that is tailored to the client’s precise

specifications, without the need for costly modifications after installation. To schedule a personal Dräger Design Center Tour, contact the local sales representative, who will accompany the tour Draeger Medical India Registered office: Ground Floor, Goldline Business Centre,Link Road, Malad (W), Mumbai - 400 064. Tel.: +91-22-4084 3838 Fax.: +91-22-4084 3898 Toll Free: 1800 220 225 Email id: info.MT.india@draeger.com Website: www.draeger.com

Fourth edition of e-Radiograph releases Imaging of Pancreas Focuses on imaging of pancreas, anchored by Dr Anirudh Kohli FOLLOWING THE first three editions of e-Radiograph, a bi-yearly clinical ejournal, Carestream India has recently released the fourth edition titled, ‘Imaging of Pancreas’. Every edition of eRadiograph covers a different topic of interest, which is selected based on the feedback received from practicing radiologists and readers. In order to provide varied views and

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September 2014

perspectives, every edition is authored by an eminent radiologist acting as the guest editor. The content for this edition is developed by Dr Anirudh Kohli, Head of Radiology, Breach Candy Hospital, Mumbai. The current edition of eRadiograph discusses imaging challenges involved in the diagnoses of acute and chronic diseases infecting various

parts of the Pancreas. For easy and better understanding, the entire edition is divided into eight distinct chapters, and each chapter discusses a different disease. Collectively, these chapters emphasise the need of early identification of the infection, suggest suitable diagnosis method and accordingly the route of treatment. To access the ejournal log on to www.carestream.in/eradi-

ograph and subscribe to the current and subsequent issues free of cost. The e-book format allows busy medical professionals to access this comprehensive educational tool from anywhere, while on the go. Nilesh Sanap, Marketing Manager, Carestream Health India states, “This easily accessible ejournal perfectly serves our philosophy of continuously helping radiologists

in bettering their practices by providing leading edge knowledge and information about Industry’s best practices to them.” Sanap concludes, “As each edition of eRadiograph focuses on a new and interesting topic, supported by relevant case studies and images, many of our readers preserve eRadiograph editions for the future reference.”

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