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A Monthly Magazine on Healthcare ICTs, Technologies & Applications www.ehealthonline.org | vo l u m e 4 | is s u e 2 | Fe b r u a r y 2 0 0 9 | I N R 7 5 / U S D 1 0

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The first MR guided breast biopsy in India Dr. A. Jena, Chief of MRI Rajiv Gandhi Cancer Institute & Research Centre Dr. Sangeeta Taneja, Radiologist, MRI Department Rajiv Gandhi Cancer Institute & Research Centre

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Map of Medicine Mike Stein, Chief Medical Office Map of Medicine,United Kingdom

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Telemedicine - Myths & Realities Lieutenant Colonel Salil Garg Cardiologist, Command Hospital, Pune Squadron Leader Mudit Mathur DD Space Ops, DSCC, Bhopal

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Molecular Imaging modern-day diagnostic miracle Dr. Sameer Sonar Chief – Molecular Imaging Centre Ruby Hall Clinic, Pune

Cut above the rest

Exclusive interview with Dr. Vineet Gupta, Group Medical Director, HealthCare Global Enterprises Ltd. and the first Asian to be awarded the prestigious Jean H. Lubrano Distinguished Scholar Award 2009 for his exemplary work on cancer research.


EDITORIAL

Volume 4 | Issue 2 | February 2009

When the going gets tough… president

Dr. M P Narayanan editor-in-chief

Ravi Gupta group directors

Maneesh Prasad Sanjay Kumar Sr. manager - PRODUCT DEV ELOPMENT

Dipanjan Banerjee mobile: +91-9968251626 email: dipanjan@ehealthonline.org research Associates

Susan Thomas Sarita Falcao Sales & MARK ETING

Arpan Dasgupta mobile: +91-9911960753 email: arpan@ehealthonline.org

As the actual effect of the ‘near-apocalyptic’ credit crisis hits us, we must understand its direct and indirect impact on public health. Those who lose jobs in this scenario also lose the health cover linked to their jobs; older, retired persons, already suffering from ailments related to old age often end up losing their entire savings, and being pushed back in to the job market – hoping they can still find one. On the hospital front too, one sees drastic measures being taken to tide over the crisis. In the US, perhaps the worst hit by the credit crisis, a recent survey by the American Hospital Association revealed that 56 percent of hospitals surveyed are reconsidering or holding off on renovations or plans to increase capacity. The healthcare industry, however, while also considering ‘trimming the fat’, must be prepared for medical errors, coming from the already over-worked medical staff, expected to work even harder. Tough times such as these, however, are ideal times to reinvent oneself and for adopting innovative and low-cost solutions. Often the best solutions are those developed indigenously – keeping in mind the socio-economic conditions of the region. And often the best drivers of such emerging technologies are governments. Early and large-scale uptake by the govern-

Bharat Kumar Jaiswal mobile: +91-9971047550 email: bharat@ehealthonline.org Sr Graphic D esigner

Bishwajeet Kumar Singh Graphic Designers

Ajay Negi Chandrakesh Bihari Lal Om Prakash Thakur web

Zia Salahuddin subscriptions & circul ation

ment leads to increased production of the technology, which in turn helps bring down cost of production and large-scale major help – in other words, economy of scale. Recently, US President Obama, announced a major rural broadband initiative committing nearly USD 20 billion for national health IT investments. He added that broadband investment could also help modernise healthcare systems, through storing and sharing medical information and health records online, enabling doctors to offer care more efficiently, “We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year,” Obama said. This and other such initiatives are necessary, today more than ever, to help economies recover and continue delivering quality life to each citizen. This is a time when India and other

Manoj Kumar (+91-9971404484) manoj@ehealthonline.org

countries can take similar decisions. In fact, hailing India’s public health initiatives, Prof. Jef-

editorial correspondence

(NRHM) and the Advisor to the UN Secretary General Ban-Ki-Moon has said that the NRHM

eHEALTH G-4 Sector 39, NOIDA 201301, India tel: +91-120-2502180-85 fax: +91-120-2500060 email: info@ehealthonline.org is published in technical collaboration with Centre for Science, Development and Media Studies.

frey Sachs, the Chairperson of International Advisory Panel of National Rural Health Mission is one of the most remarkable achievements in public health sector and is one of the largest scaled increase witnessed in a short period of time. However, he added “India should step up the budgetary allocation in health sector to four to five percent of the GDP.” This issue of eHEALTH puts the focus on people who have dedicated their lives to research and work in the field of medicine, such as, the lead interview with Dr. Vineet Gupta, recently awarded the prestigious Jean H. Lubrano Distinguished Scholar Award; felicitations for the recent Padmashree awardees; the role of telemedicine as seen through the eyes of medical practitioners in the armed forces; and also an insightful article on Molecular Imaging by an

does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. Owner, Publisher, Printer - Ravi Gupta. Printed at Print Explorer 553, Udyog Vihar, Phase-V, Gurgaon, Haryana, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP Editor: Ravi Gupta

Oncologist, passionate about his work. Do tell us how you like the latest issue of eHEALTH.

Ravi Gupta Ravi.Gupta@ehealthonline.org February 2009




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Editorial Guidelines eHealth is a print and online publication initiative of Elets Technomedia Pvt. Ltd. - an information research and media services organisation based in India, working on a range of international ICT publications, portals, project consultancy and highend event services at national and international levels. eHealth aims to be a rich, relevant and wellresearched information and knowledge resource for healthcare service providers, medical professionals, researchers, policy makers and technology vendors involved in the business of healthcare IT and planning, service delivery, program management and application development. eHealth documents national and international case studies, research outcomes, policy developments, industry trends, expert interviews, news, views and market

intelligence on all aspects of IT applications in the healthcare sector. Contributions to eHealth magazine could be in the form of articles, case studies, book reviews, event report and news related to e-Health projects and initiatives, which are of immense value for practitioners, professionals, corporate and academicians. We would like the contributors to follow the guidelines outlined below, while submitting their material for publication: Articles/ case studies should not exceed 2500 words. For book reviews and event reports, the word limit is 800. An abstract of the article/case study not exceeding 200 words should be submitted along with the article/case study. All articles/ case studies should provide proper references. Authors should give in writing stating that the work is new and has not been published in any form so far.

Book reviews should include details of the book like the title, name of the author(s), publisher, year of publication, price and number of pages and also have the cover photograph of the book in JPEG/TIFF (resolution 300 dpi). Book reviews of books on e-Health related themes, published from year 2002 onwards, are preferable. In the case of website, provide the URL. The manuscripts should be typed in a standard printable font (Times New Roman 12 font size, titles in bold) and submitted either through mail or post. Relevant figures of adequate quality (300 dpi) should be submitted in JPEG/ TIFF format. A brief bio-data and passport size photograph(s) of the author(s) must be enclosed. All contributions are subject to approval by the publisher.

Please send in your papers/articles/comments to: The Editor, eHealth, G-4, Sector 39, NOIDA (UP) 201 301, India. tel: +91 120 2502180-85, fax: +91 120 2500060, email: info@ehealthonline.org, www.ehealthonline.org



February 2009

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CONTENTS

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w w w . e h e a l t h o n l i n e . o r g | volume 4 | issue 2 | February 2009

COVER INTERVIEW

Cut above the rest Dr. Vineet Gupta Group Medical Director Healthcare Global enterpris4es Ltd.

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TECHNOLOGY TRENDS

mHealth-mobile connectivity for healthcare Susan Thomas eHEALTH Bureau

PADMASHREE AWARDEES

India hounours its doctors on the occasion of Republic Day eHEALTH Bureau

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SPOTLIGHT

The first MR guided breast biopsy in India Dr. A. Jena, Chief of MRI Rajiv Gandhi Cancer Institute & Research Centre

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Going Places

Dr. Sangeeta Taneja, Radiologist, MRI Department Rajiv Gandhi Cancer Institute & Research Centre

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Sumedha Sen CEO EPOS Health Management

APPLICATIONS

Map of Medicine

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Mike Stein, Chief Medical Office Map of Medicine,United Kingdom

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PERSPECTIVE

EXPER T CORNER

Molecular Imaging modern-day diagnostic miracle

TELEMEDICINE

Telemedicine - Myths & Realities Lieutenant Colonel Salil Garg Cardiologist, Command Hospital, Pune Squadron Leader Mudit Mathur DD Space Ops, DSCC, Bhopal

Dr. Sameer Sonar Chief – Molecular Imaging Centre Ruby Hall Clinic, Pune

REGULAR SECTIONS India News 16 World News 28 Business News 36 Numbers 44 Events Diary 46



February 2009

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COVER INTERVIEW

Cut

above the rest Dr Vineet Gupta, the latest to join the list of luminaries in the field of Cancer research, having been felicitated by one of the top Cancer Institutes, has made India proud being the first Asian to be awarded the Jean H. Lubrano Distinguished Scholar Award for 2009. eHEALTH recently caught up with this dynamic Group Medical Director of HCGL to felicitate him and understand his vision for the future.

Dr Vineet Gupta is the first Asian to be honoured with the prestigious Jean H. Lubrano Distinguished Scholar Award for 2009 by the Harvard University/Dana Farber Cancer Center, Boston. He joins the list of elite cancer specialists worldwide honoured as Lubrano scholars. Dana Farber Cancer Institute has been consistently voted amongst the top three cancer centres in the US. Jean Lubrano Distinguished Visiting Scholar Award acknowledges the spirit of helping others and continuing the fight against cancer. The award acknowledges the contribution of Dr Gupta in furthering the cause of science and brings a respected clinician and researcher in women’s cancers to Harvard University/Dana-Farber Cancer Institute, Boston in the hope of fostering education and collaboration.

Dr Vineet Gupta Group Medical Director HealthCare Global Enterprises Ltd.



February 2009

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Widely recognised for his work in Breast Cancer and Hematological diseases including Leukemias and Lymphomas, Dr Gupta in the current position as the Group Medical Director of HealthCare Global Enterprises Ltd. (HCG), provides leadership to align the clinical and research expertise of oncology professionals at the HCG institutions, ensuring that the medical care given to cancer patients is advanced, innovative, comprehensive, and multidisciplinary. Dr Gupta is an alumnus of University of Delhi. His initial training was at the famed Wayne State University and Barbara Ann Karmanos Comprehensive Care Centre, Detroit. Later he was at the world renowned Moffitt Comprehensive Cancer Centre in Tampa, USA.


COVER INTERVIEW

Q. Please tell us something about your experience starting from your early career and after having worked in world renowned cancer research institutes, and currently as Group Medical Director at HealthCare Global Enterprises Ltd. (HCG) A. I received my initial medical education at University of Delhi, subsequent to which I moved to the US. I was part of an era of high velocity scientific change, massive acceleration in new medical procedures, pharmaceuticals, medical devices, diagnostics and methodologies. I realised that our ability to ingest new knowledge is a key saviour in re-engineering of healthcare. I think this was a defining moment in my career. At HCG, South Asia’s largest Cancer care network, I use my learning, coordinate patient care among myriad of clinical and research professionals; ensure that the care is advanced, innovative and multi-disciplinary. Q. You were recently awarded the prestigious Jean H. Lubrano Distinguished Visiting Scholar Award for 2009 by the Harvard University-Dana Farber Cancer Centre; the only Asian to have received this award. Could you share with us key moments in your career that stand out in your memory at this juncture that contributed to this huge success? A. Few people have one defining moment where they decide their future career path and rest of their lives. Even as a child, I always knew that I wanted to be a physician. My father is a doctor, and a doctor’s job is to help sick people. That’s all I needed to know. That, however, does not make for an interesting story. The defining moment in my career was the decision to come back to India, leaving behind the lure of gold and glory. Q. The award acknowledges your contribution in furthering the cause of science and your research in oncology. How do you think India differs from other countries in terms of awareness about cancer and efforts to increase awareness by the State machinery? A. Cancer is a leading cause of death globally. WHO estimates 84 million will die in the next 10 years if action is not taken. More than 70% of all deaths occur in low-income countries.

Cancer cells

We as a developing world have yet to make the transition from “fixing people after they are sick” to preventive medicine. This will drastically reduce spending, and improve quality of lives. Every 6.5 minutes, a woman is diagnosed with breast cancer in India. It takes USD 1500 to provide effective treatment, however the accompanying emotional trauma and expense are avoidable if she undergoes USD 15 screening mammography. The government, despite its good intent, has confused ‘activity’ with ‘achievement’ and hence has been unable to drive real change. The private sector, which dominates healthcare has been unable to create opportunities for itself in the preventive space. Q. How well and effectively do you think has the medical fraternity adopted technology so far? And where do you think more rapid uptake is required to improve health outcomes? A. I think the medical community is misunderstood as being techno-phobic. Consider Azyxxi (now part of Amalga) that’s designed by doctors, for doctors.

“Cancer is a leading cause of death globally. WHO estimates 84 million will die in the next 10 years if action is not taken. More than 70% of all deaths occur in low-income countries.”

I believe we must evolve to a user interface that is intuitive of clinicians processes. Community doctors move from hospital to hospital. We are becoming February 2009




COVER INTERVIEW

About Dana Farber Cancer Institute and Dana Farber Cancer Institute has been consistently voted amongst the top three cancer centers in the US, and the Jean Lubrano Distinguished Visiting Scholar Award has been acknowledged as one of the most prestigious in the field of medicine. Past visiting scholars have included: May 1999: Aron Goldhirsch, MD Aron Goldhirsch, MD, is the Director of the Department of Medicine at the European Institute of Oncology, Milan, Italy; Professor of Medical Oncology at the University of Bern, Switzerland and head of the Division of Medical Oncology of the Oncology Institute of Southern Switzerland, Lugano, Switzerland. He is also the Chairman of the Scientific Committee of the International Breast Cancer Study Group. June 2000: Mark Levine, MD, MSc Mark Levine is a professor in the Department of Oncology and the Department of Clinical Epidemiology and Biostatistics. He holds the Buffett Taylor Chair in Breast Cancer Research at McMaster University. His focus is in the areas of breast cancer and venous thromboembolism. A number of the trials he has conducted have had an impact on healthcare in Canada and also internationally. He helped establish the Ontario Clinical Oncology Group (OCOG) in 1982. Dr. Levine has over 220 publications in peer-reviewed journals and has brought much research funding to McMaster. He is Director of the Clinical Trials Methodology Group (CTMG) of the Henderson Research Centre. He was chairman of Health Canada’s Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Dr. Levine is currently an associate editor for the Journal of Clinical Oncology. July 2003: Martine Piccart-Gebhart, MD, PhD Dr. Piccart-Gebhart is a member of numerous profes-

so mobile that we need solutions that work wherever we are with whatever device. We cannot expect healthcare professionals to change the way they work depending on the particular hospital they are visiting. Think of driving a car. You familiarise yourself with the controls for a given model and then adjust for regional variations by country. But once you know how to drive, you can generally jump in and start driving it, no matter

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sional organisations, including the American Society of Clinical Oncology (ASCO), the American Association for Cancer Research (AACR), the European Society for Medical Oncology (ESMO), and the European Organisation for Research and Treatment of Cancer (EORTC). She is also the President of EORTC (since June 2006). She plays an active role in new drug development. In 1996, Dr. Piccart-Gebhart founded the Breast International Group (BIG) and currently serves as chair. Created to facilitate breast cancer clinical trials and to reduce the unnecessary duplication of efforts, BIG coordinates 38 clinical research groups based primarily in Europe, South America, and Australasia. A translational research consortium created to complement BIG’s clinical research network, TransBIG, was founded by Dr. Piccart-Gebhart in 2004. July 2004: Kathleen Pritchard, MD, FRCPC In 1984, she was named Chair of the Breast Cancer Site Group of the NCIC Clinical Trials Group and has served in that role, or as Co-chair, up until the present time. In 1987, Dr. Pritchard moved to the Toronto Sunnybrook Regional Cancer Centre (TSRCC) as Head of Medical Oncology (subsequently Medical Oncology and Haematology) and in 1997 was also appointed Head, Clinical Trials and Epidemiology at TSRCC. She has served as Chair and Co-chair of the Breast Cancer Site Group of the Ontario Practice Guidelines Initiative from 1990 through 2002, and in 1998, was also appointed as Clinical Director of the Ontario Clinical Oncology Group. Dr. Pritchard was a founding member of the Canadian Oncology

where in the world you are. A great ICT architecture is a means to an end not an end in itself. ICT will eventually be source of evidence based information about therapeutics and practices for clinical and policy decisions. ICT will foster partnerships among providers, insurers, employers and consumers to bring a sustainable change. Q. How do you approach the potential of Information and Communication Technolo-

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About HealthCare Global Enterprises Ltd. (HCG): South Asia’s largest cancer care network, currently owns and manages a network of 15 state-of-theart cancer treatment centres across India. HCG focuses on the entire value chain in cancer care from Diagnostics to high end Imaging Services to cutting edge research and clinical trials HCG has had a vision to provide high quality,


COVER INTERVIEW

Jean H. Lubrano distinguished Scholar Award Society (1978) and subsequently their Vice-President (1992-1994). She was also a Founding Member of the Canadian Association of Medical Oncology (1988), and their second President (1990- 1992). Dr. Pritchard was awarded the O. Harold Warwick Prize for Cancer Control in Canada in 2005 by the Canadian Cancer Society and the NCIC for her work in clinical and translational trials in breast cancer. In 2006 Dr. Pritchard was elected to the Board of Directors of the American Society of Clinical Oncology. Dr. Pritchard has also served as Chair of the Management Committee of the Canadian Breast Cancer Research Initiative, a partnership that funds much of the breast cancer research done across Canada (1999-2002). July 2005: Timothy Whelan, BM, BCh, MSc Timothy Whelan, MD Professor, Department of Oncology and Head of Department of Radiotherapy, McMaster University Hamilton, Ontario, Canada July 2006: Ian Smith, MD Professor Ian Smith is Professor of Cancer Medicine at the Royal Marsden Hospital and Institute of Cancer Research, London. He is also Head of the Breast Unit. He trained in Edinburgh and at Harvard before coming to work at The Royal Marsden where he has spent many years specialising in the medical treatment of breast cancer and, until recently, lung cancer. Professor Smith is a past Chairman of the Association of Cancer Physicians and of the UK National Cancer Research Institute Lung Cancer Group. He is on the steering committees of several major international clinical research trials and has recently been closely involved in the development of Herceptin for early breast cancer. He has published over 350 research papers and lectures widely around the world.

affordable, and comprehensive cancer care to all segments of society. Bangalore Institute of Oncology (BIO), the flagship of HCG, was set up almost 2 decades back by Dr. B S Ajai Kumar who had just moved back from the US and was the first dedicated comprehensive cancer centre in the private space.

July 2007: José Baselga, MD Jose received his MD degree from the Universidad Autonoma of Barcelona in 1982. He performed Internal Medicine Residencies at Vall d’Hebron University Hospital in Barcelona and at State University of New York and a fellowship in Medical Oncology at Memorial SloanKettering Cancer Center in New York. On completion of his fellowship, he joined the staff at the Breast Medicine Service, Memorial Sloan-Kettering Cancer Centre until 1996 when he returned to Spain. Presently, Jose is Chief of Medical Oncology and Professor of Medicine at the Vall d´Hebron University Hospital in Barcelona, and Scientific Chairman of the Spanish Breast Cancer cooperative group SOLTI. He is on the editorial board of several major journals and has published over 100 peerreviewed articles, in addition to over 300 abstracts and book chapters. July 2008: Mitchell Dowsett, PhD Mitchell Dowsett, Ph.D., a leading international researcher on the endocrinology of breast cancer and the use of biomarkers to measure response to treatment, received the 2007 William L. McGuire Award at the 30th Annual San Antonio Breast Cancer Symposium (SABCS). Supported by GlaxoSmithKline Oncology (GSK) since its inception in 1992, this award acknowledges distinguished researchers for their significant contributions in the field of breast cancer. Widely recognised for his research on aromatase inhibitors and biomarkers of response and resistance to treatment, Mitchell Dowsett, Ph.D., is Head of the Academic Department of Biochemistry at The Royal Marsden Hospital, Professor of Biochemical Endocrinology at the Institute of Cancer Research and Professor of Translational Research in the Breakthrough Breast Cancer Research Centre, London.

gies (ICTs) in your current role as the Group Medical Director of HCG? A. The current buzz is about Personalised Medicine based on our genetic make up (Pharmacogenomics), which I think is restrictive. Personalised medicine will extend far beyond - it is the interface between diagnostics and therapeutics, a union between drugs and devices. HCG is South Asia’s largest Cancer Care provider, with close to 24,000 patients

in the countrywide network. I call this our IT DNA - a major initiative guided by the vision of Dr. Ajai Kumar. When completed, it will enable many things - oncology EMR, virtual care and justin-time decisions. Operations will be enabled by a centralised HIS, an integrated compliant backend and a secure robust infrastructure. We want to create a brand, using our clinician portal, a well laid-out website and social networking. February 2009

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PADMASHREE AWARDEES

India hounours its doctors on the occasion of Republic Day The President of India, Shmt Pratibha Patil conferred nineteen Padma Awards in the field of Medicine for the year 2009. These awards were announced on the eve of Republic Day. eHEALTH wishes to congratulate these awardees. Padma Vibhushan

Prof. Jasbir Singh Bajaj, Punjab Dr. Purshotam Lal, Uttar Pradesh

Padma Bhushan

Dr. Brijendra Kumar Rao, Delhi Dr. Vaidya Devendra Triguna, Delhi Dr. Khalid Hameed, NRI

Padma Shri

Dr. A.K. Gupta, Maharashtra Dr. Alampur SaibabaGoud, Andhra Pradesh Dr. Arvind Lal, Delhi Dr. Ashok K. Vaid. Delhi Dr. Ashok Kumar Grover, Delhi Dr. Balswarup Choubey, Maharashtra Dr. D. S. Rana, Himachal Pradesh Dr. Govindan Vijayaraghavan, Kerala Dr. Kalyan Banerjee, Delhi Shri P.R. Krishna Kumar, Tamil Nadu Dr. R. Sivaraaman, Tamil Nadu Dr. Shaik KhaderNoordeen, Tamil Nadu Prof. (Dr.) ThanikachalamSadagopan, Tamil Nadu Dr. Yash Gulati, Delhi

About the Awards According to the procedure, an ‘Awards Committee’ makes the final recommendations on awardees after receiving ‘recommendations’ from various sources like state governments / UTs, central ministries and departments and institutions of excellence, and the names have to be finally cleared by the President’s office. Padma Vibhushan: is India’s second highest civilian honour. The Bharat Ratna, is the highest award that can be conferred by the President of India. Padma Vibhushan is awarded to recognize exceptional and distinguished service to the nation in any field, including government service. Padma Bhushan: is India’s third highest civilian decoration, awarded by the President of India. It is awarded to recognize distinguished service of a high order to the nation, in any field. Padma Shri (or) Padma Shree: is an award given by the Government of India generally to Indian citizens to recognize their distinguished contribution in various spheres of activity including Arts, Education, Industry, Literature, Science, Sports, Social Service and public life. It stands fourth in the hierarchy of civilian awards after the Bharat Ratna, the Padma Vibhushan and the Padma Bhushan.

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INTEGRATED EMR Helps you eliminate paper charts Faster document processing Easy storage and retrieval of data Instant access to patient records Support for Charts and Schematics

EASY TO USE User friendly interface Simple mouse-click access Quick learning curve

CUSTOMIZABLE Designed for individual requirements Integration with existing applications Workflow based technology Selective modules

SECURE Access control passwords Encrypted data for confidentiality HIPAA compliant Audit on all transactions HL7 transactions

ADVANCED FEATURES Publish Charts/EMR Follow-ups Referral Management Voice Recognition Workflow Management Correspondence Manager SMS and Email Alerts Centralized/Distributed Implementation


SPOTLIGHT

The first MR guided breast biopsy in India Rajiv Gandhi Cancer Institute and Research center, India has taken yet another quantum leap by conducting the first MR guided breast biopsy on 15 December 2008 in the country. The dedicated team of trained professionals with high-end MRI machine and now the facility to do Breast Biopsy under MR guidance, the department of MRI has launched its world class MR mammography program to boost the existing breast cancer care under one roof in the institute. Spearheading the team with Dr Jena, Chief of MRI and a pioneering figure in MRI in the country, is Dr Sangeeta Taneja, a promising young Radiologist and experienced MR specialist who received advanced training on MR Guided Breast Biopsy in Seattle Cancer Care Center and Washington University under prominent luminaries in the field like Dr. Lehman C and Dr. Bruce Porter to carry the program to success.

Dr. A. Jena Chief of MRI Rajiv Gandhi Cancer Institute & Research Centre

Dr. Sangeeta Taneja Radiologist, MRI Department Rajiv Gandhi Cancer Institute & Research Centre

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MR Mammography is a safe and powerful imaging technique that detects lesions, as small as 2-3 mm without the use of radiation. With its capability to detect cancer in almost 100 per cent cases, it makes for the best early detection tool for breast cancer, which, if removed results in cure. It is often so, that many of these are “only MR detected lesions� i.e. not seen on conventional modalities like mammography (xray) or ultrasound for biopsy. So far, such suspicious cancer foci, which usually pose anxiety to both the patient and the treating doctor, were only left up to follow-up when they could actually be dealt with through biopsy under MR guidance - a popular and routine practice in the west. The procedure was not available till now in India and our patients were either denied such need or they had to go abroad to seek help. Now that we have MR

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guided biopsy facility at hand the whole spectrum of breast lesions can be appropriately addressed. In about 7 per cent of cases of known breast cancer, it harbours additional lesions in the affected or contra lateral normal breast, a finding that significantly influences an important decision like breast conservation vs. mastectomy. Some of these unexpected lesions may require biopsy under MR guidance for histological proof for accurate local staging. We have found it beneficial like many leading cancer centres in the world to include MR mammography in the routine presurgery work up of cases to depict the true extent of the lesion in general and in those scheduled for breast conservation in particular. Besides this, breast biopsy under MR guidance is going to play an important role along with MR mammography


SPOTLIGHT

Fig 1: MRI system with Dual breast coil and biopsy device in position

About 7% of cases of known breast cancer harbor additional lesions in the affected or contra lateral normal breast, a finding that significantly influences an important decision like breast conservation versus mastectomy. in exclusively addressing issues like recurrence versus scarring due to surgery/radiation therapy, benign and malignant causes of nipple discharge or cancer in implanted breast. In these areas, MR guided biopsy can promptly allay any anxiety by providing a quick and

Fig 2: MR mammography done for extent evaluation in diagnosed case of cancer left breast reveals small (2.5 mm) “only MR detected” malignant lesion (histology proved) in contra lateral right breast This highlights the fact that MR does detect such early lesions, can help prove its nature through guided biopsy, which has altered the management as in this case and can be cured had it been the only detected lesion.

reliable answer as regards the nature of the lesion. MRI has been reported to detect smaller and more cancers in high risk population (BRCA mutations, family history of breast cancers etc.) as also a number of unsuspected indeterminate lesions, during MR mammography done with well-defined indications like search for breast primary etc. The American Cancer Society (ACS) in 2007 has recommended the use of MR mammography as an adjunct screening modality for high-risk population. It is also added, by breast

authorities, that for units practicing breast MRI to have MR guided breast biopsy facility as mandatory. RGCI envisages providing the best breast care to the population with a dream to reduce the mortality due to breast cancer with early diagnosis and hence early treatment. Creation of a comprehensive ‘MR Mammography Program’ is a humble effort towards this direction. This pioneering effort will go a long way towards setting up of a dedicated breast care center in the country as has been the practice in any cancer care centre elsewhere in the world. February 2009

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NEWS REVIEW >> INDIA

TCG Lifesciences conferred excellence award by Inst of Economic Studies

GCS to pump in INR 722 cr to upgrade Cancer Hospital

TCG Lifesciences Limited has been conferred with ‘Excellence Award’ and its Managing Director, Swapan Bhattacharya with ‘Udyog Rattan’, by one of India’s premier research institutes ‘Institute of Economic Studies’ (IES) for outstanding achievements

The executive board and general board of Gujarat Cancer Society (GCS), has recently approved an ambitious plan to convert the hospital into a super speciality cancer care and research institute that will provide treatment at par with international standards by pumping in INR 722 crore, which will be available through public private partnership. The number of beds in the cancer hospital will be increased from current 650 to 1000. Health minister Jaynarayan Vyas, who is also a member of the board, said that the Society has also decided to establish a stateof-the-art general hospital and a self-finance medical college at the cost of INR 396 crore. The state government has already allocated land at the New Swadshi Mill compound to GCS, which is valued at INR 200 crore. Talking about another major decision by the GCS board, Vyas said that INR 10 crore has been allocated for screening and early detection of cancer in the rural areas of the state. Using mobile medical units, which will be going to different villages across the state for screening of cancer patients. A network of satellite cancer treatment centres will be set up across the state so that even below poverty line (BPL) families can use the facility.

in the field of life sciences and contribution in India’s industrial development. The awards were presented by HE B. P. Singh, Governor of Sikkim in the presence of Dr. Bhishma Narain Singh, former Governor of Tamil Nadu and Dr. G.V.G. Krishnamurthy, former Election Commissioner of India at the award ceremony in New Delhi. TCG Lifesciences Limited (formerly Chembiotek Research International) is a leading research services and informatics company with operations in India, Europe, Japan and the United States. TCGL offers cutting edge drug discovery and development platform whereby the R&D process is seamlessly transitioned from ‘bench to bedside and back’, and laboratory data easily accessed and managed across the product development lifecycle. Its relationships with the customers and collaborators span from specific solutions and sourcing services to integrated projects across multiple domains to complete translational research programs.

Maharashtra’s govt hospitals to be connected All the 14 government-run medical colleges and 19 affiliates of Maharashtra will be linked through integrated software. The move is expected to bring with it transparency in accounts as well as an increase in administrative accountability. Each patient visiting the hospital will be given a unique health identity number and will have access to his medical history at any hospital across the state. This Hospital Management and Information System (HMIS) project was flagged off by the state government’s Medical Education and Drugs Department (MEDD) in 2007. The HMIS project will cost approximately USD 56 million and seven years to complete. The work of laying underground cable and installing computers has started at the Sassoon hospital and the hospital will formally come under the HMIS project in the next two months. The remaining hospitals and medical colleges in the state will get electronically inter-connected with an electronic medical records (EMR) facility in the next two years.

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NEWS REVIEW >> INDIA

Indian army to modernise its medical services Recent terror strikes in the country’s financial capital, Mumbai have forced action in India’s Armed Forces to modernise their medical services so as to minimise the reaction time during emergency situation. Commenting on this, Lt Gen Yogendra Singh, Director General of Armed Forces Medical Services (AFMS) said, “We are streamlining the disaster management system in all the major hospitals to minimise the response time from two hours to one hour.” Speaking on the occasion of Army Medical Corps anniversary, Lt Singh said that the decision to compress the response time to ease medical services to the injured at the earliest has been taken following the Mumbai carnage.He also pointed out that the earlier concept was a reaction time of six hours that has now been cut down to two hours and now armed forces are working out to respond it within an hour. He further added that as per the modernisation plan, army hospitals have been provided with the latest medical equipment such as MRI, Lasik Laser machine, oxygen generation plants.

Hospitals in Chandigarh to be snychronised Jolting the health department in Chandigarh out of its slumber, the recent case in PGI where a patient died after being admitted to ICU allegedly due to bed shortage, has once again raked up the issue of synchorinsing all hospitals. We will ensure that all hospitals share information. The private hospitals having required facilities will also be empanelled to provide the same service at agreed rates.

The available services with rates will be circulated in the government hospitals where the patients can take their relatives. People who come from far flung areas to PGI are unaware of the facilities in the Tricity’s private hospitals. In order to take care of service deficiencies in the healthcare system and avoid disruption of treatment, the Indian Medical Association, Chandigarh, will send the list of the empanelled hospitals with the facilities to all government hospitals. Chandigarh unit IMA president Zora Singh said, “There are 25 private hospitals in the city. But we have to include those centres, which agree to the rates we want. We are working on that and will take another two weeks.”

Asclepius Clinic- new software for consulting doctors & physicians DesignTech Systems Ltd, a leading solutions provider in healthcare and Product Lifecycle Management has introduced a range of healthcare solutions for small to large hospitals. They have launched a new affordable workhorse especially for consulting doctors and medical practioners. Coming at a price tag of less than a high end mobile phone, this ‘Asclepius Clinic’ handles a host of tasks for the doctors like managing queues, patient data base, billing, tracking the treatment for each patient and many more.

Mr. Vikas Khanvelkar, MD, DesignTech Systems Ltd. Said, “For consultants and doctors today, the availability of patient’s full data at a click of a mouse and the ability to archive the data and manage the queues will be really useful. It will also save valuable time they spend on keeping records year after year.” Further, Asclepius Clinic will enable doctors to meet the critical ensuing IRDA regulations he added. With growing demand for this product, DesignTech is increasing the reach by appointing dealers / stockist’s for distributing it all over Maharashtra and Gujarat. Product will be rolled out all over India and abroad by first quarter of 2009. February 2009

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APPLICATIONS

Map of Medicine The Map of Medicine is a bold step towards the creation of a benchmark of clinical processes so that everyone involved in the management of patients, including patients themselves, can be on the same page. A Map of Medicine has become urgent as the explosion in information and technology available to treat and/or inadvertently harm the patient means that healthcare professionals are working in everdeepening silos of care; we now expect our orthopaedic surgeon to just “do knees”. A visual benchmark or “SatNav” that covers over 80% of patient journeys is both feasible (The Map of Medicine has made a good start) and necessary to support generalists provide overarching care for their patients.

T

Mike Stein Chief Medical Office Map of Medicine,United Kingdom

he challenge to the generalist is the ever-increasing array of healthcare technologies. Individuals cannot possibly stay up to date across all areas of healthcare, yet general practitioners (GPs) and hospital-based consultants on postintake ward rounds (generalists) are expected to help patients to make informed decisions across a wide range of conditions. In addition, shift working has created many more handover points in a patient’s ever more complex healthcare journey. Few would argue with the need for a professional map of care processes - one that describes the ideal patient journey across all the silos of care, and makes specialist evidencebased healthcare information more accessible to generalists. However, the task of creating such a map is complex, requiring the distillation of a very large amount of healthcare literature (over 1000 clinical research articles are published every day), which must then be put into context. This distillation requires a resource intensive multidisciplinary team approach including specialists, generalists, specialist nurses and allied healthcare professionals. In addition, there are often conflicts of professional opinion both within and across specialities and any map must be

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able to accommodate such conflicts in a transparent manner so as not to stifle innovation, nor to promote cook-book medicine. This demands the creation of a tool that is clinically intuitive and can mediate a meaningful dialogue among healthcare professionals about what are (and what are not) acceptable standards of care. A dynamic or “living” map that can continually change and evolve. The “Map” The Map of Medicine (the “Map”) is a dynamic web-based clinical knowledge resource allowing the creation and communication of evidence based clinical pathways. Each of the 396 topics in the Map is published as a “first draft” where new evidence-based information can be embedded within the context of the patient journey every 3 months, creating an ever-evolving synthesis of expert opinion-based best-practice and evidence. There is a long way to go; but the first 300 topics cover 80% of a GPs typical week. Formally starting life in 2001 as a project within University College London in partnership with a large teaching hospital (Royal Free Hampstead NHS Trust), the Map has been entirely clinician-led, and was originally developed to support the re-design of healthcare processes; with a visual interface to


APPLICATIONS

mediate a productive dialogue across the care settings and potential silos of care. For example, one of the first uses of the Map was to assist community-based doctors prepare patients in advance of a specialist referral so that specific diagnostic blood or urine tests could be done with the results available in advance of the patient appointment at the hospital. Too often patients would arrive for an appointment only to be brought back following some basic tests that could have been arranged in advance by the GP clinic. First coming to the attention of national organisations such as the NHS Institute for Innovation and Improvement in 2005, the Map was deployed across 14 NHS Trusts in 2007. Taking little steps and incorporating lessons learnt from each implementation, the Map is now active in 35 “early adopter� local healthcare communities, each comprised of 150,000-600,000 patients. Adoption is driven by the

Local Metric in the Localised Breast Cancer Pathway capability to make changes according to local priorities. Indeed, locally spe-

cific information allows the merging of local policies and protocols with the


APPLICATIONS

power of the international evidence base within the Map to create a flexible national, but locally controlled clinical knowledge framework for the healthcare system. The Map of Medicine (reference version) is also available license-free to individuals across the NHS England and Wales, and is named as one of the genuine success stories within the National Programme for IT. Full organisational deployment is scheduled to be completed in 2009/10 and will cover over 10,000 GP clinics that refer patients into over 2000 hospitals within the NHS England and Wales. Support from the clinical community Crucial to the success of the Map has been the support of the clinical community; agreements are now in place with the Royal Colleges of Physicians, the Royal College of General Practitioners, the Royal College of Obstetrics and Gynaecology, and the Royal College of Emergency Medicine with stakeholders within the surgical community expected to come on board in the very near future. Each Surgical Association is asked to provide recommendations for subject experts to undertake peer review of the Maps that are drafted by Map Fellows (up and coming Registrars) supported by a large team of publishing experts using state-of-the-art and web-based information technologies. All topics are peer reviewed and clearly notated as to whether the content has received formal NHS accreditation or not, with the vast majority of topics (over 95%) being accredited. As a result of its emerging national success and the requirement for major financial and technological investment as well as content expansion to support product development, the Map was acquired by Hearst Corporation in May 2008 remaining a UK company but with the backing of a robust and independent global player. As a consequence of Hearst’s backing, contracts are already in place with the government of Queensland (Australia) with national procurements in process in further nations. Furthermore, Hearst Corporation

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is supporting license-free access to healthcare information for the Global South, specifically the World Health Organisation’s (WHO) Sharing eHealth Intellectual Property for Development (SHIPD) initiative. SHIPD was established to strengthen health systems through the adaptation and deployment of shared intellectual property, by partnering organisations willing to provide free access to selected e-health products and services to developing countries. The Map of Medicine was the first product chosen by SHIPD to be provided to six African countries: Nigeria, Tanzania, Uganda, Zambia, Cameroon and Kenya. Following successful pilots, the Map will be deployed license-free across all eligible countries in Africa commencing in 2009. Interested governments can contact the Map of Medicine (see below) for further information. Current uses of the Map within the UK The Map is currently being used to support priority projects of the National Health Services (NHS) of both England and Wales, such as healthcare planning (commissioning), cancer management and the diagnosis to treatment programme (also known as the 18-week wait programme). In addition, its visual user interface is proving very popular with trainees and discussions are underway to explore how the Map can be used to support revalidation and re-accreditation of doctors in the UK. In the interim, many GP Trainers and Postgraduate Deans are using the

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Map to support continuing professional development, while both doctors and nurses are promoting its use for multidisciplinary team working at and around the point of care. Case studies on pathway re-design and commissioning: The future - getting evidence into practice everywhere - The Map team is passionate about making access to the high quality and validated information within the Map available to all clinicians and indeed, patients whenever and wherever they need. The Map can be loaded onto Windows Mobile compatible devices such as PDAs and related devices. In addition, work over the past two years with Cisco Systems means that the underlying technical platform links directly to all telecommunications platforms with final testing of the “Expert Network” software application due for completion within 2008 and pilots under way early in 2009. Accessing the Map Go to www.mapofmedicine.com to learn more about the Map. Please note that individual access is only available to doctors and nurses resident in England and Wales; proof of residence is required. If your organisation would like to request licensed access to the Map of Medicine, please email aneta.lasyk@mapofmedicine. com quoting “Map Asia”. For organisations within the WHO HINARI or SHIPD programmes, please email as above quoting “Map SHIPD programme”.


TELEMEDICINE

The armed forces have forever been the hub of innovation and also consistently been early adopters of innovative technology from various fields. Some of the finest doctors and surgeons serve in this honourable vocation. They are also one’s to face the most difficult and trying of situations, where they must explore all possible tools to function efficiently. The following article will give more insight into the same. “It’s not enough that we do our best; sometimes we have to do what is required.” Winston Churchill

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Lieutenant Colonel Salil Garg Cardiologist, Command Hospital, Pune

Squadron Leader Mudit Mathur DD Space Ops, DSCC, Bhopal

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ecent developments in computing and networking have enabled collaborative biomedical engineering research by geographically separated participants. One of the other most promising aspects of these technologies is to use them to extend the human intellectual capabilities for medical decision-making. Since these technologies can make the expert’s information available at any location, the emerging technologies are poised to drastically reduce healthcare cost and provide medicare service including diagnostic capabilities in remote locations. The medical services using the tools of information technology are now grouped under a new discipline called telemedicine. Telemedicine consists of various medical services where patients can be examined, monitored and treated, even while the patients and doctors are located in different places using Information Technology i.e. computer and telecommunication technology (Samaddar & Samaddar, 2003). Patient’s records can be sent via text, voice, images or even video and medical advice offered from a remote location on Internet or off-line

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as digital content. We have to realise that Doctors are becoming increasingly expensive and if telemedicine is used judiciously, it may help in rationalising medical care. This series of papers intends to review the status of this discipline and propose some novel applications of the recently developed interactive and distributed system in medical consultation and education. Our approach is built on the notion that interactive and distributive capabilities of the system open new dimensions in the area of medical education and patient’s consultative treatment. The presented applications use a multi-user, collaborative environment with multimodal human/machine communication in the dimensions of sight, sound, and touch. Need for telemedicine Telemedicine has various aspects including TeleConsultation, TeleDiagnosis, TeleEducation, TeleTraining, TeleMonitoring and TeleSupport and incorporates complete information about patients’ medical record (in the same hospital or any virtual hospital


TELEMEDICINE

online). Patients can also carry their basic medical records stored on their digital identity cards, for keeping communication reliability between medical practitioners. In case of emergencies, the patient transport may become very difficult due to adverse weather conditions or for poorly available materials or loss/failure of normal infrastructure; and at times the patient may be too critical to be transported. Many times a small population may be either isolated or spread over a huge stretch of area and be devoid of professional medical care and facility. Often health clinics may be either dysfunctional or may not have any facility for treating serious illnesses or injured patients. Remote area clinics do not have the requisite trained manpower or medical facilities for intensive care of serious patients. At times even if expert advice is available, there may not be people capable of carrying out even resuscitation - as in intubating a patient with a cardiorespiratory arrest. Another example where telemedicine may be of real use is on high seas, where big ships commanded by small crews cannot afford the luxury of a doctor. Such geographically isolated areas can be connected by network connectivity with reputed medical colleges and hospitals and telemedicine can play its role. Not only can this particular use of technology be helpful in management of disaster situations but it may also be helpful in predicting disease outbreaks, as a recent article in this journal brought to fore the efficacy in predicting cholera outbreaks. Telemedicine system is well suited for disaster management as it is even more reliable, than the physical system. Nitzkin et al. (1997) has discussed the reliability of telemedicine system and other related issues. Conventional examinations and telemedicinal examinations were conducted on a number of matched pairs of observations. The study shows that some experience is necessary for practicing telemedicine as the findings raise some doubts about the reliability of occasional consultations done by doctors inexperienced in the use of the technology. The study revealed that for ophthalmology, physical therapy and cardiac auscultation, 91.2

physician for the purpose of rendering a diagnosis and subsequent treatment plan. Remote patient monitoring uses special devices to remotely collect and send data to a monitoring station for interpretation. This could include checking vital signs, such as blood glucose or ECG. This is usually accomplished with speciality hardware devices and with integrated/fixed communications capabilities. percent of the conventional findings and 86.5 percent of the telemedicine findings were identical. The kappa coefficient* on a matched pair analysis was 0.66. For tracing and images both conventional and telemedicine findings showed 92 percent reliability with a kappa coefficient of 0.87. The reliability factors prove that telemedicine can be applied to, Tele-radiology, Tele-surgery, Tele-dermatology, Teleotolaryngology and Tele-pathology. The various types of data that can be transmitted are voice, clinical findings, video clippings, high resolution photographs, radiological images like plain X-rays, CT scan and Ultra sound etc. Malone et al (1998) objectively evaluated the effect of different bandwidths on the ability to interpret obstetric ultrasound scans transmitted live over a commercial telephone network. Usually telemedicine projects face difficulties in the form of low technology proficiency of health professionals in remote areas, language barrier, and lack of human resources, lack of proper infrastructure, low bandwidth or poor connectivity, and lack of familiarisation with telemedicine services. Telemedicine support facilities Telemedicine can enable / facilitate various other services also, such as: Continuing medical education for health professionals and special medication education seminars for individuals and groups in remote locations. Nursing call centres for referrals and patient services. Patient consultations: Audio, video, and data are shared between a patient and

Specialist referral services usually involve a specialist assisting a general practitioner in rendering a diagnosis. Video-conferencing enables the patient to see a specialist during a remote consultation accomplished in real-time, through transmission of images, such as x-rays, along with patient data for later viewing. This is especially important for patients living in rural areas, or for those who are too ill to travel great distances to visit a specialist or a clinic. Disease management is a relatively new telemedicine application. It refers to the on-going consultations between a patient and two or more multi-disciplinary practitioners whose intent is the treatment and management of long-term disease. This often involves interaction between medical, pharmaceutical and behavioral professionals on a single case. With the increasing aged population and subsequent increase in certain diseases such as type II diabetes, HIV, etc, the disease management arena is expanding. It may also be helpful in reducing visits to a specialists clinic where an online consultation may suffice and if the doctor is satisfied, the visit may delayed further thus reducing transit costs. Support services in campus facilities and remote offices. Healthcare is often rendered in a distributed office environment, and almost every process falls under privacy and other regulatory requirements. As such, nursing and support services are often the first to adopt secure telemedicine and communications-related technologies in order to reduce inter-office delays, improve the patient experience, and to reduce operational costs. February 2009

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Issues and heavy costs associated with the present telemedicine models in India In India the implementation of the concept of telemedicine involving hospitals has been halfhearted and has really not taken root. The causes are many; one of the main being the inability to take the ground realities about illiteracy and absence of compulsory social medical care into account (in a developing economy it is very common), though there has been a rapid development of communication technology. More importantly, how do we measure the impact of telemedicine on the health systems of developing countries? Will strengthening secondary care for a few disadvantage basic primary care or environmental health for the many? Will investment in the required rural telecommunications be at the expense of providing drinkable water? Will developing countries too be seduced by the expensive impact of technology led tertiary care for the few, while ignoring the endemic impact of modified health related behaviour? Will opportunistic global traders exploit the vulnerable? This brings us to the question once again -whether development will lead to better medical services or better medical services will help in accelerating development. The Classic- who came first? Egg or the hen conundrum! The basic unit in a medical care set up is a Primary Health Centre (PHC) for every 5,000 population They are supposed to provide a wide range of services such as health education, promotion of nutrition, basic sanitation, the provision of mother and child family welfare services, immunisation, disease control and appropriate treatment for illness and injury. Each PHC is a hub for 5-6 sub-centers and covers 3-4 Villages and is coordinated by a ANM (Auxiliary Mid Wife) PHCs also work as Referral Centers for Community Health Centers (CHC), which is a minimum 30 bedded-hospital or higher at the Taluk or District Levels. Model projects were launched at various PHC`s and implemented on small scale. Their impact and usefulness to the large rural audiences is fairly limited and does not even constitute 0.0001 % beneficiaries in India.

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is not ready with very costly and heavy overheads involved present models of telemedicine. The pace of technology development has fast outpaced the development of nodal centers resulting in a situation where technology that may have been approved may have become dated by the time of implementation.

Generally the motive behind launching these kinds of model projects is to serve the particular specific requirements of an NGO or demonstration of technology and they usually end up as means for garnering some limelight. Many of them were started with fanfare and unveiled plans to interlink thousands of PHCs in the country and now they are barely running the single outfit they had originally commissioned. As it is with any technology project, it is very easy to set up by installing a set of machines and links, but it needs real motivation to sustain them on a continuous basis. Except for one or two projects the rest of them aimed at connecting one city based hospital with a metropolitan hospital. The rural focus remained limited to couple of model projects. Government which must be encouraging viable models to remove the lacunas in the primary care access and coverage problems, has not been able to do much and is following the regular route of construction of new PHCs and supplying sophisticated equipment. They are oblivious to the fact that all these infrastructure developments cannot motivate the doctors and Reproductive Health Specialists to the villages. Where as dialup models are not effective, the costs and maintenance of VSAT based network is prohibitively expensive and requires skills to set up and maintain. This hinders the opportunities for business and governments to mass replicate the model projects. The end result being that rural India

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Practicing telemedicine consultant: A perspective In the past few years we have seen the efforts of various technological groups to incorporate telemedicine in their integrated plans for providing better health care .Notable among these have been the military, corporate hospitals and large apex institutions such as AIIMS. However, they have somehow not managed to meet their objectives as they got lost either in beauracratese or the technology involved got outdated with every new version of computers. We are dealing with a set of people who may not be very technology savvy. For example, the remote areas from where the doctors or the paramedical staff may want help may not have computers, electricity or Internet connections. On the other hand the Doctors from whom this help maybe sought may so highly specialised in their fields that they may actually be incapable of using the interfaces on their own and may require help in dealing with technological gizmos, which in the minds of others may be of a very basic variety. Maybe, this also led to a concept of having dedicated connections and dedicated nodes, which had huge logistics requirement and were expensive and therefore could not really take off. Meanwhile, technology grew by leaps and bounds and with the easy availability of the Internet and mobile telephony telemedicine hubs may soon become an anachronism. The need therefore maybe to be able develop systems that can be connected through mobile telephony, or the ubiquitous internet and which can made cheaply available at the cost of an SMS or an MMS, use less bandwidth and maybe accessed by a busy clinician by just plugging it into an adequate port connected to a laptop, a TV screen or a


TELEMEDICINE

personal computer. This will not only adequately take away the financial burden but also make it more accessible and user friendly. The more important requirement would be finding the appropriate doctors to be available at the required time and this system of human resources will have to be adequately developed and put in place. In future, even distant surgery with the help of robots may become possible as a routine practice. A recent example is a news item cited in the Times of India dated Dec 08, 2008 on page 15(Pune edition), where a doctor who was not trained in surgery manage to amputate the shoulder of a teenaged boy in Congo, while operating on the basis of SMSes that he received from a colleague in faraway London. This subsequently saved the boy’s life. An example may be drawn in the management of two major diseases that contribute largely to the mortality and morbidity and where timely institution of therapy and involvement of physicians may save lives and reduce physical disabilities. These are Acute Myocardial infarction and Stroke management. The onus in management of acute myocardial infarction is shifting from drug induced fibrinolysis of the clot with the use of `clot busters’ to a more invasive strategy involving Primary angioplasty where the operators take the patient up immediately for breaking up the clot mechanically. However, time and logistics are the problem, as cardiac catheterization laboratories are expensive and can only be started in high catchment areas. Therefore, the patient who is suffering from a heart attack may have to be transported for this treatment. This may take time and therefore it maybe more prudent if the patient is thrombolysed either enroute to the hospital by paramedics, a concept referred to as `Pre-hospital Thrombolysis’, in which the ambulance should have the ability to transmit ECGs of the patient to an attending doctor who can then take a decision on the management protocol to be followed. Similarly, in an ischemic stroke it is advisable that

the patient is thrombolysed early. However, that decision is hard to take even by Internal medicine specialists and the interpretation of the CT Scan by a trained neurologist maybe imperative. This again is an expensive proposition but quite in the realm of telemedicine where timely action may result in preventing lifelong crippling disabilities in an individual. Conclusion Telemedicine is not the magic pill that will cure our ailing health care system, but it is a potentially miraculous method that promises improvements to our delivery systems, bettering quality, access and eventually even costs. Telemedicine will not thrive on a one-shot approach; it requires a regimen of treatments. Its future solution to our health care system’s problems of access, quality and costs is best insured by a collaboration of efforts—by the center, state and private sectors and by the bureaucrat, physician and technician. Regardless of telemedicine’s potential, significant regulatory and policy barriers threaten to disrupt the development of distance medicine. These barriers include reimbursement limitations and uncertain funding, cumbersome credentialing requirements, legal liability uncertainties and malpractice exposure, unclear data on cost-effectiveness, and a lack of uniform national practice standards and telemedicine standards. Additionally, telemedicine has neither practice guidelines nor measurement criteria, and scant information exists regarding clinical efficacy. There is even debate in the medical community regarding telemedicine’s direction and infrastructure. As a result, telemedicine is being legislated, regulated, studied, reported, journalised, conferenced, advanced, propounded, debated, bibliographed, and webbed. Telemedicine is being researched and piloted, both on small scale and large commercial endeavors. It is the subject of multi-government laws and laws in waiting. However great telemedicine’s promise, its full potential to address issues of quality, access

and costs are imperiled by the lack of a strategic plan. Telemedicine can open a world of health-care delivery by building clinical bridges between patients and available health care, albeit contingent upon the costs and development of ancillary infrastructure and services. The telemedicine experiences in this study transcend India. Such experiences could have far-reaching benefits for poorer communities in developed countries as well as for developing countries. This collaborative effort should have one driving force and end: acting in the best interest of the patient. By moving toward this goal, all players can compete and even without a strategic plan, guarantee improvements and better access and treatments to patients. These are real issues, but they should be debated on the grounds of local values of appropriateness and priorities. The pull of needs, not the push of supply, should be the determinant. The voices of local experts, rather than external commentators, should be heard as the lead voices. Initiatives to identify culturally and locally relevant yet sound sites should be encouraged and open debate initiated on the core issues. If telemedicine is to have any significant and safe impact in developing or other countries, global agencies such as the World Health Organisation need to encourage and accumulate studies on its local impact, while also seeking a global framework to ensure its safety and ethics.Opportunities for benefit from telemedicine are great; so are the opportunities for harm. The future debate should rest on issues of local health priorities and impact, and on global ethics to ensure sustainable assured solutions. “This work provides the overview of the field of Telemedicine practices done by various experts and institutes. Author(s) takes no claim in either designing the models or its concepts, however, direct integration of isolated works in the field of Telemedicine practices has been done in this article. Suitable cross-references are marked. ” References are available on the website: www. ehealthonline.org

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NEWS REVIEW >> WORLD

Greek scientists develop heart attack calculator

New data tools on how infectious diseases spread

Researchers have developed a quick and easy artificial intelligence approach to successfully calculate a patient’s heart attack risk with respect to many lifestyle factors. Named online analytical processing (OLAP), the approach makes it possible

The European Science Foundation (ESF) has called for development of new mathematical and statistical tools capable of probing deeper into existing databases relating to human contact and pathogens. The lack of tools was highlighted in a recent ESF workshop on infectious disease transmission. “One of the most exciting conclusions we came to was the realization that vast amounts of information were already available in various data banks,” said Mirjam Kretzschmar, convenor of the ESF workshop, from the Medical Centre at Utrecht University in the Netherlands. Particular pathogens such as the influenza virus as identified by their genotype can have different transmission patterns. Therefore correlating details of the unfolding contact networks

for physicians to just use their system to provide patients with a personal risk factor and so advise on lifestyle changes or medication to lower their risk. It is well known that lifestyle factors including depression, education, smoking, diet, and obesity, play a part in the risk of cardiovascular disease. But, epidemiologists who study how health risks vary through populations have not found a way to extrapolate from such broad studies to individual risk levels. Now, Hara Kostakis of the TEI Piraeus Research Centre, in Methonis, Greece, and colleagues have investigated patterns of cardiovascular risk factors in a large population by collecting data for almost 1000 patients enrolled in the CARDIO 2000 study who had been hospitalised with the first symptoms of acute coronary syndrome (ACS). Instead of using conventional methods for analysing statistics, the researchers borrowed an approach from the computer science field of artificial intelligence, OLAP, which was developed in the early 1990s and was exploited primarily in industrial and commercial applications, for financial and marketing analysis.

between sufferers, as a disease spreads, with the possibly evolving genotype of the pathogen involved can yield valuable insights into the molecular factors relating to transmission. These factors can also be analysed, leading to appropriate strategies to combat a disease, such as development of a vaccine or public health recommendations, for example that certain high individuals stay at home where possible. For more information on the European Science Foundation see: www.esf.org

Global resource for free ehealth education Health Sciences Online (www.hso.info) has launched a website where anyone can access more than 50,000 courses, references, guidelines, and other expert-reviewed, high-quality, current, costfree, and ad-free health sciences resources. The up-to-date, authoritative information is aimed primarily at healthcare practitioners and public health providers, enabling their training, continuing education, and delivery of effective treatments to patients. The information is delivered by powerful search technology from Vivisimo, Inc., which allows users to easily see comprehensive search results and quickly find the answers they need with an intuitively navigated graphic interface. Through integration with Google

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Translator, users can search and read materials in 22 languages. HSO is a portal that includes more than 50,000 world-class healthsciences resources, selected by knowledgeable staff from alreadyexisting, reliable, professional sources and resource collections. Founding collaborators for this site include CDC, World Bank, the American College of Preventive Medicine, and the University of British Columbia, and financial support has come from WHO, the NATO Science for Peace Program, the Canadian government, the Annenberg Physician Training Program, and many volunteers. HSO’s next phase will be developing programs using the gathered materials to help train and educate public and clinical health providers around the world.


NEWS REVIEW >> WORLD

Ambulance service- a case study for Harvard Business School

Mobiles to monitor HIV and malaria patients’ conditions

Four years ago, five friends in Mumbai decided to do something to save lives. Today, their ambulance service, 1298, is likely to be taught as a case study in social entrepreneurship Harvard Business School. A team of post-grad students from the Harvard Kennedy School-widely considered as one of the best schools for leadership studies-visited the 1298 office at Bandra Kurla Complex. This was the second batch of students that visited Mumbai for the purpose. One of the founders, Sweta Mangal, explained that as they had no marketing budget in the beginning, they used innovative branding devices like painting the fleet yellow to make their ambulances stand out on the crowded Mumbai street. They networked with hospitals (which receive the maximum calls for an ambulance) and conducted radio campaigns to spread the word. When they learnt that in the West the concept of ambulances was drilled in from a young age, we started firstaid training across schools and colleges.

In future, cell phones could be used to monitor the health of HIV and malaria patients. Scientists at the University of California, Los Angeles (UCLA) have created a cell phone that can monitor the condition of HIV and malaria patients and test water quality at disaster sites and undeveloped areas. UCLA electrical engineering professor Aydogan Ozcan has constructed the new innovative imaging technology, which has been miniaturised by researchers in the lab to the point that it can fit in standard cell phones. The imaging platform, known as LUCAS (Lensless Ultra-wide-field Cell monitoring Array platform based on Shadow imaging), has now been successfully installed in both a cell phone and a webcam. Data collected by LUCAS can then be sent to a hospital for analysis and diagnosis using the cell phone, or transferred via USB to a computer for transmission to a hospital. LUCAS is not a substitute for a microscope but rather a complement. Unlike microscopes, which produces detailed images, images produced by LUCAS are grainy and pixelated. “This technology will not only have great impact in healthcare applications, it also has the potential to replace cytometers in research labs at a fraction of the cost. A conventional flow-cytometer identifies cells serially, one at a time, whereas tabletop versions of LUCAS can identify thousands of cells in a second, all in parallel, with the same accuracy,� said Ozcan.

Research to improve early diagnosis of breast cancer

Pan-European 112 emergency number a reality

HAMAM - European Highly Accurate Breast Cancer Diagnosis through Integration of Biological Knowledge, Novel Imaging Modalities, and Modelling - consists of 9 project partners from 7 countries with leading expertise in the field of breast imaging diagnosis, with EIBIR as the coordinating partner. The 3-year project started in September 2008 and is supported by the European Commission with a financial contribution of EUR 3.6 m. The exact diagnosis of suspicious breast tissue is ambiguous in many cases. HAMAM will resolve this using statistical knowledge extracted from the large case database. The clinical workstation will suggest additional image modalities that may be captured to optimally resolve these uncertainties. This ultimately leads to a more specific and sensitive individual diagnosis. HAMAM goes beyond currently available technology by developing a prototypical solution that will be able to efficiently integrate all relevant clinical and imaging information within a single platform. The overall strategy of the project is to foster the exchange and collaboration between basic scientists, clinicians, and IT experts, and to condense all information and knowledge in a common database and prototypical platform for multi-modal breast diagnosis.

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Citizens across all European Union countries can now access emergency services by dialling 112, the single European emergency number, now that 112 can be called from any phone in Bulgaria (the last country in EU to provide this service). It achieved complete availability just before the Christmas period when thousands of people travel between EU countries. In September 2008, the Commission referred the case to the European Court of Justice, but delayed by three months to allow Bulgaria to finalise its implementation plan. The Commission says it has since verified that, that 112, together with caller location - which allows emergency services to locate people when they dial the number - is now fully available in Bulgaria. The European emergency number 112 was introduced in 1991 to complement national emergency numbers and make emergency services more accessible in all EU Member States. Since 1998, EU rules require Member States to ensure that all fixed and mobile phone users can call 112 free of charge.


NEWS REVIEW >> WORLD

American Journal of Medicine launches blog The American Journal of Medicine (AJM), a leading medical journal for more than 50 years has launched a blog to create a dynamic

forum where physicians and other healthcare professionals can discuss the research and applications for clinical practice that have been published in the Journal. They plan to call it a Blog AJM. The editorial and administrative arms of the Journal and publisher Elsevier feel that the time is right to take greater advantage of the interactivity and social networking opportunities offered by the web. They welcome opinion, relevant statistics, quotations from other sources, rational and thoughtful commentary and academic debate. Their expectation is that the Journal’s blog will spark informative - perhaps even spirited - discussions, similar to those found on other media blogs. Primary content for the blog is taken from the pages of the Journal including most editorials, commentaries and lead research articles.

European drugs to carry barcodes

Philips leads European SonoDrugs project

Medicines sold across Europe will have to carry barcodes and other improved security mechanisms, under proposals unveiled by the European Commission to crack down on counterfeit drugs. The Commission says it aims to use technology to enable “total traceability” of all medicines bought in pharmacies or online. Even with the new measures, some repackaging will continue to allow the parallel trade in pharmaceutical products to continue. Under the new proposals, products will have to employ mandatory safety measures such as seals and barcodes that only certified manufacturers will be able to use. The move was announced as part of a package of measures that would also allow drug manufacturers to promote information about their prescription-only products directly to EU citizens – direct to consumer (DTC) - for the first time. As part of the package of measures the Commission says it wants to give patients access to centralised EU information on the side effects of drugs. Moreover, to ensure clarity of information, the EU executive calls for advertising of prescription medicines to be scrapped. It also wants to introduce stricter rules regarding the content of pharmaceutical adverts, including those on the internet, in the form of an EU code of conduct.

Royal Philips Electronics recently announced that it is leading a new European project to develop drug delivery technologies that could significantly impact the treatment of cancer and cardiovascular disease. The project, which involves a total of fifteen industrial partners, university medical centers and academic institutions from across the European Union (EU), will run for four years and has a budget of EUR 15.9 million, EUR 10.9 million of which is being funded under the EU’s 7th Framework program.

Cardiovascular disease and cancer are currently the two biggest killers in the world. Although powerful drugs are available to treat certain types of cancer and cardiovascular disease they are mostly administered as intravenous or oral doses. This allows only very limited control over the distribution of drugs in the body, which can circulate in the patient’s bloodstream and interact with many different tissues and organs, both diseased and healthy. The SonoDrugs project aims to address this challenge by developing drug delivery vehicles that can be tracked by ultrasound or magnetic resonance imaging (MRI) and triggered by ultrasound to release the drugs at the desired location. It is hoped that such control of the drug delivery process will increase therapeutic efficiency and minimise side effects, while also providing a means of tailoring the therapy to individual patients. February 2009

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TECHNOLOGY TRENDS

mHealth

mobi e connectivity for healthcare Humanitarian calls such as ‘healthcare for all’ require care to be available over a much larger area than covered presently, and also allow greater mobility – these are challenges easily tackled by the already available mobile telephony. The medical community is limited by only their imagination.

A

fter taking the telecom sector by storm mobile phones are set to change the way healthcare is delivered. Be it sending an SMS to track down the closest healthcare facility, or an attempt to track truant government doctors who neglect their official duties by practising privately on the side, or even a more evolved form of a cell phone that can monitor the condition of HIV and malaria patients and test water quality at disaster sites and undeveloped areas. The virtual encyclopedia ‘Wikipedia’ defines mHealth as “a term for medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, PDAs, and other wireless devices. mHealth applications include the use of mobile devices in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vital signs, and direct provision of care (via mobile telemedicine).” Lets explore some innovative ways how the mobility of cellular phones are been capitalised upon in the field of medicine today.

Mobile phones to track doctors In a recent news the Bihar State Health Minister Nand Kishore Yadav announced that the state government has decided to give free mobile phone services to its doctors in an attempt to reduce truancy. Many government doctors neglect their official duties by practising privately on

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the side. The main purpose of the move is to be able to get in touch with the doctors at any time. Their movements will also be tracked by a system. The doctors have been given instructions to keep their mobile phones switched on permanently, even if not on duty. It is hoped that this will help to improve the functioning of the government hospitals in the state. The Indian state mobile provider, BSNL has already provided about 800 connections. According to the plan, doctors will have unlimited talk time among themselves but there will be a bar on making outside calls. This will also let them know where the doctor is serving - at his place of posting or doing private practice. In which case stern action will be taken.

SMS for the nearest healthcare facility A government project named ‘Dr SMS’ in the southern Indian state Kerala’s Kozhikode district, has implemented a system allowing citizens to obtain information about the nearest healthcare facility anytime of the day by sending an SMS. The individual seeking medical attention anywhere in the district has to SMS a prescribed format including his pin code to 9446460600, the same number which returns information on government files in the district collectorate. The system extracts information from a database prepared by the government machinery under the district medical centre. Within seconds, a message containing the nearest hospital’s whereabouts will be sent back to the user.


TECHNOLOGY TRENDS

Mobile penetration is very high in the developing world, and the technology available today is most accessible and not complicated at all.

Mobile penetration is very high in the developing world, and the technology available today is most accessible and not complicated at all. Even those who are not proficient in English can send a simple SMS in English. “Since reality shows are able to exploit SMS in a big way, we decided to explore it for life-saving purposes,” said Kozhikode district collector A Jayathilak, at the inauguration of the project, which will be gradually extended to the entire state. The system also gives pointers to blood banks, diagnostic centres, private hospitals, speciality centres, facilities for surgery and ventilators and the list of specialist doctors in the district.

Mobiles to monitor patients’ conditions Scientists at the University of California, Los Angeles (UCLA) have created a cell phone that can monitor the condition of HIV and malaria patients and test water quality at disaster sites and undeveloped areas. UCLA electrical engineering professor Aydogan Ozcan has constructed the new innovative imaging technology, which has been miniaturised by researchers in his lab to the point that it can fit in standard cell phones. The imaging platform, known as LUCAS (Lensless Ultra-wide-field Cell monitoring Array platform based on Shadow imaging), has now been successfully installed in both a cell phone and a webcam. Both devices acquire an image in the same way as using a short wavelength blue light to illuminate a blood, saliva or other fluid sample. LUCAS captures an image of the microparticles in the solution using a sensor array. As red blood cells and other microparticles have a distinct diffraction pattern, or shadow image, it becomes easier to identify and count them almost instantaneously by LUCAS using a custom-developed “decision algorithm” that compares the captured shadow images to a library of training images. Data collected by LUCAS can then be sent to a hospital for analysis and diagnosis using the cell phone, or transferred via USB to a computer for transmission to a hospital. This technology will not only have great impact in health-

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care applications, it also has the potential to replace cytometers in research labs at a fraction of the cost. A conventional flow-cytometer identifies cells serially, one at a time, whereas tabletop versions of LUCAS can identify thousands of cells in a second, all in parallel, with the same accuracy. In the current study, Ozcan described an improvement in the LUCAS system - this improvement allows for identification of smaller particles such as E. coli that were not previously possible.

‘Doctor on Call’ on your mobile For the first time in India, a mobile phone doctor-to-patient service called ‘Doctor on Call’ was launched. The 9 to 9 service that provides live interaction was pioneered by BPL Mobile, Mumbai’s leading mobile service. BPL Mobile has launched this Value Added Service to provide a virtual channel that will give subscribers instant access to quality medical assistance. The service will provide a first time telephonic consultation, where the doctors will diagnose the patient’s problems under three categories depending on the condition of the patient, ‘Acute’, ‘Chronic’ and ‘Emergency’. While the Doctor who attends the call will try to understand the present condition of the patient on the phone, and will offer some palliative home remedy to the subscriber under the type: ‘Acute condition’, the attending doctor will suggest a future course of action in terms of lifestyle change, preventive measures and specialist to be consulted for further management of the chronic condition. In the case of an Emergency, the doctor will suggest if the patient needs to be rushed to the nearest hospital. The service will cost the users an amount they would otherwise spend on travel and so on. Using this would not require them to take time off from work or schedule an appointment. More so, the aged or the frail would not need to worry about their mobility. This service is in fact being provided with assistance from HealthcareMagic.com, a Bangalore-based company providing healthcare consultation over the Internet. This is also another example of how the Internet is itself becoming more accessible through mobile phones and Blackberries!


PERSPECTIVE

Going Places Sumedha Sen, CEO of EPOS Health Management, gives us an insight into the scope of the growing medical tourism industry in India.

“Travelers who are looking abroad for treatment do know the risk elements involved in going abroad.”

Q. What has been the real term growth of international medical tourism industry in India over last 3 years? How much has been achieved on ground as compared to industry projections about this market segment? A. MedicalValue Travel is growing in India at15% p.a. The initial projections in the CII-McKinsey report were of USD 2.2 billion. While we are far from anywhere near there, it gave the directions to Indian Hospitals of chasing this market. However, it should also be noted that the Health Industry cannot service this market alone- communication facilities; the immigration policies; civic amenities and now the “unstable situation for tourists” directly affect this market entering our country. Q. What was the approximate number of international patients who came to India in 2008? What is the geographical spread of these patients and what is the estimated revenue that would have been generated? A. We do not have any confirmed reports on numbers and revenue however, estimates hover between

1,80,000 - 2,20,000 arrivals to India primarily from SAARC, Middle East and Africa. Patients also come from the CIS and South Pacific Region. There is a growing trend emerging from the US and Canada besides the UK. Revenue generation is also approximated at USD 450 million. The persons coming to India to avail of the Herbal and Spa facilities should not be accounted for in this estimate. Q. Which medical procedures are most commonly availed by international patients coming to Indian hospitals? Is there any pattern and/or linkage between the geographical origin of patients and the medical services that they avail? A. Countries with little or no convincing Health Infrastructure avail the services of all hi-end tertiary care services of Indian hospitals- Cardiac, Renal, Neuro Sciences, BMT, Stem Cell, Liver transplants, etc. From the developed world it is more for Cosmetics, Dental followed by Orthopaedics, Gastric Bypass, over and above the above menFebruary 2009

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PERSPECTIVE

tioned specialties. It would be a matter of interest to know that people who come out of their country to avail of hi end Health Care services choose India. Such persons are not tourists and more often than not, they do not combine Healthcare with tourism. Q. Lack of international coverage by insurers in the West is often attributed as a bottleneck in the growth of global medical tourism. However, rising healthcare cost is making it increasingly economical for insurers to cover expenses in cheaper overseas destination. How do you see developments happening at this front in western markets? A. Quite so... Already the top International Insurance companies are working with Indian Hospitals for their expat and travel Insurance members. This was the first step of recognising Indian Hospitals. Earlier the same were sent to Singapore, Thailand. It has been observed this year that many International Insurance Companies are seriously mulling at the options of offering their members the options of traveling abroad for treatment to destinations like India which offer high quality treatment at affordable costs. This is going to gain momentum in the coming years. Q. How do medico-legal issues and regulatory constraints pose challenge for patients seeking treatment in foreign shores? Are there substantial steps and measures taken by international healthcare associations and governments to make things easier? A. All countries which offers medical treatment to health travelers puts it upfront that the law of the land will prevail. Health travelers who are looking abroad for treatment do know the risk elements involved in going abroad. This is where the associations from the government for ‘treatment visa’ communication and carrier organisations for cheaper transportation fares should be introduced for follow up visits. We also feel that the medical fraternity from these countries should play a part of follow up treatment in terms of post op clinical care. Many doctors from Africa and SAARC countries have begun taking training in these specialties and attending CME’s to keep themselves

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abreast of the technological advances made in this area. The patient’s should be recommended by their physicians for hi-end treatment and the treating hospital should refer back the patient to the respective physician for after care. Another factor is selecting the right kind of provider for a particular procedure. Price war should not effect making the correct choice. However, risk factor exists in every medical practice and cannot be discounted. Q. What special services and privileges can Indian healthcare providers offer for attracting more international patients in the country? A. Reputed hospitals have created special departments to handle International Patients. The services offered are:

 Airport transfer service  Scheduling of all medical appointments  Coordination of the admission process  Cost estimates for anticipated treatment  Processing of medical second opinions  Booking of hotel/service apartments  Flight arrangements & extensions / Visa assistance  Provide language interpreters  Special dietary needs / religious arrangements  Local sightseeing  Foreign exchange  Remote consultations via Telemedicine

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 Providing news & information of patient’s relatives back home. Price transparency is another element which needs to be provided as this is observed as the single most worrying factor when patients travel abroad for treatment. Building of Indian healthcare brands in key international markets will be an important factor in attracting patients from abroad. Q. How does EPOS Health India plan to contribute in the growth of Indian healthcare industry? What expertise and skills does EPOS brings to table for stakeholders? A. EPOS is a leading multi dimensional resource organisation for health care service providers and has over the last two decades extended its expertise and know-how to clients in nearly 75 countries and has successfully completed over 280 assignments. EPOS aims at contributing to the growth of the health care industry through providing national and international expertise in areas related to hospital design and planning, hospital systems strengthening, quality management systems and accreditation, professional management support for hospitals, industry-partnered cutting-edge skills development programmes, designing and facilitating public private partnerships, turnkey management of health tourism services.


NEWS REVIEW >> BUSINESS

Idhasoft to improve University of Pennsylvania’s tracking software University of Pennsylvania Health System Department of pharmacy selected Idhasoft mobility division to achieve data accuracy through Customised Integrated Tracking System software solution. The department of pharmacy dispenses approximately 2000 – 3000 doses of medication daily. As each medication is prepared for dispensing, a label is affixed to the item to identify the patient, the drug, and the unique order number, which identifies the drug order for a specific patient. At set times throughout the day technicians pick up items to be delivered for “route” and deliver them. The pharmacy needed the ability to track the medication, location, time/date stamp, and the technician picking up and delivering items within the hospital. The hospital had a wireless network running in approximately 70 percent of the hospital. The system’s main goal was to track the delivery of pharmacy items from the pharmacy out to the secure nursing dispensing stations and provide the pharmacy with accurate data to maintain their compliance to the hospital’s policy. Idhasoft Mobility Division created a custom software solution that interfaced with the University of Pennsylvania’s legacy SQL database.

Apollo Hospitals, Well Point sign agreement Apollo Hospitals recently announced that it has entered into an agreement with US-based Anthem Well Point through its subsidiaries for treating patients recommended by the insurance company. “As per the agreement, Anthem Well Point will initially send the employees of Serigraph Inc, a corporate client of Anthem Well Point, to Apollo Hospitals in India,” the hospital chain said in a statement. Anthem Well Point will send the patients to Apollo Hospitals in Bangalore and Delhi, and later it will send to all JCI accredited hospitals of the chain, it added. Anthem Blue Cross and Blue Shield are the subsidiaries of Anthem Well Point. Apollo will cover 700 members of the US-based group and their dependents. The Apollo group comprises a network of 43 hospitals in India and overseas with a total capacity of 9,000 beds.

CMPMedica, iSOFT sign contract for drug info decisionsupport tools CMPMedica, a division of United Business Media Limited, and healthcare IT sysytems supplier iSOFT, have signed a worldwide agreement to supply iSOFT with comprehensive evidence-based drug information. CMPMedica’s information solution will power iSOFT’s suite of decision-support tools. These tools enable healthcare professionals to make better-informed decisions at the point of care and thus improve patient outcomes. CMPMedica has provided iSOFT with drug information systems since the 1960s and the two companies have worked together to develop their respective businesses in Australia and Asia. Both companies are looking to expand their relationship into new territories around the world as demand for evidence-based decision support tools continues to grow.

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NEWS REVIEW >> BUSINESS

GE Healthcare to acquire Indian medical cos GE Healthcare is planning to acquire and provide seed capital to Indian medical device and diagnostic companies. The USD 17 billion healthcare company is looking at acquiring companies which either possess low cost solutions or have unique technology. GE would target diagnostic equipment manufacturers in the local market that can complement its product portfolio and help expanding its rural network. The healthcare giant also plans to provide seed capital to Indian medical companies and pick up a majority stake in them. It expects a major chunk of its growth to come from the expansion of its imaging and infant care products range in the tier II and III cities. The company expects its sales to increase to 50% of its total revenue by 2010 by expanding in to the rural areas. Keeping with its strategy of viewing India as a low-cost solution market, GE launched its first fully digital X-Ray system, Tejas DR-F, in India. The X-Ray system, expected to cost 40% lesser than imported digital machines, would be manufactured in India, and exported to Southeast Asia, Latin America, Russia, East-

Vodafone invests in mobile health firm Newbury, Berkshire-based, mobile phone giant Vodafone has invested in t+ Medical, a UK provider of mobile health services acccessed across mobile handsets. Vodafone Ventures Ltd, the corporate venture capital arm of Vodafone Group, has made an undisclosed investment in t+ Medical, which specialises in the use of mobile phone-based transfer of patient biometric data as part of mobile healthcare services. Spun-out of Oxford University in 2002, t+ Medical is currently involved in two of the Department of Health’s Whole System Demonstrators - large scale projects to test the benefits of telehealth services. The company is involved in the pilots in Newham and Cornwall. The company specialises in the transfer of patient data using standard mobile phones, into which a patient either enters data or to which vital signs data is automatically relayed – using technology such as bluetooth - from a range of personal monitoring devices. The company has invested in its own dedicated medical call centre. t+ Medical also offers a range of chronic disease management programmes – for areas including diabetes, COPD, cancer, cystic fibrosis and hypertension - customers to date had mainly been PCTs interested in “admissions management and reduction”. The company said that providing services to 2m patients could potentially save the NHS one billion pounds a year.

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ern Europe and Africa. GE Healthcare also plans to deploy its medical imaging and diagnostics, patient monitoring systems, and biopharmaceutical manufacturing technologies in various states, under a private public partnership (PPP) model.

Loans to hospitals no longer commercial real exposure Loans extended by banks to hotels and hospitals may no longer be treated as commercial real exposure. The Reserve Bank of India (RBI) recently revised norms on real estate exposure where it included loans extended against security of future rent receivables from commercial real estate exposure. The revised norms will not immediately impact banks’ balance sheet. This is because standard provisioning for real estate companies were brought on a par with all other industries on November 15, 2008.

As a part of the stimulus package, the general provisioning requirement on standard advances for commercial real estate sector has come down from 2% to 0.04%. However, under reducing the standard provisioning for commercial real estate, RBI had said that they were counter cyclical prudential measures. This means that as and when the economic cycle changes, RBI may increase provisioning norms on commercial real estate sector.


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EXPERT CORNER

Molecular Imaging

modern-day diagnostic miracle Molecular imaging enables the visualisation of the cellular function and the follow-up of the molecular process in human body without perturbing it. Thus it was quickly adopted by the medical fraternity, given the clarity and non-invasive method. This technique helps improve the treatment of diseases such as cancer, and neurological and cardiovascular diseases by optimising the pre-clinical and clinical tests of new medication. They are also expected to have a major economic impact due to earlier and more precise diagnosis.

W

hen a hospital plans to buy a multi-crore, hi-tech equipment, the initial few months of planning are typically spent over the question, “What return on investment (ROI) can we expect?“ Most imaging equipment have gone through this phase and have matured in terms of both utility and viability. Molecular Imaging, the latest technology wave in diagnostic imaging is not an exception.

Dr. Sameer Sonar, MB, DRM, RSO, MPhil. Fellow, Harvard Medical School, USA Nuclear Oncology Consultant Chief - Molecular Imaging Centre Ruby Hall Clinic, Pune

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But for a diagnostic consultant like me return on investment is measured differently. How many times is a life saved due to timely diagnosis? How many times was the quality of life after the treatment dramatically improved with accurate predictions and visualisation of the disease? Answers to these questions are the basis for real ROI. Let us have a look at this clinical case. Figure 1 shows a fusion image of 18FDG uptake in malignant cells and fusion of the image with a CT scan, which helps

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in accurate understanding of the location of cancer cells in lymph nodes (A), bones and other soft tissues (B). Treatment for cancer is traumatic as the disease grows and inaccurate or partial diagnosis often leads to more trauma. Molecular Imaging can be very useful not only in oncology but in many more clinical areas. Diagnostic Imaging - how far we have come? Diagnostic imaging has come a long way. The aim of diagnostic imaging has been to visualise pathology noninvasively. Ever since the invention of X-rays, clinicians started directly visualising the anatomy of the body. More sophistications in the technology led to accurate visualisation of structural part. CT provided thinner slices at a faster rate of scan. Faster processing and better software for Doppler machines made real time 3D a reality!


EXPERT CORNER

Figure: 1A

The end result is that, we now can see the face of a fetus in the mother’s womb non-invasively; one can diagnose minor calcification in the coronary arteries that supply blood to the heart without any invasive procedure; we can have a sub millimeter level measurement of body detecting hairline fracture, or even a small stone in bladder etc. Functional imaging of cellular processes started with MRI and MR spectroscopy and have now reached up to Nuclear Medicine and fusion imaging. Current Reality is measurement of the disease processes primarily using nuclear medicine, PET & SPECT fusion with CT. 131 Iodine, MIBG, HIDA, Octreotide are some of the conventional Molecular Imaging agents. In the present scenario functional imaging talks about 18FFDG for Malignant pathology imaging, Tissue Hypoxia imaging, Dopaminergic activity (Alzeimer’s disease), Caudate / putamen degeneration (Parkinson’s disease).

Figure: 1B

Figure 1a & 1b: This patient who was clinically known as having stage I malignancy, that is beginning of the Cancer, underwent whole body PET CT scan, which showed extensive spread of disease - Stag IV.Generally stage I disease may need surgery as primary line management for local disease along with Chemo added to it for Stage I, on the other hand Stage IV disease would need Aggressive chemotherapy for long period.

Understanding Molecular Imaging Molecular Imaging: What is it? The Society of Nuclear Medicine defined the term molecular imaging as ‘‘The visualisation, characterisation, and measurement of biological processes at the molecular and cellular levels in humans and other living systems’’ When one talks about biological processes at cellular and molecular level,

all the three major streams of sciences, namely, molecular Physics, Molecular Biology and Molecular Chemistry have to join hands to translate these processes into visible image. Figure 2 The differential metabolism in cancer cells permits intense Radioactive Glucose (18F-FDG) concentration in these cells and takes the first step of the current Molecular Imaging (PET scan). Figure: 3

Figure 2

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EXPERT CORNER

these images to clinicians and integration with electronic medical records. We have “time-of-flight” PET CT scanner from Philips with Advanced Imaging solution for archival and tele-radiology from 21st Century Health Management Solutions at Molecular Imaging Centre, Ruby Hall Clinic.

Figure 3: Uptake of D-Glucose and FDG in Normal cell & Neoplastic cell

MI: Is there a better future? Molecular imaging is a key component of 21st century cancer management. The global efforts are on for quantitative imaging of tumor that can lead to a more robust and effective monitoring of personalised molecular cancer therapy. The American College of Radiology has recently set practice guidelines for [90Y] Zevalin and [131I] Bexxar, which are approved by the FDA for radioimmunotherapy of non-Hodgkin’s lymphoma. Both antibodies are directed against the CD20 antigen, which is found on the surface of normal and malignant B lymphocytes. Targeted Imaging for Breast cancer will be available in India in the near future. Trastuzumab (A recombinant antibody against HER2) for HER2 Imaging study is available with Ab fragment to match the Ga-68, which is a Positron Imaging agent.

Molecular Imaging - Hospitals and Healthcare providers’ role Multidisciplinary approaches and cooperative efforts from many individuals, institutions, industries, and organisations are needed to quickly translate multimodality molecular imaging into multiple facets of cancer management. Not limited to cancer, these novel technologies can also have broad applications for many other diseases. Molecular Imaging and Information Technology High end imaging modalities need better image management and archival systems. The diagnostic outcome of molecular imaging is necessary to be made available to clinicians treating the patients. Healthcare IT and Molecular Imaging go hand in hand. If one wishes to exploit the real advantage of these systems, one should ensure effective distribution of

American College of Radiology (ACR) primer describes Molecular Imaging in glossary of terms used. “A growing research discipline aimed at developing and testing novel tools, reagents and methods to image specific molecular pathways in vivo, particularly those that are key targets in disease processes.” Novel tools Reagents: Scanners, coils, hardware etc. Paramagnetic materials, radiopharmaceuticals, DNA or peptides. Methods to image: Imaging protocols that make use of TOOLS & REAGENTS to demonstrate cellular functions and processes. Disease process:

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Conclusions The future of Molecular Imaging is very promising and the Hospitals and other Healthcare providers will need to prepare themselves for this futuristic technology. The investments in infrastructures as well as technology are definitely worth it. Acquiring basic technologies like PET CT scanners can be immediate actions, as this fusion Molecular Imaging has already shown its unprecedented growth in cancer diagnosis and management.

This is based on assumption that we know Normal in vivo cellular processes.

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But there should be provisions for expansion of this into a more promising Radioimmuno-based imaging and individualised therapies. Setting up small peptide synthesisers and use of Positron emitter generators like 82Rb, 68Ga will prove its worth in the next five years. These are modules required for Molecular Imaging of Gastro-neuro-endocrine tumors, cardiac perfusion and metabolic imaging. Molecular imaging will assume an ever more important role in furthering our understanding of human disease and patient care in the future. Strategic planning for investment on MI modalities is key to success.


1 2 3 4 5 6 7 India : Mumbai • Delhi • Kolkata • Bangalore • Hyderabad Overseas : Kuwait • Dubai • Kenya • Singapore • Kuala Lumpur

w w w. 2 1 c h m s . c o m


NUMBERS

The new US government commits USD 20 billion for national health IT investments.

More than 8% of India’s population is estimated to be suffering from cardiac diseases.

Only 1.08% of Indians have a secured medical insurance cover.

Medical equipment market in India is growing 15% annually.

China has nearly 60,000 hospitals for its 1.3 billion population. 44

February 2009

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