Healthcare Radius February 2018 by Itp India

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UNLOCKING OPPORTUNITIES

Sinking in

Bureaucracy THE NMC BILL, 2017, IS BEING PROTESTED AGAINST FOR BRIDGE COURSE AND BRINGING MEDICAL EDUCATION UNDER THE CLUTCHES OF BUREAUCRACY

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Contents 14

20 26

COVER STORY The National Commission Bill, 2017 is being objected to for bringing the medical profession under the clutches of bureaucracy.

BULLETIN 10 This month's important news

QUALITY 26 Hospital design should include

updates.

infection prevention aspect as one of the core designs.

IT 20 The deluge of data can unlock insights on patient medical conditions and eliminate inefficiencies in health care delivery.

MANAGEMENT 29 The determination of brain death requires the identification of the proximate cause and irreversibility of coma.

TREND 24 The growth spurt in digital

INFRASTRUCTURE 35 The design of the mother

healthcare stems from the need for quality healthcare.

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FEBRUARY 2018 | HEALTHCARE RADIUS

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ANNIVER

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EDITOR'S NOTE

FEBRUARY 2018 • VOL 6 • ISSUE 5

Rethink required

ased on the report that was submitted on March 8, 2016, by the Parliamentary Standing Committee, the Government of India came up with the draft National Medical Commission (NMC) Bill, 2017, to create a robust medical education regulatory system. The bill also aims to overhaul the corrupt Medical Council of India. While a certain section of the industry has welcomed it, the bill has mostly been widely objected to by industry leaders. Firstly, concern has been raised on the unfair representation of elected representatives from medical fraternity in the proposed NMC 2017. Secondly, there have been country wide protests against the proposed bridge course that would enable alternative practitioners to turn over to Allopathy. The cross learning mechanism would undermine patient safety and pave the way for quackery. And would those who do not get admission at quality medical colleges opt for the bridge course and cross over to modern medicine, ask experts. Thirdly, the suggestion of another National Licentiate Examination to test the quality of the graduating MBBS students has been deemed superfluous, especially since the government has introduced the common medical entrance exam for all colleges – the NEET (national eligibility cum entrance exam). Met with such fierce protests, the government must have a re-look at the “undemocratic” bill.

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FEBRUARY 2018 | HEALTHCARE RADIUS

A DV I S OR Y B O A R D OUR EDITORIAL BOARD HOLDS UP A MIRROR TO THE HEALTHCARE INDUSTRY, HELPING US UNDERSCORE THE KEY TRENDS AND DEVELOPMENTS OF THE INDUSTRY

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DR GIRDHAR J GYANI Director general, Association of Healthcare Providers

DR RAVINDRA KARANJEKAR CEO, Jupiter Hospitals

DR G BAKTHAVATHSALAM DR MK KHANDUJA

Chairman, KG Hospital & Post Graduate Medical Institute

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DR SANJEEV SINGH Medical superintendent, Amrita Institute of Medical Science

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FEBRUARY 2018 | HEALTHCARE RADIUS

BULLETIN

HealthAssure to invest $15 million HealthAssure, a seven-year old health tech firm providing access to primary care across 1,000 cities to most insurers and corporate, has announced their intent to invest $15 million over the next three years in order to strengthen their already extensive primary care network and tech capability to ensure more and more people can gain access to quality healthcare which is affordable and accessible to them. The company which is India’s leading primary care aggregator and already has a network of 3,100 primary care centres across 1000 cities in India, plans to expand and enriched its medical network to include more and more consumer needs and create a robust primary Varun Gera care ecosystem. A majority of this investment will be made in creat-

ing an ecosystem through consolidating the vast primary care network by creating new medical networks and consumer products. It would also be focused on building distribution channels to cover individuals, corporates and insurers, augment technology investments to make easier access to primary health across the country and acquisitions of other healthcare startups. Varun Gera, Founder & CEO, HealthAssure, said, “Our vision is and will remain to bring good health closer to everyone and in this endeavor we are committed to invest $15 million over the next three years to creating and efficient ecosystem in the fractured infrastructure of primary healthcare in India so that more people can gain access to better healthcare and do so at significantly affordable rates.”

Patanjali ties up with 1mg to push online sales Patanjali has entered into a strategic alliance with 1mg, India’s largest digital healthcare platform. 1mg has become their official online sales partner. The announcement of this exclusive partnership was made by HH Baba Ramdev and PP Acharya Balakrishna. As part of this partnership, 1mg will become their official partner for the range of Patanjali’s Divya Pharmacy products. In addition, it has also created a custom online store for Patanjali products on its platform www.1mg.com and 1mg mobile application. Patanjali will be making exclusive promotions to attract more customers to indulge in online purchase of its FMCG and Divya Pharmacy range of products. Prashant Tandon, Founder & CEO at 1mg, said, “Our mission is to provide the consumers with the best information, products and services for them to live healthier and better. As India's largest eHealth platform, we believe a strategic partnership with Patanjali creates a strong alliance to further the access and awareness of quality Ayurveda products and information.”

FEBRUARY 2018 | HEALTHCARE RADIUS

Study on HIV and viral hepatitis patterns Strengthening India’s efforts in combating HIV and hepatitis viruses, Abbott has announced its partnership with YR Gaitonde Centre for AIDS Research and Education (YRGCARE) to study the country’s viral diversity to improve accuracy of diagnostic tests. Abbott will provide study protocol and diagnostic equipment and YRGCARE will help in screening and sequencing rich patient data from infected populations in India. Dr Sushil G Devare, Director of Diagnostics Research at Abbott, said, “In the fight against HIV and viral hepatitis, we are pleased to collaborate with YRGCARE as they are pioneers of AIDS research and have extensive experience in understanding the HIV patient communities across the country.”

BULLETIN

Rainbow ties up with Chinmaya Mission Hospital

The partnership will help extend Rainbow’s services to residents of Indira Nagar and central Bengaluru.

Rainbow Children's Hospital at Marathalli in Bengaluru is to set to run the neonatal and paediatric intensive care services at Chinmaya Mission Hospital, Indira Nagar, Bengaluru. A team of neonatologists from Rainbow Children’s Hospital under the leadership of Dr Rajath Athreya, lead consultant neonatologist, will provide neonatal intensive care services at the Chinmaya Mission Hospital.

Dr U Sudhir, Medical Director, CMH, said, ‘CMH has always tried to serve all strata of society at affordable cost. We are happy to provide consultants from Rainbow Children’s Hospital to provide world class treatment to our new born babies admitted to the NICU at an affordable cost.’’ Dr Rajath Athreya added ‘’CMH has provided yeoman’s service for decades now. They have a fantastic team of obstetricians who deal with a large number of deliveries and high-risk pregnancies. Our team of trained neonatologists from Rainbow with years of collective experience in the field, strict adherence to standard clinical guidelines, our family centred and parent-friendly approach and round the clock availability at the hospital will complement the obstetric services and ensure best possible outcomes for premature and sick newborn infants at CMH.’’ Neeraj Lal VP, Rainbow Children’s Hospital, Bengaluru Cluster, said, ‘I am excited about this collaboration which brings our services closer to the residents of Indira Nagar and central Bengaluru.’’

Johnson & Johnson joins forces with Govt of Maharashtra Johnson & Johnson Private Limited has announced a strategic partnership with the Government of Maharashtra to implement focused disease interventions that have the potential to significantly improve the health of people and strengthen healthcare in the state. A Memorandum of Understanding (MoU) for the partnership was signed in the presence of Minister of Public Health and Family Welfare, Government of Maharashtra, Dr Deepak Sawant. Said Dr Deepak Sawant, “Johnson & Johnson India will help the state government in raising awareness amongst mine workers and their families in the state who are at an increased risk of tuberculosis. Nine districts in Maharashtra face the maximum rate of infant mortality. In these districts, Johnson & Johnson India will organise skill development programmes for nurses, along with other activities to train them for providing proper care to infants and their treatment during the Golden-Minute. Apart from these initiatives, a collaborative awareness campaign would also be undertaken to educate people about the various infectious diseases during pregnancy.”

Sahajanand Medical raises Rs 230 crore Sahajanand Medical Technologies (SMT), the leading manufacturer of cardiac stents in India, has announced that it has successfully raised equity to the tune of Rs 230 crore in a funding round led by Morgan Stanley Private Equity Asia. Existing Investor Samara Capital also participated in the round. Founded in 2001, SMT became an early champion of the ‘Make in India’ initiative by being one of the first companies in Asia to indigenously develop and manufacture coronary stents. SMT is the largest developer, manufacturer and market leader of minimally invasive coronary stents (drug-eluting and bare metal), renal stents, PTCA balloon catheters and other cardio vascular accessories in India.

HEALTHCARE RADIUS | FEBRUARY 2018

BULLETIN

Start-up launches next-generation medical devices vTitan Corporation, a global medical device manufacturer and solutions provider, has officially launched their patented Accuflow SP-550 and Accuflow IBP-550 Syringe Infusion Pumps for critical care medication administration. The pumps are powered by indigenously developed and patented closed-loop motion control technology. The syringe infusion pumps Peri Kasthuri are used for critical care of patients in hospital and home environments for accurate and safe infusion of medication. Accuflow SP-550 is designed to be used in hospitals with uninterrupted power supply and the Accuflow IBP550 includes an integrated battery pack for portable and patient transfer applications. Both pumps provide higher infusion accuracy combined with easy-to-use, award-winning user interface. These devices aid hos-

pitals and healthcare professionals to improve treatment efficacy and patient outcomes in critical-care cases. Peri Kasthuri, Co-founder and CEO of vTitan Corporation, said, "We are truly excited to be building high quality healthcare products in India, for the world. At vTitan, we believe in creating a culture where employees embrace advanced technology to develop innovative and superior products, with the philosophy of continuous improvement catering to dynamic global market requirements and changes. We aim to make medical device technology and product solutions available, accessible and affordable for everyone." vTitan has teamed-up with doctors from leading institutions around the world, who provide adequate guidance to ensure that the design meets the current requirements and future needs.

Report on stroke rehabilitation at home In the interest of bridging the gap in community re-integration of stroke patients, finding insights regarding current practices in stroke rehabilitation in the community and understanding patients’ behaviour, Nightingales Home Healthcare Services took the lead to conduct a survey using a novel approach by incorporating clinicians’ perspective. According to the survey, 80% neurologists perceive home rehab to be a feasible option for their stroke patients. Improved feasibility was due to factors like compliance to prescribed therapy (78%), cost effectiveness (61%) and improved access to quality comprehensive care (61%) as per the neurologists. Also, it found out that 90% neurologists perceive multi-disciplinary services/comprehensive rehabilitation as an ideal solution to managing disabilities due to stroke at home. Another interesting finding was that patients’ drop out of rehabilitation due to lack of motivation due to severity of disability (56%) and lengthy rehabilitation phase (29%)- a very important finding since effects of a stroke are very complex in nature and patients’ might be taking rehabilitation for years together which requires a lot of dedication by the patient and the therapist to see positive outcomes.

FEBRUARY 2018 | HEALTHCARE RADIUS

Columbia Asia Hospital performs rare surgery Columbia Asia Hospital, Hebbal, performed a life-saving surgery on a 16-yearold boy from Iraq who was treated for an aggressive bone malignancy called osteosarcoma. The patient was treated through a surgery process called ‘limb salvage’ wherein only the tumor is removed from the arm or leg instead of the entire limb. “The primary challenge before us was that we were unable to comprehend how much of cancer had actually proliferated in the bone on the joint areas of knee, thigh and hip. We had to go for a customised implant considering that the situation might always alter based on what we might have found inside,” said Dr Ravichandra Kelkar, Consultant – Orthopedics, Columbia Asia Hospital, Hebbal.

BULLETIN

Group CEO – India Operations, VPS Health

arish Trivedi, earlier Vice President with Max Healthcare, has joined the VPS Health as Group CEO – India Operations. He is responsible streamlining India operations and growth (both organic and inorganic). Apart from this, the group will launch homecare service ‘Care@Home’, a chain of retail pharmacy in FY 2017-18. VPS Health has plans to diversify and launch their 'Keita' brand in India, central kitchen catering to

hospitals, private corporates, Govt agencies, flight kitchen, etc. VPS group will also set up factory for wet wipes /tissue paper brand. Harish will head all above businesses as Group CEO – India operations. VPS Healthcare is an integrated healthcare service provider with 20 operational hospitals, over 125 medical centres, 10,000 employees and medical support services spread across the Middle East, Europe and India.

Chief People Officer, AMRI Hospitals

itin Barekere, CHRO, Narayana Health (NH), has assumed charge as Chief People Officer (CPO) of Kolkata’s AMRI Hospitals, a part of Emami Group. He was with NH for over three years. In his new role, he would be responsible for people strategy, growth and organisational learning for AMRI Hospitals. He would be reporting to Group CEO, Rupak Barua. Prior to NH, Nitin worked in the Landmark Group as Head-HR for Middle East and Africa. He has also worked with Walmart and

Spar International. He has over 17 years of experience in HR from start ups to multinationals with a track record of performance and stakeholder management. He specialises in talent acquisition, employer branding, employee relations, training, performance management, talent engagement, balance scorecard, client relations, change management, technology deployment, ecommerce, international mobility and corporate strategy.

Chief Operating Officer, Jaslok Hospital

eorge Alex has assumed charge as Chief Operating Officer (COO) of Mumbai’s Jaslok Hospital & Research Centre. Prior to this, he was Chief Marketing Officer of the same hospital. He has been with Jaslok Hospital from May 2015. In his current role, he would look after the operations of the hospital, known for its state-of-the-art facility and being in the forefront of technology. He would helm the operations of the hospital and would report to Dr Tarang Gianchandani. The marketing and busi-

ness development team of the hospital would report to George. Prior to Jaslok, George worked with Fortis Healthcare as Head of Sales and Marketing, Mumbai. He has also worked as Zonal Manager, Etisalat DB Telecom, for around two years. He was responsible for revenue growth through customer acquisition with clear focus on bottom line and channel development to grow incremental market share month on month. He also worked as Zonal Sales Manager with Bharti Airtel Ltd for over four years.

HEALTHCARE RADIUS | FEBRUARY 2018

COVER STORY

Sinking in Bureaucracy The National Commission Bill, 2017, is being protested against for the proposed bridge course and bringing medical education under the clutches of bureaucracy BY RITA DUTTA

FEBRUARY 2018 | HEALTHCARE RADIUS

COVER STORY

he Indian medical education system has been plagued by charges of corruption and unethical practices that have flourished unabated. To that effect, the National Medical Commission Bill, 2017, which was introduced by Minister of Health and Family Welfare, JP Nadda, in Lok Sabha on December 29, 2017, had proposed a sweeping overhaul of medical education. However, met with vociferous protests, the Bill has been referred by the Lok Sabha to a Parliamentary Standing Committee for a re-look. The Bill is primarily based on the 92nd report of the Parliamentary Standing Committee on Health that was submitted to the Parliament on March 8, 2016. As per the authors of the NMC Bill, a committee headed by ex-vice chairman of Niti Aayog, Arvind Panagari, there is a wide gulf in availability of qualified doctors, specialists, and super specialists, and a huge geographical maldistribution of medical colleges under which two/three medical colleges are in the regions representing one third of the population. According to Panagari, now Professor of Economics at Columbia University, the report has listed numerous failures of the current Medical Council of India (MCI), which included “the failure to maintain uniform standards of medical education, devaluation of merit in admissions and failure to create any summative evaluation of medical gradu-

ates and post-graduates.” It also highlighted the failure to put in place a robust quality assurance mechanism and gave undue focus on infrastructure and human staffing of medical colleges. Accordingly, the government of India came up with the draft NMC Bill, 2017, which proposed to repeal the Indian Medical Council Act, 1956 and dissolve the MCI. Formed under the 1956 Act, MCI was set to establish uniform standards of higher education qualifications in medicine and regulating its practice. As per the Bill, the NMC will function in sharp contrast to the MCI, which looks into a gamut of activities- from inspecting medical colleges to action against errant doctors. The Standing Committee report is broadly based on the report of an expert committee led by late Prof Ranjit Roy Chaudhury. As per the Roy Chaudhury committee’s recommendations, the NMC ill proposes a commission at the apex assisted by four autonomous boards, one each to oversee undergraduate education, post-graduate education, accreditation and ethics and registration. But unlike the Roy Choudhury committee report, which had recommended fewer members of the commission and no elected members, the NMC Bill proposes 25 members, a majority of them medical doctors and five of the latter to be elected by and from

Bhavdeep Singh, CEO, Fortis Healthcare Limited

HEALTHCARE RADIUS | FEBRUARY 2018

COVER STORY

1 amongst registered medical practitioners. The commission includes non-doctors like patient-rights advocates and ethicists, in line with the medical regulators of the UK, Australia and Canada. According to an article by Panagari, “To put an end to the tyranny of inspections, which focus microscopically on infrastructure and personnel and threaten closure of institutions on the pretext of the slightest deviation from the prescribed norm, the NMC Bill proposes to replace them by an accreditation system and an exit examination.”

Dr Alexander Thomas, President, AHPI 1. The bill has suggested a national licensiate exam to test the quality of the graduating MBBS students.

he Bill has been hailed for suggesting reforms in the medical education that would have a long-term impact on healthcare delivery. Says Bhavdeep Singh, CEO, Fortis Healthcare Limited, “The Bill has the potential to be a game changer in transforming the healthcare landscape in India. On the positive front, the Bill proposes to make NMC act as an apex body to bring in transparency and inclusive governance around medical education and practice in India. It also seeks to make clinical practice more standardised and uniform.” However, various sections of the industry have been vehemently protesting against certain sections of the Bill. The Indian Medial Association (IMA) has termed the Bill “undemocratic”, alleging that the functioning

FEBRUARY 2018 | HEALTHCARE RADIUS

of the medical profession would now come under the clutches of bureaucracy. Key areas of concern in the NMC Bill: A. The bridge course: To meet acute shortage of doctors, the NMC Bill has proposed a bridge course to enable alternative practitioners to turn over to Allopathy. Clause 49 of the Bill mentions a joint sitting of the NMC, the Central Council of Homoeopathy and the Central Council of Indian Medicine "to enhance the interface between homoeopathy, Indian Systems of Medicine and modern systems of medicine". Says Dr Alexander Thomas, President, Association of Healthcare Providers of India (AHPI), “The founding principles of modern medicine are evidence-based and are rooted in standard treatment protocols, which have nothing in common with the traditional systems of medicine. Therefore, mixing up of these systems of medicine through bridge courses will in no way be appropriate. On the contrary, it will undermine the patient safety and pave the way for promoting quackery.” The cross learning would also impact medical education, lament experts. “And those who do not get admission at quality institutes, will most likely take up a traditional medicine course, opt for the

COVER STORY

bridge course and cross over to modern medicine. Is that something we want to encourage,” asks Bhavdeep. B. NMC’s selected members: To address the pitfalls of the electoral process, the Bill has suggested the central government to select most of the commission’s members. The major representation in the committee comprises people selected either by the government or from the government. The authors of the NMC Bill argue that the electoral process through which MCI members were picked was fundamentally flawed, because conscientious doctors avoid such elections. Because there was no ceiling on re-elections, the same group of members have monopolised MCI for years. To corroborate its point, the Standing Committee has questioned the appointment of Dr Ketan Desai, who was elected MCI president in 2008, even though he had been prosecuted in the Delhi High Court for misuse of power as President in 2001. The IMA has been up in arms against the government selection of NMC members and the fact that the representation in NMC for elected medical professionals is limited to just five members. If there are

almost 8 lakhs doctors in India, why NMC will have just five elected representatives from the medical profession, IMA has sought to know. Says Dr KK Aggarwal, Immediate Past President, IMA, “The nominated model of the regulatory authority has been experimented by the government of India in 2010 itself and it has failed. The regulatory authority stands reduced down to a group of handpicked nominated people by the central government, ending up becoming a government-controlled department rather than an autonomous regulatory authority.” He contended that in the year 2001, the Delhi High Court had appointed a full time administrator who supervised the functioning of the MCI for one year until he was replaced by a four-member monitoring committee appointed by the Supreme Court in the year 2002. “In the entire year, the full time administrator did not and could not bring even a single event pertaining to the functioning of the council, which could be said to be contrary to the governing rules and regulations,” points out Dr Aggarwal. Echoes Dr BS Ajaikumar, Chairman, HCG, “An autonomous and independent body governing licensing, standardisation,

Dr K K Aggarwal, Immediate Past President, IMA

Dr BS Ajai kumar, Chairman, HCG

2. The bill has proposed a bridge course to enable alternative practitioners to turn over to Allopathy.

HEALTHCARE RADIUS | FEBRUARY 2018

COVER STORY

3 accreditation, governance and monitoring of medical education is the need of the hour. The Government should restrict itself to an advisory role and not become a decision-making body or a pseudo decision-making body with major representation of the Government.”

Dr Arvind Kasargod, Director of Medical Services, Cloudnine Group of Hospitals

3. If there are almost 8,00,000 doctors in India, why NMC will have just five elected representatives from the medical profession?

C. National licensiate exam: The Bill has suggested a national licensiate exam to test the quality of the graduating MBBS students. This is meant to eliminate corruption in medical education and also to test the quality of the medical graduates like the UK, Japan, Canada and many other countries do. However, the proposal was made at a time when the government had not introduced the common medical entrance exam for all colleges – the NEET (national eligibility cum entrance exam). “Following the successful completion of the MBBS examination enforcing another licentiate examination is superfluous. However, those aspiring to do post-graduate courses can be made to appear for common PG-entrance examination,” says Dr Alexander. Adds Dr Arvind Kasargod, Director of Medical Services, Cloudnine Group of Hospitals, “The NMC Bill needs to monitor the quality of the education being imparted and the enforcement of the laws against

FEBRUARY 2018 | HEALTHCARE RADIUS

the colleges and doctors who violate the written law of the country. Instead of penalising the people involved or improving the medical education system, we have decided to penalise the students. That is unfair, as students have to study hard to get into medical schools and then work harder to pass multiple exams during their course in the hope of practicing medicine with what they were taught in Government recognised colleges and hospitals.” With the Parliamentary Standing Committee re-assessing the Bill, experts opine that the Committee is likely to recommend to the government to consider testing the MBBS students while they are studying medicine rather after they have graduated.

ccording to Bhavdeep, the current system has an over dependence on doctors and less emphasis is laid on training, experience of allied areas such as nursing and community health. “This is an area which needs to be urgently addressed,” says he. Whether integrating all the streams of medicine is a possibility to meet dearth of doctors needs to be debated on, before it is discarded. To address shortage of doctors in rural areas, Dr Arvind suggests training of mid-level practitioners like physician assistants and nurse practitioners. “The training should mainly be in outpatient and preventive medicine and after completion, they should be licensed to work,” says he. Now that the government is working on fine-tuning the Bill, the industry expects the Government to make necessary amends that would not only root out corruption but also pave the best way forward for the future of medical education. Concludes Dr V Narendranath, Joint Secretary, The Consortium of Accredited Healthcare Organisations, "A comprehensive NMC Bill, will be instrumental in monitoring the quality of medical institutions, thereby ensuring the quality of medical graduates and in turn the quality of healthcare delivery."

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Unlocking opportunities The deluge of data can unlock insights on patient medical conditions and eliminate inefficiencies in healthcare delivery BY PADDY PADMANABHAN

I 1. Many of the firms have taken to investing in building capabilities organically as well as acquiring aggressively.

ndian IT firms had a relatively low focus on healthcare till the Affordable Care Act (ACA, also referred to as Obamacare) in 2009 and its companion HITECH Act were passed in the early years of the Obama administration. Together, these Acts led to the creation of a national electronic health record backbone and a shift towards value-based care which will lead to an unprecedented level of healthcare IT spend in the coming decade. In my latest book, The Big Unlock, I discuss the massive opportunity ahead in unlocking insights from the tsunami of existing and emerging data sources, and why much of healthcare IT spend will follow the data in the foreseeable future. In addition to the recently digitized patient medical records, we are witnessing the emergence of new data

FEBRUARY 2018 | HEALTHCARE RADIUS

sources to help patients and providers with healthcare: these include genomics data, socio-economic data, and data from connected smart devices or the Internet of Things (IoT), just to name a few. This deluge of data, when harnessed, can unlock insights on patient medical conditions, eliminate inefficiencies in healthcare delivery, and enhance the quality of the healthcare experience for patients and providers alike. Big unlock in healthcare Healthcare in the US is in the midst of a significant transition. There are three important forces that are driving this transition. Payment reform and the shift to valuebased care or VBC: Alarmed by the runaway rise in healthcare costs and the high level of costs (per capita costs of over $10,000 in

2016), the Obama administration brought in controls on reimbursement rates for healthcare, and instituted quality metrics for measuring healthcare outcomes. Population health management (PHM): The shift from fee-for-service payment models to value and outcomes based models forced healthcare providers to look at patients at a population level instead of just individually, with the goal of identifying high-risk patients for early interventions. The rise of healthcare consumerism: The rising costs of healthcare in the US have forced health insurers to shift some of the financial responsibility towards consumers. In turn, consumers are actively taking control of their spending choices, seeking alternatives, and are demanding better service. These trends, combined with a rise in smart medical devices and the IOT, have led to healthcare providers using data and analytics to manage patient risk proactively, prevent hospitalisations, reduce waste, and design engaging experiences. A digital transformation is underway in healthcare to help achieve the triple aims of lower costs, improved healthcare outcomes, and enhanced patient experiences. Technology plays a central role in this transition. With the growing adoption of cloud computing and the emergence of advanced analytical tools such as artificial intelligence (AI), there is a new opportunity for technology solution providers to increase revenues by helping healthcare enterprises navigate the digital transformation journey successfully into the value-based care era of the future. The opportunity for Indian IT Major Indian IT firms such as Wipro, Infosys, TCS, HCL and Cognizant (who I refer to collectively as the WITCH group) have focused on building a client footprint in healthcare for the past 15 years or more. As a member of the North American leadership team with one of these firms, I saw the opportunity reach a

tipping point with the passing of the ACA and the mandate to implement electronic health record (EHR) systems. However, most Indian IT firms were left out of the initial opportunity to implement EHR. Neither hospitals nor the dominant technology vendors in the EHR space showed any interest in leveraging the offshore

delivery model which was the central value proposition for Indian IT. Indian IT firms mostly worked with health insurance and pharma/life sciences companies who were either on homegrown mainframe systems or ERP systems such as SAP. However, with the near-total penetration of EHR systems in the healthcare provider space, and the emergence of cloud-based and alternate technology delivery models, the time for Indian IT companies has come to either make a big push into healthcare and stake a claim to a big chunk of the market, or risk losing relevance altogether. Many firms have attempted to do that over the past several years, building vertical industry-focused teams and acquiring healthcare tech firms with in-depth domain

2. A digital transformation is underway in healthcare.

HEALTHCARE RADIUS | FEBRUARY 2018

3. Most Indian IT

firms have large cash reserves on their balance sheets as a result of years of double-digit growth.

knowledge (e.g., Cognizant's acquisition of Trizetto). As the market matures and evolves, each of these companies is defining a strategic position for itself; some, like HCL, are leading with their IT infrastructure management capabilities, while others such as TCS, are focusing on their digital transformation capabilities. However, significant headwinds lie ahead for Indian IT firms, despite the aggressive push to expand within the healthcare markets. An analysis of the latest earnings releases by global tech firms, including many based in Europe and the US, points to some interesting trends: ⊲ Revenue growth rates are declining steadily for most firms for the past several quarters, presumably from a shift away from traditional IT services, and the impact of automation that eliminates the need for labour. ⊲ Policy uncertainties from the current Republican-led administration have slowed down technology spend in some areas, impacting some firms more than others. Wipro lost $125 million in revenues in the past few quarters from Health Plan Services; a company acquired in 2016 that was heavily dependent on the ACA exchange markets which have been seriously undermined in 2017.

FEBRUARY 2018 | HEALTHCARE RADIUS

⊲ The growth of cloud computing and the emergence of digital health startups have eroded market share for many traditional IT firms, with budgets increasingly allocated towards cloud enablement and SaaSbased solutions, and away from enterprise IT functions which have been the traditional hunting ground for Indian IT. Most Indian IT firms have large cash reserves on their balance sheets as a result of years of double-digit growth but have been conservative about deploying the cash to invest for the future. Many of the firms have belatedly taken to investing in building capabilities organically as well as acquiring aggressively to maintain growth and profitability. We now see the big firms investing in automation and AI, analytics, digital, and IoT. Late entrants to the healthcare market, such as Tech Mahindra, are making aggressive plays through the recent $ 100 million acquisition of HCI, and EHR consulting firm. The road ahead for the large Indian IT firms in healthcare is paved with gold, but it is a rocky road. While policy uncertainty has somewhat abated, the impact of the new tax reforms in the US on entitlements such as Medicare and Medicaid could significantly influence technology spending. Healthcare in the US is in a state of transition, with existing players consolidating to improve negotiating power while preparing for the entry of disruptive non-traditional players such as Amazon. Regardless of how the story plays out, healthcare is an exciting space to be in for technology professionals, and all tech firms can take comfort in some fundamental aspects of the demand environment. Our annual survey of healthcare IT indicates that the demand environment is robust. IT firms just need to follow the money.

Paddy Padmanabhan is the author of ‘The Big Unlock: Harnessing Data and Growing Digital Health Businesses in a Value-Based Care Era’.

CONSUMER CONNECT

Speedy and user-friendly Nihon Kohden recently launched latex agglutination turbidimetric immunoassay based clinical chemistry analyser BY NITIN SRIVASTAVA

bA1c or Glycated Hemoglobin is one of the best indicators of glucose control over time. Glycated hemoglobin is an irreversible complex that forms when glucose and hemoglobin binds together. It is used to determine the average glucose level in a patient over the past seven to nine weeks. It is useful in diagnosing diabetes or increased risk of diabetes and also helps in monitoring the effectiveness of diabetes treatment. Sixty per cent of world’s diabetic population is in Asia (approximately 200 million diabetic patient) and Indian’s tops in this ratio- which is alarming. Technology and HbA1C: New and developed technology based on different assay methods gives good and more accurate results. HbA1c technology based on either high-pressure liquid chromatography (HPLC), Boronate affinity or immunoassay combined with general chemistry. These technologies are very expensive and carried out in expensive instruments and require trained laboratory personnel for operation. More recently, HbA1c has been incorporated into POC devices, allowing for immediate availability of A1C measurements, greatly facilitating diabetes care in both specialist and general practices. POC A1C tests should have acceptable performance, standardisation to the national reference (National Glycohemoglobin Standardization Program or NGSP), NGSP certification, simple operation without the need for expensive instrumentation, and Clinical Laboratory Improvement Amendments (CLIA) waiver. The ADA recommends that A1C methods be NGSP certified. Nihon Kohden recently launched its latex agglutination turbidimetric immunoassay based clinical chemistry analyser. The Celltacchemi CHM-4100 clinical chemistry analyser is designed to be “speedy and user friendly” and can measure both HbA1c and CRP. With compact body and the ability to steadily and speedily output data with high precision. Much reliable and easy to use instrument as compared to POCT methods. CelltacChemi’s HbA1c data is NSGP certified and highly correlated with HPLC method. Use of unique cell-based reagent and this reagent can be used immediately after taking out of

the refrigerator and sample preparation is not required with an EDTA whole blood tube. The measurement cell already contains the correct amount of reagent. Each reagent cell has a QR code with lot information, expiry information and calibration curve which can be automatically scanned and registered into Celltacchemi. This instrument performs auto self-check with priming and cleaning. Only 5ul of whole blood is required for the test. In CelltacChemi, external sample preparation is not required, measured directly and takes approximately six minutes for the complete measurement. A 3 color indicator on the main screen clearly shows the current measurement value as a triangle mark over the low, normal or high range. Up to 4 past data for the same ID can be seen on the screen. This helps to check the data variation during the HbA1c screening. Nitin Srivastava is National Sales Manager- In Vitro Diagnostics, Nihon Kohden India Pvt Ltd.

HEALTHCARE RADIUS | FEBRUARY 2018

1. D fou Sh of

2. D Ge Sh of

TREND

Investing in a digital healthcare platform The growth spurt in digital healthcare stems from the need for quality healthcare BY VINOD KUMAR REDDY

1. A thriving concept is that of healthcare e-commerce that plugs the ‘shopping’ model into treatment, patient care and diagnostics.

ealthcare may have been a laggard in the fast-changing world dominated by digital technologies and internet-of-things, but the field is catching up with newer entrants and startups that tap into the opportunity by shaping the landscape with disruptive business models. Aimed at the tech-savvy generation, these forces bring to their customers a slew of online services ranging from doctor’s appointments to healthcare at the doorstep. The key drivers The growth spurt in digital healthcare stems from the need for quality healthcare that

FEBRUARY 2018 | HEALTHCARE RADIUS

leverages the country’s competitive advantage of well-trained professionals. Improving accessibility through partial or complete elimination of geographical limitations is yet another requirement. With an increased preference for availing treatment at private hospitals, and most expenses being made out-of-pocket, there is also the need to bring down healthcare costs tremendously. Startup companies that operate in the digital healthcare domain by solving one or more of these problems find increased acceptance not only among its end users but also investors. Focusing on solutions and reinvented business models that cater to such needs help them gain ground and competitive ad-

TREND

vantage in a field that is majorly dominated by traditional healthcare service providers. Niche Vs. unified services The domain of digital healthcare includes both niche players as well as those that offer a basket of services under one umbrella. Startups that bring disruptive products and solutions by combining technology with medicine are as lucrative as those that solve pain points of medical practitioners and patients. Personalised medicine that employs genome focused research and development to treat chronic illnesses is one such niche offering that has attracted investor attention in recent years. So are the wearable devices! With an improved ability to detect, collect, and store specific biometrics, these devices are poised to compete with clinical grade devices in the near future. Yet others include companies that offer digital solutions for therapeutic impact, supporting healthy lifestyle, and preventing or curbing chronic illnesses. An equally thriving concept is that of healthcare e-commerce that plugs the â&#x20AC;&#x2DC;shoppingâ&#x20AC;&#x2122; model into treatment, patient care, diagnostics, and the like. Such startups that focus on bringing healthcare services to the doorstep add value to patients as well as service providers. Through location specific offering, these new age companies are able to improve discoverability and bring transparency into an area, otherwise dominated by referrals, and word-of-mouth information and choices. Their ability to solve operational inefficiencies and tap into the internet, gadget, and information savvy consumers is what makes them tick with investors. Another field of interest to healthcare investors is m-health. With smartphone users ever on the rise, startups are plunging themselves to gather consumer, patient or end-user data, and convert them into actionable insights. Combined with wearable and implantable devices, as well as remote technologies, mobile health apps can collect patient records, improve doctor-patient

2 engagement, tweak treatments, promote a heathy lifestyle, and much more. Building scale through value The share of investments in the digital healthcare industry continues to be on the rise and with increasing competition, more investors are choosing to partner with digital healthcare start-ups. Though recent trends indicate a focus on mature start-ups which bag the prize by unlocking value and spurring growth, a number of independent innovative start-ups have also captured the eyeballs of investors through their disruptive ideas and dynamic business approach. All big or small entrants in the digital healthcare domain who have seen success with their value-adding products and services, or that have been embraced by the market as a unique solution provider garner more attention and money, which is then used to scale their offering. As more companies and investors venture into the domain of digital healthcare, the start-ups that make a mark will be those that bring in medical cost savings, better health outcomes, and seamless experiences by integrating healthcare services to a single platform.

Vinod Kumar Reddy is CEO of Zoylo Digihealth.

2. With an improved ability to detect, collect, and store specific biometrics, these devices are poised to compete with clinical grade devices in the near future.

HEALTHCARE RADIUS | FEBRUARY 2018

QUALITY

Engineering controls for preventing HAI Hospital design should include infection prevention as a core part of the design BY DEEPAK AGARKHED

T 1. Flaws in engineering design may contribute towards patient infections.

he newly commissioned ICU of one of the hospital set-ups had less than one and a half feet space between two beds. The split air conditioning was found to be in use in one of the operating theaters in a super specialty hospital. These examples are a few potential flaws in engineering design that may contribute towards infections of a patient who was admitted for reasons other than acquired infection. For a hospital acquired infections (HAI), the infection must occur in any of these conditions: up to 48 hours after hospital admission, up to three days after discharge or up to 30 days after an operation. HAI occurs in both government and private hospitals across globe including

FEBRUARY 2018 | HEALTHCARE RADIUS

developed countries. In the US, on an average day, one in 25 patients has at least one infection contracted from a hospital visit, according to the Centers for Disease Control and Prevention. We in India do not have information on HAI from any agency but it will certainly be more. The awareness of HAI and its implications to patient and treatment is not available to the common public. The infection is ratio of multiplication of dose, site, virulence and time with level of host defence. HAI can occur mainly due to contact (major cause), sneezes, couches, inhalation, deposition, water mists i.e. Legionella or biting of insects. The germs come from staff, patients, utensils, air, water and insects. The sources of infections are spirilla, bacilli, cocci, aspergillus, square and curvularia fungus.

QUALITY

The engineering controls form major role in infection prevention within hospital environment. The hospital design should include infection prevention aspect as one of the core designs.

he air flow is important route of infection. The heating, ventilation and airconditioning infection control methods are: • Air Filtration • Irradiation, UV • Pressures difference ( i.e. clean to dirty area) • Reduction of impingement ( air velocity @ wound) • Evaporation of droplets (RH) • Maintaining proper air changes per hour as per function of clinical area • Maintaining proper relative humidity as per functional of clinical area The level of air filtration, pressure difference with adjacent area, number of air changes per hour, temperature, relative humidity and maintenance practices of HVAC will contribute to proper infection control measures. Protective isolation room for immune compressed patients should be planned with 100 % fresh air with air filtered at 99.997 % purity. The cleaning of AC ducts and filters, air handling unit maintenance, including filter cleaning/ replacement are to be carried out routinely as a part of preventive maintenance programme. The space design in any hospital should be in accordance with the available literature on good practices (Indian or international standards) and directives from government agencies. The distance between two patient beds should be between 1 to 2 meter while planning patient room design. It is preferred to have more single bed rooms than twin or multiple beds in the same room from infection prevention perspective. The design of hospital central water tank should have controlled access. The daily check on water quality should be carried out after treating it on parameter like pH, TDS, hardness, colour, etc. There has to be an

adequate number of elbow /foot operated clinical sinks for hand washing in clinical area. The pipeline cleaning and flushing should be done routinely as part of maintenance programme. There should be proper service access to get inside the water tank and perform proper cleaning on regular basis. The water needs to be regularly tested in as per the NABL national guidelines. The RO water provided for hemodialysis equipment should be of AAMI standard. The regular monthly check of endotoxin level to be monitored for dialysis RO water. The sterilsation of instrument should be done as per guidelines provided by equipment manufacture including regular validation like Bowie Dick tape test and leak rate test The biomedical waste collection, storage, transportation should be done in such a way that there is no mix of clean/sterile material with dirty or soiled waste. The dedicated chutes like linen and garbage will ease the movement of waste rapidly. The Biological Oxygen Demand (BOD) level of final treated water from STP plant should be routinely checked before recirculating for gardening, flushing purpose in rest

2. Engineering controls play a major role in infection prevention within hospital environment.

HEALTHCARE RADIUS | FEBRUARY 2018

QUALITY

3. The cleaning of

AC ducts and filters, AHU maintenance, including filter cleaning/ replacement should be carried out routinely.

rooms. The biomedical waste yard should be properly fenced and waste should be regularly transported. During the operational phase, one should practice periodic checks and balances like arresting seepage which may lead to fungal colonisation so that all the parameters are well within the planned control limits. The expansion projects or renovation of area within hospital should be done in consultation with infection prevention team. The precaution of sealing AC ducts, traffic movement of men and material should be done to prevent spreading of infection. One of the illustrations of engineering control is of super specialty operating room HVAC design for multi specialty hospital. As per national accreditation guidelines for hospitals, the following design criteria are taken in to consideration for requirement of super specialty operating room: ⊲ Minimum total air changes should be 20. ⊲ The fresh air component of the air change is required to be minimum 4 air changes. ⊲ The airflow needs to be unidirectional, laminar and downwards on the OT table. It should have air velocity of 25-35 FPM at

FEBRUARY 2018 | HEALTHCARE RADIUS

the grille/ diffuser level. ⊲ There should be minimum 2.5 Pascal positive pressure differential between OT and adjoining areas. ⊲ Air to be supplied preferably through terminal HEPA filters. ⊲ The air quality at the supply i.e. at grille level should be Class 100/ ISO Class 5 (at rest condition). ⊲ The temperature should be maintained at 21 +/- 3 Deg C inside the OT (18 +/- 2 degree for orthopaedic) all the time with corresponding relative humidity between 20 to 60%. Appropriate devices to monitor and display these conditions inside the OT may be installed. ⊲ Three stages of filtration consisting of pre-filter of efficiency 90%, final filter 99% efficiency & 99.997 % HEPA filters up to 0.3 micron particle size should be considered. ⊲ The AHU of each OT should be a dedicated one and should not be linked to air conditioning of any other area. ⊲ During the non-functional hours, AHU blower will be operational round the clock ⊲ Window and split A/c should not be used. ⊲ The flooring, walls and ceiling should be non-porous, smooth, seamless without corners and should be easily cleanable repeatedly. ⊲ Validation of system to be done as per ISO 14664 standards for filter integrity, air velocity, temperature and humidity, etc. ⊲ Periodic preventive maintenance to be carried out in terms of cleaning of pre filters at the interval of 15 days. Proper engineering design, execution and maintenance of hospital will definitely help it to prevent infection to patients and staff.

Deepak Agarkhed is General Manager-clinical engineering, quality and facility, Sakra World Hospital, Bengaluru.

MANAGEMENT

Understanding brain death The determination of brain death requires the identification of the proximate cause and irreversibility of coma BY DR RAHUL PANDIT

rain death is defined as the irreversible loss of all functions of the brain, including the brainstem. The three essential findings in brain death are coma, absence of brainstem reflexes, and apnoea. An evaluation for brain death should be considered in patients who have suffered a massive, irreversible brain injury of identifiable cause. A patient determined to be brain dead is legally and clinically dead. There is a clear difference between severe brain damage and brain death. Brain death is the principal prerequisite for the donation of organs for transplantation. The 1994 Transplantation of Human Organ Act defines brain stem death in India, as opposed to the whole brain dead in many countries like United States.

Evolution of brain stem death Historically, death was defined by the presence of putrefaction or decapitation, failure to respond to painful stimuli, or the apparent loss of observable cardio respiratory action. The widespread use of mechanical ventilators that prevent respiratory arrest has transformed the course of terminal neurologic disorders. Vital functions can now be maintained artificially after the brain has ceased to function. In 1968, an ad-hoc committee at Harvard Medical School reexamined the definition of brain death and defined irreversible coma, or brain death, as unresponsiveness and lack of receptivity, the absence of movement and breathing, the absence of brain-stem reflexes, and coma whose cause has been identified.

1. A patient determined to be brain dead is legally and clinically dead.

HEALTHCARE RADIUS | FEBRUARY 2018

MANAGEMENT

2. Vital functions can now be maintained artificially after the brain has ceased to function.

Brain Drain Certification Prerequisites: (1) Identification of history or physical examination findings that provide a clear etiology of brain dysfunction. The determination of brain death requires the identification of the proximate cause and irreversibility of coma. Severe head injury, hypertensive intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage and hypoxic-ischemic brain insults are potential causes of irreversible loss of brain stem function. The evaluation of a potentially irreversible coma should include, as may be appropriate to the particular case; clinical or neuro-imaging evidence of an acute CNS catastrophe that is compatible with the clinical diagnosis of brain death. (2) Exclusion of any condition that might confound the subsequent examination of cortical or brain stem function.  Shock or Hypotension  Hypothermia with temperature < 32°C  Drugs known to alter neurologic, neuromuscular function and electroencephalographic testing, like anaesthetic agents, Neuroparalytic drugs, Methaqualone, Barbiturates, Benzodiazepines, high dose Bretylium, Amitryptiline, Meprobamate, Trichloroethylene, alcohols.  Brain stem encephalitis

 Guillain-

Barre syndrome associated with hepatic failure, uraemia and hyperosmolar coma  Severe hypophosphatemia  Encephlopathy

Brain death examination Test all the three components of coma, loss of brain stem reflexes and apnoea. Before starting ensure the following oxygenation with 100% oxygen for 15 min  Core temperature ≥ 36.5°C or 97.7°F  Euvolemia- positive fluid balance in the previous six hours  Normal PCO2 - arterial PCO2 ≥ 40 mm Hg  Normal PO2 - pre-oxygenation to arterial PO2 ≥ 200 mm Hg  Pre

Demonstration of coma of movement/ grimace to central deep painful stimuli in cranial nerve distribution Supraorbital Ridge, Temporo – Mandibular Joint (afferent V and efferent VII) or Trapezes Muscle squeeze (afferent and efferent spinal accessory nerve)  Painful stimuli in spinal dermatome distribution will not test response to central pain  Patient may have spinal reflexes present in brain stem death  Absence

Absence of brain stem reflexes no response to bright light Size: mid-position (4 mm) to dilated (9 mm) (absent light reflex - cranial nerve II and III)  Ocular movement- cranial nerve VIII, III and VI  No Oculocephalic Reflex (testing only when no fracture or instability of the cervical spine or skull base is apparent)  No deviation of the eyes to irrigation in each ear with 50 ml of cold water (tympanic membranes intact; allow 1 minute after injection and at least 5 minutes between testing on each side)  Facial sensation and facial motor response  No corneal reflex (cranial nerve V and VII)  No jaw reflex (Cranial Nerve IX)  Pupils-

FEBRUARY 2018 | HEALTHCARE RADIUS

3  Pharyngeal

and tracheal reflexes (cranial nerve IX and X)  No response after stimulation of the posterior pharynx  No cough response to Tracheo-bronchial suctioning Demonstration of apnoea  Complete monitoring and disconnect the ventilator  Deliver 100% O2, 6 l/min, into the trachea. Option: place a cannula at the level of the carina  Look closely for any respiratory movements (abdominal or chest excursions that produce adequate tidal volumes)  Measure arterial PO2, PCO2, and pH after approximately 8 minutes and reconnect the ventilator  If respiratory movements are absent and arterial PCO2 is ≥ 60 mm Hg (option: in carbon di oxide retainers 20 mm Hg increase in PCO2 over a baseline PCO2 ), the apnoea test result is positive (i.e. it supports the diagnosis of brain death)  If respiratory movements are observed, the apnoea test result is negative (i.e. it does not support the clinical diagnosis of brain death)  Connect the ventilator, if during testing  the systolic blood pressure becomes < 90 mm Hg (or below age appropriate thresholds in children less than 18 years of age)  or the pulse oximeter indicates signifi-

cant oxygen desaturation, or cardiac arrhythmias develop;  Immediately draw an arterial blood sample and analyze arterial blood gas  If PCO2 is ≥ 60 mm Hg or PCO2 increase is ≥ 20 mm Hg over baseline normal PCO2, the apnoea test result is positive (it supports the clinical diagnosis of brain death)  if PCO2 is < 60 mm Hg and PCO2 increase is < 20 mm Hg over baseline normal PCO2, the result is indeterminate and a confirmatory test can be considered (not allowed in |Indian law)



When two doctors either neurologist, intensivist, anesthesiologist or physician who are nominated by appropriate authority, perform the test independently at least six hours apart, and if both tests are positive for brain death, the patient is declared as brain dead. The complete process is also observed by primary admitting doctor of the patient and the hospital head, who along with the two doctors complete the Form 10 and certify death. The time of death is end of second apnoea test. Once death is declared, the next of kin of patent are informed and counseling for organ donation should be done. 3. Once death is

Dr Rahul Pandit is Director- Intensive Care, Fortis Hospital, Mulund.

declared, the next of kin of patent are informed and counseling for organ donation should be done.

HEALTHCARE RADIUS | FEBRUARY 2018

OPINION

Budget buzz Industry leaders make a wishlist for the healthcare industry for budget 2018-2019 BY HEALTHCARE RADIUS

P M Bhujang President, Association of Hospitals Healthcare services have played a major role in nation building with the governments focus on developing more and more hospitals in the country. In order to meet these objectives, it is important that the services rendered to hospitals should keep away from the ambit of GST. The hospitals should be allowed to claim refund of GST on inputs as it will help the healthcare industry in cost optimisation by making the healthcare more affordable. Additionally, charitable hospitals should be exempted from GST/ Central Excise/ Service Tax on supply of Disposable, Medicines Implants, stents and lenses so that more indigent and poor patients can be provided free and concessional medical Services, as more funds will be available to serve more needy patients. The exemption on GST on the inputs will reduce the cost to the hospitals and consequently cost of medical services to a patient.

Manish Sacheti CFO, Ziqitza Healthcare Ltd We hope that the Union Budget 2018-19 offers a major relief to the healthcare scenario in our country. While the Government has introduced various amendments in the budget last year, there are still persistent issues which should be addressed this year. With more than 68% of people living in the rural areas, amendments should be made for better public healthcare services in the interiors of the country. Investments should be made in increasing the number of health professionals in the public health sector. Also, very little importance is given to the Emergency Medical Services which plays a crucial part in saving lives of people. The Government should invest in establishing skill centres which can train paramedics who are well versed in handling accidents and various other emergencies, as this will help the quality of emergency response services in our country. The government should allocate budget to develop technology that will help in reducing the time taken for an ambulance to reach the emergency. This can be in form of advanced GPS technology, live traffic monitoring and updates, fitness devices that can monitor health and transfer emergency signals

FEBRUARY 2018 | HEALTHCARE RADIUS

in real time. If a push is given to the Emergency Medical Service sector, it will, in turn help the healthcare professionals to save more lives.

OPINION

Ameera Shah MD & Promoter, Metropolis Healthcare This year has been an important one for healthcare. Various initiatives ruled under the National Health Policy have helped in larger strata of the Indian population to access medical services at affordable prices. Post introduction of GST, the tax rate on medical devices was pegged at 12%, this, if reduced further can positively affect the overall cost structure, thereby providing cost effective healthcare services to the society. The last budget had a lot of focus on policy direction and targets for elimination of chronic diseases which is laudable. In addition to increased spending, we also hope that this year’s budget with address the National Health Protection Scheme and also set impetus to generate demand for health insurance through additional exemptions.

Suneeta Reddy MD, Apollo Hospitals By according National Priority Status for healthcare, the Government can signal its intent to put in place an enabling environment that will attract capital – both financial and intellectual, and stimulate the creation of high-quality capacity. Several approaches in combination can be used for this – in public-private partnership (PPP) models, or purely by incentivising the private sector with carefully structured tax benefits. We urge the Government to adopt Universal Health Insurance at viable rates for all players, and to incentivise the consumers through higher tax deductions for healthcare expenditure and insurance payments. Zero rating of healthcare services and healthcare insurance premiums under the GST regime would be most important to ensure that the cost of care remains protected for the consumer.

Rohit MA Cofounder, Managing Director, Cloudnine Group of Hospitals It’s important to note that this would the first budget in the GST era and thereby a good chance for the government to lay claims on the so called success of a wider tax spread. The usual suspect of GDP spend on healthcare, which has not found mention in the previous budgets should be increased from the current 1%. There have been assurances through the year about an increase to 2.5% which would be a minimum spend level with our population index as has been indicated through the National Health Policy 2017. The government has been vocal about the intent to work on initiatives for reducing the current IMR and MMR and it would be good to see if the budget can address some of these concerns with universal health cover and an allocated budget for ensuring a good coverage. The government should look to increase the medical allowance limit from Rs 15,000 per annum tax deductible limit to a more realistic number for allowance on the tax payer.

HEALTHCARE RADIUS | FEBRUARY 2018

OPINION

Dr H Sudarshan Ballal

Madhur Varma

Chairman, MHEPL First and foremost, there should be increase in spend on healthcare to about 3 % Of GDP and increase yearly by 1% till it is up to 5%. There should be more focus on preventive, primary healthcare, wellness awareness and life style modifications. The country needs to strengthen PHCs, taluka level hospitals and upgrade government hospitals with facilities and personnel, so that the economically backward can get reasonable care there and do not need to use expensive private healthcare services. The government needs to try to open up medical colleges in every district by upgrading district hospitals if need as PPP. And we need to look at health coverage at least for BPL patients with reasonable compensation for hospitals providing the care.

Group CEO, Sahyadri Hospitals Ltd I hope the Government reduces the GST on healthcare as it has increased the cost of healthcare delivery. We need an increased spend as a percentage of GDP on public healthcare. The government needs to come out with concrete plans to make healthcare more affordable than just declaring increased outlay of funds for a few diseases that does not affect all. The government needs to ensure that quality healthcare reaches the rural areas. And the Government needs to come up with schemes that would make PPP more lucrative to the private sector.

Surajit Chakrabartty CFO, MedGenome Labs

Harish Pillai CEO, Kerala Cluster, Aster DM Healthcare We need to increase the percentage allocation to GDP spend on public healthcare. Currently, our country has a sub optimal level- which is less than 2%. It should be pushed to 5%,. I would like the budget to announce a big ticket item on the universal health insurance scheme. This will help increase accessibility and affordability of healthcare of the population. I hope people having health insurance be given significant tax benefits to at least Rs 1 lakh. I would also like healthcare to be given infrastructure status, to get due tax benefits. Faced with woeful shortage of beds, the government needs to give us benefits that would accelerate investments in the private sector. Also, it would help to have long-term soft loan with lower interest rates.

FEBRUARY 2018 | HEALTHCARE RADIUS

We expect the budget to make provisions for increased public health spending, investing in building and maintaining public health infrastructure, setting up new medical academies and consider making health insurance mandatory for all. Ensure public health spending is utilised in an efficient manner by involving representatives from corporate sector, research institutes and bureaucrats to oversee the progress and guide accordingly. Priority status to healthcare sector including hospitals and diagnostic centres and incentivising technologydriven companies would boost expansion of healthcare services across the country. Apart from budgetary allocations, the government should also take steps to create an ecosystem that brings together academia and industry to boost innovation in healthcare.

INFRASTRUCTURE

A feminine touch The design of the mother and child hospital is focused on accentuating womanhood BY TEAM HR

oosama Sambhu Shetty Memorial Haji Abdullah Mother and Child Hospital, located at Udupi in Karnataka, was recently commissioned. This 220-bed hospital is a PPP between Karnataka Government and BR Life, a group of hospitals owned by the father-son duo of Padmashree Dr BR Shetty and Binay Shetty. It forms an integral part of the philanthropic vision of Dr Shetty to give back to the town and state to which he belongs. BR Life already has a 700-bed hospital in Alexandria, Egypt and another one in Nepal. Says Col Hemraj Parmar, Country Manager and Group CEO, BR Life, "The hospital will provide totally free services to the mother and child patients of the state of Karnataka and will bridge the gap on a long felt need." The brief given to Modular Concepts, the architectural firm and interior designer for the project, was to plan a hospital with international facilities that reflects the intention

and noble goals of Founder Chairman Dr BR Shetty.” Being a mother and child hospital, having an attached doctors and staff accommodation was also mandatory so that emergencies could be attended to. Even if it’s a charitable hospital, the group was keen to make the hospital look and feel like an international hospital with facilities like central air conditioning, full generator back up, UPS back up for emergency and critical care areas, ELV systems, modular operating rooms and intensive care, etc. The construction was to be completed within 12 months from the site hand over. Says Manoj Dharman, Managing Director, Modular Concepts, “The design of the hospital, whether interiors and exterior design and colours-was to accentuate feminity.” A rain tree, referred as the heritage tree or mother tree, was made the focal point in design- making entry and outlook of hospital with spacious landscaped gardens. During

Col Hemraj Parmar, Group CEO, BR Life

1. The hospital construction was completed within a span of a year.

HEALTHCARE RADIUS | FEBRUARY 2018

INFRASTRUCTURE

2. A rain tree,

referred as the heritage tree, was made the main focal point of design. 3. To speed up

construction technology, modular systems were used.

designing stage owing to site size and shape, the hospital was designed as one block maintaining the independence of hospital and housing part. The challenges to the project were sand availability and water availability for construction. Sand supply was overcome with support of government authorities and arranging alternative approvals for m sand. The project was fully dependant on buying water from the local vendors. To speed up construction technology, modular systems were used. The ground and first floor is RCC construction, while the upper five floors are modular PFPFVC (pre fabricated pre finished volumetric construction) where in modules are constructed in factory with up to 95% prefinishing possibilities. Design of various areas Lobby: The main lobby has been designed

FEBRUARY 2018 | HEALTHCARE RADIUS

with a sense of femininity which was introduced via soft looks, light colours and discreet lighting. The hospital offers a dedicated entrance, welcoming double height space and the reception has a play area for kids. The soft curves in the flooring patterns and pink colours lend a soothing effect to match the theme of mother and child hospital. “Using nature as healing element, the hospital has used flower patterns in double height wall of the lobby, which also has a connecting open café to welcome visitors and patient with healthy food and beverages while enjoying a big screen TV,” says Manoj. OPD waiting area: The OPD area has been segregated into gynaecology and paediatrics with dedicated staff station for controlling patient flow. A vast common waiting area has been provided along with sub wait near particular consultant rooms. Diagnostic wing: Ultrasound is a part of the gynaecology OPD wing. X-ray and lab with staff station are at the ground level for ease of access for all. Consultation rooms: “They are spacious rooms with proper privacy curtain provided for all the OPD rooms. For the ease of consultant, hand wash is a part of the side desk of consultant. All consultant room are designed to have natural light, thus giving sense of next to nature to consultant during long working hour,” says Col Parmar. Types of rooms: For the hospital, the design brief was to give free and affordable facilities to all. “To serve that purpose, all patient rooms are five-bed patient room. The patient room has been designed to have individual BHU with desired medical gas and electrical services for each bed and attached toilet. The provision for locker for five persons is there,” says Manoj. OTs: There are six state-of-the- art OT work stations in the facility equipped with laminar flow and pendant surgical lights. To optimise and have large no of patients treated, each OT comes with two operating tables. To maintain good standard of hygiene, modular panelling from Europe has been used

INFRASTRUCTURE

At a glance Name of the project: Koosama Sambhu Shetty Memorial Haji Abdullah Mother and Child Hospital Promoted by: BR Life Total bed strength: 220 Duration of the project: 12 months Date of commissioning of the project: 19 Novemer, 2017 soft opening, 18 January, 2018 operational opening. In built area: 17,343 square metre Land area: 7,116 square metre False Ceiling/Roofing: • Gypsum board ceiling with ascent design in Lobby area- Gyproc/Boral • 60 x 60 gypsum tile with Gypsum board bulkhead in corridors. Gyproc/Boral • 60 x 60 gypsum tile with Gypsum board bulkhead in corridors. Boral • 60 x 60 Metallic tile in toilets- Armstrong Use of drywalls: • Gypsum board with Stud and track framing and rock wool insulation in dry areas. Vendor is Gyproc/Boral • Moisture resistance Gypsum board with Stud and track framing and rock wool insulation in dry areas. Vendor is Gyproc/Boral • Cement Board with heavier Stud and track framing and rock wool insulation in external walls with EIFS treatment in outer surface and ACP as per elevation • HIL cement boards, Eurotech ACP Paints: Low VOC hygienic Paint in interior. Asian/ Nerolac/Berger Architect: Modular Concepts Interior designer: Modular Concepts

with painted stainless steel, HPL and digital printed panels. Cafeteria, kitchen, dining & laundry The cafeteria is a part of lobby extension and merges with lobby and carries similar

4 feature as the lobby to create seamless transition. Apart from cafeteria, a kitchen with dining hall has been provided at the ground floor at some distance. It helps in maintaining the cleanliness of the cafeteria, as it will be acting as dry café. Dining hall being at short distance, visitors can use it as per the need. The entral laundry with all washing and drying machines has also been installed. Kind of flooring For the lobby area, the hospital has used quartz stone with free flow design to give feeling of invitation and luxury. For functional areas, homogeneous vinyl has been used to have minimum joints and noise free areas. For the OTs, the flooring used is antistatic homogeneous vinyl to maintain good standard of safety. For wet area, porcelain and ceramic tiles have been used to maintain proper water sealing and cleanliness. Use of green landscape The design has been centred around the existing heritage tree. It has given shade and sense of canopy to frontage of hospital. Along the ramp vertical, a garden has been created. Use of paintings, glass and colour Digital printed glass with natural and flower patterns have been used widely in the operating rooms, ICU, labour and delivery areas to relieve stress to make a patient friendly environment. The colour used represented the femininity along with its grace and strength. The main colour used is white in combination with verity of pink and red for different areas.

Manoj Dharman, Managing Director, Modular Concept

4. The main lobby

has been designed with a sense of femininity which is introduced via soft looks, light colours and discreet lighting.

HEALTHCARE RADIUS | FEBRUARY 2018

EVENT

Fire & security expo FSIE 2018 to bring fire safety and security industry to Bengaluru

he second edition of the leading trade event for fire safety & security â&#x20AC;&#x201C; Fire & Security India Expo (FSIE) will be held for the very first time in the garden city of Bengaluru from 22-24 February at Bangalore International Exhibition Centre (BIEC). The fair will witness over 150 leading brands displaying their technological advancements and products and solutions catering to the wide demand of the industry. With over 10,500 square metre. of exhibition space, FSIE 2018 will have live product demonstrations along with conferences and workshops addressing key topics related to fire safety and security. Buyer-seller meetings, trade delegations are some of the other concurrent events to be a part of the expo. The Finest India Skills & Talent (FIST Awards) 2018 in the field of fire safety and

FEBRUARY 2018 | HEALTHCARE RADIUS

security will recognise the achievements of the most innovative, reliable and costeffective products, services and solutions spanning a wide range of fields across the fire safety and security industries. The three-day trade fair will be a part of the Build Fair Alliance, a consortium of co-located events that are proposed to be conducted at the same venue coinciding with FSIE, thereby ensuring maximum number of footfalls from stakeholders of building automation and construction industry. This year the event will be co-located alongside ACREX India â&#x20AC;&#x201C; leading exhibition on HVAC technology and ISH 2018 - leading exhibition showcasing plumbing systems. The alliance of the three events together is expected to attract over 50,000 business visitors during the three days. In India, awareness about fire safety and

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security has grown exponentially and intensified over the last decade as a direct result of the country’s economic evolution. As IT and retail markets rapidly expand coupled with an increase in set up large commercial factories, the stakes in terms of assets, investments and resources are too huge to be put at ¬fire and security risk. Continuing to drive the demand for fire safety and security is also the government’s focus on infrastructure development, especially with initiatives like the Smart City Mission. Said Pankaj Dharkar, President, Fire & Security Association of India, “The Indian fire and safety equipment market is expected to reach $4.94 billion by 2019. With the increased growth of the economy coupled with the government rules and regulations, the future of the Indian fire safety and security market is very bright. Fire & Security Association of India (FSAI) along with NuernbergMesse India joined hands together to organise the very first Fire & Security India Expo earlier this year. The upcoming edition will be the second edition of the annual trade event. The event is poised to attract the largest gathering of trade professionals witnessing product demonstrations and latest innovations by the leading brands participating at FSIE 2018 from world over.” Said Anish Unni, Director Sales - Fire & Suppression Group, IDEX Corporation, “IDEX India Fire & Safety has decided to participate in FSIE 2018 looking at the great success of the 2017 edition. We expect a great show this year as well, and will have our senior leadership team from Europe and USA visiting the show at Bengaluru. All the brands of IDEX Fire & Safety, i.e. Lukas, Vetter, Godiva, Akron Brass and AWG will be showcased during the event. We also have plans to have live sessions where our products will be demonstrated. We look forward to the opportunity to meet with all customers and key decision makers from the industry, thereby expanding brand IDEX within the fire safety and security segment in India.”

Sajid Desai, CEO, NuernbergMesse India, “The second edition of FSIE is a multi-dimensional platform that combines solutions for passive, active and organisational fire safety and security management. Here, official experts, architects and developers, MEP consultants, OEMs, security experts, building engineers, members of leading security and fire prevention bodies as well as fire safety and security representatives from retail, hospitality, healthcare,real estate, facility management, IT-ITEs industry and other stakeholders will gather to disseminate information, gather knowledge, exchange ideas, exhibit, debate innovative perspectives, solutions and products for ¬fire safety and security.” Leading players including ADN Fire Safety Pvt Ltd, Advanced International, Apollo Fire Detectors Ltd, Arihant Fire Protection Services Pvt. Ltd., Bharti Fire Engineers, Coopro Safety India Pvt Ltd, DDS Limited, FFE Ltd, IDEX India Pvt Ltd, Lubi Industries LLP, Naffco India Pvt Ltd, New Age Firefighting Co Ltd, Nohmi Bosai (India) Pvt Ltd, NSC Sicherheitstechnik GmbH, Prama Hikvision (India) Pvt. Ltd., Rapidrop India Pvt Ltd, Ravel Electronics Pvt. Ltd., Safex Fire Services Ltd, Securiton AG, Shah Bhogilal Jethalal & Bros, Topaz Fire Systems Pvt Ltd, Winco Valves Pvt Ltd among many others are ensuring that the event is the standalone platform for business excellence in the fire safety and security domain. Scheduled from 22-24 February at BIEC, Bengaluru, Fire & Security India Expo is supported by all leading associations and major trade bodies of India.

HEALTHCARE RADIUS | FEBRUARY 2018

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Why healthcare is human The conference gave new directions and ideas that can be incorporated in healthcare practice BY TEAM HR

he fourth edition of HEAL (Healthcare Excellence through Administration and Leadership) was held recently at Baby Memorial Hospital (BMH), Kozhikode, Kerala. Research Foundation of Hospital & Healthcare Administration (RFHHA) was the knowledge partner and Association of Healthcare Providers India (AHPI) was the associate partner. The event saw students, healthcare professionals and dignitaries participate in large numbers and industry best practices, areas that required focus. Dr Vineeth Abraham, Director, BMH proposed the welcome address and Dr Soman Jacob, CEO, BMH gave the presidential address. He highlighted the commitment of BMH and the journey of the institution from a 52-bed hospital to a 800-bed hospital. The event was inaugurated by Dr Shakti Kumar Gupta, Medical Superintendent (Dr RPC), AIIMS, New Delhi. While he started his address

showering praises on BMH for their commitment and care and the leadership of Dr KG Alexander, Chairman, BMH, Prof Mohammad Masood Ahmed, Director, Indo US Hospital, Hyderabad and Col.(Dr) Saroj K Patnaik, O/o DGAFMS, Ministry of Defence, New Delhi were guests of honour. Dr C Vinoth Kumar, Conference Director, proposed the vote of thanks for the inaugural session. Prof Ahmed started the academic session with his talk on 'Strategic Management in Healthcare Organisations' in which he discussed the importance and need for strategic management in hospitals and also enthralled the audience with case studies and insightful thoughts. Following that, Dr Vijay Tadia, Senior Resident Administrator, AIIMS, New Delhi addressed the gathering on 'Application of Lean Six Sigma in Healthcare' in which he detailed about the about the application of the principles of Lean Six Sigma in healthcare. He emphasised on the fact that defects

1. The event saw students, healthcare professionals and dignitaries participate in large numbers.

HEALTHCARE RADIUS | FEBRUARY 2018

EVENT

2. The event was inaugurated by Dr Shakti Kumar Gupta, Medical Superintendent (Dr RPC), AIIMS, New Delhi.

in processes as well as variation in processes lead to sub-optimal use of the resources in any healthcare organisation. Day one ended up with a 'Special Comedy Show in Healthcare' by Dr Jagdish Chaturvedi, a medical device innovator and a renowned stand up comedian on 'Inventing Medical Devices'. As a doctor who has evolved into becoming an innovator of affordable medical devices designed for our Indian setting, he shared his experiences and learnings with the medical community which includes doctors, paramedical and hospital administrators. Day two started with Lt Col (Retd) Sunny Thomas, CAO, BMH on 'Hospitals – A Tryst with Environment' which was an eye-opener for many, providing figures from energy saving initiatives and measures adopted at BMH. This was followed by Dr Shakti Gupta who talked about innovation and entrepreneurship and intelligent hospitals. He said that healthcare innovation and entrepreneurship are the cornerstone for success of any organisation. He pointed out that healthcare has traditionally lagged behind other industries in the area of innovation and entrepreneurship. Dr Sadik Kodakat, Chairman, Starcare Hospitals Group, addressed the gathering on 'Disruptors in Healthcare: Managers & Entrepreneurs Perspective.' He explained in detail the various disruptors in healthcare with thought provoking insights and examples. This was followed by the Col (Dr.) Saroj K Patnaik who addressed the gathering on 'Role of Level Five Healthcare Leadership in India'. He gave a blueprint for healthcare leadership

FEBRUARY 2018 | HEALTHCARE RADIUS

in organisations, more so in the organisational setting thus enabling high standards and impactful governance. Sri Harsha Govardhana, Managing Director, Sarvagnya Solutions, Hyderabad, spoke on 'Medical Leadership: Competencies for Clinicians'. In his address, he said “I have interviewed and observed over 90 plus doctors who have built their practice by following highest standards of care, getting outstanding medical outcomes. I checked the validity and application of these competencies over period of last 17 years. These doctors whom I call 'Super Star Doctors' rigorously demonstrate nine medical competencies that provide excellent clinical outcomes in Indian healthcare setting.” This was followed by Saji Mathew, Chief of IT & HR, BMH on 'The Employee Experience is the Future of Workplace'. In his talk, he said “Healthcare is considered the most ‘human’ of all endeavours. The performance of healthcare professionals such as physicians and nurses directly affects the physical and mental well-being of patients. Research has clearly identified links between healthcare work attitudes and patient outcomes. In the digital age, employee experience is an important concept worthy of attention to drive positive customer experience”. The last session of the day saw Prof (Dr.) Anand Gurumurthy, IIM, Kozhikode who delivered a talk titled 'Can car making methods be applied to hospitals?'. His talk dealt with how the concepts of Toyota Production System (TPS) can be applied within the healthcare setting such as hospitals to improve the efficiency of the various processes and thereby reduce the overall cost, which would enable health care services to be more affordable and accessible. He highlighted the similarity in terms of the objectives for TPS and healthcare institution such as hospital. The two-day session gave new directions and ideas that can be incorporated in healthcare practice to the healthcare professionals and a ringside view to the students community.

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