Express Healthcare (Vol.12, No.5) May, 2018

VOL.12 NO 5 PAGES 64

Market David Perez, President & CEO, Terumo BCT

Radiology Trends in radiology www.expresshealthcare.in MAY 2018, `50

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CONTENTS MARKET Vol 12. No 5, May 2018

Chairman of the Board Viveck Goenka Sr Vice President-BPD Neil Viegas Editor Viveka Roychowdhury* Chief of Product Harit Mohanty BUREAUS Mumbai Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das, Mansha Gagneja Swati Rana

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DAVID PEREZ, PRESIDENT & CEO, TERUMO BCT

POLICY

Delhi Prathiba Raju Design National Design Editor Bivash Barua Asst. Art Director Pravin Temble Chief Designer Prasad Tate Senior Designer Rekha Bisht

THE WOUNDED SHARK AND ITS SUITORS Caught in the red ocean trap,Fortis Healthcare's journey teaches us three key lessons | P-14

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DR SARVESHWAR NARENDRA BHURE, MISSION DIRECTOR (NHM), CHHATTISGARH

Graphics Designer Gauri Deorukhkar Artists Rakesh Sharma

KNOWLEDGE

STRATEGY

Digital Team Viraj Mehta (Head of Internet) Dhaval Das (Web Developer)

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Photo Editor Sandeep Patil

START UP CORNER RADIOLOGY

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ZAHABIYA KHORAKIWALA, MD, WOCKHARDT HOSPITALS

MARKETING Regional Heads Prabhas Jha - North Harit Mohanty - West Kailash Purohit – South Debnarayan Dutta - East Marketing Team Ajanta Sengupta, Ambuj Kumar, Douglas Menezes, E.Mujahid, Nirav Mistry, Rajesh Bhatkal, Sunil Kumar PRODUCTION General Manager BR Tipnis Manager Bhadresh Valia Scheduling & Coordination Santosh Lokare CIRCULATION Circulation Team Mohan Varadkar

TRENDS IN RADIOLOGY

Dr Shankar Vangipuram, HOD, Radiation Oncology

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DR R HEMALATHA, DIRECTOR, NATIONAL INSTITUTE OF NUTRITION

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THE WELLTHY APPROACH TO DIABETES CARE

Prashant Warier, Co-founder & CEO, Qure.ai

Express Healthcare® Regd. With RNI No.MAHENG/2007/22045. Postal Regd.No.MCS/162/2016-18. Printed and Published by Vaidehi Thakar on behalf of The Indian Express (P) Limited and Printed at The Indian Express Press, Plot No.EL-208, TTC Industrial Area, Mahape, Navi Mumbai-400710 and Published at Express Towers, Nariman Point, Mumbai 400021. Editor: Viveka Roychowdhury.* (Editorial & Administrative Offices: Express Towers, 1st floor, Nariman Point, Mumbai 400021) * Responsible for selection of news under the PRB Act. Copyright © 2017. The Indian Express (P) 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.

EXPRESS HEALTHCARE

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EDITOR’S NOTE

Fortis Healthcare: The good, the bad and now the ugly?

O

ops, they did it again! We're referring of course to Malvinder and Shivinder Singh, the promoter family of the erstwhile Ranbaxy and Fortis Healthcare Limited (FHL).

Both brands were considered one of the best benchmarks in their sectors, trusted by patients, stock market darlings, poster boys of Indian pharma and healthcare.

Today, the companies and their promoters could prove to be classic case studies in corporate misgovernance. Luckily for both Ranbaxy and FHL, the underlying fundamentals of their sectors remain strong enough to attract buyers. In fact, the line of bidders for FHL expanded to as many as five contenders at one point of time! (For a detailed analysis of this developing story, read Raelene Kambli's story: The wounded shark and its suitors) But whichever bidder wins FHL, patients will benefit only if the sector self regulates and holds itself up to higher standards. And even if the due diligence clears the Singh brothers of fraud, though that looks highly unlikely with the information we have at present, the loss of trust will damage not just the FHL promoters and the board. The entire corporate hospital sector in India will face increased scrutiny from various stakeholders.

Firstly, from the investor community. PE funders will have to plan for deeper due diligence when considering an investment in healthcare.

Many regional level hospital chains, and single facility entities which started out as doctor-promoted clinics and nursing homes, are reportedly gasping for survival. Consolidation in the sector is picking up. Some recent examples include Ahmedabad-based Shalby Hospitals, and Trivandrum-based KIMS Hospitals. Overseas players like Aster DM too are catalysing this wave of consolidation. The scale of the FHL deal has PE investors salivating at the cost efficiencies, PE funders have many choices, but what if they land up with a lemon?

The second group of stakeholders who should ideally be watching such deals more closely are patient groups. Unfortunately, the trust deficit between the patient community and the healthcare sector seems to be decreasing to new lows. Most recently, Prime Minister Modi made some very critical comments on all segments of the sector during his recent visit to UK. From pharmaceutical companies, to doctors to hospitals, none were

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Whichever bidder wins,patients will benefit onlyif the sector holds itself up to higher standards

spared. Doctors have taken to social media to hit back at the PM, saying it was unfair to judge an entire fraternity on the conduct of black sheep, but the cracks only widened. The PM's stance is no surprise and only reinforces his government's crackdown on prices of medicines, medical devices and the huge margins charged at most private hospitals.

Beyond the healthcare sector, FHL is one more example of India's weak corporate governance oversight mechanism. Analysts are drawing parallels between two infamous cases of corporate fraud: Satyam Computers and the UB Group. A report dated February 21, by InGovern Research Services titled Fortis Healthcare: Repeat of Satyam?, the authors flagged frequent restructurings and directors’ resignations at FHL which had eroded investors’ trust as well as wealth.

Following the money, the "deployed" funds of Rs 437 crore with companies that became promoter owned companies is clearly not kosher.

But is this the Ranbaxy moment for Indian hospital sector? The Ranbaxy saga was a loss-ofinnocence moment for India Pharma Inc. Today, the pharma sector is a little more forthcoming about the results of US FDA inspections and deviations discovered during these inspections. At least some companies are trying to shift from a let's-hide-it to let's-fix-it mode, though of course, its still not as transparent as it can be.

Similarly, if promoter families and boards of corporate hospitals clean up their balance sheets and become true corporate citizens in letter and spirit, the FHL deal could be a turning point for the sector. After all, as the saying goes, when life hands you a lemon, make lemonade.

And this is what India's hospital management boards need to understand. Nothing will change the strong fundamentals of the sector: we need more hospital beds but expansions need investments. There will be no going back to businessas-usual. The new management will hopefully put in place stronger monitoring mechanisms. For a sector long dominated by the Apollo Group, the Fortis-Manipal or Fortis-IHH combine will shake up rankings and be true competition. But will the patient ultimately benefit? That remains unclear for now.

VIVEKA ROYCHOWDHURY Editor viveka.r@expressindia.com

MARKET I N T E R V I E W

‘India represents one of the top growing markets for Terumo BCT in Asia Pacific’ Since early 1980s, Terumo BCT, a US-based blood bank technology major has a presence in India and operates an R&D facility at Trivandrum. Recently, David Perez, its President & CEO was in India for business expansion. In an exclusive interview with Lakshmipriya Nair, he outlines his company’s vision for this country and the roadmap to achieve them Brief us on the highlights of your visit to India?

India has been important to Terumo BCT for many years.

Terumo Penpol in Trivandrum is our Indian subsidiary, which manufactures close to 30 million blood bags each year making it among the largest blood bag manufacturer in the globe. I was here to meet our team and better understand our plans for the future, and I cannot express how excited I became when I heard, saw and learned more about the work that is being done by the team in Trivandrum.

Besides meeting with my fellow associates and seeing the progress of our new R&D building in Trivandrum, I was here to meet customers, given my trip was very brief, I could meet just a few.

My trip also coincided with the announcement of our collaboration with the research and development experts at Capgemini India.

We also work with

TechMahindra. These are major firms with deep expertise in disciplines including the power of connected devices, internet of things and artificial intelligence. Technology is helping us fulfil our mission of unlocking the potential of blood. It makes perfect sense to collaborate with firms like these, and leverage their expertise learned across other industries such as telecom, life sciences and high tech.

What will be Terumo BCT's priority areas of growth in India in the times to come?

Terumo BCT recognises the potential and capability of the highly skilled and knowledgeable talent in India and is rapidly expanding our Innovation & Design Centre in India along with collaborating with various Indian companies.

We are excited to introduce the Mirasol Pathogen Reduction Technology (RPT) system, to

We will increase capacity in our manufacturing facility here in India by 33 per cent, taking our annual capacity to 40 million blood bags

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India. It is the first PRT system in India, receiving registration in July of 2017.

We believe this innovative technology will have a positive impact on the safety of India’s blood supply. The Mirasol PRT system is a simple and effective way to reduce known and unknown blood borne pathogens. It helps to protect against a broad spectrum of pathogens including bacteria, parasites and viruses. Not just this, the Mirasol PRT system also inactivates white blood cells, adding an extra layer of safety for patients receiving blood transfusions.

Where does India fit into Terumo BCT's global vision?

India represents one of the top growing markets for Terumo BCT in Asia Pacific.

In the next five years, growth is expected at a double-digit percentage rate. Globally, we are seeing increasing levels of automation in both healthcare and consumer products. Our innovation and development efforts, many of which are being made in India, will bring automation to our customers’ throughout the world.

What are the growth plans of the company for the next three years? What is the roadmap to achieve them?

Terumo BCT will increase

capacity in our manufacturing facility here in India by 33 percent, taking our annual capacity to 40 million blood bags. To meet the needs of the global market, in addition to the demand in India, we will also substantially increase our capacity for medical equipment for blood banking will also be increased.

Investments are planned to increase our I&D infrastructure and there will be a significant increase in the number of scientists and engineers hired in India to design and engineer for the globe.

required, as technology continues to play an ever larger role in healthcare. Cell therapy will play a major role in treating various diseases

and blood disorders in future.

As a leader in the blood management and cell therapy businesses, Terumo BCT is well positioned to

offer advanced technologies to meet these needs. Thanks to our vast experience and extensive global resources, Terumo BCT can lead the

industry in providing safe blood components and cell therapies. lakshmipriya.nair@expressindia.com

What are the trends which would shape the healthcare industry in times to come?

How is Terumo BCT geared to adapt and thrive in this environment?

The demand for safe blood components will increase, this will be driven by the increase in oncology, trauma cases, surgery, blood disorders and the increase in demand for modern healthcare The demand for safe blood components will increase, this will be driven by the increase in oncology, trauma cases, surgery, blood disorders and the increase in demand for modern healthcare. A growing number of easy to use and efficient devices will be

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EXPRESS HEALTHCARE

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MARKET PRE EVENTS

Healthcare Senate,coming soon The event will focus on ‘Healthcare 2.0:Strengthening Values for Sustainable Growth' EXPRESS HEALTHCARE invites CXOs of hospital chains, medical directors, owners/ promoters of hospitals and diagnostic centres, consultants, thought leaders, industry stalwarts and domain experts to congregate at India's largest private sector business summit to prepare a blueprint based on values that will make healthcare organisations successful both in terms of profitability and goodwill.

The first two editions of Healthcare Senate held in Hyderabad served an excellent platform for thought leaders, key decision makers, investors and budget holders to share and exchange strategies that are relevant to the fast changing healthcare environment as well as helpful in running sustainable, responsible and profitable businesses in India.

All stakeholders therefore, came together to share their insights on business models that will work for India. The first edition focussed on ‘Value-based healthcare delivery’, while the second edition was ‘Building a future ready healthcare sector for India’.

Taking these discussions

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further and in keeping with the rapidly changing healthcare business environment, Healthcare Senate's 3rd edition, scheduled in July 2018, will focus on 'Strengthening Values for Sustainable Growth'.

The summit and its discussion will emphasise on inculcating the below mentioned core values that will lead healthcare business to create value for all.

Ingredients for a successful organisations: ◗ Integrity: There are no moral shortcuts in the game of business or life. It is the true mark of leadership and so healthcare organisations who wish for sustainable growth will have to instill this principle in all their business dealings; be it patients, employees or partners. Healthcare organisations which operate with integrity and honesty earn immense brand value. At H e a l t h c a re S e n at e 2 0 1 8 industry stalwarts will share their stories of success which speak of goodwill and profitability earned through integrity and honesty in business.

◗ Accountability: This is a virtue that healthcare organisations cannot overlook.

Accountability entails the procedures and processes by which healthcare providers justify and take responsibility for their activities. Lack of accountability in healthcare therefore, can cause significant damage to organisations.

It can erode quality of care, ruin an organisation’s reputation, and increase the risk of lawsuits. Experts, in their discussion, will deliberate on ways and means to improve accountability of care. ◗ Quality: Quality in healthcare should be more than making the best product or providing the best service. It should extend to every aspect of the business function. A company that recognises quality and strives for it daily has a profound sense of selfrespect, pride in accomplishment, and attentiveness that positively affects every aspect of its business. At the conference, healthcare quality experts will share insights on how striving for quality facilitates organisations to improve efficiency and achieve profitable in the long run.

◗ Innovation driven: Industry leaders will explain how innovative companies deliver a consistent stream of market successes via successful businesses and products/services or improved processes that continuously translate market success into economic value.

These companies enjoy a competitive advantage and achieve sustained growth. ◗ Adaptability: With changing business dynamics the challenge that healthcare organisations face is keeping pace with these changes. Organisations which can roll with change and still perform well are prime time players and will enjoy sustainable growth. The event will bring forth case studies of such companies which have gracefully accepted change and gained better outcomes. ◗ Strategic Partner Relationships: No business is successful if it is not built on values forged and strengthened by strategic partnerships.

Here, experts will highlight the essentiality of striking sustainable partnerships which can help companies gain competitive advantage and credibility.

Topics to be covered during the event are: ◗ Healthcare 2.0: Creating value for all ◗ Creating an inclusive healthcare ecosystem for India ◗ NHPS: Building the right synergies ◗ Growth Agenda: The battle for sustained innovation leadership in healthcare ◗ Access strategies in a era of price control ◗ CEO Round table: Business culture: Why core values matter? ◗ Healthcare's unique treasury management challenge ◗ Regulating trade margins the do's and dont's On the side lines of Healthcare Senate 2018, Express Healthcare will also be hosting Radiology and Imaging conclave and the the Healthcare IT Senate. Both these knowledge platforms will gathers experts from the field of radiology and It to share in depth knowledge on the Future of radiology and the healthcare IT. Contact: Vinita Hassija Email id: vinitahassija@gmail.com Phone no: 98205990053

MARKET

Nadda reviews states’preparedness to manage vector borne diseases Before the onset of monsoon, Nadda interacted with Principal Health Secretaries and Mission Directors of 20 endemic states EMPHASISING THE need for early preparedness to be adequately in a position to manage vector borne diseases such as dengue, malaria, JE, kala azar , chickungunya, lymphatic filariasis in the coming monsoon months, Union Minister of Health and Family Welfare, JP Nadda recently reviewed the status of vector-borne diseases and the preparation of states through video conference in New Delhi. The Union Health Minister interacted with Principal Health Secretaries and Mission Directors of 20 endemic states –Andhra Pradesh, Assam, Arunachal Pradesh, Bihar, Chattisgarh, Delhi, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh,Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Tripura, UP and West Bengal. The advance review at the level of the Health Secretaries and senior officials of the states was done in view of the predicted upsurge of vector borne diseases at the onset of monsoon.

Nadda reviewed the availability of diagnostic kits, drugs, testing labs, manpower and funds. Awareness being the key to prevention of many diseases, Nadda stressed on the importance of conducting focussed and intensive IEC campaigns and sustaining them through the monsoon season. He advised that best practices from states like Gujarat and Tamil Nadu may also be emulated.

Nadda further stated that the focus should be on active case finding for source identification and reduction of vectors.

He said adequate attention should be given to building sturdy surveillance systems.

Effective surveillance and monitoring was key to success in combatting these diseases, he emphasised.

EH News Bureau

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cover )

By Raelene Kambli

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(

O

nce, there was a big blue ocean; home to many sea creatures big and small. The ocean, with all its immensity and magnificence was a thriving ground for every marine life. There were several aquatic kingdoms that dwelled and flourished in the deep blue. Amongst them, was the prosperous empire of the great shark. His province known to be teeming with riveting flora and fauna was a place that everyone wanted to be. The illustrious shark, was popular for his knack for smart warfare. Many appreciated his greatness but also feared his warfare. He was also acclaimed to be excellent in striking part-

WHAT IS THE RED OCEAN STRATEGY? T

he Red Ocean is where every industry is today. There is a defined market, defined competitors and a typical way to run a business in any specific industry. The researchers called this the Red Ocean, analogous to a shark infested ocean where the sharks are fighting each other for the same prey. A Red Ocean Strategy aims to fight and beat the competition. Red Ocean Strategies have the following common characteristics: ◗ They focus on competing in a marketplace which already exists. ◗ They focus on beating the competition. ◗ They focus on the value/cost trade-off. The value/cost trade-off is the view that a company has the choice between creating more value for customers but at a higher cost, or reasonable value for customers at a lower cost. In contrast, those who attempt a blue ocean strategy aim to achieve differentiation and at the same time, low cost. ◗ They focus on exploiting existing demand. ◗ They focus on execution (better marketing, lower cost base etc).

A Red Ocean Strategy ultimately leads an organisation to follow one of two strategies – differentiation or low cost. Whichever is chosen the organisation must align all activities with one of these strategic directions.

A N A LY S I S

nerships that helped him to expand his dominion far and wide. Over the years, the glory that the shark attained made him so self-absorbed and proud that he slowly began to ignore his people and province.

One unfortunate day, a ferocious storm hit the the ocean.

The storm was so mighty that it wiped out many kingdoms.

The situation in the deep blue worsened when a huge war broke out. Every creature big and small fought for its survival. The great shark fought fiercely to save his realm, but to his dismay, everything was lost.

Everything that was built in several years came crashing down, the beautiful empire was tarnished. He was left wounded

Fortis Hospitals' acquisitions, expansions and growth (2008-12) Fortis Healthcare Ltd acquired Super Religare Laboratories (SRL), South–east Asia's largest diagnostics laboratory network to further strengthen presence across the healthcare value chain

Dec 10, 2010: Adds Vivekanand Hospital to its network Dec 08, 2010: Unveils new hospital in Shalimar Bagh in Delhi Dec 02, 2010: Acquires O P Jindal Hospital in Raigarh, Chhattisgarh Dec 02, 2010: Strengthens presence in Central India Network; touches 50 hospitals mark

2012 Fortis Healthcare Ltd acquired Fortis Healthcare International Pte. Ltd. –Fortis Healthcare Ltd launched the first colorectal hospital in Singapore, becoming the first Indian hospital chain with a greenfield hospital abroad"

2011

2010

Jan 28, 2011: Adds 100 bed Lifeline Hospital at Alwar in Rajasthan,

Oct 28, 2010: Inks MOU with RAK Hospital and Tanzania's RMC

Jan 12, 2011: Changes name of company from Fortis Healthcare Ltd to Fortis Healthcare (India) Ltd.

Sep 23, 2010: Inks pact with Republic Of Burundi

Jan 4, 2011: Signs MoU with Utah University for specialized care in emergency medicine

Sep 02, 2010: Adds cancer institute in its hospital portfolio Jul 26, 2010: Divests entire stake in Parkway to Khazanah

Feb 25, 2009: Launches dental centre at Malar Hospital, Chennai, with the aim of promoting dental tourism in the city. The Fortis Dental Centre has been floated on partnership basis with dental chain Axiss Dental

2009 Feb 18, 2009: Announces taking over of the operational and management control of the 200–bed Apollo Modi Hospital in Kota (Rajasthan) for providing superior healthcare services in the region.

2008 Jun 05, 2008: Fortis Escorts Becomes First Hospital in Faridabad to Launch Total Knee Replacement Unit Mar 19, 2008: Fortis Hospital, Noida Becomes first hospital In Uttar Pradesh to receive the coveted NABH Accreditation

Mar 19, 2010: Completes acquisition of 23.9% stake in Parkway Holdings

EXPRESS HEALTHCARE

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cover ) and now, he would soon become prey to the hungry sea creatures that loomed around his territory as they have smelt blood.

The shark tries to swim to the other end where he will find help. But the sea is still rough…

What will the great shark do to save himself? Will he manage to tide over to the other end and find help? Or will he be hunted by the deadly creatures that await him?

Wondering why was this fairy tale narrated here?

Well, if you look at the story closely, this situation is similar to the circumstances that occurs in a red ocean trap amongst several business industries. The Indian healthcare sector is currently experiencing an identical phenomenon. A careful analysis will show that the sector is slowly brewing a red ocean trap wherein many players are falling prey to a highly competitive environment and balancing sustainability with profitability is becoming a tall task. Reasons being, a defined market but fragmented players, increased competitiveness, growing government intervention to regulate the industry, capital intensive nature of markets, rising patient demand, lack of innovation and creative direction and so on. The extreme difficult conditions that most players operate today only leads to deteriorating corporate performance. One such case in point is the situation that Fortis Healthcare landed in today.

The Fortis Healthcare saga: The rise and fall in 10 years Once a distinguished player, Fortis Healthcare's rise and fall has been known to all. After the Singh Brothers sold their stakes of Ranbaxy, (the pharmaceutical business of the Fortis Healthcare group) to Daiichi Sankyo in 2008 (the deal was valued at $2.23 billion), the company suddenly captured global attention. Overnight, the Singh brothers became celebrities of the Indian business world.

A year before the deal, Ranbaxy was faced with strictures

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THE SUITOR’S OFFER FOR FORTIS HEALTHCARE T

o begin with, Malaysian hospital chain IHH claimed that its revised proposal is based on its assessment that FHL needed ` 4,000 crore to meet immediate liquidity requirements and to fund the buyout of Religare Health Trust (RHT) assets. With that in mind, IHH proposed a binding offer for an immediate infusion of ` 650 crore - without any due diligence - valuing Fortis at ` 160 per share. This amount was to be applied primarily to pay employees, creditors and ease FHL's debt servicing needs. In exchange, IHH wanted the right to appoint two directors on the FHL board. "We expect the independent directors of the company to constitute a majority of the board after the appointment of our nominees," said the offer letter.

It also stated that the offer was subject to confirmation that it will be given "immediate access to carry out a legal and financial due diligence". IHH also made a non-binding proposal to infuse up to ` 3,350 crore subsequently, subject to satisfactory completion of the due diligence exercise in a three-week time frame.

The Malaysian hospital chain further stated that the revised proposal had to be accepted in its entirety and set a deadline of 5 pm on May 4 before the revised offer would be withdrawn. This, incidentally, is the third offer that it has made to FHL in 10 days.

Meanwhile, the offer letter from KKR-backed Radiant Life Care proposed a binding offer to purchase the Fortis hospital in Mulund, Mumbai, "without due diligence and as a going concern at an enterprise valuation of ` 1,200 crore as the first step".

This followed the company acknowledgment that "due to liquidity constraints, FHL has been unable to run a formal auction process" and was only considering binding offers. The second part of Radiant's offer - non-binding at this stage and subject to due diligence - proposed spinning off SRL Diagnostics "for the time being so that FHL can run an independent competitive sale process".

Radiant further proposed a demerger of the hospitals business from FHL into a new company followed by an all-cash open offer to shareholders of the new entity at a price of ` 126 per share.

The offer is subject to Radiant being able to acquire 26 per cent or more shares of the new company. "In order to fund RHT stake acquisition, we propose a rights issue offer by NewCo [new entity]. The entire rights offer amount would be back-stopped by Radiant," the offer letter added.

That brings us to the last revised offer on the table for FHL as of April 24. MHEPL, revising its offer for a second time in two weeks, has now proposed to offer a premium of ` 1,319 crore to FHL shareholders, over and above the equity valuation for FHL's hospital business of ` 5,003 crore.

This is a hike of 25 per cent over its previous revised offer dated April 10. Under the fresh offer, an equity value of ` 6,322 crore will be attributed to the hospital business, up from ` 6,061 previously.

Manipal also offered to buy up to 5 per cent of the paid-up capital of SRL from Fortis at the same price as it will buy from private equity investors of SRL. It will buy the stake from private equity investors of SRL for ` 11,134 crore, added the offer letter. In return, it has sought control over at least 51 per cent of voting rights in SRL along with Fortis and also majority representation on SRL's board. It has also sought limited veto rights pertaining to certain matters of SRL. Moreover, MHEPL offered to "arrange financial assistance of up to ` 750 crore"either by way of debt financing of by way of guarantees or comfort letters to lenders of FHL to take care of immediate liquidity. But this is subject to applicable laws and FHL approving the new proposal.

MHEPL also said that it did not have any objection to the merger of Fortis and SRL subsequently provided all pending investigations into Fortis and other entities were completed without any adverse implications, including any reputational damage.

Source: Fortis Healthcare

from the US FDA. Despite, the merger with Daiichi, Ranbaxy’s trails and tribulation continued to multiple. After the long-term FDA ban on exports of their medical products, the company was in deep jeopardy. Their corporate performance went for a toss. The company’s woes added when the Singh Brother got embroiled in a legal tangle with Daiichi. The Singh Brothers were also said to have disappeared around ` 10,000 crore.

However, their hospital business was a saving grace. A year after the Daiichi deal, Fortis Healthcare had acquired 10 hospitals from Wockhardt whose corporate performance was experiencing a tailspin at that time.

The acquisition of Wockhardt Hospital was one of the largest deals then. Later, the company tried to bid for the Singaporebased Parkway Pantai group of hospitals but was unsuccessful.

The company further contin-

ued their efforts to get more healthcare chains under their fold, but couldn’t succeed. Later, Fortis’s global operations were merged into Fortis Healthcare and their number hospitals stood at 78 with a cumulative total of 12,000 beds, 580 primary health centres, 188 day care speciality medical centres and 190 diagnostic laboratories. For a short while, they were the largest healthcare provider in the Asia-pacific region. Alas!

They couldn’t maintain this glory for long.

The company’s dynamic healthcare leaders that cradled the hospital business for so long also could not stop the downslide. They had to withdraw from the international operations.In order to improve their balance sheet, they came up Religare Healthcare trust.

However, sometime later, news broke out that the Singh Brothers had deployed ` 473 crore from the healthcare business into their own business which raised a red flag. This mystery still remains moot.

There are also contemplations about Fortis Healthcare going the Satyam way. After Fortis admitted that it had lent around `470 crore to some companies as of December 2017 and that these companies had now become part of the promoter group two proxy advisory firms – Ingovern and Institutional Investor Advisory Services release reports that showed similarities in the Fortis and Satyam case. The Ingovern report mentioned, “The issue of transferring funds to a wholly-owned subsidiary, which in turn lends to promoter entities in order to skirt the shareholder approval requirement, seems to be a blatant fraud. Much like the Satyam case, the cash and cash equivalents on the books of the company seem to be non-existent. The company’s subsidiary has conveniently given loans to related parties without seeking shareholder approval and regulatory filings.” Sebi has instituted an investigation on the same as well.

The legal tangles based on fraud, malpractices and financial scam continues to haunt the business performance. The only resort left with the company is to merge their healthcare business (hospitals and diagnostic chain) with a responsible, well performing player and win back its glory. But how will they do this swiftly?

A lease of life or a road to destruction?

Fortunately, there are suitors who still find Fortis Healthcare as an attractive business acquisi-

( tion. There have been several business proposals for buying stakes in Fortis. The highest bidders being: Manipal- TPG, IHH group and Burman- Munjals.

(Refer to the box: The suitor's offer for Fortis Healthcare) Will merger with any one of these groups be a fruitful move for Fortis? How will this deal impact the suitor who wins this bid? Is buying a distressed asset such as Fortis, a wise decision for the investors? How will this merger impact the industry at large?

Industry analysts and leaders from the healthcare sector feel that a merger with Manipal will be a good move for Fortis.

Says, Amit Mookim, General Manager, South Asia, IQVIA, “The deal between both companies that combines complementary footprints of the two chains in north and south India is strategic. Combination of Manipal Hospitals and Fortis Hospitals will result in the creation of the largest provider of healthcare services in India by revenue with 41 hospitals in India and four hospitals overseas and an installed bed capacity of over 11,000 (including teaching hospital beds of Manipal Hospitals).

The deal will create a large hospital entity across India which could look at additional acquisitions going forward. It may also lead to additional consolidation among organised players in the hospital space. ” Farhan Petiwala, Executive Director and Head Development – India & South Asia, Akhand Jyoti Eye Hospital (AJEH) also feels that a merger with Manipal will give birth to India's largest chain and with the strong reputation that Manipal pocesses, Fortis will be able to revive its glory once again.

Moreover, Manipal Group also seems to be upbeat of this deal but is unable to comment much at present. (Read interview with Rajesh Moorti,Group CFO, Manipal Education and Medical Group (MEMG).

While there are some who are positive on its merger move, some industry experts raise a red flag. “Fortis doesn't have a great reputation for good corpo-

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rate governance - and there are likely to still be skeletons in their cupboard which will come tumbling out . This will delay the deal”, opines Dr Aniruddha Malpani,Angel Investor. Malpani Ventures.

While speaking on the impact on the industry and patients, Dr Malpani adds, “ My worry is that while bigger is better for VCs, this is not always true for patients or doctors.

These large hospitals become

quite impersonal and get bogged down by bureaucracy.

They often employ more administrators than clinical staff, and patients get low priority in their scheme of things, because they put profit before patients”. Peti-

A N A LY S I S

wala also shares a similar concern for patients. He says that corporatisation of healthcare usually leads to increase cost of healthcare which patients have to bear. However, if the group conceives its expansion and

cover ) growth plans keeping patients in mind, this can be a game changing move for the sector.

Well, the Fortis’s story doesn't end here. While the entire industry is eagerly waiting to know who would win the bid, the board at Fortis Healthcare is witnessing a hive of activities.

Changes in some board of directors, renewal of bids and more.

The evaluation process continues and the wait for the bidder still on.

What can we learn from this episode?

Learning lessons Fortis Healthcare story teaches us some significant lessons. In times when the industry is experiencing a dramatic change, it is significant that companies do not get trapped in the complications of the red ocean. It is imperative to be more creative in developing and executing competitive strategies, create niche segments, market spaces which can act as differentiators. Mentioned below are three key learnings: Strategic planning for consolidations, partnerships and growth: Consolidations, merger and partnerships will be the name of the game in future. Informs Suresh Satyamurthy, CEO and Co-Founder, Tarnea Technologies Solutions, “There are numerous hospitals which are up for sale. As we speak, just in the hospital segment there is even a dedicated website which is offering hospitals for sale https://www.hospitalforsalelease.c om/ .A very sure sign that a major consolidation is already underway. The same goes for the Diagnostic Services. The high capex and technology for diagnostics at large scale, has changed the business. Now collections are localised, the analyses are done centrally in a few chosen locations for the entire country, and the results are disseminated via email ! This sector too is undergoing rapid consolidation.”

While Satyamurthy speaks of the rise in consolidations, Jose Punnoose, Independent Director, CEO & Mentor : Hospitals & Health Systems speaks

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INTERVIEWWITH RAJESH MOORTI,GROUP CFO, MANIPAL EDUCATION AND MEDICAL GROUP (MEMG) Fortis has 2x the number of beds and 2x revenue compared to Manipal. There is also significant brownfield expansion for Fortis in key markets. Are these project apart of the deal?

This transaction encompasses all the assets of the hospitals business. MHE has spent significantly higher amount on new projects (both brownfield and greenfield) in the last three to four years.

What is Manipal Hospital's vision on this merger? What is the strategy that they will adopt to increase its market share?

This is a compelling strategic fit with complementary geographic presence and clinical strengths. The combined entity will also have very good market share in a number of clinical services. This can be further leveraged through shared commitment to provide excellent patient care.

Will they look for further expansion?

A significant increase in demand for quality healthcare provides great expansion opportunities. This platform will be well suited to exploit these both in new geographies and existing ones. We will have to ensure that we fully utilise the new infrastructure created in the recent past first, before embarking on further expansion.

Manipal Group had a strong educational background in Southern India. How will they transform Fortis Hospitals into centres of excellence? What positive impact will this deal create within the Indian sector?

The combined entity will be the largest hospital service provider in India by revenue and will have talented staff of 4,200+ doctors and 9,300+ nurses. The hospital industry has been impacted by lack of availability of quality doctors and clinicians, a large pan-India network can provide great career opportunity for many. Both Manipal and Fortis are strong brands and Manipal is backed by over 65+ years of heritage. A strong focus on ethical clinical practices and excellent patient care can be true differentiators in the market.

on the pros and cons of consolidations in a highly competitive market. “Consolidation in terms of mergers can give access to geographies and market to which one may not have access to. The flip side of this coin is the possibility of lack of synergies due to conflict in mission, vision , values . Diversity in geographies, culture and practices are known to have had catastrophic results . Being too large also effects control , with inefficiencies creeping in into systems and processes . HCA in the US is a classic example which had to downsize after facing such a situation . The solution is to find the right balance. Consolidation will also mean synergising and finding the fit and not just adding assets. It could also mean downsizing and offloading non core businesses . Achieving financial strength, reducing clinical variation, increasing scale, and forming clinically integrated networks for improved

care delivery are major considerations in various forms of consolidation, which ultimately should result in better returns for all stakeholders including patients.”

Mookim explains the prerequisites, “Companies going for consolidation should have a sound strategy and a clear communication plan to articulate the same to its shareholders.

Early and transparent guidance to investors is also one of the key requirements to have long term benefits. Further, companies should be prepared to transition smoothly to the new requirements. They should be able to scale a sustainable business with robust corporate governance and systems and processes.”

Create new market spaces: Experts opine that payoffs of market creations are immense.

Today the start-up community in healthcare is constantly in

search of new areas to build business models that can make competition irrelevant. That can be an excellent strategy to go forward. This is a strategy suggested by W Chan Kim and Renée Mauborgne, Professors of Strategy at INSEAD and authors of The New York Times Bestseller Blue Ocean Shift and the global bestseller Blue Ocean Strategy. According to their concept, Blue Ocean Strategy generally refers to the creation by a company of a new, uncontested market space that makes competitors irrelevant and that creates new consumer value often while decreasing costs. This can be a good way to do business in healthcare. Referring to a perfect example of the same, Satyamurthy expounds, “If you look deeply, the Indian system of specialisation has done better at exploiting economies of scale. Who can do the cheapest eye operations in the world? Its Arvind Eye Hos-

pitals ! They even produce the cheapest intraocular lens in the world. They have dramatically changed the economics of eye surgeries on the strength of their specialisation. Likewise, we have specialised chains for - Diabetes - MV Diabetes, HCG for oncology etc. Each does one specialised service, but at huge scale! Their unit economics work well, and they are profitable. And none of them are looking to become a DGH (hopefully!) Rather than pursue consolidation to create a bigger entities what might have a greater impact on access and affordability is a drive towards specialisation of a therapeutic area, and building scale only in those specialisation.”

Strengthen business values and revamp mental models: The Fortis Healthcare's rise and fall is mainly attributed to the lack of strong business values that make a business empire attain brand equity and goodwill.

Strengthening values of integrity, accountability, flexibility and innovation are paramount for any organisation to be successful in their business.

According to experts, it is important to build a culture that inculcates an ethical value system, only then can a healthcare organsation achieve excellence in service delivery and corporate performance.

What happens next...

Moving forward, we are certain that the final outcomes of Fortis Healthcare's merger and acquisition will be out soon. We only hope that whoever wins the bid, would in future crack the code for Fortis's distressed assets and not be sucked into the spiral of debt, misfortune and malpractice. Hope, that this move will be a new beginning for Fortis and that this new beginning will lead the company on the path to building a responsible and sustainable healthcare business empire.

Stay tuned to catch more updates on the Fortis deal on our website (http://www.expressbpd.com/healt hcare/) raelene.kambli@expressindia.com

POLICY I N T E R V I E W

‘Affordability, availability and accessibility of quality healthcare is our intent’ Dr Sarveshwar Narendra Bhure, Mission Director (NHM), Chhattisgarh, in a free-wheeling interview with Prathiba Raju speaks on the innovative measures taken by the Chhattisgarh government to improve the healthcare delivery in the naxal heartland What efforts have been taken by the Government of Chhattisgarh to improve healthcare of the state?

Government of Chhattisgarh has taken many innovative steps towards improving the healthcare delivery system.

The state government intends to improved the affordability, availability and accessibility of quality health care to every citizen of the state. Towards this direction, the state has initiated Rashtriya Swasthaya Bima Yojana (RSBY) for the unorganised workers and Mukhyamantri Swasthaya Bima Yojana (MSBY) to provide protection to every uncovered household against the risk of health spending leading to poverty. Other major steps initiated are: ◗ Improved the number of doctors, nurses and pharmacists are appointed in the national healthcare system to overcome shortage of medical personnel ◗ Developed a healthcare system which will dedicatedly work for providing medical help in less time in rural areas through mobile medical units. ◗ Increased healthcare spending for healthcare development. ◗ Regulating distribution and sales of drug public pharmacies often run out of free medications it will help to reduced health service cost. ◗ Developed health infrastructure. ◗ Arranged different health checkup campaign for free in rural areas. ◗ Run different program to spread awareness about NCD's and it’s awareness. ◗ Initiate transparency by

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accreditation of hospitals and healthcare providers. ◗ Engagement of private players and international health agencies.

NHPS is expected to provide sum coverage upto Rs 5 lakh per family per year for both secondary and tertiary care services. Currently RSBY is providing only Rs 30,000 sum insurance coverage primarily for secondary care services. The NHPS is expected to handle the treatment load of critical care diseases like cancer, cardiac, neurosurgery and trauma

Being a naxal hit area, what are the added challenges you face and how do you combat it and while you deliver healthcare to the insurgenthit tribal areas? What steps have you taken to bridge acute shortage of doctors/nurses in the state?

Bijapur, district in Chhattisgarh is now turned out to be a model which has elevated the healthcare availability and delivery of the tribal region, by designing attractive incentive for doctors, specialists of this district hospital has made tremendous improvement in healthcare. Bijapur is been highlighted in every healthcare forum pan India.

Shortage of health human resource in these areas was the major challenge in delivering healthcare services.

To check this Chhattisgarh Rural Medical Core scheme was implemented to provide both cash and non financial incentives to the health staffs who served in these areas.

Deployments of 2nd ANM and Rural Medical Assistants had made a big change in scenario.

Interrupted supply of electricity, which hampered the services has been tackled by installating solar panels at sub-health centres and primary health centres. HR outsourcing, transit hostels, fixed day out reach service camps, birth waiting homes, Sirha guniya sammelans are innovative initiatives taken for

strengthening the health system.

How are vaccination and institutional delivery carried over in these areas, the ways in which they are improved? What efforts have been undertaken to upgrade the MMR/IMR rates, neonatal intensive care units?

To achieve 90 per cent full immunisation coverage, various steps are taken as follows – ◗ The state conducted special immunisation drive at poor performing blocks. ◗ Number of left out and drop out children are vaccinated by conducting Mission Indradhanush in four phases, state's vaccination coverage was 96 per cent, 83 per cent, 8621 and 11520 in Phase 1,2,3,4 respectively. ◗ Strengthening of cold chain and vaccine logistic system through establishment of e VIN and EVM assessment is done in the state, according to the assessment result, improvement plan has been circulated to all districts. ◗ New cold chain point are established to deliver the vaccine at session site timely and after analysis of need based area. ◗ To achieve 90 per cent full immunisation coverage districts are instructed to emphasis in following points – ◗ Prepare micro-plan for routine immunisation based on head count and revised/updated micro-plan expected to be ready at a time. ◗ Session site should be open timely so that child won’t be missed by any vaccine. ◗ For effective vaccine delivery and coverage improvement, it is necessary to have vaccine delivered at right time and similarly return to cold chain point in the evening. ◗ Supervision by health supervisor (LHV, MO, BMO, DIO) & others (Mitanin trainer) is extremely important for supportive supervision of RI. ◗ District with difficult terrain, naxal hit area and tribal areas have

Bijapur, district in Chhattisgarh is a model which has elevated the healthcare availability and delivery of the tribal region, by designing attractive incentive for doctors, specialists of this district hospital has made tremendous improvement in healthcare immunisation session in mela, Haat bazaar, communicating with local leader and by AVDS. How much dedication and hardwork is required by doctors, Asha's, ANM's to work in a state like Chhattisgarh? How do they manage it and what support do they get from NHM and the state government?

It is a very well known fact that human resource density is directly related to achievements in health outcomes such as Maternal Mortality Ratio (MMR), Infant Mortality Rate (IMR) or coverage with preventive and promotive interventions.

Huge investments have been made in NHM over last 10 years to add contractual staff in service delivery and managerial positions. Number for nurses and doctors are really impressive. In addition, 70000 Mitanins at village level also provide much needed support for poor women and children to seek timely care.

Skilled HRH are critical to achieve health policy goals.

There has been a rapid expansion of medical colleges, dental colleges and nursing schools and colleges in past decade. Several concerns have been articulated about poor quality of training due to nonavailability of faculty, lack of clinical material and present environment in examination system. Due to limited exposure in skill based training even fresh postgraduates are not confident and competent enough to perform simple clinical procedures such as interval tubectomies. To motivate and refresh them regular capacity building programmes have been conducted with the help of

technical agencies like WHO, Unicef, HLFPP, Jhpiego etc.

Can you give us the status of NCD burden in the state?

In the National Family Health Survey (NFHS) the percentage of people having high blood sugar and blood pressure in the state has been surveyed. Based on the sample survey done, separate data of urban and rural are reported. Blood sugar level among women (age 15-49 years) the data sheet highlights that the high blood sugar more than 140 range is seen in urban area with a percentage of 6.6 per cent whereas in rural areas it is 5.4 per cent and very high blood sugar of more than 160 range is seen in urban areas with 3.1 per cent than rural area which is less 2.4 per cent. In men (age 15-49 years), the data sheet highlights that the high blood sugar of more than 140 is high in urban areas with a percentage of 12.9 per cent whereas in rural areas it is 8 per cent and very high blood sugar of more than 160 is also very high in urban 7.2 percent than rural area which is less 3.7 percent. Male are more affected with high blood sugar levels. The status of hypertensive patients are again more in the urban population than the rural population When it comes to nutrition, women in the state are severely malnourished, particularly woman from Chhattisgarh Baiga tribal group. Any particular scheme implemented for the same?

NHPS is expected to provide a sum coverage of upto Rs 5 lakh per family per year for both secondary and tertiary care services. Currently,

Rashtriya Swasthya Bima Yojana (RSBY) is providing Rs 30,000 sum insurance coverage primarily for secondary care services. The NHPS is expected to handle the treatment load of critical care diseases like cancer, cardiac, neurosurgery and trauma. The NHPS is also expected to attract corporate and bigger hospitals for the services provided by them.

Chhattisgarh was doing well under the Rashtriya Swasthya Bima Yojana (RSBY). With NHPS, what are the changes expected?

NHPS is providing equal opportunity for both public and private hospitals under the scheme. Public hospitals can earn additional fund by providing treatment under NHPS, same fund may be utilised for the development of hospitals and upgrading the services. RSBY and Mukhyamantri Swasthaya Bima Yojana scheme tries to include critical issues like : ◗ Provision of effective and affordable family care to the entire populations. ◗ Extension of tertiary care to poor people of rural areas. ◗ Decrease the out of pocket of pocket expenditure. ◗ Ensure access and quality of service to those with no influence. ◗ Protecting the poor from indebtedness and impoverishment resulting from medical expenditure. ◗ Ensure choice to patients among multiple service providers What do you think would be the value addition to the public sector through NHPS? Definitely NHPS will be leading to reduce the out of pocket expenditure in health.

The economic burden of disease on common people may be reduced which further results into the prosperity and human development.

Are tele-medicince and digitisation used for healthcare delivery in these areas? How has the technology helped to reach such unreached places?

Department of Health and Family Welfare, Chhattisgarh has come up with an MoU with Arvind Netralaya, Madurai (Tamil Nadu) for setting up of vision centres in remote areas of Chhattisgarh, wherein consultation with doctors would be provided through telemedicine. Under this project, training of ophthalmologists is on-going in Madurai. With the help of telemedicine and digitisation, healthcare services can be reached to unreached.

What is the role of private players in such areas?

The issue of public-private partnerships (PPPs) in health has been highlighted by the recent draft NITI Aayog document about a PPP arrangement for certain noncommunicable diseases (NCD). The National Health Policy (NHP) 2017 clearly prioritises strengthening of public health systems as a key approach. However, it also recognises a critical gapfilling. Currently, under PPP we are running several health projects in Chhattisgarh. One is with GVK EMRI for providing referral transport services. 108 emergency ambulance service and 102 non-emergency services are provided under PPP model.

The state is planning to run the diagnostics services under PPP for which process are under pipeline. Like this with the help of Hindustan Latex Family Planning Promotion Trust (HLFPPT), we are doing capacity building of frontline health workers for providing IUCD/PPIUCD services under family planning programme. prathiba.raju@expressindia.com

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KNOWLEDGE I N T E R V I E W

'We are planning to soon revise the RDAs which were last recommended in 2011' Last year, NIN through NNMB and ICMR conducted a nutritional study on chronic non-communicable diseases (NCDs) that evaluated hypertension, diabetes and dyslipidemia in urban population of 16 Indian states. Dr R Hemalatha, Director, NIN reveals outcomes of the research report with Usha Sharma What are the key findings of the research report on Urban Nutrition Data of India 2017?

Considering that India’s nutrition transition has been rapid in the last few decades, it was thought necessary to look into the nutritional status of the urban population especially because most of our earlier surveys through the National Nutrition Monitoring Bureau (NNMB) were among rural areas. The last few decades are marked by phenomenal changes with liberalisation, job opportunities, urban areas have been swelling with population and also there have been phenomenal lifestyle and dietary changes that have occurred. Gone are the days when India was thought to be the home for only undernourished people, but today, we are confronting a paradox in which we have undernutrition and overweight/obesity and associated non-communicable diseases co-existing. From double burden of malnutrition (undernutrition and overnutrition), we are now confronting the triple burden where the micronutrient deficiencies are seen both in undernourished and overweight/obese population.

All these necessitated a study to see what the current nutritional situation is like.

What role has ICMR and National Institute of Nutrition (NIN) played in bringing out the research report?

This study was implemented by National Institute of Nutrition (NIN) through National

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Nutrition Monitoring Bureau (NNMB) units located in different districts. Financial support was provided by Indian council of Medical Research (ICMR).

In this comprehensive study, nutritional status, chronic noncommunicable diseases (NCDs) such as hypertension and diabetes, and dyslipidemia were evaluated in urban population of 16 states of India.

The results showed high frequency of hypertension and diabetes, and high cholesterol levels in one fifth of the urban population. Of the 16 states studied, Kerala has the highest numbers of men (46.6 per cent) and women (38 per cent) with hypertension followed by Assam; while Puducherry has the highest numbers of men (42 per cent ) and women (30 per cent) with diabetes, followed by New Delhi (36 per cent).

Relatively lower numbers of men (28 per cent) in Madhya Pradesh and women (21 per cent) in Andaman and Nicobar Islands have hypertension; and again, Madhya Pradesh men (17

per cent) and women (13 per cent) recorded the lowest level of diabetes. Income was directly associated with hypertension and diabetes in both men and women.

As for overweight people, a whopping one half of urban men (52 per cent) and women (59 per cent) are overweight (BMI=23) or obese(BMI=28) with Asian cutoffs.While the highest number of overweight and obesity among men was observed in Rajasthan (63 per cent) and Puducherry (62 per cent), Tamilnadu recorded highest number of women (69per cent) with overweight and obesity after Puducherry (74 per cent).As per the global cutoffs (BMI =25), 34 per cent men and 44 per cent women are overweight or obese.

Nearly a fifth of the preschoolers living in the same regions are undernourished (17 per cent, low weight for age) and stunted (20 per cent, low height for age). While, more children are stunted in Uttar Pradesh (40.8 per cent), Puducherry recorded the

lowest prevalence of stunting (11.6 per cent). Even though low birth weight (LBW) prevalence is relatively low at an average of 16.4 per cent, ranging from 10 per cent to 30 per cent , stunting persisted at an average of 28.7 per cent, ranging from 11.6 per cent to 40.8 per cent in preschool children. Infant and young child feeding practices were poor in these regions with only 50 per cent complying with early initiation of breast feeding and 34 per cent following timely initiation of complementary feeding at six months of age.

Although 82 per cent of urban households have sanitary latrines and around 85 per cent have access to protected drinking water, we still have nearly a fifth of all urban population who do not have access to these basic requirements.

Which diseases are more prevalent in urban areas?

As we can see from the urban data, NCDs like Hypertension, Diabetes and Cardiovasular dieseas are on the rise. The India State-level disease burden initiative, in which also draws from the Urban Survey data, estimated a 36 per cent reduction in Disability Adjusted Life Years (DALYs) in India, from 1990 to 2016, suggesting an overall decrease in disease burden due to infectious diseases, maternal and neonatal and nutritional disorders in India. At the same time, DALYs due to NCDs are going up rapidly. It is indeed a cause of concern. Despite reduction in maternal, neonatal and nutritional disorders, child

and maternal malnutrition still topped the five leading risk factors for DALYs in 2016, the others being air pollution, dietary risks, high systolic blood pressure, and high fasting plasma glucose. While deaths due to diarrhoeal diseases lower respiratory infections and tuberculosis decreased, deaths due to ischaemic heart disease (heart attack) and diabetes increased significantly as per the State-level Disease Burden. Epidemiological transition is occurringwith increase in diseases due to NCDs such as diabetes, ischemic heart disease, stroke, cancers etc; with infectious diseases, and maternal, neonatal and nutritional disorders continuing to be public health problems.

Will this trend be soon visible in rural areas and in which states?

Some regional studies in India have reported NCDs as theleading cause of deatheven in rural India. Projection estimates from the WHO have shown that by the year 2030, CVDs(ischemic heart disease, stroke) will emerge as the main cause of death (36 per cent) in India. And majority of deaths in India are premature with substantial loss of lives during the productive years adding to economic loss to the country.

Why men in urban areas suffer more than women from hypertension?

Comparatively, more men have hypertension than women due to biological factors like hormone- estrogen, which is protective in women.

Additionally, behavioural factors such as increased smoking, alcoholism among men may also contribute to a higher prevalence of hypertension.

developmental delays or other medical problems and can be life threatening.

These disorders are due to genetic abnormalities and therefore difficult to control.

Tell us about NIN's role in formulating strategies to promote food safety and streamlining regulatory mechanisms ?

NIN- ICMR, ministry of health and family welfare, works closely with ministry of women and child development (WCD) and Food Safety Standards Authority of India (FSSAI).

Most of the nutrition programmes in the country are supported by NIN- ICMR research findings. Diet and nutrition related regulations are also guided by NIN- ICMR research findings. The Dietary Allowances for Indians are recommended by NIN-ICMR and are revised from time to time depending on what India is eating and latest research findings. In this centenary year, we are planning to soon revise the Recommended Dietary Allowance (RDAs) which were last recommended in 2011. In addition, NIN constantly has been evaluating various nutrition programmes and providing advice to state governments. In fact some of our district-level studies have mapped undernutrition among children and have provided valuable inputs for state governments like Madhya Pradesh, Gujarat etc., to plan targeted interventions.

Why new born screening is not mandatory in India? How do we make it mandatory in

What is inborn metabolic disorder? Has there been a progress so far to control it?

In contrast, Inborn errors of metabolism (phenylketonuria, maple syrup urine disease, glycogen storage disease, lipid storage disease etc) are rare genetic disorders in which the body is not able to utilise the food to derive energy. These disorders are generally linked with defects in specific enzymes needed for digestion and metabolism of food. Foods that are not metabolised into energy can build up in the body and cause a wide range of symptoms. Several inborn errors of metabolism cause

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our country?

Hypertension, diabetes and obesity cannot be detected at birth. These are lifestyle diseases (diet and physical activity) and can be prevented by making smart choices in food and by resorting to regular physical activity.

New born screening for

IEM is available, primarily in metros, but given the multitude of possible mutations underlying inborn errors of metabolism, it is not possible to recognise all inborn errors of metabolism by neonatal screening. However, screening for congenital hypothyroidism and deafness

may be prioritised due to grave consequences if these conditions are left untreated and proven benefits with appropriate and timely treatment. But this needs a lot of manpower and funds, but we can aim to get there soon. u.sharma@expressindia.com

OPINION

Code of Conduct for Today's Doctors!

Dr A K Khokhar, Professor (Hospital Management) and Dean(Training), International Institute of Health Management Research, New Delhi speaks about the needs for doctors to evolve as responsible healthcare leaders who have a patient-centric approach in providing care

O

ver a period, there has been a tremendous change in society’s approach and attitude towards medical professionals. There was a time when doctors were considered next to God and patients blindly followed their advice. Rapid industrialisation, technology transformation, spread of knowledge through internet, artificial intelligence, and easy availability of information/misinformation about medical facts and varied methods of medical treatment have brought about a crisis of confidence between doctors and patients. Sociological and technological advancement in last few decades have not only changed the standard of living of people but have also brought about massive changes in healthcare.

With fast-paced changes, demanding patients, regulatory bodies and media intervention, doctors are feeling the pinch of lack of trust in medical services and have lost their traditional relationship with patients.

Doctor’s Dilemma Today, with frequent incidences of violence against medical professionals, doctors are feeling threatened and are working under stress leading to a crisis in delivery of medical/ healthcare services. Today’s generation of doctors are “the most challenged by moral choices in perhaps a century– and physician must break their silence or assist the harm that silence perpetuates because, there is no third choice”- writes Don Berwick, Former (MS Administrator in JAMA).

The ethical issues in medical practice require respect for autonomy of the patient. They need to provide required information about patient’s ailment and available treatment options. Informed consent must include all possible complica-

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The paying capacity of a patient’s vis-a-vis the treatment/ prescription is another issue that medical professional needs to consider. The affordability of required medical care must be given priority in order to make universal healthcare available to all. Doctors themselves are a part of society and the medical community. There is a need to adopt blameless strategies towards their colleagues as well as towards the society as a whole. This requires honest transactions.

skills, safety, quality and team spirit. Fundamental values like compassion, kindness and caring attitude are at the heart of good medical practice.

Today’s doctors must decide, based on their conscience, what to do in certain situations about issues which may not have been taught in their medical curriculum. Physicians must work as a team in delivering good healthcare. This requires interpersonal skills, besides the technical skills of medical treatment. Further, it requires the medical professionals to think beyond their clinics/ hospitals and see themselves as part of the total healthcare system involving health professionals and the community at large.

Fundamental Values

Holistic Approach

Medicine will continue to evolve around societal, technical, and demographical changes. The medical profession has to identify potential challenges and respond to shape its practice accordingly. It has to aim at developing trust amongst patients, respect for human life, continuing upgradation of

To be an effective doctor today, he/she will have to look into the holistic aspects of healthcare as well as of healthcare management. This requires that some important issues related to health management/ hospital management viz human relations, leadership, legal and ethical issues are incorporated into the undergraduate medical syllabus itself. Those already in practice, need to acquire, these professional skills through shortterm management development programs/ training on health and hospital management. Doctors who would be involved in management of the health institutions should take up professional course in health and hospital management. Many institutions are providing MBA/PG Diploma in such subjects and in service training to doctors to address these issues.

To conclude, today’s doctors need to have emotional quotient and humanitarian approach in addition to management skills and technical knowledge of medicine and medical procedures.

calls for sacrificing the personal and financial interests of individual doctors. There is a need to avoid all malpractices prevalent in the profession.

Patient’s Affordability

tion so that patient is mentally and psychologically prepared to choose and accept the offered treatment.

Continuing Education Good medical practice require doctors to be familiar with latest development in their respective field. Continuing medical education and training are

vital to their development. They need to continually update their knowledge, skills and practices to provide quality medical care expected from them by their patients and by society at large.

Enunciation of ethics does not automatically result in ethical practices. The ethical practices need to serve the society as a whole and this at times

STRATEGY I N T E R V I E W

‘A strong presence in a city like Mumbai has various advantages’ While a lot of industry experts feel that venturing into B-towns, Tier II and III cities can be a profitable bet to healthcare providers, Wockhardt hospitals opts to focus more on metros, especially Mumbai. Zahabiya Khorakiwala, MD, Wockhardt Hospitals in a free-wheeling conversation with Raelene Kambli explains the strategy and benefits behind Wockhardt focus on metros cities such as Mumbai What are the core principles that you follow at Wockhardt?

We strongly believe in the principal of quality and collaboration. All our efforts are put in providing quality care to our patients and all this is done with a collaborative approach among doctors, nurses, paramedic and the support staff. We believe in staying ahead in terms of skills and focus on constant upgradation of our knowledge.

Our goal at Wockhardt Hospitals is to set clinical benchmarks in quality and contemporary treatments in the tertiary and quaternary care space.

Tell us about Wockhardt Hospitals's current strengths?

Focus on Quality and Patient Care – With 2,600 number of employees, we at WHL practice highest quality standard to deliver superior clinical care. We have ensured that all our hospitals are NABH accredited and also the group’s flagship Hopsital the “New Age Wockhardt Hospitals” at Mumbai Central has received the coveted JCI accreditation within first three and half years of its operation.

Group of Hospitals – Being a group of seven superspeciality tertiary & quaternary care hospitals hospitals has its own merits such as – ◗ Exchange of best practices, ◗ Patients transfer/mobility, ◗ Doctors/Consultant

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innovative approaches – At Wockhardt Hospitals we have a strong focus on research and development of innovative clinical approaches and procedure to better serve our patients. In Mumbai with a wider spectrum of demographics the adoption of such innovations is faster.

Presence of eminent superspecialists – In Mumbai, the country’s leading superspecialists are associated with Wockhardt Hospitals. Hence, the commencement of our various accomplished programmes like multi-organ transplants and pediatriccardiac started from Mumbai.

Equipped with the learnings from our Mumbai hospitals, we replicated such programmes in our nonMumbai based hospitals.

expertise sharing Strong presence in Mumbai - We have seven hospitals in total with three hospitals in Mumbai of about 750 beds all together. We are able to bring in new modalities of treatment and easily incorporate it in our Mumbai hospitals because it is a metro city with an appetite for innovation.

Wockhardt Hospitals was also associated with Boston based Partners Medical International (PMI) for 17 years. This exclusive association gave Wockhardt

Hospitals access to a network of Harvard-affiliated hospitals around the world and their immense expertise and knowledge, ensuring that we adopt and deliver global best practices at our superspeciality tertiary care hospitals.

What are the advantages of having a strong presence in a city like Mumbai?

A strong presence in a city like Mumbai has various advantages Faster adoption of

So, is the pediatric cardiac space a profitable solution for you?

In India, over two lakh children are born every year with congential heart diseases (CHD). To make the situation worse, many families are not able to afford the cost of available treatment at corporate/private medical centres. Aware of this grim reality, we established state-ofthe-art Wockhardt Paediatric and Congential Heart Centre at Wockhardt Hospital, Mumbai Central. For us the aim of this programme is to meet this unmet need in the community maintaining highest standards of quality care in this specialised

surgery space.

For the people who can’t afford the CHD surgery for their children we provide the same at a subsidised rate and also we have partnered with various foundations and charities which provide further financial support to them.

What is your outlook on the future healthcare business?

The healthcare business and all its constituents/stakeholders are evolving at a fast pace and the future looks radically different from present. For example – Greater penetration/adaptation of technology with digitisation and creation of integrated patient-centric databases is changing the nature of how healthcare operates. Also, Artificial Intelligence and Machine Learning led clinical care will be the game-changer.

Increasing awareness among patients - People are equipped with easy access to information through google and other online resources, and they expect better service, faster diagnoses and treatments. This will lead to higher quality focus in the healthcare Industry Human Capital - Given the demographic and Industrial growth markers of our country, the future of Healthcare business is bright provided Human Capital needs (Nurses and Doctors) can be bridged urgently. raelene.kambli@expressindia.com

START UP CORNER

The Wellthy approach to diabetes care This March, Mumbai-based Wellthy Therapeutics raised $2.1 million in seed funding, the first significant funding since its launch in 2015. The funding is proof that investors are willing to bet on its blend of health coaches, powered by AI, to coax behavioral changes in patients of chronic diseases. Does the startup have what it takes to make a real impact? By Viveka Roychowdhury

I

t takes a village to manage an illness believes Abhishek Shah, CEO and Co-Founder, Wellthy Therapeutics. The statement is a nod to Hillary Clinton's bestseller but that is exactly what Wellthy promises to do: build a virtual village around patients to help them defeat their diseases. As Shah points out, "Diabetes needs you to go beyond the pill or the diagnostic test."

Described as an artificial intelligence powered software as a drug, this digital therapeutic company aims to solve better chronic disease management.

The company blends Shah's BS in Chemical & Biomolecular Engineering from Georgia Institute of Technology, with his family's entrepreneurial background, to supply a solution to India's growing disease burden linked to diabetes.

With fresh seed funding of $ 2.1 million from big names like Dr Ranjan Pai's family office, Beenext Ventures, GrowX Ventures, Currae Healthcare and other strategic HNIs like Ashutosh Taparia and Karan Bhagat, Wellthy seems to have caught the rising tide of investor interest in health tech.

There is no doubt that diabetic patients in India need all the help they can get. With the breakdown of the joint family system, Indians are increasingly finding themselves coping with life changing diseases all on their own, without the traditional support systems of parents, grandparents. Patients find themselves coping with the stress of hectic work lives, unbalanced sleep schedules and no one to cajole them to change their lifestyles. The same is true for diabetics across the world.

Touted as 'India’s first clinically tested diabetes ‘digital pill’ for physicians, by physicians', the Wellthy Diabetes (WD)

Every key healthcare stakeholder stands to benefit as patient outcomes improve. Our job is to help each one of these healthcare stakeholders improve their patient outcomes at an individual and at a population level and connect the dots between improvement in patient outcomes and economic benefit to the stakeholder ABHISHEK SHAH CEO, WELLTHY THERAPEUTICS

mobile app for patients with type II diabetes, was launched this February, at a conference held by the Maharashtra chapter of the Research Society for the Study of Diabetes in India (RSSDI).

Such interventions have made their debut in developed nations quite a while back and it seems India is catching up. In the US, WellDoc received FDA clearance of a non-prescription version of its BlueStar diabetes management system in January 2017, while FDA clearances for earlier prescription-only versions of the platform were received in 2010.

The field of prescription digital medicine in India is currently unregulated, and according to Shah, Wellthy will be working closely with regulators to regulate this new category. For now, the Wellthy Care platform and its Type II diabetes management programme have been endorsed as India's first prescribable digital diabetes intervention by RSSDI.

The WD's core differentiator Consumers are spoilt for choice when it comes to health related

app so what's different about the WD app? Agreeing Shah says, "There are more than 300,000 digital health apps on the app store, and 3000+ just for diabetes.” Hence, his mantra has been about proving outcomes.

"Only a handful of the available apps have shown and published real world clinical evidence.

While most will choose fancy digital marketing and user acquisition strategies for downloads and upsell, the true digital therapeutics are focusing on outcomes and clinical evidence as their core differentiator."

Shah explains that the launch came after they were able to prove outcomes clinically in their pilot programme. The interim results of this ongoing real-world pilot study showed that at the end of the 16 week programme, patients showed improvements in blood sugar control, measured as a drop in mean HbA1C levels (1.04 per cent), mean weight loss of 3.4 kg and savings of upto Rs.15,000 in diabetes-related expenses per year. Of course, there's the mandatory caveat that results would vary from person to person, but these seem attractive outcomes.

These interim results have been presented at conferences as well. For instance, the 11th International Conference on Advanced Technologies & Treatments for Diabetes (ATTD 2018) this February, saw a poster board with the results of the study, ‘Effectiveness of a Digital Therapeutics for Improving Outcomes in South Asians Living with Type 2 Diabetes’. After a 16 week life style modification programme delivered through WD, the 39 participants reported a mean reduction of 0.61 per cent A1c post intervention.

The paper concluded that WD was a clinically effective intervention for health insurers in South Asia to improve health outcomes and reduce risk for people with type II diabetes.

Besides RSSDI 2017, similar presentations have been made at International Diabetes Federation (IDF) 2017 and American Diabetes Association (ADA) 2017. Shah also informs that they are planning another trial, the #WeDiDiT (Wellthy Digital Diabetes Therapy) trial which is expected to start in H1 2018.

Getting on board WD Currently targeting type II

diabetes, doctors can now prescribe the WD app to their patients, who download it to smartphones. Once connected, patients sign up for a 16 week programme. Each patient is assigned a dedicated diabetes expert in addition to Carey, an AI powered health coach.

Based on patient self-reported data on meals, blood glucose, physical activity and weight, the expert, along with AI augmentation like gamification etc, helps patients track and manage their diabetes better.

Patients can chat with their personal expert and clear their diabetes-related questions and concerns, clearly something that they cannot do real time with their doctor beyond the consultation. (See screenshots from the WD app) WD uses content developed along the guidelines of the American Association of Diabetes Educators (AADE) which had defined seven self-care behaviours (AADE7) as a framework for patient centered diabetes self-management education (DSME). Shah stresses that the interventions on WD, developed scientific collaboration with RSSDI, are customised

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Screenshots from the WD app

for South Asians and this is crucial as the app marries global clinical protocols with knowledge of local food and life style habits.

WD is available on Google Play Store with limited access to some information. Shah specifies that the fully active version needs to be prescribed by a doctor, after which the patient gets a kit containing an activation code for the app, a glucometer with testing strips from a partner company. Shah emphasises that the app and the programme is built to augment and complement, not replace, the doctor's role.

A win-win proposition ...

The launch is typical of the cross sector collaborations that Shah has stitched up since he cofounded Wellthy in December 2015. He has worked in partnerships with stakeholders across the healthcare chain. Wellthy graduated from the Merck Global Digital Health accelerator, Swiss Re’ Global and ICICI Lombard’s Nova InsurTech accelerators. Though Shah doesn't name names, Wellthy collaborated with an insurance provider

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for the study presented at ATTD2018 and hints that announcements are due with pharmaceutical and medical device companies as well as insurers.

As Shah puts it, "Every key healthcare stakeholder stands to benefit as patient outcomes improve. Our job is to help each one of these healthcare stakeholders improve their patient outcomes at an individual and at a population level and connect the dots between improvement in patient outcomes and economic benefit to the stakeholder." While they have already achieved product market fit in this area, Shah promises that through 2018 more such partnerships will materialise.

Digital medical interventions promise benefits to each stakeholder. Patients could see better outcomes, quality of life, and clinically validated tools to manage their care. All of which cold in time reduce spend on medication. Pharma and medical device companies get real world clinical evidence, better outcomes and adherence. The Wellthy website has testimonials from both doctors and patients who were on the pilot trial. Shah refrains from

spelling out details of his revenue model, only emphasising that, ''Wellthy is paid for positive outcomes."

... with some challenges But the benefits also come with some challenges in this nascent field. As Shah explains, "It’s a new category of medicine and it will take some time to generate and show clinical evidence. This makes patients and doctors less receptive to exploring this avenue and helping it find its place in standard healthcare. If the doctor is not convinced, you hardly have a chance of getting a patient to change their mind.

So, you get a catch-22 situation: Because people are skeptical of something new and unverified, so to speak, they are hesitant to use it; but unless more people use it and more often, generating those trustworthy results is difficult."

The second challenge is that in a digital market saturated with health and wellness apps, it can be daunting for a user to tell the difference between a “health app” and a prescription digital therapeutic like Wellthy. Because on the surface they appear

to be the same, points out Shah.

But he is confident that these challenges can be addressed.

"Trust and reputation come with time, perseverance and results. There are no shortcuts, he says.

"Providing clinical evidence is a must for any digital therapeutic that is serious about healthcare. Not only that, it must show clinically significant improvements, along with showing it repeatedly in real world settings. And clinically significant outcomes coupled with clinical evidence published in peer reviewed journals are the defining factors. Physicians, insurers, and pharma companies are wary of digital health products with tall claims and no data to back it up.

And rightly so. Thus, demonstrating, with clinical support and evidence, what digital therapeutics are capable of is a necessary precursor to convince healthcare stakeholders,"he explains.

Beyond WD A snowballing health epidemic, diabetes leads to other cardio metabolic conditions and chronic kidney disease. Shah

says the $ 2.1 million seed funding will be used for product expansion - to further personalise the digital therapeutic for larger types of patient behaviours and expand the therapeutic portfolio across select cardiometabolic conditions that are associated with diabetes. In fact, the next launch could be as early as May, though Shah clearly doesn't want to spook things by giving too many details.

Also in the works is an extension of the skill building 16week programme to a 36-week programme where the goal is to build habits. Wellthy takes forward the value proposition of numerous chronic care clinics mushrooming in India and indeed globally. The challenge going forward will be to differentiate themselves from their peers. Not just to attract more funding but to also continue to get the buy in from doctors and show patients tangible outcomes.

Wellthy seems to have the right mix of scientific/clinical expertise and business savvy. Let’s hope they can sustain themselves to the next level. viveka.r@expressindia.com

START UP CORNER I N T E R V I E W

‘Our main aim is to encourage patients to reach out to institutional care’ Ajoy Khandheria, Founder, Gramin Healthcare (GH), in an interaction with Prathiba Raju, explains how GH model will help to improve healthcare delivery in villages and make it economically viable How did the concept of Gramin Healthcare evolve?

How do you think it will help to change the rural healthcare scenario in the country?

Gramin Healthcare (GH) aims to provide institutional healthcare to the underserved. Mostly, the underserved in rural areas are farmers. We wanted to provide them with consistent quality care and this passion made us to develop the concept of GH. We were fortunate to get a lot of positive feedback from patients which helped us in our quest to deliver consistent healthcare in rural India.

We want to further enhance our model with a insurance or packaged primary care service for rural India, which will encourage them to take advice and thus promote wellness. Our main aim is to encourage patients to reach out to institutional care such as ours instead of marginal medical care from existing providers who may or may not be qualified.

Can you elaborate on the partnership with the cooperative fertiliser major IFFCO? Indian Farmers Fertiliser Cooperative (IFFCO), is a partner to our healthcare initiative as well as a shareholder. This partnership has allowed us to scale up fast.

GH has a shop in shop within IFFCO bazaar. This has increased the patient trust and helped the patient acquisition at a lower cost.

IFFCO also provides us corporate governance and

patient may have undergone in the past.

Does GH play the catalyst role by helping the ASHAs, ANMs in villages? If yes,how.

GHC creates better job opportunities for frontline workers (ANM, SNM, ASHA) where we provide training to these professionals and upgrade the existing skill sets, providing them with higher income. They also bring a connect to the farmers, which helps us to get patient trust.

great insights on the behaviour and needs of the farmer.

How many farmers have been benefited by GH? What are your expansion plans?

We are currently serving six states and hope to penetrate these states deeper. The current run rate of patients we support is around 18,000 per month. We have treated over 150,000 patients till date.

How does your primary centres function? What facilities do you offer? Tell us about the health cards you have introduced?

GH is a company, which focusses on making affordable and accessible healthcare to rural and semi-urban areas of India, we would want to serve at the grass-root level, wherever there are less or no healthcare services.

Our aim is to provide

timely medical advice and advanced diagnostics through manned and digitised healthcare centres by bringing the best of both worlds, that is, human intervention and advanced technology. GH has created a scalable model which involves conducting diagnostics tests on ground and using modern technology to get real-time medical consultation from qualified doctors. These centres offers following services: ◗ Blood pressure diagnosis ◗ ECG ◗ Diabetes diagnosis ◗ Eye care ◗ Haemoglobin and pregnancy tests ◗ Women health and hygiene Health cards are prepaid cards issued for a period of one year for the entire family.

It offers product discounts, free tests, secondary healthcare services through

partner hospitals.

Give us details about the ICT used by GH, particularly the tele-diagnostics kit and other innovative digital technology used to connect doctors and patients? Do you have only virtual doctors, specialists apart from the team of nurses deployed on the ground?

The GHC platform is an endto-end telemedicine solution that connects patients, ANM, nurses, doctors and stakeholders to facilitate complete patient treatment fulfilment from physical diagnosis to regular follow ups later.

While doing so, it collects the most comprehensive and invaluable Electronic Health Records (EHR) that include patient vitals, medicine history, allergy history and any previous medical test/treatment records the

What is your view on converting the primary health centres into wellness centres under Ayushman Bharat- National Health Protection Scheme (NHPS)?

We think we are very complimentary to the NHPS. We hope that in future, we shall assist the government run PHC’s effectively and provide consistent quality healthcare to the farmers.

What are your future investment plans? How are you going to raise the amount for the said investment? Do you plan to go for any tie-ups?

We will continue to invest as required to scale up and grow our reach. We are in dialogue with a few investors, both, financial investors and strategic investors.

Additionally, we are constantly evaluating partnerships in products and services that are complimentary and will help enhance the service we offer to our patients. prathiba.raju@expressindia.com

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‘CAREDOSE has been developed keeping a global footprint in mind’ With its proprietary technology and packaging system, CAREDOSE claims to bring down healthcare cost. In an conversation with Raelene Kambli, Gauri Angrish, Founder & CEO, CAREDOSE expounds on the her business model, innovative technology and her vision to provide cost-effective products

The complete service is available to consumers for between Rs 200 - 350 per month, depending on number of doses

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You have integrated IOT mechanisms to discover actual time medicine adherence. Can you elaborate on the same.

Medicine non-adherence is a silent epidemic that exists in more than 50 per cent of people on regular medication (World Health Organisation).

What makes the problem worse is that more than 68 per cent of people do not communicate their nonadherence to their doctors or caregivers. This not only results in a worse disease progression but can also lead to wrong diagnosis.

Additionally, since not adhering to one’s medication is a behavioural problem, we thought one way of ensuring 100 per cent adherence is by getting the patient's caregiver and/or doctor involved, by sending them alerts when the patient does not take his/her dose (negative adherence alerts), so that they can do something about it. Our smart dispenser uses IoT to remind patients about each dose and track their adherence, in real-time.

If patients do not take their doses on time, as prescribed by the doctor, then a "negative adherence alert" is automatically sent to the patient's chosen caregiver, in real-time. Once they receive an alert they can then ensure that the patient takes his/ her dose.

The Smart dispenser tracks the patient’s adherence patterns and each time the patient goes for

his/her doctors appointment, the adherence data is provided to the doctor. Now the doctor knows exactly how the patients have or have not taken their medication as prescribed and this helps the doctor with easier diagnosis and gives the doctor more confidence in altering future prescriptions.

customisation and easy adoption.

What is your strategy for scale and sustainability in the future?

CAREDOSE uses proprietary technology and packaging to help ensure and track medicine adherence, whilst creating big data for healthcare entities & public health organisations. To achieve large sustainable scale, we follow a B2B2C (Business to business to consumer) model. This means that we partner with healthcare entities, equip them with our technology and products and help them manage, track and optimise their patients’ care. Since medicine non-adherence negatively impacts each and every stakeholder in the healthcare spectrum, we partner with all types entities including hospitals, pharmacies, public health organisations, pharmaceutical manufacturers, home health companies, corporate health management companies, etc.

To top it off, our technologies and systems are completely modular and can easily integrate with existing systems, allowing for

Tell us about the cost effectiveness of your product?

We have worked extremely hard on making our product cost effective. The complete service is available to consumers for between Rs 200 - 350 per month, depending on number of doses. This in turn not only helps them manage their medication and ensure adherence, but also helps them reduce their overall healthcare expenditure by avoiding disease progression and healthcare complications. Additionally, in most cases, the healthcare entities we partner with bear the cost of the consumer service as they get multiple additional benefits including retention, better management and access to data.

Tell us about your funding activity?

After launching in 2016, we raised a friends and family round. That has now been followed by a seed round by GEMS Partners in January, 2018.

Tell us more about your tieup with the government for the TB programme?

As discussed with you earlier, we would not like to give details about this. However, it would be great to mention that we are in talks to provide our service to TB patients via

START UP CORNER TB health facilities run by the RNTCP. Tell us also about the robot that you have developed to make your processes and system stronger?

Our proprietary robot, DoseDroid, is an automated multi-dose dispensing robot.

Once a prescription has been digitised into an Eprescription in our software, DoseDroid automatically cuts, sorts, pouches and labels patient's medication exactly according to prescription. It has additional features like tracking a pill journey, which when combined with the data from the smart dispenser allows us to map the journey of a pill from purchase to consumption. Lastly, the

THE MODEL IN A GIST Caredose operates via a B2B2C model as follows: ■ For the patients ◗ Multi-dose dispenser - medicines are delivered to patients pre-organised and labeled by dose so they always take the right medicine at the right time ◗ Timely dose reminders - patients are sent a reminder for each dose so they never miss a dose ◗ Automated refills - refills are delivered on time, every time so they never run out of their medicines ■ For the partners ◗ Automated multi-dose dispensing robot so they can package their patients medication as per prescription ◗ Customised dashboard so they can manage, track & optimise their patient care ◗ Customised data report so that they can make data driven decisions using our insights ◗ Co-branded dispensers so they can increase market value & brand presence amongst their patients ◗ Data mining happens at each point to enable tracking of drug from purchase to consumption

medicines that are pouched are retained in the manufacturers’ packaging to ensure maximum efficacy of each pill. However, keeping a

global footprint in mind, the DoseDroid can package both foiled and open pills.

What is your vision for the

future of your company?

CAREDOSE has been developed keeping a global footprint in mind. We want to save lives by making

CAREDOSE ubiquitous. Our main aim is to provide our proprietary adherence technology, products and services across the globe by partnering with various healthcare entities. Keeping this in mind we have made our systems completely modular and we provide open APIs for easy integration. We believe in the power of collaboration and feel it is the only way forward to be able to provide the transformation that the healthcare industry today, needs. We are focussing equally on private and public healthcare and provide various add-ons to our consumer services for easy adoption by patients from various geographies and socio-economic backgrounds. raelene.kambli@expressindia.com

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Monitoring of health at home will compel people to make healthier choices The concept of healthcare at home is soon becoming a popular business model for innovative companies and start-ups. Meet, Aayush Rai, Co-Founder, Inito who believes that his company has the potential to ride the diagnostic device market in India. He shares his plans with Raelene Kambli Tell us about your company and its innovations?

Inito is a medical technology company building portable diagnostic devices that are not just accurate and reliable but are also smart and easy to use.

Inito is backed by our proprietary technology, FlatLens, that enables smartphones to perform labgrade medical diagnostic tests like diabetes, cholesterol, vitamins, fertility, infections, thyroid etc., at home using a single portable device. So far, the company has four patents pending in its name in six geographies including US, European Union, Japan, India, Russia and China. It has also bagged the three prestigious design awards - CII Design Award, India Design Mark and Japanese Good Design Award.

Our first test, the fertility monitor is a home diagnostic test that enables women to track their fertile days at home in an easy and convenient manner. The fertility test works by identifying up to six fertile days of a woman’s cycle. The device has been medically tested and the results were found to be comparable to those acquired with clinicgrade instrumentation which cost 100 times more and are 10 times bigger.

So, your focus is on diagnostic devices?

Yes, our focus is home diagnostic devices. Data from US Centre for Disease Control (CDC) says that most of the chronic conditions can be managed by regular monitoring and minor

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Our first and foremost aim is to achieve 10X sales of the fertility test in the next 12 months lifestyle changes.

Hence they are now more than willing to take corrective actions for their health in their own hands.

This saves them from repeated visits to the labs which are expensive, time taking and painful a lot of the times. And, it is not just a western or urban phenomenon anymore, Tier II and Tier III cities are joining the band wagon as well. In fact, 40 per cent of our sales come from non Tier 1 cities. We now have buyers from places like Kashmir and Assam too.

When did you start your company?

We started building the product in 2015, started a pilot with 100 people in 2016 and finally launched the product commercially in Dec 2017. We have been growing at a rate of 15 per cent week on week since then.

Why do you think that you are solving a health issue in India? How? India has traditionally been plagued by the issue of communicable diseases like cholera, malaria, dengue etc.

Now, with changing lifestyles

and increasing urbanisation, it is also facing an increase in the number of cases of non communicable diseases like diabetes, heart disease, infertility, Thyroid etc. A report by World Health Organization has revealed that the predominance of chronic diseases is expected to rise by 57 per cent by 2020 with developing nations like India the hardest hit. This is putting enormous pressure on an already burdened healthcare system. This is where home diagnostic technologies can help. Regular monitoring of chronic conditions through these devices allows one to take corrective actions specific to the individual’s body.

Monitoring of health at home will compel people to make healthier choices and reduce visits to the already over burdened hospitals.

What is the differentiator for your business?

The differentiator for us lies in our patent pending technology that allows a single device to perform dozens of diagnostic tests. All the data is stored on the App and the cloud which allows monitoring of data trends. Our App also analyses data to suggest lifestyle changes that will help the user achieve his or her health goals.

What is your current growth rate?Any funding received so far?

We have been growing at a rate of 15 per cent every week since our commercial launch in Dec 2017. The company

raised $1 million from angel investors in India and Singapore last year.

What is your perspective on the diagnostic device market in India?

The diagnostic device market in India is considerably smaller than the west at the moment. But it is bound to grow significantly in the next 10 years owing to rapid urbanisation, sedentary lifestyle and a large percentage of young population entering their 40's.

What opportunities do you see for your company and the segment that you cater to?

Our first test is a fertility test targeted at couples trying to conceive. It allows women to track there fertile days without going for follicular lab scans repeatedly. The device has been recognised to increase their chances of getting pregnant naturally by 89 per cent by giving the fertile days specific to their body.

In the next six months we plan on launching tests for Diabetes, Thyroid and Vitamin D. These would help both younger and older generation to monitor their health.

What are your business plans in the coming year?

Our first and foremost aim is to achieve 10X sales of the fertility test in the next 12 months. Meanwhile, we also want our device to start supporting Diabetes, Thyroid & Vitamin D tests. raelene.kambli@expressindia.com

RADIOLOGY I N T E R V I E W

Trends in Radiology T

echnology is ever evolving and innovations across sectors are spawned in the blink of an eye. These advancements are snowballing and creating a huge impact on global healthcareindustry. For instance, a RedSeer report states, “Market for diagnostic services has been growing in India over the past couple of years at a rate of 15-20 per cent and is at nearly `40,000 crores as of 2016”.

A crucial diagnostic tool Radiology, a major diagnostic and therapeutic tool, is another major example. Digital technology is transforming and innovating in this segment at an exponential rate, be it machine learning, 3D printing, or Internet of things.

These technologies are complementing healthcare in India by assisting the radiologists to

ensure timely and accurate diagnosis. In many, cases, identifying ailments at an early stage provides better treatment outcomes to the patients.

agnostic services, even in the remotest parts of the country. Even if it gives only a marginal relief at the moment, the benefits are bound to grow exponentially in the coming times.

Improving healthcare access The doctor/patient ratio is India is abysmal.

Even more so, in the case of radiologists. In India, there is approximately one radiologist for every 100,000 population, compared to the US where the corresponding ratio is 1:10,000. Thus, the western countries are still better off when it comes to doctor/patient ratio whereas the developing nations are in the direst need of assistance to make up for this shortfall. This is where technology rides to the rescue. To cite an example, teleradiology can redress the acute imbalance between the demand and availability of di-

Unlocking its true potential In a bid to explore the new trends in radiology and understand where India stands in their deployment, Mansha Gagneja spoke to two experts, Dr Shankar Vangipuram, HOD, Radiation Oncology and Prashant Warier, Cofounder & CEO, Qure.ai.

While the former highlights the changing paradigm in treatment of moving cancers through 4D radiotherapy, the latter briefs on how automating the reads of X-ray, CT and MRI scans will aid in improving TB diagnosis protocol, so that more people can be detected.

‘4D IMAGES ASSIST IN ANALYSIS OF DEFORMATION AND MOTION’ Can you elaborate on 4D radiation therapy in clinical practice and its implications on quality and patient care improvement ?

Radiation therapy is a cancer treatment method that employs high-energy radiation beams to destroy cancer cells by damaging the ability of these cells to reproduce. The need for normal tissue sparing is of increasing importance as there is clinical evidence that technologies that allow an increased dose to the tumour while sparing healthy tissue will improve the balance between complications and cure.

Barring brain, motion affects all tumour sites in the thorax and abdomen, even the pelvis motion broadly has two components: 1. Predictable quasiperiodic motion due to respiration (relatively stable from minute-to-minute and day-to-day, and can be predicted to first order by a few seconds).

Dr Shankar Vangipuram, HOD, Radiation Oncology

2. Unpredictable as in motion due to swallowing, peristalsis, organ filling (bladder and bowel). Patient motion and organ distortion, whether as a result of voluntary patient movement or natural functions such as respiration, can make radiotherapy planning assessment less precise and accurate.

Traditionally, the planning and delivery of radiation therapy has been conducted as if the patient was static over the several weeks of therapy. Although it has long been understood that this approximation is incorrect, technology was not available to deal with patient motion directly.

Instead, a common strategy employed was to expand the target volume by a ‘safety margin’ to accommodate estimated motion of the target volume, and to then irradiate larger fields under the expectation that this would compensate

for the unknown motion.

In the past two decades, imaging, planning, and delivery technologies have progressed to the point that it is now possible to deal with a 4D model of the patient, consisting of three spatial dimensions plus time as the fourth dimension which is simply called 4D radiotherapy.

4D technology uses the time and space concept that provides four dimensional, real-time images of the projected organ. While 2D scans simple image of the projected organ and the 3D technique provides three-dimensional images of the organ by assembling a series of 2D images using a specific computer programme, 4D allows scanning 3-dimensional, real time images rather than capturing delayed images.

Because there is no one solution to deal with the different types of motion encountered over all potential treatment sites, techniques to

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RADIOLOGY model and deal with various types and magnitudes of temporal change in anatomy are necessarily specific to the site and type of motion. Thus, it would be difficult to provide a general but an in-depth review of 4D imaging and planning methods for all sites.

Instead, we have chosen to review 4D imaging and planning techniques for dealing with respiration since this area is the most mature and respiratory management has become very common in the field.

projections) from separate breathing cycles to be combined into a full volumetric image representing a breathing state. Stacked acquisition can be acquired prospectively (by gating the imager to acquire the partial image at only a particular breathing state) or retrospectively.

The 4-D images provide geometry (functional) data for treatment which can be used for the spatial/extrapolation margins prediction during the treatment course.

What role does it play in cancer treatment?

Basic 3D medical imaging acquisition and reconstruction principles are based on the assumption that the object being imaged is static over the course of the acquisition. Imaging moving anatomy (such as the thorax and upper abdomen during respiration) violates these principles and results in the presence of artefacts in the reconstructed image. These artefacts can lead to incorrect object position, shape, and size in the image, blurring or distortion of the object boundary, decrease in contrast resolution, and increased image noise.

In radiation therapy applications, the motion pattern impacts target design and delivered dose, and is therefore necessary information to generate an acceptable treatment plan. 4D imaging techniques developed specifically for radiation therapy applications have emerged to capture this information. The introduction of 4DCT into radiation therapy was quickly followed by 4D MRI, 4D cone beam CT (CBCT), and 4D PET. AAPM TG-76 recommends use of the proper motion management and 4D technologies when greater than 5mm motion is observed in cancer (target) in any direction.

4D PET-CT Imaging: Captures the movement of your organs and tumour over time, while also recording the metabolism of the tumour.

Creates the most complete and accurate imaging data on your tumour and critical organs. Makes it possible to see the make up and function of the tumour. 4D PET and 4D CT images fuse together and show how the tumour moves; how breathing affects the tumour, and how movement of nearby organs affects the tumour.

What are the tools used in 4D Imaging?

4D-CT Imaging: Stacked acquisition Requires partial images (e.g., reconstructed slices or partial sets of

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4D PET-CT Imaging

4D-MRI

4D-MRI It has a superior soft-tissue in contrast to CT and has no risk of radiation exposure. It is flexible in image plane selection and offers a variety of image contrasts Potential MRI Sequences used for 4-D MRI: ◗ TrueFISP/FIESTA (balanced steady state gradient echo) - T2*/T1, sensitive to fluid, band artifacts from long TR ◗ HASTE/SSFSE (single shot fast spin echo) - T2, good CNR, signal decay from lung echo train, blurring ◗ FLASH/Fast SPGR (fast spoiled gradient echo) - T1 (poor), tumor hypo-intensity ◗ EPI (echo-planner imaging) GE-EPI (T2*), SE-EPI (T2), IR-EPI (T1) - susceptibility, ghosting, chemical shift, fat suppression How effective is it in emergency medicine?

4D technologies have no utility in emergency medicine. 4D technologies have gained

relevance whenever significant normal tissue sparing can be achieved using proper respiration motion management strategies. This technology is useful whenever we are using high precision radiation therapy in conventional fractionation i.e.

5 fractions a week spread over 6 weeks or Stereotactic Body Radiotherapy (SBRT) where surgical doses of radiation are delivered in 3-8 fractions based on the location of the tumour.

What are the differences between 4D and 5D imaging?

In medical imaging, 2D implies a axial image, 3D implies volume image and 4D implies dynamic 3D volume image. 4D images significantly assist in the analysis of deformation and motion. 5D implies a 4D volume image that are acquired at multiple points.

The serial correlations in 5th dimension using robust automated efficient and consistent workflows (e.g. the

patterns of deformation) can be extracted for recognition, object - tracking and diagnosis.

Now there is an advent of 5D imaging, how long will it take for India to adopt it?

5D image processing has become a major challenge within the field of medical imaging. 5D images are dynamic 3D images (4D) that are acquired at multiple time points and patterns of deformations are analysed. A typical example would include dynamic cardiac CT scans and/or gated cardiac MRI acquired at threemonthly intervals and dynamic cell growth and shape change in weekly intervals. 4D images significantly assist in the analysis of the deformation and motion. The pattern of this deformation and motion can be used for recognition and diagnosis when another dimension is added. Another dimension usually comes

from atlas, template, historical data, etc. The correlations in 5th dimension (e.g. the pattern of deformation for dynamic cardiac CT) can be extracted for recognition, tracking and diagnosis. The correlation in the 5th dimension can be widely used in objects tracking and recognition using radar image, cell and sub-cell particle monitoring using microscopic image and medical diagnosis using dynamic CT or MRI. 5D technology is a form of automation where you go through and do a scan and you get the results autopopulated for you.

5D technologies are also used in the ultrasonography and Samsung is the only player in the 5D ultrasound technologies. The whole concept of 5D is workflow building efficiency, consistency and speed into the reporting by standardising the entire process.

5D imaging technology can digitally scan living tissue and is useful in detecting important biological molecules, especially signs of disease giving insights into understanding how diseases interact within a living organism. The dubbed Hyper-Spectral Phasor analysis (HySP) uses fluorescent imaging to locate proteins as well as other molecules situated in cells and tissue. Using a dye which glows under the skin under certain types of light to tag molecules, HySP is able to pick up specific clusters of diseased cells or tissue. This would make it easier for medical professionals to diagnose and administer targetted treatments.

It is very possible that 5D technologies can be easily adopted into India in the next one to two years as awareness of modalities become more evident. Only factor which precludes early adoption is the prohibitive cost of equipment. As times passes by, pricing will come to more reasonable levels where it can become viable for regular usage.

RADIOLOGY

QURE.AI IS FOCUSSED ON AUTOMATING READS OFX-RAY,CTAND MRI SCANS Can you give us an over view of Qure.ai?

Fractal is the larger entity and Qure.ai is a subsidiary of Fractal. Fractal is a 17-year-old company now with offices in around 13 locations around the world. We have about 1100 plus people and we work with fortune 500 clients. We provide analytics and AI services for all these clients. Now, Qure.ai is focussed on automating the reads of X-ray, CT and MRI scans. Both, Fractal and Qure.ai use artificial intelligence that’s the only common part.

Can you throw some light on evolution of radiology and how is Qure.ai leveraging the new advancements?

Starting around 2012, there was a revolution about how machines understand.

Concepts like deep learning and machine learning were widespread. In 2012, a professor in University of Toronto built the machine learning which works like a human brain. Typically, layers of neuron which learns to understand images just like we do. For example, if I have to train an algorithm what the bottle is, I have to give a lot of details about the bottle, like features of the bottle i.e. there is a cap, there is a theoretical shape, colour of the bottle and so on. It’s a rule-based thing, the algorithm figures out the bottle based on the rule that I have coded in. Today that’s not the case, given millions of images with different labels, the algorithms today will automatically learn to understand that it’s a bottle. It functions in the same way as the human brains. For example, in 2015, algorithm could look at an image and automatically label it, saying that there is black and white dog jumping over a ball. It’s a detailed annotation. It can extract a lot of the meaning from the image. So, we thought if an algorithm can do that, why can’t we start doing this for X-rays, CT and MRI medical images. Around October 2015, we started working on this par-

Quantifying and measuring the volumes of tumour region is extremely time-consuming.

We can automate this process to make more time available for radiologists to diagnosis of diseases

Prashant Warier, Co-founder & CEO, Qure.ai

ticular problem. The number of images in the world is at very high scale, if you look at for example Kenya, they have got 200 radiologists for a population around 54 million people. From 1999 to 2010, the number of images that radiologists had to go through has increased by seven times in developing or developed countries. Compared to the number of images to be read, radiologists are just two to three per cent. Secondly, because of lack of radiologists, there is a huge number of diagnostic errors.

When you look at the chest X-rays for example, today the error rate is 20 to 23 per cent, where 20 per cent of the diagnosis is missed or wrong. There is huge opportunity to reduce diagnostic errors in reading X-rays, CT and MRI scans by using automation there. Also, quantifying and measuring the volumes of tumour region is extremely time-consuming. We can automate this process to

make more time available for radiologists to diagnosis of diseases. We are training an algorithm to understand something which is complex and requires a lot of expertise.

When we speak of all the development that is happening in machine learning and in AI from last few years in organisations like Google and Facebook, they have million and billions of images to train on. Various categories are assigned to different images. This has been created by different organisations like Stanford University, Google and Facebook. Getting access to similar size of data set for radiology images was very hard initially, but we cracked it.

It is very hard process to get access to same size of data primarily because there are a lot of privacy issues.

Automation can help to generate a report but how do you think it would be able to replace a doctor or a radiologist?

Radiology is just one part of the chain, but final confirmatory test is the microbiology test.

So, diagnosis that is performed by radiologist will be replaced

by AI and report could be generated automatically. We can only speed up the process.

We are not saying that we will replace the radiologist completely, but we could help the physician to take final decision.

For example, when the trauma patient visits the emergency care, radiologist might not be available, but physician can easily take decision based on auto-generated report. We are not recommending the treatment based on auto-generated report at this point. It’s risky.

This report can act as an extra evidence to identify the disease and thereby physician would get more confidence. The idea is to augment the radiologist and the physician instead of replacing them.

We have integrated multiple devices and these devices are used by radiologist, integrating

with their workflow. Currently we are residing at Mumbai, Delhi and Bangalore.

We know that human bias is present in report but what would happen if there’s an error in the report generated

by AI? We are deploying AI solutions in two different ways. We are doing a pre-report where report will be generated immediately unlike in case of scanning done by radiologist. This report is available for the radiologist as a major report. But, there is an opportunity of radiologists getting biased by what they observe in the report.

So we are also planning to do a post-report too. We are trying to eliminate the bias and create an opportunity where we ask the physician to make a report first and then it is rectified using AI generated report. It is difficult to say which one is a better way, since second method eliminates bias, but first method is more productive.

When we look at most practises, 80 per cent of cases are normal. If I as a radiologist have to look at 100 kids in a day, some of them will be normal and some of them will be abnormal. But, if the algorithm helps to determine that 80 kids are normal and 20 are abnormal, the radiologist can start looking at the abnormal kids first and then look at the other 80. It helps radiologist to processes and increases the productivity.

We are still in the stage where we are yet to figure out which method is better. This is completely new as hardly any companies are doing it. So, we have an opportunity to build a market and see how people start reacting to it.

What are your plans on expansion?

We are located at Bangalore, Delhi, and Mumbai and expanded to Nepal. We are also planning to expand to many other countries like Canada, Myanmar, Zimbabwe etc. mansha.gagneja@expressindia.com

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RADIOLOGY

Role of imaging in clinical trials Dr Arjun Kalyanpur, CEO and Founder, Teleradiology Solutions opines that imaging offers better efficiencies in clinical trials and provides evidence for improved decision making DRUG DEVELOPMENT refers to the entire process required to bring a new drug to the market. This includes discovery, preclinical and clinical, regulatory filing and life-cycle management of a drug. A trial drug needs to pass the rigorous scrutiny of each of these phases to aid in the go or no-go decisionmaking process. However, failure at any one of these stages is unfortunately very common, and the cost to this is exorbitant.

Hence, the challenge here is to accelerate the investigation right at the early stage of drug development and focus on the most promising drug compounds.

But unlike other trials, in case of oncological trials, failures occur in the later stages of drug development. In such cases, to ensure that trials are conducted efficiently, it is necessary to opt for improved clinical trial methodologies such as imaging.

Imaging techniques are being increasingly used in oncological clinical trials to provide evidence for decision making. The conventional morphological imaging techniques and standardised response criteria based on tumour size measurements are used increasingly for defining key study endpoints. Non-invasive imaging using computed tomography (CT), magnetic resonance imaging (MRI) and fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT plays a significant role in generating primary, secondary and exploratory study endpoints. In later stages of oncological drug development, imaging forms the basis of robust response and progression criteria to interrogate the drug in a large number of clinical trial subjects.

IMAGING IN DIFFERENT PHASES OF CLINICAL TRIALS Preclinical phase: The primary objective of drug development's pre-clinical phase is to establish the safety profile of the drug molecule before clinical testing.

This phase evaluates mutagenic-

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ity, carcinogenicity, teratogenicity, pharmacokinetic and pharmacodynamic properties of the molecule that provides insight into in vivo properties before initiating clinical investigations.

Imaging techniques such as CT, MRI (including functional imaging techniques such as magnetic resonance spectroscopy (MRS), dynamic contrast-enhanced MRI (DCEMRI), diffusion-weighted MRI (DW-MRI), PET imaging and ultrasound may be used for this.

In the preclinical trial stage these may need to be performed in the laboratory setting.

Phase I Clinical Trial This phase of clinical trial aims at evaluating drug pharmacokinetics and pharmacology across a range of drug doses. In oncology Phase I trials, subjects typically have refractory advanced solid tumours.

Imaging such as CT is routinely applied to either acquire any evidence of anti-tumour activity (in the form of lesion shrinkage) or interrogate pharmacodynamics that may relate to drug action. One of the unique challenges in imaging applications in this phase of the trial is these are typically multi-centre small trials in which patients have advanced diseases that may present heterogeneously.

Such scenarios require imaging techniques that involve different organs and may lead to increased radiation exposure.

But since they are conducted across a small number of centers, standardisation of more complex imaging methods can be done which can reduce multiple and unnecessary radiation exposures. Thereby enabling imaging to be the backbone and support drug development right from the beginning until the end.

studies, molecular imaging is non-invasive and easily repeated, overcoming the significant issues associated with tissue collection and quality.

Integrating imaging into cancer informatics

cation. In this phase, the bi-dimensional or three-dimensional imaging is typically used and assessed using standard criteria such as RECIST and the lesion size is assessed by various imaging techniques. However, drugs may not show much reduction in the tumour size despite the clinical benefits hence other functional techniques are used that provides a different quantitative assessment of tumour pathophysiology.

Phase III Clinical trial Phase III aims at providing substantive evidence regarding the safety and efficacy of a drug within a large population for which drug administration is indicated. These trials can typically span hundreds of centres across many countries to enable accrual of sufficient subject.

Endpoints are designed to bridge efficacy of the drug with patient outcomes such as such as progression-free survival. For a typical Phase III solid tumour study, lesion size measurements as part of RECIST evaluation use mostly CT (>90 per cent of evaluations) with the remainder provided by MRI.

Molecular Imaging Phase II Clinical Trial This phase aims at evaluation of drug efficacy and safety within a targeted patient population which establishes the evaluation of efficacy for an intended indi-

Molecular imaging involves the use of agents or techniques that enable visualisation of physiological or biological processes in an intact organism.

In contrast to tissue biomarker

Imaging meta-data includes information such as the device used, the settings used, contrast agents, and possibly any processing of the data. This information is critical to image appearance, and therefore, to the proper conduct of a clinical trial. Integration of imaging metadata into the clinical trials database allows easier assessment of variations in imaging methods hence is valuable for the conduct of clinical trials.

Role of imaging in generic drug development Logistical and technical factors may limit the ability to use imaging in a confirmatory clinical trial. The use of imaging in clinical trials may be limited because of reduced availability of imaging technology. Imaging may help in the assessment of safety and efficacy as well as patient eligibility. The value of an imagingbased efficacy endpoint depends upon the investigational drug benefit, nature of underlying condition and precedents for the use of imaging in specific drug development therapeutic area and unique trial designs. It is anticipated that a medical practice standard for image acquisition will be sufficient for clinical trial eligibility and safety assessment, however in some scenarios even if the use of imaging does not involve assessment of efficacy the use of clinical trial standards should be considered. These standards of image acquisition in case of a clinical trial would probably apply to the eligibility criteria for an imaging trial of a drug to be used solely among patients with certain quantitative imaging features of the metastatic disease. Use of detailed imaging methods can ensure that all patients meet the

quantitative imaging expectations for enrollment.

How image core lab helps At Image Core Lab we understand the unique challenges that pharmaceutical companies face when it comes to adding imaging in clinical trials. We provide all services necessary to support the Clinical Imaging Management including training of site personnel, equipping the site with proper tools, quality assurance of the captured images, quality check of the acquired images, expert reading, adjudication, formatted reporting, till the submission of EDC. Our cloudbased server protects all medical imaging records from any natural disaster and facilitates faster and easy retrieval.

Therapeutic expertise Our therapeutic expertise includes oncology, musculoskeletal, central nervous system, neuro-oncology, neuro radiology, cardiac and vascular, thoracic and pulmonary imaging.

Pool of experts We bring you the same outstanding consistency and professionalism, backed by the pioneers of cross-border reporting- Teleradiology Solution. Our large team of expert advisory board and highly qualified, fellowship trained, and boardcertified radiologists provide an innovative environment for a broad range of image interpretation scenarios.

CLINSpa- technology A web-based platform that’s convenient and customisable designed tried and tested for an end to end management of imaging trial workflow. It allows you to customise workflows output templates thereby automating the process. We aim to leverage our deep set expertise in technology and image interpretation service to accelerate drug development trials at the right speed.

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UKAND INDIA STEP UP THEIR HEALTH PARTNERSHIP THERESA MAY, PRIME MINISTER, UK AND NARENDRA MODI, PRIME MINISTER, INDIA

P

rime Minister Narendra Modi’s recent visit to the UK has given a fillip to the health partnership between the two countries. Both the countries will share research, knowledge and technology in diverse areas pertaining to health. The UK government will invest GBP 1 million in an Artificial Intelligence project that will support India’s national health programmes. This follows Niti Aayog’s announcement of piloting AIbased initiatives in healthcare. UK-based companies with innovative healthcare technologies will be able to participate in this project which is expected to generate GBP 50 million business for UK’s digital health industry.

Prime Minister Modi in his discussions with Prime Minister Theresa May also discussed plans to come up with 5,000 diagnostic centres in India using UK’s National health Service (NHS) expertise, equipment and suppliers. This will be a big boost to India’s healthcare infrastructure. The Indo UK Clinics will operate with the highest NHS standards and clinical governance processes. Our eHealth and m-Health platforms will facilitate exchange of patients’ medical records electronically using telemedicine,

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PM Modi in his discussions with PM Theresa May discussed plans to boost India’s healthcare infrastructure tele-radiology and tele-pathology for diagnostics etc. It’s all about covering the last mile and taking healthcare services down to patient’s doorstep. We shall also have mobile diagnostic units functioning in the catchment area. These mobile diagnostic units will be GPS-enabled and provide facilities like X-ray, blood test etc.

Around 10 mobile diagnostic units will serve every three lakh population and bridge the demand-supply gap that exists when it comes to primary healthcare.

Eleven medicities are already being developed in India by Indo UK Institute of Health (IUIH). According to Dr Ajay Rajan Gupta, Managing Director and Group CEO, IUIH, “Our objective is to provide 400 million Indians world-class NHS standard healthcare that’s available, affordable and accountable. Up to 20 per cent patients will be given free treatment at IUIH Medicities.”

It is noteworthy that NHS, as per a recent study done by Commonwealth Fund, has been rated as the best healthcare system in the world when compared to healthcare systems in several countries including USA, Australia, Canada, France and Germany.

UK’s Secretary of State for Health and Social Care, Jeremy Hunt, said, “I am

DR AJAY RAJAN GUPTA

MR JEREMY HUNT

MR STEVE BRINE

MD and Group CEO, IUIH

UK’s Secretary of State for Health and Social Care

UK’s Health Minister

Our objective is to provide 400 million Indians world-class NHS standard healthcare that’s available, affordable and accountable. Up to 20% patients will be given free treatment at IUIH Medicities

I am proud that our NHS will be used as an example of gold standard healthcare in India – it is only right that our world-leading knowledge and expertise is shared across the globe

This partnership between Britain and India represents a firm trajectory for healthcare into the modern world.

Through new research,shared expertise and attention to groundbreaking technologies,both nations can continue to lead the world in health and care

proud that our NHS will be used as an example of gold standard healthcare in India – it is only right that our world-leading knowledge and expertise is shared across the globe.”

UK’s Health Minister Steve Brine said, “This partnership between Britain and India represents a firm trajectory for healthcare into the modern world.

Through new research, shared expertise and attention to ground-breaking technologies, both nations can continue to lead the world in health and care.”

Each of the 11 medicities shall have a 1000-bed hospital, a medical college, a nursing college, PG academy and a training facility for allied health professionals.

IUIH is running the medicities programme in partnership with leading UK hospitals, the first of which is King’s College Hospital. IUIH Medicities will also have a separate zone for medical equipment and device manufacturing, and pharmaceutical production. Cutting edge medical research shall be carried out at the IUIH medicities in areas as diverse as

genomics & stem cells, translational research and clinical research leveraging on the patient data available. Besides 11,000 beds, they are slated to have 5000 doctors, 25,000 nurses and 400,000 employees. The medicities, put together, shall have 22,440 residential units, 2750 hotel keys and up to 98 million sq. ft. of development space with 400 megawatts of energy requirement. The vision is to create a health ecosystem that’s self-sustainable and generates employment for people in the region.

“The intention is to make each of the IUIH medicities a global medical tourism hub that’ll attract patient traffic from across the globe. NHS standard healthcare at lower price points is our winning formula to tap the medical tourism business potential. This shall not just contribute to the exchequer but lead to overall development of the region too, in line with the government’s Smart Cities initiative. IUIH has tied up with leading implant companies and leading medical equipment companies too. Many of them

would start their manufacturing operations in IUIH Medicity Amaravati in accordance with Prime Minister’s ‘Make in India’ program bringing the healthcare cost further down for patients,” informed Dr. Ajay Rajan Gupta.

On November 12, 2015, the British Prime Minister then, Mr. David Cameron, and the Prime Minister of India, Mr. Narendra Modi, had signed a historic Health Collaboration Agreement to support the development of 11 IUIH Medicities across 11 states in India. On 7th November 2016, the British Prime Minister Ms. Theresa May and Mr. Narendra Modi inaugurated the Indo UK Tech summit in New Delhi where IUIH celebrated its 1st year anniversary. IUIH has been making steady progress as far as its projects are concerned. The construction of the IUIH Medicity Nagpur is in full swing. In fact, Zimmer Biomet, one of the leading orthopaedic implant companies is setting up a Post Graduate Training Academy at the facility for which the design work has commenced. Preparation of designs and

site plans for the hospital at IUIH Medicity Amaravati, in the new state capital of Andhra Pradesh, have commenced and the construction is in the planning phase.

Land acquisition for IUIH Medicity Hyderabad has also been done. Recently, IUIH has signed up an MoU with Government of Assam and Government of UP for setting up an IUIH Medicity in both the states.

Besides Maharashtra, Andhra Pradesh, Telangana, Assam and UP, the other states to benefit from the IUIH Medicity programme include Punjab, Gujarat, Rajasthan, Karnataka, West Bengal, Madhya Pradesh and Haryana. Healthcare UK and Department for International Trade (DIT) India are supporting IUIH with its plans. The project is supported by Ministry of Health and Family Welfare, Government of India and Invest India, which is the national investment promotion and facilitation agency for India promoted by Department of Industrial Policy and Promotion, Ministry of Commerce and Industry, Government of India.

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TRADE AND TRENDS

PSRI’s trio ortho surgeons on setting bone right The Pushpawati Singhania Research Institute (PSRI) multi-specialty hospital’s, orthopaedic department is committed on providing comprehensive state-of-the-art orthopaedic care to the patients, informed Dr Prakash P Kotwal, Chairman, Institute of Orthopaedics and Joint Replacement. His team includes experienced surgeons, Dr Anil Mishra, Senior Consultant and Spine Surgeon and Dr Gaurav Bhardwaj, Chief-Arthroscopy, Knee and Hip Replacement

THE TEAM of orthopaedic surgeons, collectively represent the multiple sub specialties orthopaedics and are enriched with abundant knowledge, experience and qualification. They are confident that the PSRI will soon turn out to be a centre of excellence in orthopaedics in Delhi.

Dr Prakash P. Kotwal, who specializes in the management of complex trauma (injuries) upper extremities and has worked in the Orthopaedic department of the All India Institute of Medical Sciences (AIIMS), New Delhi for about 40 years, said, “The Orthopaedics has seen a sea change globally which is also reflected in our country. The total joint replacement is now available not only for the hips aand knees but for every other joint such as shoulder, elbow, wrist, ankle, to name of few. Deformity correction is also undertaken for the grotesque crippling deformities of the upper and lower extremities. For the treatment of simple and complex fracture, newer implants, in the form of nails/plates/screws are available which can fix every bone in the body – be it of a 96-year or 6 year-old patient.

Talking upon the procedures of the upper extremity, prof. Prakash P.Kotwal said that a lot of congenital anomalies (birth defects) need reconstructive surgery of the hand to improve the function as well as the cosmetic appearance. Old neglected fractures and deformities of the hand are also routinely treated at PSRI with good performed for deformities of the hand and feet due to Rheumatoid arthritis, a type of crippling disease.

Prof Kotwal shared that a navigation system is now avail-

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Dr Prakash P Kotwal, Chairman, Institute of Orthopaedics

Dr Gaurav Bhradwaj, Chief-Arthroscopy, Knee and Hip Replacement

Dr Anil Mishra, Senior Consultant and Joint Replacement

able which assists the surgeon in precise placements of the implants while fixing fractures of the limbs and spine also during difficult total joint replacement.

In the spine surgery today, Prof Kotwal added that apart from the routinely fixation of fractures and correction of spinal deformities, even the intervertebral disc are replaced in the treatment of slip disc. It helps relieve the patients symptoms at the same time restores the bio-machines of the spine.

In orthopedics, there ate many life-style disorders such as backache, some form of arthritis, cervical pain and cer-

tain musculo-skeleton pains.

These can be prevented, to a large extent, by regular exercises, a good nutritious diet and maintaining a good body posture. Calcium and vitamin D supplements may also be taken in consultation with physician/orthopaedic surgeon Talking about working as a trio, Bhardwaj said, “Our skill sets are complementary to one another, which allows us to easily meet the needs of patients.

As a whole, we can say the advancement in the technology is helping the patients with quicker recovery and, lesser days in hospitals.

“Since last year, price cap-

ping on knee implants has made joint replacements of the knee have become even more affordable,” he added.

Giving details about the knee replacement procedures, Bhardwaj said, “ As of now, we are getting bio-inert metals. In India, most of us are using a new technique called gap balancing where we use soft tissue texture for the knees. Besides, we are trying to look for techniques which can save the natural joints. Earlier, even if one part of the knee used to be damaged, we would need to do the surgery for the whole knee. But, now we can perform surgery only or replace the part which is damaged. In fu-

Dr Prakash P Kotwal, Chairman, Institute of Orthopaedics : Our goal is to make PSRI hospital a single resource specialty ortho hospital and offer quality and affordable musculoskeletal care for all patients

ture, we can see more minimal invasions surgery and the twoto-three day hospital stay will be reduced to few hours. As for availability of robotics, it is yet to pick up in most of the hospitals.”

Pointing out that PSRI hospital's orthopaedic department gives a boutique of orthopaedic care, Dr Anil Mishra, Senior Consultant for Joint Replacement, said, “The acceptance of minimal invasive surgery with less painful procedures is increasing as many now want pain- free mobility. Many people in tier II and tier III cities are coming to get these procedures done. PSRI is known for liver, renal and digestive diseases but soon it will be a centre of excellence for orthopaedic too.

Further adding that the hip replacements are comparatively less than the knee replacements, Mishra said, “We Indians are cross-leg sitters and squatters, knee osteoarthritis are more than the hip arthritis. Hip arthritis are mostly occurs due to the trauma, previous infection or avascular necrosis of hip, a condition that occurs when there is loss of blood to the bone.”

Touching upon the price cap in the knee implants, Bhardwaj added, “People are still concerned that whether the price capping is affecting the quality of the implants. We are trying to explain the patients who are skeptical.”

Highlighting that most of the arthritis happen due to genetics, Dr Bhardwaj and Dr Kotwal suggest that the young Indians should have a control over weight. They must take a well-balanced diet and, avoid impact and deep-bending exercises while, maintaining the Calcium and Vitamin D levels.

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

‘Our strength lies in our ability to reach the last mile’ BPL Medical Technologies, a leading medical manufacturing company, since its inception in 1967 has been growing from strength to strength backed by technology and innovation.

Sunil Khurana, CEO & MD, BPL Medical Technologies divulges more details about the company’s plans to leverage the growth opportunities in medical devices sector and more, in an exclusive interview with Express Healthcare

It is important for all medical devices to continue to invest in R&D to improve patient care and outcome to stay upbeat against the competition

What is your outlook for growth in the medical devices sector in India and other global markets?

In India, there have been many surveys conducted by various market research companies to capture this data. The consensus is that the medical devices market is growing in the range of 10-15 per cent. However, the sector is diversified, and the growth rate is varying for various segments in line with the change in disease patterns.

For example, the shift from communicable to noncommunicable diseases is getting reflected in the growth rate of surgical and imaging related equipments.

Now, if we look at other developing markets like India such as Latin America and China, the growth rate indicates a similar trend.

However, if we look at developed markets like the US and the UK, there the growth rate is in mid-single digits varying from country to country. The demand in developed markets is driven by replacement of existing products due to ageing of equipments or introduction of new advanced technologies. That’s why it is important for all medical devices to continue to invest in R&D to improve patient care and outcome to stay upbeat against the competition.

How do you see this sector evolving in years to come and what are the potential growth drivers?

The medtech space is evolving very well on back of growth fuelled by new

projects in private healthcare in urban coupled with focus of government on improving rural healthcare in the country. Over the last three decades, the sector has witnessed rapid growth. Yet, there is enough room for growth.

In fact, the growth rate in rural areas is better than in urban areas. So, a lot of hospitals are venturing into rural areas using the huband-spoke model. They have a large hospital at one place and set up tele-clinics or smaller clinics, as referring centres, with a couple of doctors in multiple areas.

There is a lot of positive change happening in healthcare especially with government focus coming in the form of Ayushman Bharat and increasing government spend on healthcare. Ayushman Bharat is a great initiative as it addresses the root cause of problem in addressing the healthcare needs of rural India by bring the families under insurance coverage.

This would empower the poor of this country by giving them a sense of security as far as family health is concerned. This is also likely to spur huge demand in years to come and would shift the entire paradigm of how healthcare is delivered in our country.

In terms of empowerment, the biggest beneficiary of this are the patients. Today, we see lot of private service providers moving to smaller places to extend healthcare service delivery to rural parts of the country. So, there is a lot of

change happening. A lot of knowledge sharing with the patient is also happening.

Internet penetration has also enabled the patients to gain information about their health, irrespective of whether it is a city or a village. Thus, all stakeholders in the healthcare sector, whether it is the device suppliers, pharma companies, or service providers i.e. hospitals and nursing centres are poised for a good growth on the back of huge demand required to cater to healthcare needs of our country.

How does BPL Medical have an edge in an extremely competitive industry?

Yes, it is a competitive sector, but we personally feel there is enough space for everyone to operate. We believe our strength lies in our ability to reach the last mile which is reflected in our vision as a company. We continue to work on this strength and try to improve our reach further to ensure we can serve every citizen of this country.

Another major differentiating factor is our ability to provide last mile service through our distribution channel. Often providers buy equipments which are marginally cheaper and get stuck because they do not receive appropriate service for faulty equipments, this is where we have an edge over fly by night operators whereby we stand committed by our customers when needed.

How has BPL Medical’s

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TRADE AND TRENDS journey been since the time they started and what are the challenges you face today?

We started four and half years back primarily known in the market as a cardiology brand.

We have done well to diversify our product range across many verticals. During this journey to strengthen ourselves in the critical care segment we acquired Penlon, a UK-based company specialising in anaesthesia segment. We have also diversified into ultrasound imaging through our cobranding partnership with Korean manufacturer Alpinion. Similarly, we have invested lot of efforts in indigenizing our own range of C-Arm and X-Ray products to design products specific to

No Indian medtech company has been able to make a big impact globally and we are inching in that direction towards making BPL Medical as the No. 1 medical devices company from India

the requirements of Indian hospital eco-system. To strengthen this range, we have range of offerings in digital radiography (DR) and fluoroscopy (DRF) solutions and can also provide retrofit solutions for our customers.

Our most recent product introduction is in the neonatal range whereby we have tied up with global leader Atom to provide best in class Japanese

products for new-borns.

Today. we can proudly claim that we have most of the solutions to cater to need of hospitals. BPL Medical has transformed as a one stop shop for most of requirement for any customer from a clinician to a multi-speciality hospital.

Our investor is committed to the growth of BPL Medical and confident on the

management team to deliver the plan. We have sufficient facilities to fuel expansion for years to come. The larger issue is getting the right talent and a favourable ecosystem to make more and more products in India.

What is your vision for BPL Medical Technologies?

What is the roadmap to achieve it?

Today, still about 80 per cent products in India are imported. Although the needle is moving towards Indian products but at a very slow rate. We at BPL Medical, have the right talent, experience and backing by strong investors to make this as the largest Indian medical devices company. We have added the right products in recent years to diversify our product portfolio but now we need to expand geographies to make a global footprint. I feel no Indian medtech company has been able to make a big impact globally and we are inching in that direction towards making BPL Medical as the No. 1 medical devices company from India.

India to double its Global IVD share with CAGR of 15-18 per cent by 2020 Harshad Bhanushali, Product Manager- Instruments, DiaSys Diagnostic India informs about his company’s foray into the field of hematology by launching innovative hematology analysers christened as respons 3H and respons 5H THE INDIAN IVD market can be classified into multiple segments. Biochemistry, Immunoassay and Hematology segment dominates the IVD market with 65-70 per cent share.

60 per cent of medical diagnostic equipment’s are imported and distributed within the country through regional distributors and their network of sub-distributors.

Reagents account for 60-65 per cent of value share as equipment’s are generally placed on rentals or seeded at customer place.

Hematology is the third largest segment in the Indian IVD market with 18-20 per cent Indian market share and a value of approx. 800-900 cr.

Out of this, 63 per cent is on

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account of reagents. Balance 37 per cent is on account of instruments.

Technological developments, integration of basic flow-cytometry techniques and developments in the high sensitivity point-of-care (POC) hematology testing are some of the key factors that are fueling the growth of the hematology market.

Factors such as developing healthcare infrastructure, large patient population, increasing investment toward the development of hematology products, growing focus of both international and domestic players and Increase in incidence of diseases such as dengue, swine flu, malaria and chikungunya are stimulating the growth of hematology

market in India.

However, slow adoption of the advanced hematology instruments, high cost, safety

and quality of analysers and reagents are some of the key factors hampering the growth of this market.

Potential customers for hematology are pathology laboratories, commercial organisations, private & government hospitals, research institutes and CRO’s where increasing instances of reagent rental partnership among hematology instruments and consumables is a popular trend.

DiaSys Diagnostics India, a subsidiary of DiaSys Diagnostic systems GmBH, announced its foray in the field of hematology by launching innovative hematology analysers christened as respons 3H and respons 5H. These technologically innovative systems perfectly

compliment the broad existing DiaSys product portfolio of biochemistry, urine analysis, and point-of-care.

With a footprint of A4 size paper and weight of approximately 9 kilograms, these are the new gen-next instruments in the field of hematology currently present in the Indian IVD market.

Respons hematology systems are state-of-the-art instruments with elegant design, exiting features and utilise only three reagents in the smallest of quantities.

With respons hematology, we also contribute to the “go green initiative” with use of low volume cyanide free reagents generating very less waste, low power consumption and no paper printing.

TRADE AND TRENDS

Carestream installs imaging system at hospital near Mount Everest base camp Radiographic images help medical staff diagnose illnesses and injuries; Determine if patients need to be transported to Kathmandu CAPITAL ENTERPRISES, a Carestream distributor, transported and installed a CARESTREAM Vita Flex CR System that provides imaging services to 8,000 local residents as well as mountaineers, sherpas and others who support those who climb Mount Everest.

The Kunde hospital is located 24.6 kilometers (15.3 miles) from Mount Everest Base Camp. The imaging system was transported by plane to Lukla, Nepal, which is ranked as the world’s deadliest airport due to its high elevation and unforgiving terrain. From there porters carried the X-ray equipment on their backs for 30 kilometers (18.6 miles) to the hospital, which is staffed and op-

Nepal - The Journey_carestream

Nepal -Medical Image-carestream

Nepal Hospital_carestream

erated by local physicians and nurses.

The Carestream Vita Flex CR system is used by medical staff to capture digital X-ray images of shoulders and extremities that have been broken or sprained; the head and neck area to diagnose sprains or con-

cussions; as well as chest exams that may indicate a patient has pneumonia, altitude sickness, or evidence of a heart attack or other serious medical conditions.

“These imaging studies are essential to diagnosing diseases and injuries to climbers, sherpas

and other workers at base camp.

The images are available in minutes and physicians decide if a patient can be treated at the hospital or must be transported to Kathmandu by helicopter or airplane,” said Charlie Hicks, Carestream’s General Manager, Global X-ray Solutions.

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TRADE AND TRENDS

nice Neotech Medical Systems launches unique features and benefits nice Neotech has launched the following products: Respiratory Humidifier (nice 8010) ◗ Capable of operating in noninvasive control mode with low, medium and high temperature setting. ◗ It can be used for invasive ventilation, non invasive ventilation and oxygen therapy.

Infant care ◗ Capable of operating in non invasive control mode with low, medium & High temperature setting. ◗ It can be used for Infant Bubble CPAP, Resuscitation, and oxygen therapy.

Reusable Paediatric/Neonatal Humidifier Chamber ◗ Autoclavable low compressible volume humidifying chamber. ◗ Chamber compressible Volume for high flow 360 ml. ◗ Maximum water capacity 230 ml. ◗ 360 deg viewable water line for ease to monitor the water level from all angles. ◗ Highly durable intended for multiple usages. ◗ Gas Sterilisation up to 218ºC. ◗ Water fill port for refilling water during operation. ◗ Bio-compatible material minimises risk on patient with safer material. ◗ Burn-free design minimises risk of accidental burn.

nice 8050 Servo Control Respiratory Humidifier Adult Care ◗ Capable of operating in either invasive or non-invasive control mode with flow detection. ◗ It can be used for invasive ventilation, non-invasive ventilation and oxygen therapy.

Infant Care ◗ Capable of operating in either invasive and non-invasive control mode with flow detection. ◗ It can be used for invasive ventilation, Infant Bubble

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CPAP, resuscitation, and oxygen therapy.

Reusable Adult Humidifier Chamber ◗ Autoclavable humidifying chamber with peak flow bypass. ◗ Chamber compressible Volume for high flow 700ml. ◗ Maximum water capacity 280 ml. ◗ 360 deg viewable water line for ease to monitor the water level from all angles. ◗ Highly durable intended for multiple usages. ◗ Gas sterilisation up to 218º C.

while the need for circuit change is minimised. ◗ Comprehensive audible and visual alarm constantly protects against potential problems. The nice 8050 will alert at variations of set temperature Vs actual. ◗ The design of nice 8050 and nice 8010 makes it the ideal humidification system for Adult Ventilator, Infant Ventilator, NCPAP, Bubble CPAP, Infant Resuscitator & Oxygen Therapy for Adult, Paediatric & Neonatal care. The nice 8050 & nice 8010 accommodates both high and low flow ventilation

nice 8010

nice 8050

◗ Water fill port for refilling water during operation. ◗ Bio-compatible material minimises risk on patient with safer material. ◗ Burn-free design minimises risk of accidental burn.

therapies, as well as heated and non-heated wire breathing system.

The nice 8050 and 8010 delivers precise, reliable performance. An advanced microprocessor controller assures the control of the system. The system responds immediately to any change in settings, and constant self diagnostic verify proper operation every second of use. High and low temperature protection is assured through out operation, including warmup and setting changes. if the delivery temperature exceed 41°C independent circuitry shutdown all heating elements.

Features: ◗ Designed for use in hospital environment wherever medical gas is being supplied to patients, nice 8050 and nice 8010 heated wire humidifier incorporates latest technology that provides physiological level of humidity at body temperature. ◗ The nice 8050 features dual servo control feedback system, incorporates to constant monitoring and control chamber and proximal temperatures in the airway line. As a result high temperature gases cannot exist anywhere in the system.

When use a heated wire breathing system from nice 8050, ventilated gas continues to warm during delivery. Rainout and waste are reduced,

Provides essential equipment for safe and easy delivery of Neonatal CPAP Optimise lung protection and breathing support Continuous Positive Air- way Pressure (CPAP) supports infant breathing by providing respiratory support through-

out the respiratory cycle. OxyPAP maintains the infant's functional residual capacity by helping to prevent airway closure. CPAP pro- motes gas exchange in the alveoli, which acts to enhance airway patency, improve lung volume recruitment and maintain infant energy reserves, without the complications associated with endotracheal intubation.

Optimal humidity (37°c, 44mg/L) with CPAP is vital to support an infant's breathing and protect its developing lungs. Optimal humidity protects the lungs to optimise outcomes for the infant by minimising airway drying, improving secretion clearance, reduce airway constriction.

OxyPAP nice 5060 Bubble CPAP

OxyPAP nice 5060 Bubble CPAP

during therapy. The integrated pressure monitoring line allows the monitoring of nasal prong pressure without having lines near the infant's face.

Offered in seven different sizes, it can be used on a wide range of patients from premature to new born baby. ◗ Bubble generator Bubble generator provides a convenient means to apply positive airway pressure, freeing the clinician to focus on patient care, not the device. This design delivers accuracy and stability throughout the course of therapy.

The ergonomic design allows airways pressure to be easily set without the cumbersome time consuming tasks normally associated with bubble devices.

Water feeding port allows water to be added or removed by disconnecting the expiratory circuit. Minimum and maximum lines clearly visible in highly transparent jar with overflow container.

◗ Optimum humidification The Bubble CPAP system provides respiratory supports with body temperature saturated gas to the infant. Optimal humidity promotes mucociliary clearance and reduces the work of breathing. ◗ Infant nasal prongs Contoured nasal prongs made from non-reactive silicone along with a unique cannula body provides stability

Contact details nice Neotech Medical Systems No: 85, Krishna Industrial Estate, Mettukuppam, Vannagaram, Chennai-600 095 Tamil Nadu Tel: +91 44 2476 2594 / 2476 4608 M: +91 98408 73602 / 98408 74902 Web: www.niceneotech.com

Features: ◗ Safe and reliable The Unique Bubble CPAP generators provides consistent and accurate delivery of CPAP. The Reusable Pressure Manifold with pressure relief valve for infant safety. The manometer is provided to ensure the delivery of accurate PEEP. Rotating PEEP adjustment knob to prevent the use error of setting the PEEP. Servo control humidifier with temperature indication with heater wire for humidity of delivered gas. ◗ Easy to use Easy to adjust the PEEP setting on the Bubble CPAP generator. Easy to set modes of humidifier. Easy to fix the nasal prong with the neonates.

TRADE AND TRENDS

Importance of medical-grade monitors in tele-radiology Tele-radiology helps solve many of the issues brought about through digitalisation, by providing a service on an as-required basis. An insight by Anantha Narayanan, Country Head, EIZO Corporation THE MEDICAL industry has seen some great technological advances in the last few decades. One of the more substantial advancements has been the replacement of physical scans with PACS and digital scans. With PACS and the digital age, radiologists are now able to access and view more data in a shorter time frame than ever before. Not only can multiple images be placed side by side on a screen, but hundreds of images can be stacked and then scrolled through, all in a matter of seconds. Thanks to the new increasing possibility of capturing more images in deeper details from each patient, the numbers of medical images being taken for diagnostics are increasing year by year.

Ultimately more data means that radiologists have to look through more scans than ever before, and hospitals are requiring more radiologists and specialists to cope with the increased amount of information. This technological leap from physical to digital, although improving the quality and efficiency of medical care, has brought with it many logistical problems. Some of the challenges of being able to provide the best patient treatment are unsatisfactory hospital environments, cost aspects or not having enough skilled radiologists available on-site.

One potential solution to overcoming these issues in the future is tele-radiology. Teleradiology is the practice of sending digital images to an external radiologist to interpret data for you. Recently many independent radiologists and tele-radiology firms have started up, which focus on pro-

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Teleradiologist Dr Krisztina Nahm uses an 8 megapixel multi-modality medical grade monitor from EIZO

viding interpretations by qualified radiologists.

Tele-radiology helps solve many of the issues brought about through digitalisation, by providing a service on an as-required basis. Small clinics and emergency rooms no longer need to hire several radiologists to cover a fluctuating workload – they can simply call a tele-radiologist (TR) during busy times or when needed. On the other hand, large hospitals can ‘hire out’ their own radiologists – providing support to other clinics and hospitals. Tele-radiology also helps to create new benefits – such as allowing radiologists to

easily consult with specialists from anywhere in the world, ultimately improving the quality of their interpretation, and helping to share knowledge.

But these benefits are only possible if all TRs are using medical grade monitors that follow the DICOM Part 14 calibration standard, otherwise the images will be seen differently from monitor to monitor, and the benefits explained above will not be possible.

Due to the nature of tele-radiology, many radiologists are opting to work from a home office. In a bid to reduce costs, quality is often neglected.

Many TRs may choose to work

in unsatisfactory environments, with non-medical grade monitors or notebooks.

It is important to ensure that your working environment is ideal for the job. For tele-radiology, this means working in a dark room (with room ambient light between 20-100lx), and using quality medical grade monitors.

For tele-radiology, a 6 or 8 megapixel medical monitor offers the ideal cost-performance balance. The increased screen space allows for most images to be viewed in full resolution, and also allows the TR to compare images side-byside. Multi-modality wide screen monitors have actually been shown to be more effective than dual monitors as there is no distracting bezel in between. The size and resolution of the medical grade monitor should be selected based on the images displayed and the workflow.

It’s also important to choose a medical grade monitor with specifications designed for diagnostics. So what makes a medical grade monitor different from others? One of the most important differences is the ability to calibrate the monitor to the DICOM Part 14 GSDF standard, to adjust the monitor whenever needed and to stabilise the image quality. If your monitor cannot be calibrated, then it cannot be adjusted to the working environment, meaning that it cannot show image content correctly, meaning that cancers may be easily missed, leading to a false diagnosis. To make calibration easier, nowadays several medical monitors have a calibration sensor already installed inside

the monitor, and some devices even do automatic calibration so there is no IT Expert needed to support the TRs working from home.

Another important aspect to consider is the medical device classification. FDA 510(k) (USA) for diagnostic usage or CE (European Medical Conformity declaration) classify medical grade monitors in all details referring to harmonised medical standards. They provide the TR the needed safety requirements to use a medical device built for medical purpose and to not misuse a nonmedical device. Often monitors are selected purely on technical parameters while ignoring the above required certifications. By having such certified equipment the TR can be sure that they have the right equipment that is suitable for accurate diagnostics.

Consumer-grade monitors are not built or declared with an 'intended usage' for the medical industry, and therefore are not able to show all needed image contents and a false diagnosis can easily happen. Therefore it is recommended to ask the medical equipment supplier to submit such certification documents for the safety of the TR. Tele-radiology has helped solve many problems that arose during the shift from physical to digital medical imaging. However it isn’t problem-free in itself. Finding the right cost-performance balance can be difficult for TRs. But quality and investment in medical grade monitors shouldn’t be overlooked. In the end, it is the difference between having a monitor that shows the image correctly or not.

REGD. WITH RNI NO. MAHENG/2007/22045, POSTAL REGD. NO. MCS/162/2016 – 18, PUBLISHED ON 8TH EVERY MONTH, POSTED ON 10TH, 11TH, 12TH EVERY MONTH, POSTED AT MUMBAI PATRIKA CHANNEL SORTING OFFICE, MUMBAI – 400001