v o l u m e 3 | issue 7 | J UL Y 2008
A Monthly Magazine on Healthcare ICTs, Technologies & Applications
Cover Story: Clinical Information Systems - An Overview Dr. Pramod D. Jacob, Consultant, Clinical Information Systems/EMR Page 8
Spotlight: Innovating Integrated Healthcare Vir Chopra Chairman InterSystems (India) Pvt. Ltd.
Spotlight: Complete Care Solution Dr. Hemant Kumar Director, Health Solutions Group, Microsoft India Page 16
Industry Speak: Driving Health IT on Ajay Shankar Sharma CEO, Srishti Software
In Conversation: Cutting Edge in Healthcare Technology Tarit Mukhopadhyay Head HIS & PACS Business Siemens Medical solutions
www. e h e a l t h o n l i n e . o r g
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Watch out for upcoming issues for exclusive regional surveys on IT usage and automation in Indian Hospitals.
August - North India || September - West India || October - South & Central India || November - East & North East India
For advertising opportunity in this issue, get in touch with - Arpan (firstname.lastname@example.org, 9911960753)
w w w . e h e a l t h o n l i n e . o r g | volume 3 | issue 7 | July 2008
Clinical Information SystemsAn Overview
Dr. Pramod D. Jacob Consultant, Clinical Information Systems/EMR
Innovating Integrated Healthcare
Vir Chopra Chairman InterSystems (India) Pvt. Ltd.
Complete Care Solution
Dr. Hemant Kumar Director, Health Solutions Group Microsoft India
Bangkok Hospital Medical Centre, Thailand
Project Franchise Lab- Healthcare at the bottom of the pyramid
Shibaji Mandal, Director - Healthcare, Krishi Gram Vikas Kendra Usha Martin
Networks That Help Care
Kapil Khandelwal Director - Healthcare & Life Sciences (APAC and Emerging Markets) Cisco
Driving Health IT On
Ajay Shankar Sharma CEO Srishti Software
w w w . e h e a l t h o n l i n e . o r g | volume 3 | issue 7 | July 2008
Electronic Medical Records A luxury or a necessity?
Prof. (Dr.) Prashant Sathe Principal Consultant (EMR and Academics) 21st Century Health Management Solutions Pvt. Ltd.
Mobile Future for Medical Diagnostics
Pavan Behl Country Manager SonoSite India Pvt. Ltd.
Consultations for a Healthy Future
Cutting Edge in Healthcare Technology
Dr. Vivek Desai Managing Director Hosmac India Pvt. Ltd.
Tarit Mukhopadhyay Head - HIS & PACS Business Siemens Medical Solutions
58HIMSS AsiaPac 08
20 - 23 May 2008, Hong Kong
Alliance for Solutions
Road Ahead - Health Insurance 62 Summit
Eddie Toh Chairman Itanium Solutions Alliance
25 May 2008, Bangalore
16 - 18 April 2008, Luxembourg
Market Insight Healthcare Practice Frost & Sullivan
RE G U LAR SE C T IO NS
HL7 Critical to Tap Global Healthcare IT Markets
Saji Salam Chairman, Health Seven India
india news 42 BUSINESS NEWS
NUMBERS events diary
IN-BOX Many thanks for giving us the chance to share our thoughts in your respective journal. Also, receive my admirations for the fantastic journal you have created. Malina Jordanova, MD, PhD Solar-terrestrial Influences Laboratory, Bulgarian Academy of Sciences
eHEALTH seems to be very informative and addresses some of the many issues that I struggle with in attempting to move our health system towards e-health. Thanks for this wonderful initiative. Dr. Paul Ricketts, National Epidemiologist Ministry of Health & Environment Government Headquarters, Roseau Commonwealth of Dominica, W.I.
TeleVital and its team is thankful to you and your team for carrying this information to a larger cross section of the Healthcare professionals and IT professionals involved in providing solutions to Healthcare. The information about eHealth Technology Business Incubator (TBI) reaching them through your esteemed Magazine will aid in a larger group becoming aware and utilising the facilities at the TBI. Shivaram Malavalli President TeleVital India Pvt. Ltd. Corrigendum: We regret the error in our last issue, wherein, on page no. 3 - contents section, Mr. Yugal Sharmaâ€™s designation was wrongly mentioned as Country Manager, Polycom, India instead of Regional Head, India and SAARC, Polycom, India.
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 eHealth 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: email@example.com, www.ehealthonline.org
Volume 3 | Issue 7 | July 2008
EDITORIAL Prospecting Growth Opportunities
Dr. M P Narayanan editor-in-chief
Preparations for eHEALTH India 2008 are on at full throttle. And the huge interest in this unique platform for the Health IT community has quashed any doubts one had about the enormous need for technology to step in and play facilitator to improve healthcare delivery.
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The healthcare IT market in India is still at a nascent stage, however, it is a toddler learning fast by imitation of the market trends and movements of the more mature healthcare organisations of the West and Southeast Asia. The market in India is most conducive to the uptake of such solutions. 75% of the healthcare facilities in India are located in the cities, inhabited by only about 25% of the population. The remaining 75% of the population relies on the poorly maintained 25% of the facilities. This massive gap in the demand-supply opens up enormous opportunities for the health IT market. Even within the cities, there are issues that need addressing, such as thorough, systematised capture, storage and sharing of patient information, allowing faster but error free throughput of the patients through the clinical, administrative and billing procedures of the healthcare organisation. Such an ideal workflow is no longer unachievable, as this monthâ€™s cover story on Clinical Information Systems (CIS) points out.
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eHealth G-4 Sector 39, NOIDA 201301, India tel: +91-120-2502180-85 fax: +91-120-2500060 email: email@example.com is published in technical collaboration with Centre for Science, Development and Media Studies. 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.
The health IT industry in India has made a sincere effort through its unique solutions. However, there still exist skeptics, in both the public and private health infrastructure, especially in the non-metro cities, who need to be converted to take advantage of these solutions to provide better care to the large underserved section of the population. The total Indian healthcare sector is currently valued at US$ 34 billion and is projected to grow to nearly US$ 40 billion by 2012. The diagnostic and pathology market in India is around 2% of the overall healthcare market. The diagnostic market itself has been growing at 15-20% and by all indications shall continue this way for another 10 years. Thus, it is for us to open up our eyes to the impending future of increased adoption of IT in the healthcare industry and embrace it without further ado. Find within the pages of this pre-conference issue, a sample representation of the Healthcare IT and medical technology domain, a market ready to burst with the potential it carries within it. The eHEALTH Team invites you, our readers, to come join us in celebrating the coming of age the eHealth industry!
Owner, Publisher, Printer, Ravi Gupta Printed at Vinayak Print Media E-53, Sector 7, Noida, U.P. and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP Editor: Ravi Gupta
Ravi Gupta Ravi.Gupta@ehealthonline.org July 2008
Clinical Information Systems An Overview Dr Pramod D. Jacob Consultant Clinical Information Systems/EMR firstname.lastname@example.org
Increasingly, medical care is being provided in multiple settings and at multiple points, thus creating a need for clinicians to pool together the available clinical data and share it in order to provide a complete picture of an individual patient. The bricks-andmortar hospital is no longer the central focus of care. The “solid” remnants of the monolith are now merely supports for the information management system that has become critical to holistic care. This system, and its management, becomes the “virtual” hospital/health system.
ut simply, Clinical Information Systems (CIS) are those information technology systems that are applied at the point of clinical care. These are healthcare information systems used by doctors, nurses and other healthcare providers to provide clinical care to patients. Types of clinical information systems and applications Some of the major Clinical Information Systems (CIS) are as follows: Ambulatory or Outpatient Clinical Information Systems including the Ambulatory/OPD Electronic Medical Record (EMR) Inpatient Clinical Information Systems including the Inpatient Electronic Medical Record (EMR) and Computerised Provider Order Entry (CPOE) systems. Speciality systems like the Emergency Department Information System, ICU Information System, Cardiology Information System, and Oncology Information System. Ancillary Information Systems like
Laboratory Information System, Pharmacy Information System and Radiology Information System Briefly describing the systems above and how they work together: Ambulatory/OPD Clinical Information Systems
Ambulatory/OPD information systems have two major parts which should be well integrated with each other. One part is the clinic administration and management system which include the Registration, Scheduling and Billing functionalities (referred together as the Practice Management system (PM)) and the other part is the actual ambulatory healthcare delivery system which is the Ambulatory EMR. These systems are tailored for the typical clinic visit workflow by a patient (termed as an “encounter”), which in summary is as follows (see Figure 1). The patient is registered, an appointment with the doctor is scheduled, the patient arrives for the doctor’s appointment and is checked in, patient waits in the waiting room until called into the exam room by the nurse or approwww.ehealthonline.org
prescriptions can be made to print in the pharmacy, till this interface is set up). A messaging or emailing system to receive and send messages like abnormal test results, and communicate via email with other members of the provider team to follow up on a patient’s care. The EMR should be well integrated with the Practice Management system to automate many back office processes, for example like triggering of a charge for a clinic visit in the billing system, after the doctor closes an encounter in the EMR.
Figure 1: Flow of a typical clinic visit (encounter) by a patient
priate support staff. The chief complaint, vitals and nursing notes are taken down by the nurse/support staff. The doctor then enters the exam room, reviews the case, goes on to note history and conduct a physical examination, then orders lab and other tests and prescribes medications. The patient may then proceed to the lab for giving sample for tests like blood or urine. The patient then moves on to the pharmacy, collects his/her medicines and then checks out after paying their bill. There could be minor variations in this workflow, for example a small procedure could be done in the exam room, but the general workflow is as mentioned above. When we say an OPD clinic is paperless, besides replacing paper medical records, the EMR also replaces paper lab forms and paper prescriptions. The functions of ordering tests and medication are now done electronically by the EMR. Therefore, from the perspective of the doctors, nurses and healthcare providers, the Ambulatory EMR should have the following features to function as an effective electronic healthcare delivery system in the OPD clinic: Chart and results review – this feature allows for the review of previous visits by a patient, results of lab tests and the medications the patient is and was on. Clinical documentation like progress notes, nursing notes and clinical notes are now done in the EMR. Order entry for lab orders, medication orders and such, are done electronically on the computer. This feature has functions like drug interaction checking, duplicate order checking and so on. The EMR should definitely be interfaced with the clinic’s Lab Information System for the lab orders to go through and the results to blow back. Ideally it should be interfaced with the clinic’s Pharmacy Information System too (though as a stop gap arrangement, July 2008
At a later stage after the clinic staff get used to the EMR system and change in work flow, processes and the electronic culture, the EMR is ready to be “souped up” with more complex features being switched on like: Setting up of clinical protocols and templates e.g. the protocol for pneumonia. This helps in standardising interventions and treatments using Evidence Based Medicine (EBM) for best practice. Alerts and Clinical Decision Support (CDS) features can be set up which helps in checking for errors and improving patient safety e.g. do penicillin sensitivity test before prescribing penicillin injections. Inpatient Clinical Information Systems The inpatient world is much more complex and intense with a whole number of permutations and combinations in workflows involved. Remember the Inpatient arena is 24x7, mission critical and has to be fail proof. Patient’s lives depend on the inpatient CIS system functioning properly. In a very broad sense an inpatient visit starts from admission, goes through treatment and procedures and ends with discharge. This sequence is termed as an “inpatient episode”. In summary, after admission, the patient is bedded, an initial assessment is carried out by the doctors and nurses, admission orders for labs, other tests and medications are given, and there may be requests for consultations to other specialists like the cardiologist. After the results and referrals, a reassessment is done and new medications and additional tests may be ordered. This process keeps repeating till the patient gets better and is discharged or some other outcome happens. See Figure 2 for the general inpatient flow. As is clear, the Inpatient environment is much more dynamic and constantly changing and any CIS/EMR supporting healthcare delivery in this environment needs to handle these dynamic and constant changes in real time. Consider the variations possible in just the admission process. A patient can be admitted from the emergency room, have an elective admission or be transferred from the ward to the ICU. An inpatient episode can be for a surgery, an elective medical admission
or an emergency admission. In short, there are a 150 to 200 possible inpatient clinical workflows that have to be covered by an Inpatient EMR system. The change management and culture change is much more profound. Description of the Inpatient systems The inpatient administration and hospital management has an Admission, Discharge and Transfer (ADT) system for registration, scheduling resources and beds, and tracking the patient in transfers. There is a Hospital Billing system to do the billing functionalities. The actual healthcare delivery system is the Inpatient EMR. It is expected that a health
organisation first have the ancillary systems of Laboratory Information System, Pharmacy Information System and Radiology Information System in place for the inpatient arena, before implementing the Inpatient EMR, and they should be interfaced with the EMR. Some important features of an Inpatient EMR 1. 2.
Figure 2: General Inpatient Flow
Chart and results review - as described above. Clinical Documentation - for clinical notes like progress notes and nursing notes. Much more comprehensive than the Ambulatory EMR with features like data input flow sheets into which data like pulse rate, BP and temperature can be put in at specified intervals. There is significantly more nursing and support staff documentation in the Inpatient arena. Computerised Provider (or Physician) Order Entry (CPOE) - much more real time and robust than the ambulatory order entry system. Important to have this well interfaced with the Inpatient Pharmacy system. Has to handle many more types of orders like IV drips with rate of administration, dietary orders, physiotherapy orders etc. Electronic Medication Administration Record (eMAR) - This is a function that logs the administration of medications electronically (usually using bar code technology) or manually. It helps in reconciliation of administration of medication vis-à-vis the medication orders given for a patient in the CPOE system and dispensed by the Pharmacy system. Care Plan - Nursing Care Plans function for planning of patient care, communicating patient care needs among the nursing and support teams, document changes in the patient’s condition and the patient’s response to nursing medical treatment. This module of the Inpatient EMR provides these features and functionalities. Work-lists - this is a list generated for the nursing and support staff, informing them of the patients under their care and what is to be done as tasks and interventions for each of their patients e.g. prepare patient X in bed number Y for surgery at 9 am. Messaging/email system: as described above Order sets, clinical protocols and templates- setting up templates and order sets for standardised clinical protocols in the Inpatient arena for e.g. protocol for Myocardial Infarction (heart attack). This facilitates implementing of standard Evidence-Based guidelines for best practice across the healthcare organisation. Alerts and Clinical Decision Support (CDS) can be set up which help in checking for errors and making correct clinical decisions, like dose adjustments for renal insufficiency. These features are very important for the Inpatient EMR as they lead to significant reduction in medication and other errors and improve patient safety. www.ehealthonline.org
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It is advisable to implement the various features of the Inpatient EMR in stages rather than trying to switch on all features in one go. Like starting with clinical documentation then progressive onto order entry (CPOE), then to care plan and so on. Speciality modules These are Clinical Information Systems that cater to speciality departments with unique workflows which cannot be well configured in a general/generic EMR system. Examples are Emergency Department Information Systems, ICU Information Systems, Cardiology Information Systems, Operation Theater Information Systems and Oncology Information Systems. To elaborate by a few examples: Emergency Department Information Systems (EDIS)
The Emergency Department is a highly dynamic, high movement and quick turnover arena, with patients ranging from the critically sick to those who are trying to get their minor ailments looked into without having to go and wait in the OPD lines. Features of an EDIS system would be allowing patients to be registered into the system with minimal data entry, tracking of patients (for example a patient may be sent from an ED room to have an x-ray done and then put into another ED room), quick and easy entry into the computer using touch screens or some similar technology, quick fill templates for clinical documentation and order sets for ordering of labs and medications, and integration with Inpatient systems like the ADT system for bed assignment, and Inpatient EMR for carrying over the admission orders. Intensive Care Unit Information Systems (ICUIS)
On the other hand the ICU is a high care arena with critically ill patients, who need an intensive level of care. There is constant monitoring of vital signs and other parameters with the help of bedside monitors and devices which are recorded into flow sheets, medication administration via pumps, continuous assessment and adjustments in medication and treatment and high use of protocols. Thus an ICUIS should be able to provide protocol templates and flow sheets, have automatic capture of physiologic parameters from the monitors, graphically display trends to help in decision making, automatically calculate dose adjustments according to change in parameters and so on. Ancillary systems
These traditionally refer to the Laboratory Information System, the Pharmacy Information System and the Radiology Information System. To describe briefly what these systems do, for example a Laboratory Information System (LIS) that is interfaced with the EMR and lab testing instruments, receives an order for a given test from the EMR system, ensures that the sample received matches the order (usually using bar codes), feeds the details of the order into the instrument that does the actual test like the automated analyser, receives the result of the test from the instrument and sends the result back to the EMR into the correct patient’s record and specific encounter. 12
Finally, I would like to highlight the following take home points about CIS systems: Which ever the Clinical Information System(CIS), the secret of success in implementing it lies in designing and configuring the system to optimally suit the clinical workflow and processes of the concerned clinical environment, rather than trying to completely redesign the clinical workflow and processes of the concerned clinical environment to suit the CIS. Of course, this transition period presents an opportune time to improve and stream line the clinic’s workflow and processes for better efficiency. Make sure the Clinical Information Systems are standards compliant to standards like HL7, DICOM etc, so that they can exchange data with other systems within the organisation. Do not go for a CIS system thinking it is going to be a standalone silo. It will invariably be found that in due course of time, any stand alone CIS system will have to start exchanging information with other systems in the organisation or even in the region. Handle the change in culture with appropriate change management techniques, be sensitive to these changes and the reaction they will produce. Many cases of unsuccessful CIS implementations have been due to improper change management. It is advisable to have a Clinical Informatician experienced in implementing CIS/EMRs, involved in facilitating the interactions between the clinicians, information technology personnel and the operations/management people. In my opinion, it is advisable for health organisations to first implement the Ambulatory EMR, get a feel of the electronic culture and the change it brings about, before going in for the more intense implementation of an Inpatient EMR. From the patient’s perspective also it makes more sense, as normally a patient takes many more visits to the clinic or doctor’s office, than admissions into a hospital. Hence, for knowledge about a given patient’s health status and continuity of care, the Ambulatory EMR record is more beneficial as it gives a more “longitudinal” idea about the patient. Additionally, it is much more important for an inpatient clinician to have access to a patient’s Ambulatory EMR in making life saving decisions in the inpatient arena, rather than the other way round, which is an ambulatory clinician having access to the patient’s Inpatient EMR. A discharge summary can always be posted in the Ambulatory EMR to cover a hospital inpatient episode. In conclusion, at long last Clinical Information Systems have come of age and this technology is fast bringing about a revolution in healthcare, just like information technology brought about a revolution in other fields like finance, banking and travel. Those healthcare organisations that wish to be of international caliber will have to embrace this technology and implement it, as this technology will be a benchmark criterion in qualifying as a healthcare organisation of international standard. www.ehealthonline.org
Innovating Integrated Healthcare Founded in 1978, InterSystems Corporation is a US$ 220,000,000 privately-held software company with offices in 22 countries. They provide a premier platform for connected healthcare, and their innovative products are widely used in other industries that demand the highest software performance and reliability. Leading software vendors also leverage the high performance and reliability of InterSystemsâ€™ advanced technology in their own products. Vir Chopra, Chairman, InterSystems India, shares with eHEALTH the pioneering role played by the company in transforming healthcare industry across the globe.
Vir Chopra Chairman InterSystems (India) Pvt. Ltd.
That said, I believe that large nations like India and China having a national focus on improving the quality of healthcare, coupled with increased levels of education and an IT revolution could potentially learn from the experiences of countries around the globe that have embarked on the same road before them, and leapfrog ahead.
Q. InterSystems is known for its world class technology products, namely - Cache, Ensemble and Healthshare. Could you give a brief overview of the strengths and application areas of these technologies and how they are being used for developing IT solutions, particularly for the healthcare industry? A. For companies that require high-performance and reliable database system, we offer InterSystems Caché®. Caché provides a rapid development environment for complex applications along with fast, multidimensional engine that uniquely combines a powerful object database with robust SQL. For enterprises that want to rapidly connect and extend systems, we offer InterSystems Ensemble®. Ensemble enables the fast creation of connectable applications, and makes it possible to enrich existing applications easily with a browser-based user interface, adaptable workflow, rulesbased business processes, messaging, executive dashboards, Web services, and more. Its architecturally consistent design combines an integration server, data server, application server, and portal server into a single, seamless environment that delivers breakthrough time-to-results. For the creation of electronic health records (EHR) on a regional or national basis, we offer InterSystems HealthShare™. HealthShare is the first software platform that includes the technologies needed to get electronic health record systems up and running quickly across multiple organisations, plus a complete development environment for customising solutions to meet the requirements of each deployment Caché, Ensemble and HealthShare are all based on innovative technology that provides benefits the healthcare industry demands. This includes high performance, massive scalability, reliability, security, cost effectiveness and flexible interoperability supporting a wide range of healthcare standards. This has been possible because leading healthcare solution providers, worldwide use our technology; 70 percent of the clinical labs in the United States depend on our technology; and we are the platform of choice for National Health Records. In addition to the above technology products, we offer InterSystems TrakCare™, a revolutionary Web-based solution that empowers healthcare professionals by delivering rich patient-centric information at the point of care. Q. InterSystems’ Ensemble has been ranked as the best interface engine in healthcare for the second consecutive year by the international health informatics evaluation firm KLAS. What is the differential advantage that Ensemble brings for healthcare? A. As opposed to most Application Integration platforms,
which include a suite of separate products, stitched-together to work together, Ensemble has been created as a single, architecturally consistent technology stack - Integration Server, Data Server, Application Server, and Portal Development Software. Ensemble projects are therefore typically completed in significantly less time than integration projects with older generations of integration products. Ensemble supports a wide range of standards found in healthcare solutions including HL7 (v2 and v3 and X.12 (HIPAA). It has a Persistent Messaging Engine, which guarantees message delivery, processing messages much faster than other messaging engines that neither support persistent messaging nor FIFO. There are a lot of standards in use in healthcare, some even competing with each other. As patient or episode data moves around, it often needs to be transformed to make it amenable for reuse. Ensemble eliminates barriers to project completion raised by the differences in semantics and data schemas between applications or services. Ensemble’s powerful graphical and code-based data transformation capabilities bridge these differences using simple formulas or lookups in data tables (internal or external), and can be extended to any degree of complexity by adding customised functions. Finally, given that needs, and even standards, evolve over time, the easy-to-use, Web-based, Ensemble development interface allows an IT team to easily manage the impact on the interfaces used for application integration. Q. There are many national ehealth projects running across the world (either in the process of integration or already implemented), which are based on your product ‘HealthShare’. Do you see considerable differences in maturity and demands for such technologies in different markets across the globe? A. The needs are the same worldwide – effective delivery of top-quality patient care. What varies is the level of maturity of the supporting systems and infrastructure and the relative priority of this goal vis-à-vis other national/regional goals. That said, I believe that large nations like India and China having a national focus on improving the quality of healthcare, coupled with increased levels of education and an IT revolution could potentially learn from the experiences of countries around the globe that have embarked on the same road before them, and leapfrog ahead. Q. Asian health IT market is estimated to reach US$ 4.8 billion by 2012, with India and China as major contributors. What is the percentage of market share that InterSystems would target in Asia vis-à-vis the world? A. That’s a tough one to call!! I believe that there will be many players in the space with July 2008
There is a shift in terms of perception of value and hospital administrators are increasingly looking to beef up their IT infrastructure both in terms of hardware and software. significant market share. It’s hard to say what we will target, but I am certain that we will get there on the shoulders of a set of happy customers. Based on the precedents of our technologies in other geographies, our contribution to this market segment will be both directly through our products, as also indirectly through the use of our platforms to power applications developed by Application Providers, or in-house/outsourced IT teams. Q. Among the emerging markets how do you gauge the position of India with respect to IT uptake in the healthcare industry? A. In many domains, the Indian subcontinent has already proven beyond doubt that there is willingness to adopt the best solutions and the ability, dynamics and desire to push the envelope in terms of the product functionality and performance. The Indian healthcare industry has been somewhat slow “off-the-block” in terms of adoption of IT, but all of us in the industry see the pace picking up. There is a shift in terms of perception of value and hospital administrators are increasingly looking to beef up their IT infrastructure both in terms of hardware and software. The CEO of a hospital chain I met on a recent trip said quite candidly – “I don’t know where we are headed, but I know that wherever it is, we wont get there without good IT systems”. You can read a lot of things into that statement, but I chose to believe that it’s a clear sign of the position of healthcare IT in India. 15
Complete Care Solution Microsoftâ€™s focus on the healthcare sector has grown tremendously in recent times and it now has some exciting plans for its healthcare vertical. Dr. Hemant Kumar, Director, Health Solutions Group, Microsoft India, shares with eHEALTH the vision and plans for the new markets.
Dr. Hemant Kumar Director, Health Solutions Group, Microsoft India firstname.lastname@example.org
Q. What is the vision for Health Solutions Group of Microsoft? A. For more than a decade, Microsoft has invested significant time and resources into understanding the needs of healthcare organisations with one clear vision - to improve health around the world through software innovation. To achieve this vision, we are developing solutions that encompass both the provider and the consumer to help them achieve their goals - from wellness to patient care and towards improving the overall efficiency of healthcare organisations. Q. How do you plan to bring a distinct value proposition for the healthcare industry? A. The Microsoft Health Solutions Group is focused on addressing the entire ‘continuum-of-care’ i.e. helping consumers in wellness and putting them at the centre of managing their personal (and their family’s) health information. On the provider side, Microsoft is enabling organisations with solutions to improve patient care, patient safety and overall efficiency of their operations. Q. Microsoft Amalga HIS is quite successful in countries like Thailand, Malaysia and Philippines. When do you plan to roll out the same in the Indian market?
Q. Kindly elucidate the characteristic features of Amalga HIS. How do you think it bring a differential advantage to the healthcare providers? A. If I were to summarise the single most important distinguishing feature of Amalga HIS, it would be that - it’s an integrated solution, which combines cutting edge functionalities of an ERP, EMR and RIS/PACS all based on a single database. Unlike some other HIS products that have grown inorganically through a ‘patch-quilt’ approach of putting together a number of different sub systems, Amalga HIS has been built ground upwards to support operations in a complex hospital environment. When one looks at details, the value proposition to organisations is huge – there are no tedious integrations required with ERPs to manage financials and procurement; there is no requirement to engage with vendors to purchase and integrate a Radiology Information System (RIS) and a Picture Archival and Communications System (PACS). What this translates into is a vastly superior user experience; no redundant/orphan data; seamless access to all the information relating to a patient or to any type of records, be it related to the Human Resources or Materials Management or Pharmacy or Labs. From the organisation standpoint all these features have favorable implications for cost as well as system maintenance.
A. In all the new markets (including India) that we are entering, we are looking carefully for what we call the ‘Early Adopter Partners’ (EAP). These are organisations that share our vision of transforming healthcare experience for patients; those who put a huge premium on patient safety and improved outcomes; and those who are willing to take the necessary steps to realise this vision. We are in discussion with some prominent healthcare providers and hopefully we will have our first EAP soon.
Q. Microsoft HealthVault promises to revolutionise care delivery by empowering patients with complete control of their health records. Kindly elaborate on how this will be done.
Microsoft Amalga Hospital Information System, Home Page
Microsoft HealthVault, Home Page
A. The current system of healthcare delivery across the world is centered around the providers. The patient’s information is fragmented all across the different providers that s/he interacts with – different physicians, hospitals, labs, etc.
HealthVault represents a paradigm shift in the status quo. It puts the consumers at the centre of their health information and thereby empowers them to be the aggregator of such information for themselves and their families. The most apt analogy is with the shift that happened in the travel industry. Today, the consumer is in-charge of his/ her travel plans. S/he goes online, to look for the best deals for airlines tickets, cars and hotels and all this happens across multiple service providers. And this shift has been a win-win for both the consumers as well the service providers. There has been an all-round increase in efficiency and decrease in cost for both parties. HealthVault is aimed at bringing about a similar paradigm shift for consumers of healthcare. HealthVault is a platform that allows, at a fundamental level, consumers to do three things– a) store, aggregate and share their own and their family’s health related data in a secure manner; b) connect with a variety of intelligent health devices like digital blood pressure measuring instruments, digital glucometers etc. such that their readings are automatically uploaded to their health accounts; and c) search health related information on the web through a search engine that’s tuned to mine health related data. Q. In what ways do you think HealthVault can transform the healthcare ecosystem? A. HealthVault will impact all the three principal stakeholders in the healthcare ecosystem – the consumer, the provider and the technologists who write applications that interact with HealthVault. As mentioned above, HealthVault puts the consumer at the centre of aggregating their health related information and puts them in-charge of how and whom they share the information with. For providers – it allows access to critical patient related data such as drug allergies, recent lab or radiology results and past medical history (should the patient desire to share the information) and thus allow doctors to take more informed decisions, more quickly. For developers – it allows easy access to the platform to write a variety of innovative applications that interact with HealthVault to provide dramatically new ways of utilising the information between different stakeholders in the health system. For example, there are applications that allow a patient to share specific parts of their health records to their physicians by interacting with the physician’s practice management system; in a hospital setting it could be an application that interacts with the hospital’s HIS and pushes the discharge summary into the patient’s HealthVault account. Q. Currently, health IT market in India is highly fragmented and considerably unstandardised. What will be your approach in this kind of a scenario? A. There are several factors that will push the market towards standardisation. As consumers become more aware they will demand better services in terms of improved safety, 18
Microsoft has made a long term commitment to the Indian healthcare market and is bringing in the necessary resources and worldclass software solutions to fulfill this commitment. improved outcomes - and in a highly competitive environment like the private healthcare sector in India, it will force the hospital to adopt practices and solutions that enable them to deliver such results and enable improved overall efficiency. Another big driver towards more demanding consumers is the booming health tourism in India. These consumers will want world-class services. To distinguish themselves as premium brands, private hospitals are moving towards accreditation of their institutions by national and international agencies like NABH, JCI, INGRES, etc. Interestingly, several public sector hospitals are also going through NABH accreditation in India. All these are drivers towards standardisation of care and information management, and will automatically lead to hospitals choosing IT solutions based on benchmark industry standards. Microsoft is an active partner in most of the standards bodies in the world, for example, Microsoft is a benefactor member of the HL7 body, the most widely used standard in hospital information systems today. All our solutions are compliant with multiple industry leading standards. Q. What is your perception about market prospects in India? A. We believe India is one of the most exciting emerging markets in the world in healthcare. There is a tremendous demand supply gap in terms of net beds required per unit population and all the major hospital groups and several corporate houses are actively engaged in planning and executing massive growth plans. At the same time, the Indian market has its own peculiarities and to be successful, one needs to have lots of patience and flexibility in market approach. Microsoft has made a long term commitment to the Indian healthcare market and is bringing in the necessary resources and world-class software solutions to fulfill this commitment. We are actively working towards making Microsoft a trusted partner for all the key stakeholders in the Indian health system to support the rapidly growing Indian health sector. www.ehealthonline.org
Bangkok Hospital Medical Centre Bangkok, Thailand
angkok Hospital Medical Centre (BMC) is one of the most technologically sophisticated hospitals in the world today. Located in Bangkok, Thailand, BMC is an expansive state-of-the-art medical campus providing comprehensive medical care through multidisciplinary teams of highly trained specialists. With its four hospitals and broad range of specialised clinics, BMC is equipped with all of the diagnostic and treatment facilities not generally available at local hospitals. The centre has received Joint Commission International (JCI) accreditation and is known throughout the world for delivering world-class, award-winning healthcare. July 2008
The flagship of Thailandâ€™s largest hospital group, BMC has more than 650 full-time and consulting physicians, 700 nurses, and numerous teams of support technicians and specialists. Their medical campus offers every amenity imaginable, from concierge services and luxury accommodation, to translation and visa assistance, shopping and dining, ensuring that every patientâ€™s stay is a comfortable one. Bangkok Hospital (BGH) is their primary facility for internal medicine, paediatrics and general surgery. BGH houses numerous specialised centres, including endocrinology, gynaecology, nephrology, orthopaedics, radiology, urology, cosmetic surgery, eye and LASIK, gastrointestinal tract and liver, and ear, nose and throat. BGH is one of the largest hospitals in Thailand and the institution of choice for referrals from smaller facilities that lack some of the specialised diagnostic and treatment facilities available here. Founded in 1972 by a group of doctors 19
and pharmacists with a staff of only five specialists and 30 full-time nurses, BGH has grown to become one of the most advanced and comprehensive healthcare institutions in the region. The largest hospital at Bangkok Hospital Medical Centre (BMC), BGH provides a wide range of medical services and houses most of the surgical facilities of BMC. Continuous development and investment in technology, medical expertise and support facilities have contributed to the hospital’s current stature as one of the pre-eminent medical institutions in Southeast Asia. More than 2,200 patients arrive at BMC each day, and the centre of activity is its main 16-story, 400-bed facility, BGH. Today, BGH is home to more than 20 specialised centres, covering almost every area of expertise, and supported with comprehensive emergency and ambulatory services. Each of their clinics takes full advantage of the most sophisticated medical advancements to achieve the highest quality of patient care, and through their streamlined patient management system, they have been able to reduce waiting time to nearly zero. This, combined with their excellent record of successful treatment and renowned hospitality and service, has made BMC the preferred healthcare provider for more than 3.4 million patients from 160 countries. BMC was the first private hospital in Thailand to receive the ISO 9002 and 9001:2000 accreditations and has also received the Prime Minister’s Export Award for Best Service Provider in 2001. Bangkok International Hospital (BIH) is the first hospital in Thailand developed exclusively for international patients. It is designed to address all the cultural and linguistic considerations while providing the full range of amenities expected of a world-class multicultural institution. BIH is subdivided into three designated outpatient departments: Japanese Medical Services (JMS), Arabic Medical Services (AMS) and International Medical Services (IMS). Bangkok Heart Hospital (BHT) is the only dedicated private heart hospital in Thailand and is regarded as one of the finest cardiac facilities in the country. With its state-of-theart technology and highly trained physicians and support personnel, BHT offers the most advanced and effective treatments in the fight against cardiovascular disease, and has treated more than 40,000 cardiac outpatients and performed more than 1,100 heart surgeries since opening in 2005. Wattanosoth Cancer Hospital (WSH) is the first private cancer hospital in Thailand. Through collaborative research with international 20
institutions and multidisciplinary teams of specialised physicians, WSH utilises cutting-edge technologies to provide innovative treatment methods that are pioneering advanced cancer treatment in the country. IT Infrastructure The infrastructure at BGH is based on Wintel platform with Active Directory for Security and Authentication. They use MedTrak (TrakHealth’s product) as their main Hospital Information System (HIS) and PeopleSoft Financial and HR for the back office system. MedTrak has electronic medical record (EMR) as one of the modules inside it that integrates Patient Record, Drug Allergic profile and clinician ordering system. The Document Scan system in it also helps fulfil any lack on the part of the HIS so that all information is ready for the hospital’s clinical staff. For PACS, they use EBM PACS from EBM Technologies and also have a Tele-radiology network with their network hospitals that allow each hospital to send the PACS images to be diagnosed by radiologists at the central facility, available 24/7. Teleconferencing technology is also used to facilitate many functions in the hospital like tele-consultation and training; and the hospital has plans this year to provide telemedicine to multiple locations around the Bangkok area. Cutting Edge Technology at BMC Rapid advancements in medical technology are resulting in more reliable diagnostic imaging, shorter recovery periods, and less invasive surgical procedures for patients. Bangkok Hospital Medical Centre is committed to applying the latest innovations in medical technology throughout all their clinics and specialised centres. Endovascular and interventional radiology is treatment of veins and arteries by either inserting a catheter or other medical devices into the desired spot in those blood vessels or organs using DSA (Digital Subtraction Angiography). Uterine Fibroid Embolization (UFE) is an FDA approved minimally-invasive procedure used to remove fibroid tumors in the uterus. The procedure does not require general anesthesia and recovery time is faster compared to open surgery. Digital mammography is the latest innovation in the fight www.ehealthonline.org
eased tissue or cauterise a problem area without affecting healthy adjacent tissue. Novalis has numerous treatment applications, including cancerous tumors, arteriovenous malformations and Parkinsonâ€™s disease. 4D Ultrasound. With the speed of 25 volumes per second, the latest 4D ultrasound creates a life-like motion picture. Magnetic Resonance Imaging (MRI - Intra Achiva 3.0T MRI) Advances in MRI technology are providing extremely accurate, high-contrast images of internal organs. Unlike conventional x-rays, MRI scans yield the detailed information necessary to discover blood circulation abnormalities and are particularly useful in the early detection of brain cancer. BMC is proud to possess the latest and most advanced MRI to date, the 3.0 Tesla. Gamma Knife surgery marks a turning point in the treatment of neurological diseases. Invented by a Swedish doctor, the system makes non-invasive brain surgery possible by applying highly targeted gamma radiation to the treatment of tumors, arteriovenous malformations of the brain and functional disorders. BMC is the first and only hospital in Thailand to offer Gamma Knife treatment for neurological diseases. IMRT (Intensity Modulated Radiotherapy) is an innovative cancer treatment that utilises ionising radiation in the treatment of malignant tumors. Using high-powered computers, IMRT is able to focus radiation doses on tumors without damaging the surrounding tissue. This advance in tumor targeting results in fewer side effects and better overall treatment. Minimal Invasive Heart Surgery. A breakthrough technology for cardiac surgery, the da Vinci Surgical System uses robotics to translate the surgeonâ€™s natural hand movements into the micro-movements of a robotic arm. With the aid of a viewing monitor, the surgeon is able to apply less invasive incisions with unprecedented precision, lowering risk, accelerating recovery, and greatly reducing scarring.
against breast cancer and allows more accurate diagnosis and earlier discovery than previous methods, particularly in women under 50. Greenlight PVP Laser for Prostate Treatment. One of the most common and painful afflictions experienced by men over 50 is prostate enlargement. At BMC, we offer PVP laser treatment (photo-selective vaporisation of the prostate) to precisely target prostate tissue with a high-powered laser beam. This innovative treatment is significantly less invasive than previous methods and is often performed in an outpatient setting. Positron Emission Tomography (PET)/Computed Tomography (CT) Scanner. The first combination PET/CT scanner in Thailand is a major advancement in imaging technology and patient care and is the most functional imaging technology available today. Applications range from the early detection of cancers and assessment of heart muscle viability, to the evaluation of functional brain anatomy in dementia, epilepsy and stroke. Novalis Shaped Beam Surgery System. Novalis is a dedicated system for non-invasive stereotactic radiosurgery (a high dose of radiation applied in a single session) and stereotactic BMC Website radiotherapy (radiation administered in a series of treatment Their interactive website contains a wealth of informasessions). What makes Novalis special is the precision with tion about BMC, including all of their clinics and patient serwhich it applies doses of radiation, allowing it to destroy dis- vices, their extensive facilities, and upcoming events. Users
will also find the current cost of many of the procedures and treatments offered at BMC, and can begin a dialogue with the hospital and even schedule an appointment to explore the various options available. One of the key features of the website is the ‘Find a Doctor’ program, which enables users to search for physicians by area of specialisations, read a brief biography and schedule a consultation. Emergency Services Bangkok Hospital provides 24hr emergency room facilities with physicians specialising in advanced and Critical Care. The well-trained and experienced staffs are experts in emergency care. They also have a ‘medevac’ service for first aid and patient evacuation using: Motorlance: The motorcycle ambulance is the hospital’s innovative solution to cope with Bangkok’s heavy traffic, whereby a doctor or paramedic is sent by motorcycle to provide medical support to patients in need of immediate care, before the ambulance arrives. Ambulance: A fleet of 10 ambulances includes Thailand’s only specialised Cardiac Care ambulance. Mobile CCU, which provides: special equipment to reduce cardiac pumping load in state of shock, heart failure, severe anginal (chest) pain, and refractory ventricular arrhythmias. high-energy electrical conversion of life-threatening cardiac arrhythmias. Monitoring heart rate, rhythms, respiration, and oxygen saturation in the blood, systemic and intravascular blood pressure. electrical stimulation in case of cardiac arrest, or severe bradycardia (slow heart rate). respiratory support via use of respirator in case of insufficient respiration or respiratory failure. echocardiography to examine heart muscle function and heart valves. Precise and accurate intravascular access. specialised physician, and well-trained medical personnel in coronary emergency care and transportation. special service CDMA network system to facilitate emergency situation. The CDMA links to hospital’s patient record, database system, and consultation. So, while the patient is still in Mobile CCU, the cardiologist at the hospital can arrange for immediate interventional coronary procedure, such as coronary 22
angiography, cardiac catheterization, balloon angioplasty or bypass surgery if indicated. Helicopter Emergency Medical Service (HEMS): Bangkok Hospital Medical Center in association with Bangkok Airways (PG) now offers the first Helicopter Emergency Medical Service (HEMS) in Thailand. BMC is the flagship hospital in the Bangkok Dusit Medical Services group of hospitals and this new service links the hospitals even closer together, enabling patients to be transported from almost any location in South East Asia to any of the hospitals in the group.
The BMC Helicopter Emergency Medical Services (HEMS) was inaugurated in September 2007 as the first commercially life-saving certified HEMS ever offered in South East Asia. This helicopter has the capability of both day- and nighttime flights including poor weather conditions. Installed on-board with certified Advanced Life Support equipment and attended by certified aviation medicine doctors and certified flight nurses. All medical crewmembers are highly skilled in acute care of trauma, cardiac, neonatal, obstetrics, paediatrics, burn care, and emergency cases. The service provision includes on-site patient medical treatment and patient stabilisation, air ambulance of point-to-point patient transfer, and medical logistics of equipment/supplies and personnel. Territories of operations cover all provinces in Kingdom of Thailand and neighbouring Indochina counties including maritime areas. www.ehealthonline.org
arishmaTM The Solutions People
Project Franchise Lab -
Healthcare at the bottom of the pyramid Shibaji Mandal Director-Healthcare Krishi Gram Vikas Kendra Usha Martin
The massive yet unexplored rural healthcare market is drawing the attention of many today. A completely different lens is needed to define a new market such as this. One such initiative is that of KGVK’s Project Franchise Lab. Prof. Diana Schmidt School of Medical Informatics IT Faculty of Heilbronn University and Medical Faculty of Heidelberg University
Why “Bottom of the Pyramid” healthcare? Today, almost three decades after the corporatisation of healthcare in India, it still seems that we are living in two countries within the same geography. One, the ‘shinning India’, registering a GDP growth of over 8% consistently since the last three years, and the other is the ‘Grameen Bharat’, where there are people still dying of untreated malaria or diarrhoea, there are still so many children who do not survive into the second year because of poor post natal care. The government infrastructure being inconsistent and in many cases non-existent especially in the backward states of the country, leave the rural poor with no choice but to hedge their luck in the hands of untrained quacks who enjoy monopoly in an unregulated and fragmented rural healthcare market. The corporate healthcare entities have remained suspicious of the idea that the supposedly poor rural community would be willing to pay for healthcare, who otherwise have remained in the domain of mandated free service provided by the government healthcare facilities. Krishi Gram Vikas Kendra (KGVK), an Usha Martin initiative believes that if there is a value for money proposition made, and if a product or service is created suiting the unique lifestyle and budget of the rural segments, there is then a very viable business space for rural healthcare. The same can be observed in China as well. There are so many companies that have been unsuccessful in the Chinese soil in the recent past, but one cannot continue to ignore its sheer size today? The rural population of India stands at a staggering 795 million people today that is twice the
size of United States. The rural consumption growth is also expected to be around a healthy 5.1% for the next two decades with the estimated size of India’s rural market being pegged at US$ 577 billion by 2025 (Mckinsey Global Institute). In this scenario, one would find it very difficult to ignore the massive size and potential of rural India. A completely different lens is needed to define a new market such as this. To tap the rural healthcare market is only as impossible as doing the same in the urban space. With Project Franchise lab, we are talking about that seemingly impossible idea of tapping the rural healthcare market. An asse ssment of ground realities As one would have observed the case for poverty penalty being paid by the rural poor in case of micro credit, where they end up being in perpetual poverty in the hands of local moneylenders, charging frightful rates of interest. All this happened until the concept of self-help groups emerged and they were linked quite successfully in many cases with corporate banking entities like ICICI Bank or State Bank of India. Same is the case with the rural healthcare situation. The appalling state of deficient infrastructure makes it an ideal breeding ground for quacks, self prophesied faith healers and untrained birth attendants. The untrained quacks largely exploit the rural patient community as in most cases there are no alternate service provider available in the villages, especially for those which are remotely located. Worst of all, because there is www.ehealthonline.org
The Telemedicine network: Telemedicine initiative aims to leverage maximum potential of limited medical resources available in rural areas. The franchisees will have simple kiosks that will connect them to the medical resources available in the secondary care hospitals and statewide network of super specialist panel.
no scientific treatment protocol followed, allowing indiscriminate usage of drugs, inappropriate dosages etc. complicating the disease management, and putting the life of the ailing patients at serious risk. As the quacks try to retain the patients with them till the last moment to further their commercial interest, when life threatening crisis emerges, many a times it gets too late for the patient to be referred to a more competent healthcare service provider. As a direct effect of such mismanagement, the cost of treatment spirals out of hand and most often, the poor patients family is forced to sell their belongings and fixed assets in order to cover for post complication treatment cost. With depleted financial resources, this vulnerable community also fall prey to the vicious cycle of moneylenders, a trap they mostly fail to recover from throughout their lives. It is commonplace enough in Jharkhand that a patient or a pregnant woman might need to travel across hills and rivers and walk for 10-15 km before reaching any government healthcare delivery point like primary health centre or community health centre. Even if one would reach any such place, chances are that the centre would be ill-equipped and understaffed and in most cases, without a doctor. Among other secondary effects, in the absence of any kind of monitoring mechanism and as the quacks mostly thrive beyond the realms of any regulatory agency, misuse of drugs, especially antibiotics, cause drug resistance and side effects arising out of wrong application and dosage administration. As one can see that in case of healthcare too, the poor end up paying a disproportionately huge penalty only for being poor. Background of the Franchise Lab Project Latest reports suggest that out of contractual appointment offered by the Jharkhand state government to 1868 doctors, only 350 are in state service today, while the rest have left for better opportunities. At a current deficit of 1500 doctors, with the total annual output of medical graduates in the state being only 190, it would take the state about eight years to fill up vacancies even after assuming a zero attrition rate. The state is also deficient in trained medical resources and infrastructure with only about 1700 sub centres and 284 primary health centres present out of the required number of 7000 and 1000 respectively. This kind of numeric challenge puts a serious constraint in ensuring mandated health services in the state and obviously with the present quantity nowhere close to the requirement, talking about quality of care remains a far cry. No wonder,
the state today stands with very poor health indicators like Infant Mortality Rate of 69 or Maternal Mortality Rate of 371 (National Family Health Survey-3). KGVK, a social enterprise promoted by Usha Martin Group, is now working on incubating sustainable business models in healthcare in Jharkhand, to combat this grim healthcare situation in the state. The International Finance Corporation (A World Bank body) has collaborated with us providing seed capital and technical assistance in creating such business initiatives at the grassroots. We have adopted innovative business processes as one might find in a franchising system. In the pilot stage, the Franchisee lab initiative targets to serve the rural community in Jharkhand, substantial part of which are represented by the below poverty line (BPL) population. The size of the population to be covered in the first phase is estimated at approximately two hundred thousand. Once successful within a limited region, the project aims to scale up across the country in the next three years. The Franchise Lab project has the following key components: A. The Shalini Hospitals Network- A chain of franchiser owned secondary care hospitals located in the rural area that offers: Referral linkages to primary healthcare backbone integrated training facility to run a community health program (1 year course) to groom and generate prospective franchisees. The secondary care hospital network will aim to plug the gap in the infrastructure deficiencies of the government health systems and also stand as model supplementary facilities through public private partnerships as defined under the National Rural Health Mission framework. B. The F Lab Franchisee Running a health kiosk known as Shalini Swasth Kendra, the F lab franchisees are full business format franchisees, offering a range of primary care service that includes: Ante natal, post natal care and other safe motherhood support Basic diagnostics (to be integrated with telemedicine in the next phase) Creating secondary referral linkages with Shalini hospitals network Dispensing of OTC drug and other basic medicines like DOTS, anti malarial/ anti diarrhoeal etc. Educating the community about preventive care and selling related products 25
like low cost water filter, medicated bed nets etc. Family planning service including dispensing of temporary contraceptive methods C. Support systems Patient Transportation service: Low cost transportation from franchisee locations to secondary care facility through common pooling of patients integrated to pick and drop service. The Telemedicine network: Telemedicine initiative aims to leverage maximum potential of limited medical resources available in rural areas. The franchisees will be having simple kiosks that will connect them to the medical resources available in the secondary care hospitals and statewide network of super specialist panel. In the second phase, KGVK plans to introduce telemedicine facility within the franchisee network. Simple interactive kiosks will connect the remotely located franchised Shalini Swasth Kendras with its Shalini Hospital network, where expert consultation will be available for further patient management at the franchised outlets. The communication system that is being designed at the moment for the telemedicine infrastructure is divided into two stages. Stage-1 Infrastructure is provided by Indian Space Research Organisation (ISRO), which has three components, namely, the satellite, a hub or the uplink facility and the remote terminals located at the Shalini Hospitals. The remote terminals are capable of having two-way communication to facilitate interaction. The network operates in extended C-band with uplinks for telemedicine requirement. The remote terminals have 1.8 m antenna and 2-Watts RF power amplifier. The hub or the uplink facility have 4.5 m antenna and 20/40 Watts power amplifier operating in extended C-band. The network operates with TDM/TDMA technology and is essentially a Star network. The required bandwidth for the proposed network is on INSAT-3A at 93.50 E longitudes. The hardware at each node includes VSAT, satellite modem, Multimedia PC, web cam, speakers, microphone and ISRO proprietary software. The key features of this stage -1 infrastructure are as follows: Non-redundant TDM/TDMA Central Hub DVB-S Forward link & TDMA Return link Star network with Hub as central node Shalini Hospitals as end node One Extended C Transponder Satellite support through INSAT-3A 4.5 m Antenna – 40W Power amplifier The first stage infrastructure is already established within the hospital network as of date. Stage-2 The second stage will connect the Shalini Hospitals network with the Shalini Swasth Kendra franchisees through dial up and wi fi network (wherever available). Information and external linkages available from the Stage-1 ISRO 26
The KGVK Tele Medicine Network
network will be further channelized to the franchisees. The franchisees will be equipped with low cost laptops powered by solar panels. These laptops are further integrated with tele pathology devices like Glucometer, and digital ECG machines. Apollo Telemedicine Network Foundation (ATNF) has offered technical help to design the software solutions for the second stage, which is currently being evaluated and worked out. As per plan, by the end of 2008, the F Lab franchisee network will be having end-to-end connections between the hospitals and the ISRO hub. USP of Franchise Lab project The key reasons for which the customers are likely to avail the services of the F Lab Franchisee and the secondary care hospitals are: Convenient access to quality, ensured domiciliary and primary healthcare within the community 24/7 and early secondary care in the hospitals. Fair and standardised pricing, ruling out opportunistic super normal profits resulting from malpractices of rural quacks. Shalini Swasth Health Card, a scheme that provides heavily discounted annual health care plan that acts as a cover to out-of-pocket health expenditure. Support through low cost transportation facilities that connect the franchised outlets and the hospital network on the daily basis. The facility is offered through a pooling service so that per head transportation cost is reduced significantly. By the time this article goes to press, the first round of training and orientation for twelve franchisees will have just completed and the commissioning of the project is expected within July 2008. www.ehealthonline.org
“Resources for Success”
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Sage Development Partner of the Year 2007 - 2008
Networks That Help Care A world leader in networking solutions, CISCO has grown phenomenally since its inception nearly 25 years ago. Kapil Khandelwal speaks to us about their plans to expand in the Indian market by providing innovative and cost effective solutions and platforms to cater to the ever-growing need for better connectivity.
Kapil Khandelwal Director - Healthcare & Life Sciences (APAC and Emerging Markets) Cisco
Q. What products and solutions are currently offered by Cisco for the healthcare sector? A. Cisco is transforming healthcare through its “Human Network” by using information to drive patient-centric, safe, and efficient care. Through its “Connected Health” vision, Cisco enables collaboration across the care continuum for safe, affordable and accessible healthcare. This transformation will empower patients to control, manage and influence their own healthcare. The strategic implementation of “Connected Healthcare” can drive a significant reduction in healthcare costs while improving healthcare quality. The key products and solutions that Cisco offers to transform healthcare though its “Connected Health” program is under the broad areas such as, Medical Grade Network, Connected Imaging, Location Aware, Mobility for Healthcare, Health Presence, Virtual Expert, Public Health Safety and Environment, Clinical Collaboration, Connected Pharma/ Retail Network and Connected Smart Hospital Buildings.
Q. Ensuring seamless ‘care continuum’ for patients is emerging as a key differentiator in improving quality of healthcare. How can Cisco help achieve this objective for care providers? A. Cisco is playing the role of a key enabler and a transformer through its Connected Healthcare solutions that enable seamless care continuum for the patients not only in the urban but also in the remote rural areas. Cisco’s products and solutions ensure creation of a high quality collaboration environment for the caregivers, creation of a multi-channel and multi-modal healthcare information exchange and creation of a reliable, secure, available, mobile medical grade network.
Cisco’s opportunity is in the shift in the “Human Network” to a “Societal Platform” that enables all the providers as well as the consumers in different care settings and environment
Q. Kindly give a brief account of the ‘HealthPresence Pod’ that you are piloting in India. What are the findings in terms of deployment and feasibility in Indian context? A. Cisco has already showcased its HealthPresence Pod at its Customer Briefing Center in Bangalore for its customers in the region. It has also engaged with several customers in the private, government and armed forces for this solution. The response for adoption to this platform has been quite positive. We are now exploring different solution variants to cater to different segments and needs of the market in India. Q. Healthcare industry in India is witnessing a phenomenal growth in both qualitative and quantitative terms. How do you foresee the market opportunities across the different tiers of service providers? A. The phenomenal growth in healthcare across different tiers of service providers would get a quantum jump if they were connected in such a way as to deliver seamless care across the care continuum. Cisco’s Connected Healthcare enables all the tiers of service providers and consumers of healthcare. Hence, Cisco’s opportunity is in the shift in the “Human Network” to a “Societal Platform” that enables all the providers as well as the consumers in different care settings and environment. We believe that Connected Healthcare would make the care delivery across the care continuum faster, better and cheaper, but would also increase the total pie of the market in terms of the access to care. Q. What is your level of success so far in the Indian market? What are some of your most successful installations in the Asian region? A. Cisco has been encouraged with the market opportunities in India and the developing Asian countries. Especially, given the healthcare indicators that indicate a tremendous opportunity for improvement of faster, better and cheaper delivery of “Connected Healthcare” in this region. Moreover, one must note that Cisco is one of the early movers of Web 2.0 solution enablers in healthcare.
Driving Health IT On Started in 1997, Srishti Software Applications Pvt. Ltd., a Bangalore based provider of Healthcare Management Information System, has in the last decade grown from a small indigenous software company to one with a global presence. The organisation serves a wide variety of clientele with its products and services in the areas of Knowledge Management, Healthcare Information Management System and Enterprise Application Integration. Ajay Shankar Sharma, CEO, Srishti Software, shares with eHEALTH the challenges and opportunities in healthcare IT market today.
Ajay Shankar Sharma CEO Srishti Software 30
Q. In what ways does health IT differ from general enterprise IT? What differences in complexity, functionality and performance signifies healthcare specific solutions? A. Justice to this question will perhaps require at the least an article to be written. However in brief, Healthcare IT, especially on the clinical side, deals with the lives of people, so very different degree of resilience and robustness are required in these solutions. Healthcare IT has to also deal with another eco-system, which includes Laboratory equipment, Imaging equipment etc. manufactured by other vendors. Integration of the same is complex, although integration standards exist. However, it is even more challenging in India and other developing countries since the healthcare institutions have old equipment which are not compatible with these new standards. Healthcare IT has to also deal with services organisations like the Insurance companies, since insurance is closely linked to patient care, and for this each country has different processes and practices. Patient data is extremely sensitive information and access should be allowed on only a need to know basis. With the emergence of healthcare tourism, remote availability of patient data has gained high importance. This brings a different complexity in data security and performance. Q. What solutions and products are you currently offering for the healthcare sector? A. We have a product line by the name of PARAS and it includes modules like, PARAS Hospital Management Information System (PARAS HMIS), which can completely automate any medical institution of any size, quickly and comprehensively. It supports the latest healthcare trends (including Web-enabled features, International Classification of Disease ICD for on-line diagnosis tools, HL7, DICOM etc.) to allow healthcare providers to do more advanced work, and to start using the system almost immediately. PARAS EMR (Electronic Medical Record) facilitates the capture of patient details right from patient registration up till the final stage of discharge. In PARAS, the patient’s EMR can be created, retrieved, and updated online by any authorised hospital personnel, thus providing consistent patient data. PARAS Clinical Pathways or PARAS Integrated care pathways are care plans that detail the essential steps in the care of patients with a specific clinical problem and describe the expected progress of the patient. It aims to facilitate the introduction into clinical practice of clinical guidelines and systematic, continuing audit into clinical practice; it provides a link between the establishment of clinical guidelines and their use. They help in communication with patients by giving them access to a clearly written summary of their expected care plan and progress over time. PARAS Telemedicine involves acquiring medical data (like medical images, EMR etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment. It can transmit text, sound, images and video July 2008
We have a product line by the name of PARAS and it includes modules like PARAS Hospital Management Information System (PARAS HMIS), which can completely automate any medical institution of any size, quickly and comprehensively.
from one location to another. This system optimises the organisation and delivery of medical and professional resources, reduces the need for patients to travel and allows local health authorities to purchase a far wider range of healthcare that might be possible within any one geographic region or medical infrastructure. PARAS PACS (Picture Archiving and Communication System) helps in storage, retrieval, distribution and presentation of images. It enables images such as x-rays and scans to be stored electronically and viewed on screens, so that doctors and other health professionals can access the information and compare it with previous images at the touch of a button. PARAS Clinical Decision Support System (ISABEL CDSS) support system is designed to enhance the quality of diagnosis decision-making. Its unique feature is a diagnosis reminder system. It has proved that it is fast, easy to use, improves patient safety and quality of care by augmenting providers’ knowledge and cognitive skills in hospital and family practice. PARAS Prescription Management System is a drug interaction module, which highlights a change in the effect of one drug when taking a second drug concomitantly. It helps to analyse the effect of the drug, which arises when taken with the already prescribed drug. Different colours represent the levels of effects. This way it helps to avoid medication errors preventing adverse drug effects and hence improves the patient care. As per the hospital requirement PARAS is divided into categories such as, PARAS Ultra, Paras Lite, PARAS and PARAS Premium. Q. Emerging healthcare industry in India is boosting the demand for hospital IT solutions/services. What is your view regarding the growing opportunity in the 31
domestic market? What share of the Indian market do you target in the next 3 years?
will be enough market for stand alone HIS solutions from the mid-size and enterprise healthcare providers.
A. I think the opportunity in the domestic market is expected to continue growing for another 10-12 years, and the IT-spend will zoom in the next 3 years in both public as well as private institutions. Both the public and private segments are currently on different plains of maturity from the point of view of IT-spend. The various State governments are seriously considering integrating the healthcare system by computerising the various levels of healthcare starting from District hospitals to PHCs. Many governments have attempted, but have not succeeded completely because of the sheer size. The good news is that the State governments are looking at moving ahead and starting the initiative. They have realised that an efficient healthcare program cannot be administered and monitored without an integrated IT platform. Hence, we see large healthcare IT spending from the public sector. Looking at the private healthcare IT spending, there are many institutions, which went in for the first round of computerisation. These solutions had limited functionality and are outdated. Thus, there is a big market ready for replacement. There is a huge shortage of bed capacity in India, which will translate into many new hospitals coming up in the country. The trend with the new hospitals coming up in India is that they consider computerisation of the hospital as part of the essential infrastructure. This means more IT spending from the private healthcare segment. Another emerging segment is Healthcare Tourism. From current revenues of around US$ 300 million, it is estimated to grow to US$ 2.2 billion in 2012. This means that by 2012, India will be catering to around 750,000 foreign patients per annum. This calls for higher bed capacity, ultra-modern Care Centers and availability of patient data remotely, and all of them call for higher IT-spend. While the entire ecosystem is getting digitally enabled, there will be tremendous pressure on the small and medium enterprises (SME) sector, which is huge. Most of these healthcare providers are running PAS and would be forced to computerise enterprise-wide. This will throw open a new market segment for SMEs. We have built various products keeping the above scenario in mind and we feel that our market share will be between 60-70%.
Q. How was your experience of working on the PACS implementation project at the Presidentâ€™s Estate Clinic at Rashtrapati Bhawan? Has this successful implementation at the nodal power centre inspired more confidence in other public health facilities? Which are some your other successful PACS installations?
Q. A large number of healthcare providers in India (particularly small and mid segment) are shifting towards uptake of hosted and shared IT services. In this context how do you foresee the changing paradigm in market opportunities for standalone HIS solutions? A. Both the models will co-exist for at least another 7 years. It is a little difficult for the shared services model to take off in India, as our healthcare providers do not have standard processes and procedures right from Patient Admission to Patient Discharge. There are no stringent laws against data mismanagement, which puts a question mark on data security. While we are not closed to any model, we feel that there 32
A. It was a very enriching experience for us at Srishti. The project involved connecting multiple locations for the purpose of radiology. The studies could be sent to experts at AIIMS and Army Hospital (R&R) for further expert advice. Additionally, complete archival of studies for patients is allowed, comparing previous studies for the same patient, which facilitates better decision-making by the radiologists and doctors. In all capacities this, I would say, was a great initiative from the hospital of the first citizen of our country to provide better healthcare for its staff. I think other government institutes will take inspiration from this and follow the way shown by the President of India. We have recently completed deployment at KG Hospital, Coimbatore. There the hospital is planning to use the IT infrastructure to not only diagnose patients who physically arriving at their main center, but also remote outreach centres where radio-diagnostic facilities are difficult to get. Q. What differences do you notice in terms of IT maturity of healthcare industry in developed markets (such as US, UK, Middle-East, SE Asia) and that of India? How different are your strategies in terms of addressing these different geographies? A. In India, buyers are more discerning and are not very eager to experiment. Therefore, whatever we offer has to be foolproof and time-tested. Based on this fact, we have realigned our sales and marketing strategy to meet Indian customersâ€™ expectations. Q. How do you gauge the market in Middle East, Africa and East Asia? How successful have you been so far in your efforts to enter these markets and how receptive are they to Indian solution providers? A. They are similar in nature as far as buying behavior is concerned. Few markets are more price-sensitive than India and few are more willing to pay a premium. Indian healthcare solutions are finding more acceptance in these markets now than ever before because of rich functionality and reasonable pricing. Barring a few countries in Africa, it is still a challenging market. Middle East and East Asia is a good replacement market since they had implemented legacy or out dated systems. Again, some countries are targeting Healthcare Tourism, which provides new opportunities. We have met reasonable success in these markets so far, and have a couple of implementations in the process. www.ehealthonline.org
ELECTRONIC MEDICAL RECORDS
A luxury or a necessity?
Prof. (Dr.) Prashant Sathe M.S. (Surgery) Principle Consultant (EMR and Academics) 21st Century Health Management Solutions Pvt. Ltd.
he Indian medical fraternity, especially the unorganised private sector, has been over the years quite unconcerned about preservation of patient records. I know it is a very aggressive statement, but it is a fact and every clinician will admit to this even if not on the podium, surely in private. The organised sector, though, is much better at records preservation systems, although most of these facilities are centered on manual preservation of records carrying with them all the inherent difficulties of the same. I still remember the days when we, as postgraduates use to throng the Medical Record Office (MRO) to get some retrospective data on some disease entity. Be it for the thesis or for case reports or case studies. The kind of difficulties, which we faced were enormous. Today after 20 years, as I look at the effort my postgraduate students have to put in for similar work, I see that the status of records is quite the same in most institutes. The question to be raised here is whether the times allow us to remain stagnant in this way? The answer is a clear no, simply because demands on the Indian healthcare scene are rising. The Changing Scenario Following are some of the factors which warrant accountability and also demand unambiguous, formatted, self explanatory and secured clinical data preservation: The clinician today is legally more accountable. In view of the growing consumeristic trends, the records need to be accurate and formatted, since the patient, the consumer July 2008
in this service industry is becoming more demanding, aware and conscious of what is due to him. The arrival of health insurance will also make it mandatory for the records to be strictly in a more standardised format and be based on protocols. The arrival of quality and accreditation on the scene makes a demand on clinician and healthcare organisation to have preservation of records on strict format. We are now on the threshold of the very demanding sector of medical tourism. Naturally the records need to be in tune with international norms, plus they should be accessible on the web. Globalisation of healthcare makes it a must to match international standards. Advent and propagation of telemedicine demand the data transfer and hence reliable technological back ups for data preservation. Moreover there is a need for precise statistical retrieval in current era to promote research, be it molecular, genetic or even simple registry based statistical. Corporatisation of healthcare scene demands statistical retrieval be it for financial or professional reasons at a touch of a button on the keyboard. Medical teaching and education in Institutes is awakening to the needs of Clinical research and the aptitude is taking shape amongst the new generation of Medicos. They will need easy access and retrieval of patient records.
If one surveys the level of automation across various industry verticals, healthcare industry is among the least auto33
mated. Studies have estimated that the healthcare industry as a whole is almost 20 years behind the rest of the industries in terms of automation of various processes. Whatever advances were readily accepted by Indian medical fraternity were mainly in Medical Electronics and Instrumentation. However, in terms of automated preservation of records, the acceptance of technology and/or systems has been very slow. Electronic Medical Record (EMR) or Electronic Health Record (EHR) by definition is a patientâ€™s medical record in an electronic format, accessible by computers on a network for the primary purpose of providing healthcare and healthrelated services. Even in the west, the acceptance of EMR has been quite slow and gradual. In fact, 2006 has been termed as a record year for EMR adoptation at large in the US. The reasons why the West adopted it faster than India is perhaps based on certain specific factors dominating the Western healthcare scene, such as increased patient awareness, new government initiatives encouraging EMR, high penetration of computers, new product innovations, economic pressures on healthcare organizations and increased legal compulsions for greater accountability and well-maintained records.
Fig. 2: Ideal information flow in a thorough electronic medical records (EMR) system
Advantages of EMR System In India, costs and limitations in software, hardware and networking technologies has made EMR difficult to implement, especially in small, budget-conscious and multi-location healthcare organisations. The term EMR is often used loosely to include even the demographics, which are usually included in simple patient management software. However, a true EMR system such as the 21st Century EMR, must technically be capable of handling the certain functions as a prerequisite, such as, that an EMR system must capture the entire patient data on a fixed format at the point of care. It should ideally be using a database, rules engine and knowledge base as the primary source of information; it should allow software integration of the EMR data with other data such as billing, practice management, laboratory, imaging and pharmacy systems. This
saves time for the clinician by reducing double data entry in the other systems, while also ensuring the quality of data throughout the entire system. A good EMR system has the capability of providing Clinical Decision Support (CDS), helping in developing and implementing a providerâ€™s decision making. Since, the capture of clinical and demographic data is in a pre-determined format, it allows several clinical attributes to the data processing like, clinical decision-making by accessing a rules engine to provide alerts, reminders, clinical protocols, coding assistance etc. Further, since the system integrates with other components of hospital information and management systems like Lab, Pharmacy and Imaging, it can provide real-time data to the provider in its entirety, right from symptomatology, signs and investigations, thereby facilitating better clinical
Fig. 1: Data collection and management in a complete EMR system
Fig. 3: A good EMR must allow integration of DICOM, non-DICOM, waveform and digital data
decision-making. It also allows access to large amounts of data quickly, permitting to analyse and report data quickly and easily, including clinical statistics analysis, population health, and other reports. Along with the above, basic attributes, a true EMR system should do justice to the following requirements: Patient Charting Order Communication Systems often referred to as Computerised Physician Order Entry (CPOE) Document/Image Management Patient Portal, which enable patients to access their health record from any computer with a secure Internet connection, from anywhere in the world Statistics and Reporting Data Entry Data entry has always been one of the greatest inhibitions for clinicians. It was perceived that the data entry needed to propagate the EMR systems, is difficult, time consuming, needless and involves a lot of attention. This is also feared to take away the attention from a patient’s disease and diagnosis. But one would realise within a short training period that these apprehensions are totally unfounded. The ease with which information is entered into the EMR is directly proportionate to the length of the learning curve and the time required achieving the benefits that an EMR provides. Today’s technology advancements have made things further simpler. There are many different ways that data can be entered into an EMR. One may use one or more or any combination of methods depending upon the type of system one chooses. The crucial point is selecting the right method, for the right people or job. The available options for data entry are: Keyboard/touch screen - Basic Patient Data Mouse/touch screens - History, Findings, Diagnosis, etc. E Pens on Touch screen Monitor. Cable Communications - DICOM, Non-DICOM Instrument and Digital Camera Data Video Signal Transfer - Slit Lamp, Fundus Camera Voice Storage/Transcription - Unusual Letters, Non-Standard Findings Costs Installing a comprehensive EMR system can be expensive. A system that will give the healthcare organisation all of the information available now in paper, including imaging capability, drawing, voice storage, instrument interfaces, visual fields, etc. is going to require a networked system in each examination lane. A computer will also be required at each location in the premises where information is collected from a patient or reviewed by a physician or staff member (screening rooms, visual field rooms, etc.) The typical cost is factored by a) Hardware, Software, Training, Installation and System Customisation and b) The costing per workstation (computer) in a LAN (local area network) or on the basis of WAN (wide area network). However, cost is a relative factor and one can get the reJuly 2008
turns on investment, if one takes into account the following clinical and patient benefits achieved in a comprehensive EMR System: Electronic Medical Record (EMR) improve Clinical Decision Making (CDS). The CDS capabilities of EMR systems are a well known attribute. However, this is achieved only at the ultimate or penultimate implementation stage. 21st Century EMR is packed with many tools to help doctors make better decisions. These range from diagnosis to prescription generation to treatment plan recommendations. Adverse Drug Events (ADEs) are responsible for 2.1 million injuries and 100,000 deaths every year. With medication dictionaries, the clinicians get ADE alerts, generic drug recommendations and dosage recommendations. The EMR is also capable of making treatment recommendations based on a patient’s diagnosis. (e.g. care guidelines from Milliman) Health maintenance reminders help keep the doctor and his/her staff updated on what treatments or checkups the patient is due for, through an automatic alert or report in the EMR. These alerts can even be sent to mobiles and PDAs. Due to the integration of data about the patient through the integration of external sources (labs, pharmacies, imaging centers, hospitals) the provider is informed and explained decisions quickly. Enhanced documentation will protect both the patient and the clinician from complications in the future. 21st Century EMR comes equipped with a security administration module enabling administrators to manage access to patient records only through user permission. Most academic advantage of having patient documentation computerised is the ability to extrapolate data for reporting capabilities. This becomes very useful for research reports, statistics, health maintenance reminders, drug recalls and patient marketing. Web consultations are a possibility, being able to access patient data from anywhere in the world via a secure connection even allows the doctor to conduct web consultations or generate reports from home. Telemedicine and Teleradiology is just one example of these extensions. The recent launch of Google Health and Microsoft’s HealthVault portals is an indication of things to come. Health maintenance reminders that can be automatically generated from an EMR system also contribute to providing improved patient care. Conclusion Overall, Electronic Medical Records enhance patient care, however, the benefit may be difficult to quantify at this stage. But with the increasing role of Health Insurance as payers, the increasing demand from informed patents for transparency and the ever increasing use of technology like Telemedicine etc. in the delivery of healthcare, I would recommend to healthcare providers to look at EMR adoption not from a ROI (Return on Investment) perspective but as a TINA (there is no alternative) factor! 35
Mobile Future for Medical Diagnostics Q. There are other mobile ultrasounds available in the market - what would you say is the differential advantage of your products?
Pavan Behl Country Manager SonoSite India Pvt. Ltd.
The future is bright for the mobile medical diagnotics industry as this interview with Pavan Behl, Country Manager, Sonosite indicates. At 40,000 units and counting, the company has created a niche for itself through innovations in its portable ultrasound products. 36
A. SonoSite is the specialist and world leader in hand-carried ultrasound. Our hand-carried ultrasound systems offer significant advantages over other portable ultrasound systems. Our sophisticated ASIC technology allows us to build systems that weigh about 3.8 Kgs or less, and therefore, are far lighter and easier to hand carry than products offered by other companies. Our systems use Vx Works operating system and not the traditional Windows operating system (OS). Due to the proven stability and reliability Vx Works is the chosen operating system for many â€œmission criticalâ€? uses in areas like military, airline and the space industry. The rapid 15-second boot-up time of SonoSite products, make them ideal for point of care clinical settings where seconds count, such as when assessing and treating critically ill or injured patients. There are some products that take upto 2 minutes to boot up, which is time that physicians and their patients sometimes cannot afford to lose. SonoSite systems are designed with the user in mind; they are very easy to use, reliable and durable. The importance of a battery backup time of up to 4 hours, in many cities in India, where stable power supply is limited cannot be overstated. To enable our products to meet reliability and durability expectations, the quality control and product testing requires that our transducers and systems are able to survive a 1-metre drop onto a hard surface Our products have such a strong history of reliability that our MicroMaxx and the latest models M-Turbo and S series carry an unprecedented 5-year comprehensive warranty significantly reducing the maintenance costs, passing a significant financial benefit onto the customer. Q. Please tell us about the data storage and archival methods in your product. www.ehealthonline.org
and appreciated the program. Q. Do you see a considerable rise in the uptake of ultrasound machines by doctors in different specialities and clinical situations?
A. All of our images or clips are stored on flash cards or pen drives, depending on the system, so for storage and transmission of data, the doctors can carry the flash cards or pen drives instead of the whole system. The data can be archived into a remote computer using DICOM or our Sitelink software. Our systems can capture both a stationary image as well as clip storage. A clip is critical in cases when the stationary image may not communicate all the details like in the case of Cardiology. Q. How easy is it to integrate your products to the existing IT infrastructure of the paper and wireless environment of Smart Hospitals of today? A. Our systems are DICOM compatible, so the patient data/ images can be easily transferred to the hospital information network. Many hospitals now have DICOM/PACS facility, which is integrated to a central server and all their medical equipment are configured to these servers. In all our models data can be transferred from the system to the hospital’s ospital’s Hserver and the picture can be printed or emailed as required. Our systems can be connected through LAN or Wifi. One can also transfer the data manually from flash card to computer using our Sitelink software. We have now also introduced the facility for saving the data directly on to a pen drive in our latest models M-Turbo and S-Series. Q. SonoSite is known for its intensive training programmes and involvement in continuing medical education (CME) programmes. Please tell us how successful these activities are. A. SonoSite’s strength worldwide has been the focus on education and training. We collaborate with leading teaching institutes and hospitals worldwide, to impart training, both onsite as well as online. We work with education providers across the world to offer medical professionals training on the latest clinical applications of ultrasound. We offer both standardised and customised modules to support the specific training needs. These programmes have been very successful looking at the large number of medical professionals who have attended July 2008
A. Traditionally ultrasound systems were used in Cardiology, Radiology and Gynaecology departments. But increasingly a number of other departments such as Critical Care, Emergency Medicine, Regional Anaesthesia, Operating Theatres are interested in offering a direct ultrasound services for clinical applications where imaging gives immediate answers to specific questions and so the hospitals are purchasing units for different departments. Also healthcare infrastructure is developing rapidly across India. Hence, we feel that the need for more ultrasound units, particularly hand-carried will increase rapidly. The medical fraternity is becoming more and more aware of the advantages of using these systems and the benefits in terms of timely diagnosis leading to faster patient recovery. For many years the medical device industry has been concentrating on improving the quality and sensitivity of imaging to increase the diagnostic confidence of the doctor, which is vitally important. However, this also tends to increase cost and results in high quality diagnostic imaging being available to only a limited number of the population. Technology such as SonoSite’s Chip Fusion™ Technology, allows SonoSite to provide high performance ultrasound at a reduced size and cost which is vital when we need to offer healthcare to a broader range of people. Q. How many installations do you have currently in the world and also specifically in India? What are the various marketing strategies you adopt for a vast country like India? A. SonoSite has worldwide sold over 40,000 units since 1999. Its products are known for exceptional performance, ease of use and durability. In 2007, we established a Direct Subsidiary in India headquartered in Gurgaon to support our growing sales and service operations in India and we have been delighted with the response from the market. Through a direct team of highly skilled and experienced sales, applications and Service support personnel spread across the country, SonoSite is successful in helping clinicians deliver better patient care by bringing high performance visualisation tools right to the patient bedside. The efforts of the Direct Team are supported by a team of regional distributors in all States allowing us to offer full customer support all across India. SonoSite products are affordable and competitive. Offering a free 5-year warranty on our latest products allows clinicians to use their budgets to provide the best equipment for their patients, without the worry of ongoing costs. We are supporting various CME programmes and workshops to educate clinicians about the new applications of ultrasound in Critical Care, Regional Anaesthesia, Emergency Medicine and Musculoskeletal ultrasound. 37
Consultations for a
Healthy Future Hosmac India Private Limited is a pioneering name in the field of Hospital Planning and Management consultancy in India. Since its inception in 1996, Hosmac has grown rapidly to become a unique hub of skill sets which cuts across various facets of a healthcare facility be it architecture, engineering, management, or information technology. Itâ€™s Managing Director, Dr. Vivek Desai shares with eHEALTH the vision and strategy of Hosmac.
Q. Hosmac has carved a niche for itself by becoming a one-stop consultancy for the healthcare sector in India. Please tell us in detail about the services that you provide, your primary areas of expertise and projects that have been successfully completed so far. A. Our services are broken down into two major areas. One is management consulting, wherein, we conduct market research; create detailed project reports, do management audits, public health consulting, fund syndication, recruitment and such activities. The other is project consulting, wherein we undertake architectural and engineering design of a hospital on a turnkey basis and also provide project management services for construction of hospital buildings. Equipment planning and procurement services are also provided within this vertical. We are in process of taking this further into an EPC format where we would also build hospitals.
Dr. Vivek Desai Managing Director HOSMAC India Pvt. Ltd.
The public sector is perhaps the only healthcare available in the remote regions of the country and hence, something needs to be done about it and public-private partnerships (PPP) maybe a right step in that direction. Q. Hosmac has been receiving a number of assignments from abroad. In this context, you have in the past suggested going the BPO way to meet the demands. How far has this idea materialised? What kind of services do you plan to offer to overseas markets? A. No, we are currently not providing any consultation through BPOs and most of our work is first hand designing of buildings, else management consulting assignments. Like we have undertaken a business process re-engineering study for Aga Khan University Hospital in Nairobi, Kenya or are assisting KPMG for setting standards for healthcare facilities for Ministry of Health in Abu Dhabi. To further our business in that region, we have also opened a 100% fully owned subsidiary by the name of Hosmac Middle East FZ LLC in the Dubai Healthcare City and intend to use that for furthering our overseas business. We are currently designing hospitals in Dubai, Sharjah, and Saudi Arabia. We have been operating in the region since last 4 years and have good grasp of the healthcare industry there as well as building design norms. Q. How different have your experiences been with the public and private sector in terms of having a holistic view of both technical and non-technical aspects of managing healthcare facilities and service delivery? A. In the Indian context, there is a huge disparity in the way the two sectors are positioned. Whilst one is almost a free model, it is the old, over-worked and poorly maintained infrastructure serving the low socio-economic strata; while the other is more urbane and attractive healthcare infrastructure with state-of-the-art technology serving the upper class and patronised by insurance companies as well. Both are worlds apart and hence no comparison is really possible. It is in fact, difficult to fathom how we may be able to bridge the gap. Having said that, the public sector is perhaps the only healthcare available in the remote regions of the country and hence, something needs to be done about it and public-private partnerships (PPP) maybe a right step in that direction. Q. Does your work with the development sector July 2008
partners have any significant bearing on the government enterprises? Is there a noticeable ripple effect that one project has on the other? A. Yes, I think there is movement in the right direction with the government looking keen on bringing in the private sector in some way or the other; be it in setting up of facilities, undertaking mid-term evaluation of programs to take corrective actions, or seeking investment to set up or upgrade public facilities. EMRI in Andhra Pradesh and Chiranjeevi Scheme in Gujarat are some classic examples of success, which can be replicated. Q. What is your take on Public Private Partnerships in the field of healthcare? According to you, what are the key policy changes that need to be effected for the successful implementation of these initiatives? A. I think we need to understand clearly that private sector’s motive is profit, and that should not be compromised while setting up the terms of reference for any PPP model. Some key criteria for a successful partnership between the government and private companies could be: • Limiting the role of the government to only formulating policies and providing a suitable environment. • Self-regulatory mechanism of accreditation to be pushed in more aggressively. • Practical schemes, which allow the private player to earn and retain fair profit. • Mechanism to insulate such contracts from political uncertainty. Q. Please share with us your observations on the changing scenario in Indian healthcare sector. How do you foresee the maturity and value improvements of healthcare providers in the next few years? A. The future of healthcare in India looks extremely positive due to the gross imbalance between the demand and supply. The driver for this growth in my view would be Health Insurance, as more and more people will try to insulate themselves from the high cost of healthcare by subscribing to Insurance schemes. Healthcare providers would in this case be forced to take issues such as accreditation seriously, so as to ensure their enlistment with insurance companies. This will surely improve the quality of infrastructure as well as that of service to the patients. Q. What is your current annual turnover and what share of healthcare consultancy market do you control? Keeping in consideration the present market momentum, what is your target in terms of revenue in the next 3-5 years? A. Our current consulting turnover is around INR 80 million and we expect to more than double it in the next two years. Our focus on EPC projects will help us grow exponentially after an initial phase of consolidation. 39
Indiaâ€™s Largest ICT Event
Indiaâ€™s Largest ICT Event
vCustomer to counsel health issues
ISO certification to be must for ESI hospitals
vCustomer Corporation recently announced its partnership with Jansankhya Sthirata Kosh (JSK) to provide call centre support and counseling on reproductive health, family planning and infant health. The service, available primarily in English and Hindi, would be beneficial to those people who want telephonic advice—particularly adolescents, newly married and about-to-be married couples. All calls in India to the number 6666-5555 will be routed to the centralised vCustomer contact centre based in Delhi. Under the initiative, all call centre agents will be trained by medical professionals to provide counseling. The initial launch would provide support to callers from Delhi and NCR including Ghaziabad, Bulandshahar, NOIDA, Gurgaon, Faridabad and Mewat. The initiative has received technical support from the National Informatics Centre (NIC), Nasscom and the Central Bureau of Health Intelligence (CBHI) in India. Speaking on the occasion, JSK Executive Director Shailaja Chandra said, “The idea of unique call centre came from medical practitioners who felt that even basic knowledge about reproductive health was very poor.” Helplines cannot address the width of subjects on which people need information. Hence JSK has started this initiative”. Customer CEO Sanjay Kumar said that this partnership has given the company a chance to support JSK by providing call centre services to reach a wider audience and to promote the extremely sensitive and critical issue of population stability in India.
ESI hospitals providing healthcare facilities to workers covered under the Employees’ State Insurance Corporation (ESIC) will be soon required to have ISO certification. Minister of state for labour and employment Shri Oscar Fernandes has said that the certification will be made mandatory so that hospitals provide world class medical facilities to workers of both organised as well as unorganised sector. In the first conference of revenue officers of ESIC, the minister said ESIC revenue officers should dedicate themselves to the cause of healthcare of workers and should aim at increasing the number of beneficiaries to at least 4 crores, same as EPF members. The doctors and staff at these hospitals will be given special training to meet the shortage of medical personnel in the country. The latest figures show that during 2007-08, the scheme was implemented in 37 new areas covering nearly 98,000 workers. The total number of beneficiaries were 3.94 crore. During the year, contribution income increased to a record high of INR 3,249 crore against the target of INR 2,450 crore, thereby registering an increase of INR 800 crore which is 32.61% higher than the target, Ms Pillai said. The motive of this conference was to interact with field workers and make them aware about their role in the implementation of policies and programmes of the ESIC and the ministry.
RG Stone signs on Akhil Systems’ HIS System R.G. Stone Urological Research Institute, a Super Specialty Urological Research Institute setup for providing specialised treatment for Lithotripsy, Endourology, Holmium Laser, Laparoscopic Surgeries and Diagnostics has recently signed on a new Hospital Information System. As they are setting up their chain of Urology Centres all across India and abroad and managing all the centres from Head office becomes quite cumbersome, they have selected Akhil Systems Pvt. Ltd., New Delhi (a company with vast experience in implementing their specialised HIS Software Solutions in hospitals) to connect all the Centres through VPN and implement their HIS System for better management of their Centres through Akhil HIS System. Akhil Systems has designed and implemented for R G Stone a new Multi Location HIS System to work in Centralised Server environment and connecting all the Centres with the Head Office through VPN Network. The software enables RG Stone to manage all their centers from Head Office in on-line environment. The system provides Patients Statistics, Patient Medical Records, Revenue & Collection of each Centre and cumulated Revenue and Collection for all the Centres for better analysis and management planning.
Ericsson, Apollo Hospitals bring healthcare to rural India Ericsson and Apollo Telemedicine Networking Foundation (ATNF), a part of the Apollo Hospitals Group, have taken a major step towards helping bridge the digital divide in rural India by laying the foundation for the introduction of telemedicine delivered using HSPA technology, which will enable the provision of affordable and accessible healthcare to millions of people in remote areas. More than a million people, predominantly women and children, die each year in India because of a lack of healthcare. A further 700 million people have no access to specialist healthcare, as 80% of specialists live in cities. At the same time, the teledensity of India is increasing at a phenomenal rate. A memorandum of understanding (MoU) signed between Ericsson and ATNF will enable them to work together to educate people and to publicise, promote and implement the use of telemedicine deployed as an application over broadband-enabled mobile networks. ATNF will provide expertise in telemedicine, in the form of applications that provide instant medical advice remotely over the network. This will increase access to quality healthcare once the HSPA network is in place, and sets the stage for the creation of a stable ecosystem, based on WCDMA/HSPA technology, to support a range of innovative services. This agreement is part of Ericsson’s support for the UN Millennium Development Goals, which aim to halve extreme poverty and hunger by 2015, while improving education, health and gender equality. Ericsson has been working on several initiatives to demonstrate the use of telecoms in healthcare provision.
Pvt hospitals treating poor for free can claim duty exemption
Infosys to improve healthcare access in rural regions
Only those private hospitals and health centres who provide free treatment to a certain percentage of poor patients are entitled to customs duty exemption on sophisticated imported medical equipment, the Supreme Court has ruled. Coming down heavily on the private hospitals, a bench of Justices Tarun Chatterjee and H S Bedi said: “We are also conscious of the large scale misuse of the medical equipment imported under the exemption notification... it is essential that the authorities regulatory monitor the use of the equipment.” T h e s e observations were made on a petition filed by Andromeda Foundation India Pvt Ltd which challenged the Andhra Pradesh High Court’s judgement that held the company was liable to pay customs duty on the imported equipment. While upholding the High Court ruling, the apex court said that it was incumbent on Andromeda to follow the guidelines designed to ensure that the medical equipment imported at concession terms was being properly utilised. The private hospital had imported equipment for the purpose of conducting diagnostic tests and treatment of patients with specific andrological problems in view of the Central government notification dated 1 March, 1988 that exempted importers from customs duty on equipment imported for specified purposes. However, the Director, Medical Education of Andhra Pradesh, had inspected Andromeda and submitted in its report to Secretary to the Government, Health, Medical & Family Welfare Department, Andhra Pradesh that the private hospital was not providing free services to the poor patients in accordance with the terms of exemption in the notification.
Infosys Technologies Ltd has announced that it has completed deployment of a patient management tool for an award-winning health information technology (IT) initiative to improve healthcare access for rural and underserved patients. Infosys collaborated with the University of New Mexico (UNM) to improve patient outcomes by designing and implementing a Web application that facilitates real-time flow and access of interoperable clinical data among participating health providers, as part of Project ECHO (Extension for Community Healthcare Outcomes). Project ECHO’s Web-based patient management tool has an intuitive web interface that efficiently and securely integrates patient data in real-time from all participating health providers, leveraging Infosys’ Healthcare Integration & Collaboration solution. This is expected to enhance case-based educational experiences by facilitating more informed care-management decision making and continuous training of rural physicians. The cliniciancentric tool also delivers a platform for physicians to stay connected with patients throughout the treatment, ensuring better prognosis and improved patient compliance. Responding to a pressing need to improve Hepatitis-C treatment among rural communities, the UNM Health Sciences Center and the Departments of Health and Corrections developed Project ECHO, funded by Agency for Healthcare Research and Quality (AHRQ). Since June 2004 the project has conducted 205 Hepatitis-C Knowledge Network clinics and provided 2,316 consultations for patients. The Web-enabled software will allow Project ECHO to expand to multiple chronic diseases and health conditions such as HIV, cardiac conditions, mental health disorders, diabetes, autism, substance-abuse disorders, among others. In addition, since the system is delivered via a softwareas-a-service (SaaS) model, it reduces potential technology barriers that previously existed in rural health clinics. The SaaS model is enabled through Infosys’ Healthcare Integration and Collaboration solution, an enterprise Service-Oriented Architecture-based integration solution.
US launches INR 580 m health initiative The US on Thursday launched a INR 580 million initiative to improve maternal and child health in India, with a focus on Uttar Pradesh and Jharkhand. The Maternal and Child Health Sustainable Technical Assistance and Research Initiative (MCH STAR) will work to accelerate the resource mobilisation of India’s major programmes like the Notational Rural Health Mission and Integrated Child Development Services. “Each activity will respond directly to the programme and policy needs of Jharkhand and Uttar Pradseh. It will demonstrate policy and programme successes that can help others to emulate evidence based practices.” The Indian government has some good programmes, and USAID will work with the ministry of health and family welfare to bring better success. “We need an extended reservoir professional research, public health and technical assistance institutions working at global standards that can support government programmes,” said Naresh Dayal, secretary in the health ministry. “Our country is growing well in almost all fields but our health indicators are poor. It’s a shame to talk at international podiums about Indian’s health parameters. We are trying to better the situation,” he said at the function. Currently, of every 1,000 kids born in the country, nearly 60 die. Similarly, 301 mothers succumb to pregnancy related complications after or during childbirth.
HealthSprint eyes 100-fold growth in users
MedPlus unveils diagnostics plans
Healthcare IT services company HealthSprint plans to expand its reach a 100-fold in 2 years to 5 lakh patients a month and take ehealth services to rural areas in tie-ups with microinsurance providers. By then, it expects to be connected through its internet portal to 1,000 hospitals, 2,000 pharmacies and 2,500 diagnostic centres, cofounder of HealthSprint. It currently has tie-ups with about 159 hospitals, including Manipal Group of Hospitals, the Wockhardt Group and St. Johns Medical College Hospital. Through its portal, HealthSprint provides services such as exchange of healthcare data, including health insurance procedures, searches for specialist, scheduling appointments with doctors, securing medical reports and getting prescriptions online directly from hospitals. It also helps connect customers with labs and pharmacies in the neighbourhood. The company’s e-health services for rural areas will be launched in Gujarat and Andhra Pradesh by connecting rural hospitals to those in metropolitan cities and rural customers with microinsurance companies. It is in the process of tying up SKS Microfinance and the Sewa women’s co-operative federation in Gujarat for the venture. HealthSprint also has a tie-up with Yos Technologies to collaborate for creation and maintenance of personal health records.
Pharmacy chain Medplus Health Services has opened its first five regional diagnostic centres already and has plans for 50 more by the end of the fiscal as it diversifies into the lucrative market for diagnostic services. The regional dia gnostic centres for routine tests will first be launched in Bangalore, Chennai, Pune, Vijayawada and Visakhapatnam. A total of INR 20 crore will be invested to set up the 50 centres. MedPlus Pathlabs, a fully-owned subsidiary of MedPlus Health Services, has been operating a clinical reference laboratory for complex clinical tests for the past 8 months. Being part of the organised segment, it would attempt to bring standardisation to the market for clinical testing services, he observed. “There are 40,000 diagnostic labs in the country, mostly individually run, which accounts for the high degree of inconsistency in the services.” The chain plans to add 600 outlets by March 2009, with 70% of these as franchises. MedPlus claims to have a 30% share of the organised pharmaceutical retail market, with a turnover of INR 100 crore in the last fiscal. It is aiming for leadership in diagnostic services with a 40%-50% market share.
India to earn INR 8000 cr through medical tourism Easy access to visa facilities permitted by India to overseas patients coupled with the best emerging medical infrastructure in large and tertiary towns will make the country earn to an extent of INR 8,000 crore in foreign exchange by 2012, a new study has said. Currently, the earnings accrued through medical tourism annually are estimated at INR 3,500 crore. A comparison of the medical treatment costs of various countries shows that a procedure like bone marrow transplant costs US$ 2,00,000 in
USA, upto US$ 2,00,000 in UK, US$ 62,500 in Thailand and just around USD 20,000 in India. Similarly, a by-pass surgery would cost US$ 15,000-20,000 in USA, around US$ 20,000 in UK, US$ 14,250 in Thailand and US$ 4,000-6,000 in India. As a result of higher and very expensive medical costs in the western countries, patients from economies of scale including Africa, Gulf and various Asian countries have started exploring medical treatment in hospitals located in various well-to do places in India, Director of Ganga Ram Hospital and one of the lead authors of the study said. 46
GE Healthcare IT extends collaboration with HP GE Healthcare IT, a division of General Electric Company, has announced an extended collaboration with HP to offer pre-configured, pre-installed GE Centricity® Enterprise software on HP Integrity NonStop servers. The collaboration will target midsize hospitals and developing countries with lower cost and faster deployment of GE’s clinical workflow solution, Centricity Enterprise. GE Healthcare IT is currently collaborating with HP to pilot a lowcost solution for new hospitals in the Gulf region and expects to begin marketing this globally in the second half of 2008. A wide range of offerings is expected through this expanded effort. For over 20 years, the two companies have optimised GE Centricity Enterprise Software and HP Integrity NonStop servers for the world’s leading healthcare providers, ensuring higher efficiency and 99.9999% reliability, a critical component for physicians and nurses in a variety of healthcare scenarios. Further delivering on its commitment to offer customised solutions and faster deployment, GE also announced HP is an early member of the GE Centricity Enterprise Certification Network. As a tactic to meet the growing demand for deployment and customisation, GE will train, certify and support leading systems integrators of the Centricity Enterprise suite. Starting in the fourth quarter of 2008, GE will begin offering training and an associated certification that will provide its partners with the deep knowledge to adapt Centricity Enterprise software. GE will expand the program to include dozens of partners within the next three years. Training classes and certification exams initially will be held at GE’s Enterprise Solutions offices in Seattle and will be available regionally beginning in late 2009.
GE moves US$ 17 bn healthcare business to Turkey In what analysts see as a major vote of confidence for the Turkish economy, General Electric (GE) has decided to move all managing operations in the eastern and African growth markets (EAGM) to Istanbul. Officials from GE Healthcare and Turkey’s Investment Support & Promotion Agency said at a joint press conference on Friday that GE Healthcare, a US$ 17 billion healthcare business, has decided to combine the EAGM region into a single “International Diagnostic Imaging” operation and conduct its activities from Istanbul. The company will split a major part of its operations from its London center and move it to Istanbul. The company’s Western European operations will still handled by the London center. With this new move, GE Healthcare will coordinate all its operations in 80 countries in four major regions - Central Asia, the Middle East, Russia and Africa -- from its Istanbul center. Richard di Benedetto, president and CEO of GE Healthcare, International-EAGM will be overseeing the company’s operations. The EAGM region accounted for more than US$ 600 million in revenue in 2007 and is expected to double the figure to US$ 1.2 billion by 2010 thanks to the new structuring. Currently, a total of 19,217 companies with international capital operate in Turkey, with half of them choosing Istanbul as a base. In the first three month of 2008, 754 companies and branch offices with international capital were established, while 155 international companies bought shares in domestic companies.
Indian Govt allows service sector up to US$ 100 mn external borrowing
Wipro, Cognizant among largest healthcare IT providers in US
The government has revealed its decision to ease its external commercial borrowing (ECB) norm, enabling firms in the service sector - hospitals, hotels and software companies - to borrow up to US$ 100 million for import of capital goods. The decision comes as a big solace to the borrowers in service sector, who are not currently eligible to avail ECB under the automatic route. “It has been decided that henceforth borrowers in services sector, viz hotels, hospitals and software companies may avail ECB up to US$ 100 million for import of capital goods under the approval route,” said an official communiqué issued Saturday. “The amendment in ECB policy will come into force on the date of notification of regulations or directions issued by the Reserve Bank of India (RBI) in this regard under the Foreign Exchange Management Act, 1999,” the statement said. The government reviews its ECB policy regularly in consultation with the Reserve Bank of India to keep it in tune with the evolving macro-economic situation, changing market conditions, sectoral requirements, the external sector and its experience. On 28 May, the government had amended the ECB policy to enable borrowers in infrastructure sector to avail ECB up to US$ 100 million for rupee expenditure for permissible end-uses under the approval route.
Nasdaq-listed Cognizant Technology Solutions, which has major operations in India, and Bangalorebased Wipro Technologies has been ranked among the 100 largest healthcare IT providers in the US. The list compiled by US-based healthcare informatics magazine has been topped by Mckesson. It also features Cbay systems and services inc, which also has substantial presence in the country. According to the list, Cognizant Technology and Wipro HLS, which is part of Wipro Group has been ranked as the 11th and 23rd places, respectively. Cbay systems is placed at the 84th position. The rankings of the companies are based on revenue from the healthcare segment. “This ranking is a testament to the trust reposed in US by our clients. In the highly complex healthcare industry, firms are continuously looking for innovative solutions to meet their business challenges,” Cognizant Senior Vice President & General Manager Krish Venkat said in a statement. “We are privileged to leverage our consultative, industry -specific solutions to help our clients drive process improvements, spearhead innovation and provide their customers with the best healthcare experience,” he added. Cognizant which offers systems integration, business processes and it infrastructures, and testing solutions for pharmaceuticals, healthcare plans among others, employs over 55,000 employees. Wipro HLs, which has an employee strength of about 88,000, provides IT services in the areas of consulting, application development and maintenance, IT infrastructure and business process outsourcing.
Medical transcription sector yet to tap global market India’s medical transcription industry may be showing a healthy growth trend, but it has only tapped a fraction of the global opportunity, say industry players. According to them, the industry players. According to them, the industry has emerged out of the turbulance. “The market for medical transcription is worth anywhere between US$ 6 - 15 billion per year in the US alone, and Indian companies’ penetration in the market is perceived to be barely 10%,” says Somerset CEO Ashish Vachhani. 48
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Kaiser, Microsoft test medical records technology
Kaiser Permanente and Microsoft Corp. recently announced a partnership that the two giant companies hope will push forward the effort to digitise medical records and safely transfer sensitive health data. Kaiser’s 156,000 employees will be eligible for a pilot program connecting the Oakland health maintenance organisation’s health records with Microsoft’s HealthVault, a free, Web-based medical database the technology giant launched in 2007. The slow shift of the American health industry to digitised records has been fraught with complications, particularly that hospitals, medical groups and insurance companies typically have closed computer systems that do not allow for the exchange of information. Kaiser members already have the ability to schedule appointments, e-mail their doctor, re-fill prescriptions and access test results online through the HMO’s health record, called My Health Manager, which is used by more than 2 million people, or nearly a quarter of Kaiser’s 8.7 million members. Kaiser will consider offering HealthVault to its members by the end of the year if the employee pilot, slated to end in the fall, proves successful, Silvestre said. The Mountain View Internet company has announced collaborative arrangements with the Cleveland Clinic and other providers. Partners previously announced by Microsoft, which is based in Washington, include the Mayo Clinic in Minnesota.
InterComponentWare establishes ICW labs InterComponentWare (ICW) announced today the formation of ICW Labs, a Silicon Valley based R&D organisation focused on deepening ICW’s use of leading technology as part of its eHealth solutions. ICW Labs will be headed by Thomas Odenwald, veteran SAP technology leader and visionary. The new ICW Lab is chartered with expanding the ICW eHealth solution set, which delivers fully interoperable, secure and reliable communication of medical data and associated information throughout the US. The new organisation will work in tandem with the ICW product management team also located in San Mateo, CA. ICW’s European development teams, operating from company headquarters in Waldorf, Germany, have been very successful in implementing eHealth solutions for all participants in the delivery of healthcare. At SAP, Odenwald held strategic positions such as founding director of SAP Labs India and was responsible for integrating cutting edge technologies such as open source, Green IT, Semantic Web, RFID and Sensor Networks into the SAP portfolio.
Virtual 3-D human body developed in India A virtual three-dimension human body capable of replacing cadavers in surgical studies has been developed by a medical graduate in Kerala. The software, titled ‘3-D Indian,’ developed by Dr Jerome Kalister, has been referred to the Medical Council of India (MCI) for tests and approval. The software could help surgeons to perform robotic surgery on the brain, heart and liver, pinpointing the precise location of nerves and organ parts. “The important thing is that cadavers cannot be reused whereas surgical methods can always be learnt through the 3-D virtual body,” Jerome said. Many uses which cannot be performed on a real body could be used in the 3-D structure to identify the relative orientation, shape, position and texture of the human body with the plenty of options available in the software, he said. The only objection being raised against the software was that students would not get a ‘feel’ of the human body, but Jerome said: “Skill is not developed by doing cadavers. I do not think students, teachers or anatomists are benefited by the feel.” The software could also be marketed in certain countries where cadavers were not allowed for medical studies, he said.
GE revolutionises disease detection by digitisation GE Healthcare, a division of General Electric Company, and the University of Pittsburgh Medical Center (UPMC) recently announced the formation of a new company called Omnyx, LLC to improve the speed, efficiency of diagnosis and interpretation of lab results. The new company will bring to the market digital solutions to shape a new age of patient care and apply those solutions to a science that has relied on glass slides and microscopes for over 125 years. Omnyx is the first company in GE’s history to be formed with an academic medical center and represents an aim to accelerate ideas to market through enhanced co-development. Omnyx’s digital platform will seek to enable clinicians to share images virtually, interpret results using advanced algorithms and reduce costs associated with diagnosis. The benefit to patients could include reducing medical errors, improved turnaround time for lab results and integrating pathology information as part of his or her electronic medical record. Building on early developments in GE’s Global Research Center, Omnyx will unite UPMC’s pioneering developments in digital pathology with GE’s technology to create a viable solution for highvolume clinical use.
UC Davis combines PET and MRI into one device Scientists at the University of California, Davis have built the world’s first combined PET-MRI scanner. Positron Emission Tomography (PET) and the Magnetic Resonance Imaging (MRI), the two kinds of body imaging, have been combined for the first time in a single scanner. Both the imaging modalities are logically complementary, as PET is a functional modality that reports about biological processes, while MRI offers information about tissue structure. The combined scanner can provide accurate PET and MRI images at the same time. It enables the doctors to correlate the structure of a tumour by MRI with the functional information from PET, and to know everything happening inside a tumour. The combined scanners, which are currently available in the market, comprise a combination of Computer-Assisted Tomography (CAT) and PET. MRI scanners depend on strong and smooth magnetic fields that can easily be disturbed by metallic objects inside the scanner. The researchers used a new technology named the silicon avalanche photodiode detector, in developing the new combined scanner, as the photomultiplier tubes generally used in conventional PET machines are extremely sensitive to magnetic fields.
Bartronics’ RFID device to transform patient medication in the US In a path-breaking initiative that could revolutionise the health care system, Bartronics America Inc., a wholly owned subsidiary of Bartronics India Limited, has successfully implemented its patent winning RFID based wrist band for automating patient medication process. The Radio Frequency Identification (RFID) based wrist band, the first of its kind to be implemented successfully, assists nurses by automating the process of administering patient medication. The device was used in a clinical trial involving cancer patients at the Halifax Health Medical Center. 95% of the patients involved in the study found the device easy to use and they were better able to control the pain by using it rather than relying on nurses to provide the pills. When the patient holds the wristband up to the device, he selects the number on a sliding dial to indicate the pain level, on a scale of 1 to 10. This prompts the MOD to dispense pain medication. 52
IBM technology for critical public health info IBM, in collaboration with the Nuclear Threat Initiative’s (NTI) Global Health and Security Initiative and the Middle East Consortium on Infectious Disease Surveillance (MECIDS), has created a unique technology that standardises the method of sharing health information and automates the analysis of infectious disease outbreaks, in order to help contain diseases and minimise their impact. The secure, Web-based portal system, the Public Health Information Affinity Domain (PHIAD), is being deployed in the Middle East first, and the partners are pushing for international deployment. With PHIAD, researchers at IBM’s Almaden and Haifa labs have virtually eliminated the time-consuming, tedious tasks common in the public health community by creating an electronic platform that allows them to focus on critical tasks such as detecting emerging public health trends, pinpointing potential outbreaks and performing sophisticated analysis. The MECIDS project will use SNOMED CT® (Systematised Nomenclature of Medicine-Clinical Terms), an international standard that provides a core terminology for electronic health records. The International Health Terminology Standards Development Organisation (IHTSDO) has waived license fees for use of SNOMED CT® in this project on humanitarian grounds.
Anoto enables BlackBerry integration to digital pen Swedish digital pen and paper specialist, Anoto, has partnered with wireless BlackBerry platform developer, PaperIQ, to enable digital pen and paper input to be wirelessly transmitted to the character recognition system. The Anoto Digital Pen Integration Kit for BlackBerry provides users with everything required to integrate Anoto’s digital pen technology with a BlackBerry smartphone application or enterprise system. The kit enables any existing paper-based forms to be printed with the Anoto pattern, so that they can be used with the digital pen. As the pen records everything the person writes on the dot patterned paper, using Bluetooth technology, the data can be sent wirelessly to the BlackBerry and then transmitted back to the office via the BlackBerry device for further processing – without the need to type up notes. The technology has already been piloted at the UK’s Medicals Direct, who carry out health screenings on behalf of life insurance providers, and have used the technology to streamline the processing of half a million screening forms which its nurses complete every year. An Anoto spokesperson said “The technology has reduced the turnaround time for the forms from seven days to just 24 hours. The system cost in the region of £400,000 over two years to implement - five times less than the tablet PC solution Medical Direct had originally considered. “As it is an out-of-the-box solution that requires little development, the integration kit will make it easier for channel partners and in-house IT departments to create combined BlackBerry and digital pen and paper applications.”
Cutting Edge in
Healthcare Technology Hospital Information System’s and Picture Archiving and Communication System’s (PACS) have witnessed major advancements in recent years owing to the rapid development of the healthcare IT market. In this interview, Tarit Mukhopadhyay tells us what makes Siemens a leading player in the medical technology market, discusses the ongoing trends and gives us an insight into the future of healthcare technology.
Tarit Mukhopadhyay Head - HIS & PACS Business Siemens Medical Solutions
Q. In recent years, there has been a consistent growth trend in the demand for IT solutions in the Indian healthcare market. What is the current market share for Siemens Medical Solutions in this region and what are your future strategies to make this region your stronghold? A. There has definitely been double digit growth in the healthcare IT business in the recent past, however, the addressable market is still limited (when compared with modalities). It is only the green-field hospitals who are going for IT solutions right from inception. We are experiencing resistance by the established/traditional hospitals, since the cost of conversion from analog to digital hospital sometimes is not perceived by management as a priority. Siemens Medical Solutions started focusing very strongly on developing a robust IT backbone, which will have far reaching positive effects on the growth of a patient–centric diagnosis set up in a hospital. We are now a dominant player in the PACS arena in India. Our commitment to hospital solutions include infrastructure solutions, a voice-data www.ehealthonline.org
storage and sharing, what are the possible technological solutions to reduce cost? Is open architecture a possible answer to it? A. The strongest challenge in medical data storage is to amalgamate the image with data as both require different compression in storage. As per FDA, whenever an image is deleted in PACS, it is actually hidden (since no image is allowed to be deleted once it is signed off). Hence, data storage and management for a multi-location hospital is a challenge. A central storage is expensive, which will require expensive HSM with middleware and also put huge pressure to acquire an expensive communication highway (bandwith). A more cost-effective solution will be distributed architecture at each location and a central intelligent conversion switch to transfer data suitable for each environment (it is not expected that every location in the network will have the same type of data structure). Siemens has developed a central intelligent interfacing switch/station, which converts and distributes data suitable to respective locations. This is a step ahead of open architecture at each distributed location.
network-back bone, resilient and versatile hospital information system and image management solution with centralised viewing of image/entertainment/voice-data communication, data mining and data migration tool from one source. It will be more than just EMR. Q. What are the factors working in favour of and against widespread adoption of PACS in India? A. In the present Indian scenario, we see many new greenfield hospitals mushrooming in the semi-urban areas along with consolidation, where standalone hospitals are becoming a part of corporate chain hospitals. These activities are generating a huge requirement of resources for paramedical and medical staff. PACS is perceived as a tool to share such resources efficiently and economically. Emergence of high-end modalities in Cardiology and Oncology requires archiving and post-processing of images where PACS is becoming mandatory. However, one of the drawbacks is that PACS technicians are not readily available in India. Those who are available, learn PACS by usage and are not updated with the latest (PACS being a very dynamic technology). For PACS to be working efficiently in hospitals, there needs to be a regular curriculum in universities to understand the fundamentals of PACS in a total IT perspective. We at Siemens have already taken some steps to popularise PACS technology among educational institutes. Q. Given the cost-intensiveness of medical data July 2008
Q. Could you highlight some of the strengths and advantages of syngo Suite RIS and PACS of Siemens? What sets it apart from other similar products in the market? A. Siemens has an integrated RIS and PACS solution through true portal technology. Today when we access information from RIS and display with a PACS image, people use browser technology, which is a lot of information, and users have to pick and search from them. In the Portal it is role based, context sensitive and knowledge driven, highly configurable for faster access (even through the Internet). Q. What healthcare technology products/solutions does Siemens have in the pipeline for the near future? A. Siemens works for an end to end IT solution for healthcare with intelligent data mining tool for clinical research, therapy and a role based solution for Hospital Information. We are also working to combine “in-vitro” and “in-vivo” imaging with knowledge driven diagnosis. The new Soarian Medsuite 4 is a pathbreaking technology suitable to Asian market needs with workflow driven open architecture. Q. After being involved in the medical technology business for so many years, what would you say is the future of technology in healthcare? A. Future of IT in healthcare will be a multi-layer offering to optimise the need of customers. The bottom layer will be “enablers”, which will consist of hardware, network technology, back end architecture for high availability, etc. The second layer will be “application” consisting of enhanced features, licenses, modality specific functions and cross modality functions, etc. The final layer will be “portal centric view”, which will be workflow driven user specific interface with Service Oriented Architecture (SOA) with user friendly Graphic User Interface (GUI). 55
Alliance for Solutions Eddie Toh Chairman Itanium Solutions Alliance
Q. What is the key focus of Itanium Solutions Alliance? How do you forecast the increase of Itanium-based computing solutions across industry verticals? A. The Itanium Solutions Alliance was formed by leading enterprise and technical solution providers to work together toward a common objective: Extend the reach of solutions based on Intel Itanium architecture to broaden deployments within enterprise and technical computing environments. Itanium-based systems and Windows, Linux and other enterprise operating system environments provide an industry-tested, mature alternative to RISC-based computing platforms. Continued growth of Itanium-based solutions, including doubling of applications in the past 12 months, proves the strong momentum for Itanium-based systems. We have seen great adoption of Itanium based systems across all industry. We have also done particularly well in the India market where revenue of Itanium based systems have grown by more than 100% quarter-on-quarter and year-on-year and we expect this growth to continue. Q. Itanium solutions claim to revolutionise the healthcare industry across the world. What are the critical differentiating factors that Itanium solutions are going to bring in? A. As the healthcare industry focuses on maintaining a high level of care while controlling costs, the industry is recognising the economic advantages and operational opportunities of investing in high-performance IT infrastructures. Itanium-based solutions help healthcare IT tackle the challenges of their always-moving environment by offering Prof. Diana Schmidt the scalability and flexibility to seamlessly consolidate mediSchool of Medical Informatics cal records from manyUniversity sources,andsecurely extend patient inIT Faculty of Heilbronn formation and successfully manage enterprise applications Medical Faculty of Heidelberg University like pharmacy orders and insurance claims. Efficient Itanium-based systems computing in healthcare saves more than money; it can save lives through shared data libraries built on Itanium-based systems; accelerating the insurance reporting process; keeping large batches of client information secure; and creating a detailed working model of human physiology. Q. How has the uptake of Itanium - based systems been? And how has the Alliance been driving innovation in the healthcare sector? 56
A. Itanium-based systems have been deployed in three of the top six healthcare organisations as they offer powerful, flexible and scalable computing solutions. We also have several other examples of healthcare organisations who have benefited from deploying Itanium based systems.. The Alliance is also driving innovation within the healthcare sector where last year saw Stony Brook University winning our Innovation contest for the Humanitarian category. Stony Brook University (part of State University of New York) researches pharmaceutical inhibitors for AIDS and HIV PR. Substantial progress has been made by pharmaceutical researchers, resulting in drugs that prolong and improve quality of life for some patients. However, patients typically develop HIV strains in which none of the current inhibitors can effectively prevent HIV PR from performing its job. Deployment of Itanium based solutions enabled researchers to study biomolecular systems through computer simulations that provided a view of dynamic behavior with unprecedented resolution in both time and space. The simulations represent a breakthrough because they provide researchers with new information that may identify new inhibitors and AIDS therapeutics. Q. The Itanium Solutions Alliance comprises some of the most influential companies in the computing industry, how do you safeguard each vendorâ€™s market space? A. The Alliance aims to align the efforts of all member companies to increase the number of available Itanium-based solutions while increasing awareness for Itanium-based platforms for mission-critical application environments. All our member companies share this same objective. Instead of competing directly with each other in the market, our joint efforts actually create a better business environment and extend business opportunity to all our members. It is a winwin strategy instead of direct competition. Q. How does the Alliance carry out its R&D activities? Do you have separate R&D facilities under this Alliance? A. The Alliance supports ISVs/OSV via our enabling programs which include developer days to provide technical insights for ISVs. We also have a network of solution centers around the world with technical experts providing suggestions, development tools and code optimisation support to ISVs porting their application onto Itanium. www.ehealthonline.org
HIMSS AsiaPac 08 20 - 23 May 2008, Hong Kong
he Healthcare Information and Management Systems Society (HIMSS), in conjunction with CHIK Services, organised AsiaPac08 at the Hong Kong Convention and Exhibition Centre, attended by more than 1,500 health information technology professionals. It offered healthcare IT leaders throughout the region valuable insights from their peers who have successfully advanced the delivery of healthcare through IT. Highlights of the conference included illuminating keynotes by industry leaders on trends, practical application and management of healthcare IT in the region. Keynote speakers included Dr. York Chow, SBS, JP, Secretary of Food and Health, Prof. Diana Schmidt Government of the Hong Kong Special AdSchool of Medical Informatics ministrative Region; Shane Solomon, Chief IT Faculty of Heilbronn University and Executive, Hong Kong Hospital Authority Medical Faculty of Heidelberg University (HA); Tan Sri Dato’ Dr. Abu Bakar Suleiman, President, International Medical University, Kuala Lumpur, Malaysia; and Dr. Andy Wiesenthal, Associate Executive Director for Clinical Information Support for The Permanente Federation, USA. The conference included more than 50 education sessions and 50 exhibitors on the exhibit floor. In the 3-day conference, attendees had the opportunity to attend three keynote sessions, Thought Leader 58
Sessions, education sessions and e-sessions covering four different tracks, clinical leadership and governance; ehealth; EHR, EMR, EPR, PHR; IT strategy and innovation. During the conference, HIMSS joined the other individuals and corporations in helping the victims of the recent earthquake in China. “The tragic earthquake that hit Sichuan last week has deeply saddened everyone in the region,” said Steven Yeo, HIMSS Vice President and Executive Director, Asia Pacific, in a news release issued during the conference. “A disaster of this magnitude needs help from all corners of the world to provide assistance to the earthquake victims. HIMSS has donated US$ 10,000 to the Hong Kong Red Cross relief to help alleviate the suffering of the people in Sichuan.” Dr. York Chow, SBS, JP, Secretary, Food and Health, Government of the Hong Kong Special Administrative Region and Shane Solomon, Chief Executive, Hong Kong Hospital Authority (HA) opened the conference with a welcome address. They expressed recognition of the transformation of healthcare delivery throughout the world with the adoption of health IT. A physician who worked in the public hospital system for 30 years before becoming the Secretary for Food and Health in
The conference included more than 50 education sessions and 50 exhibitors on the exhibit floor. In the 3-day conference, attendees had the opportunity to attend three Keynote Sessions, Thought Leader Sessions, Education Sessions and e-sessions covering four different tracks on clinical leadership and governance; ehealth; EHR, EMR, EPR, PHR; IT strategy and innovation. www.ehealthonline.org
Hong Kong in 2004, Dr. Chow said that “four key factors in action” helped the Clinical Management System in Hong Kong succeed: Strong leadership It being a healthcare project, not an IT project It being a bottom-up process rather than top-down development process The Clinical Management System, which is designed, developed and implemented, through a close and seamless partnership, by a team of IT-minded clinicians and ITexperts with health informatics exposure. “An electronic health system, with a population-wise and territory-wide electronic health record system at its core, is the vision that is being sought after most in health informatics,” said Dr. Chow in his opening keynote address. “It (the system) serves as a fundamental infrastructure underpinning healthcare transformation, removing the boundaries between different healthcare professionals who are providing different levels of care in different sectors, enabling them to work as a team to bring quality health care to patients. Building toward that vision is what you will see in this conference and exhibition.” Mr. Shane Solomon of the Hong Kong Hospital Authority discussed the business value of the HA’s information technology system, which was rolled out in 1995 with direct clinician documentation and order entry. The HA operates 90% of the hospital beds in Hong Kong through 41 hospitals, and delivers 7.9 million specialist outpatient attendances each year and 4.8 million primary care clinic attendances with 122 clinic sites. This system is the only source of subsidised medications in Hong Kong. In his presentation, Mr. Solomon noted that health IT has helped provide “universal access to hospital care at a very low cost to the patient and to society.” The HA is 95% dependent on government funding, but still delivers universal access to healthcare and a GDP spending on public healthcare of 2.8%.” In addition, the HA IT system is home-grown with an annual cost to the HA system of 1.96% of its total annual expenditure. While these figures present the quantitative overview of the Hong Kong Hospital Authority, Mr. Solomon noted that “there is more that IT will do to transform healthcare.” He suggested a co-production approach to healthcare, where “you should not only be able to read your own health record, but you will contribute to creating it. I can envision patients monitoring their vital signs at home, such as their blood pressure, weight, and blood glucose levels, entering this information into their own health record, where it will be graphed, with information about what action needs to be taken by the patient if it is outside the normal range.” Borrowing a business strategy from the Toyota Production System (TPS), two presenters offered case studies from Alexandra Hospital in Singapore that used the Toyota approach, which says that: the customer is the heart of the organisation’s philosophy. the organisation continuously reflects and learns. July 2008
Keynote Session attendees
Delegates in the convention centre
Dr.York Chow, Secretary for Food and Health, Hong Kong opened the HIMSS AsiaPac08 conference, emphasising the importance of sharing experiences and lessons learned.
the organisation sees processes end-to-end and removes silos. Dr. Tan Yung Ming, Product Development Manager, Health Group, Singapore, and Chew Kwee Tiang, Chief Operating Officer, Alexandra Hospital presented “Lean Healthcare IT systems: The Toyota Way” and demonstrated how this approach can be 59
transferred to healthcare organisations. They shared how the hospital used this philosophy in reviewing and revamping the hospital websites, its health screening service and the development of the IT system. For example, healthcare processes are often complex and not streamlined. Thus, they explained, an EHR system implementation and development can be challenging because applying technology over inefficient processes can amplify underlying problems and lead to project failures. “TPS principles can be used to analyse and streamline these processes before any system is designed or implemented. By studying all processes end-to-end, the goal is to create a continuous flow so that any hidden issues can surface.” Interoperability in healthcare became a universal focus of the conference, with presenters discussing how sharing of patient health information through technology can improve healthcare delivery and reduce medical errors. One speaker who provided an update on global health IT standards was Dr. Yun Sik Kwak, Medical Informatics, Kyungpook,
Dr. Tan Yung Ming Product Development Manager, Health Group, Singapore
Shane Solomon, Chief Dr. Yun Sik Kwak Medical Informatics, Kyungpook, Executive, Hospital Authority, National University, Republic of Korea
National University, Republic of Korea. As Chair, HL7 Korea, Dr. Kwak discussed, in one session, various HL7 standards, such as V2.X and V3 that have been introduced to help establish integrated and connected health information systems. Dr. Kwak is also the Chair, ISO/TC215, Health Informatics, (Republic of Korea). He, with Audrey Dickerson, Secretary, ISO/TC215 Health Informatics (USA), and Manager, Standards Initiatives, HIMSS, presented current developments for health IT standards by ISO/TC215, Health Informatics. Both HL7 and ISO are separate but collaborative standards development organisations (SDOs) that recognise that developing countries depend on standardisation for some of their IT infrastructure in hospitals and in their clinics, for health IT systems and devices. In addition, telemedicine has been used as a consultant network in some countries, especially China, where the network is advanced to assist local doctors with diagnosis. “International standards are used locally for the betterment of patient care,” said Dr. Kwak. “It is important for developing countries to see what works in other countries 60
so that they may try to implement the same types of technology in their own healthcare setting. These countries have completed their initial work in health IT that is good for patient care.” Don Newsham, Co-Chair WG9 and CEO, ISO-TC215 and COACH, Canada, and Elizabeth Hanley, Senior Project Manager, Human Services, Standards Australia, Australia, discussed “Navigating the Sea of E - Health Standards…The Harmonised Way” in their education session. With standards development organisations (SDOs) throughout the world in operation for more than 10 years, Newsham and Hanley presented the collaborative approach of three standards organisations that came together to harmonise their efforts. “CEN/TC 362 and HL7 agreed to collaborate in the spirit of mutual appreciation, respect and openness to seek pragmatic solutions to obtain unification of their set of standards for healthcare communication and to make the results globally available to ISO” said these speakers in one of their slides. This alignment is not to develop standards or change
SDO accredited processes, accountability or mandates. Instead, through the collaboration, they have organised a joint working group to develop an integrated work program. The call for ubiquitous healthcare, where quality patient care is available for patients of all ages throughout the Asia Pacific region, surfaced as one of the consistent and relevant themes at the conference. As the population ages throughout the world, the demand for quality healthcare delivery to maintain the health of and treat the maladies of these individuals increases. In his presentation, “E-Health in Developing Countries: the Philippine Experience,” Alvin Marcelo, MD, offered insights on developing the much needed health information technology for underserved areas. Dr. Marcelo is Director, National Telehealth Center, University of the Philippines, Manila. He cited human capacity, not infrastructure, as the major challenge in putting this system together because of the increasing migration of health workers to other countries. As a result, a severe lack of health providers exists in many parts of the Philippines. www.ehealthonline.org
Dr. Marcelo outlined the strategies used, such as open source software and SMS/MMS tele-referrals, a simplified technology that demands less tech support. “Health workers in developing countries comprise an important sector for ICT training,” said Dr. Marcelo in his presentation. He said that mobile devices play “an important role in rural health systems,” and that “appropriate participatory training strategies on practical work-related applications increases success in embedding e-health in their workplace.” Elisabeth Harding, Director, Legal & Governance, University Hospital, Dubai Healthcare City, United Arab Emirates, explained that “privacy legislation is not about keeping things ‘private’ or ‘secret’ but about ensuring that information is used consistently with the purposes for which it was obtained.” She also noted in her presentation that individuals must be aware of these purposes, which can best be accomplished by thinking privacy of healthcare data as “safely managing health information” or “information protection.” The conference closed with keynote presenter
Dr. Andrew M. Wiesenthal, Associate Executive Director, Permanente Federation, Kaiser Permanente.
Dr. Andrew M. Wiesenthal, Associate Executive Director, The Permanente Federation. Kaiser Permanente is the largest nonprofit health plan in the United States with 8.7 million members, 13,000+ physicians, and 159,000+ employees. The integrated health care delivery system serves eight regions that include nine states and the District of Columbia with 32+ hospitals and medical centres and 435+ medical offices. He presented an overview of the EHR implementation at Kaiser and his perspective on the lessons learned throughout this process, which began in 1997 as a corporate goal of Kaiser Permanente. His assessment of what worked – and didn’t work – is not US-centric. Dr. Wiesenthal, as many speakers throughout the conference, indicated that “deploying an EHR is a strategy, not a goal. The Kaiser Permanente HealthConnect™ is more than just an electronic medical record, said Dr. Wiesenthal. “It is a complete health care business system that will enhance the quality of patient care,” a statement that offered a fitting close to the conference so focused on delivering beneficial information on that very topic. July 2008
“I am impressed that there are so many entities in Asia that are moving aggressively toward the adoption of the electronic health record for the people that they are responsible for in their healthcare organisations,” said Andrew M. Wiesenthal. “I was pleased to be part of the conference since I felt I had something to offer to those attendees who were managing similar activities in implementing healthcare IT. This type of information exchange was valuable because I had a clear sense that the attendees at HIMSS AsiaPac08 were there to learn from each other.” When not attending education sessions, attendees visited the exhibit floor to learn more about healthcare IT solutions. The more than 50 HIMSS AsiaPac exhibitors endorsed the conference citing attendees were decision makers who were eager to learn more about their products and services. The traffic flow was constant over the three days of the exhibition as interested buyers evaluated software and hardware solutions that ranged from Homecare to EMR/Clinical Systems used in Hospitals. More than 75% of the exhibitors have secured space for AsiaPac09 while the remaining companies have provided verbal commitments to participate in this conference in Kuala Lumpur. “It is exciting to be involved with HIMSS in the AsiaPac conference and see it growing,” said Steve Reinecke, MT, Global Director, Health Care Industry, Ergotron, Eagan, Minnesota, USA. Ergotron was one of the exhibitors at AsiaPac08. “I look forward to further interactions with HIMSS Asia in the future.” HIMSS asked attendees to evaluate their experience at the conference. Dr. Rekha Batura, a hospital administrator at Tata Memorial Hospital, in Mumbai, India, said that the conference was “stimulating.” “It gave me a lot of available IT strategies and software solutions and showed me that interoperability is possible with the available software. The conference also increased my awareness about what other hospital systems are doing and the tools they use to do it.” Conference attendees also indicated that the networking was a valuable asset of HIMSS AsiaPac08. “I have made significant contacts,” said Dr. Peter Del Fante, CEO, Adelaide Western General Practice Network, Australia. “The thought leaders sessions and experience from health informatics were very good. Networking with key people is very important to further our future work and project.” HIMSS Asia has begun planning for the 2009 AsiaPac Conference and Exhibition in Kuala Lumpur, Malaysia. The Hong Kong conference was the second HIMSS AsiaPac held in the region with the first meeting held in May 2007 in Singapore, Thailand. “The benefits of healthcare IT, as an effective equaliser in the delivery of quality patient care, became even more apparent during the HIMSS AsiaPac08 Conference & Exhibition,” said Yeo. “The conference brought together many stakeholders throughout the region, and from across the globe, who shared their knowledge, innovations and challenges in the information technology in healthcare. HIMSS Asia looks forward to continuing the relationships forged at this event and to building new alliances throughout the region.” 61
Road Ahead Health Insurance Summit
25th May 2008, The Chancery Pavilion, Bangalore
ealth insurance in India is increasingly getting refined and redefined, with a population of more than a billion people, an upwardly mobile middle class, higher service demands and a positive investor perception, health insurance is one of the most promising growth sector of recent times. Like many other sectors Indian healthcare sector is getting ready for a long-haul, dream run for achieving excellence and capitalising global opportunities in the calling.
From left to right - Dr. Brahmesh D Jain, P.Rammohan R. K. Mishra, Dr. Rahul Shukla
From left to right - Nagarajan.R, K.V. Rao, Dr. Praneet Kumar, Neelamben A Christian, Dr. Brahmesh D Jain
To cater to the need for stakeholders to come together and forge partnerships through knowledge sharing, HealthSprint Networks, one of India’s leading healthcare exchange network, organised the “Road Ahead - Health Insurance Summit” on May 25th at Chancery Pavilion, Bangalore. The event conjured health insurance companies, micro health insurance providers, Third Party Administrators (TPAs), hospitals, corporates, clinicians and technology companies for a series of power packed sessions and panel discussions. The Summit was designed around some of the most 62
pertinent business issues facing the health insurance sector. With eminent professionals brought together from a cross section of business domains, the Summit focussed on issues ranging from micro health insurance financing, evolution of health insurance, standardisation, process improvements, sustainability of health insurance, healthcare and healthcare financing, patients and providers perspective, emerging needs of health insurance, role of technology in health insurance management, connected healthcare payer-provider
From left to right - Arjun Bhaskaran, Dr. Ramesh Karmugam, P Rammohan, Krishnamurthy, Dr. Ramana
From left to right - Rajeev Vasudevan, R. Basil, A.V. Rajan
network with innovative use of interactive sessions R.K.Mishra, Times of India’s Lead India Campaign Winner, marked the beginning of the Summit with the inaugural address with an emphasis on covering 1 billion plus Indian population, he also emphasised on the Public-Private Partnership. Dr. Brahmesh D. Jain, President & Co-Founder, HealthSprint, delivered the keynote address highlighting the challenges facing the health insurance industry and the need for collaborative efforts to address the challenges. The health insurance session was moderated by Dr. Prawww.ehealthonline.org
From left to right - Dr. K. Ravindranath, Dr. Kishore
From left to right - U.K.Ananthpadmanabhan, Dr. Rahul Shukla
neet Kumar, COO, Fortis Escorts Hospital; K. V. Rao, Vice President, SKS Micro Insurance highlighted the need of empowering the poor to become economically self reliant and the initiatives being taken by SKS; Nagarajan Ranganathan, National Head-Corporate Services, ICICI Lombard, spoke about the evolution and future growth of health insurance in India; Ms. Neelamben representing Self Employed Women’s Association (SEWA)-Gujarat, spoke about the challenges in processing micro health insurance claims and the strategy adopted by SEWA to reach the poor. P. Rammohan, Managing Director and Co-Founder HealthSprint moderated the TPA Session. Krishnamurthy, CEO, TTK Healthcare Services, highlighted the need for standardisation for pre-authorisation and admission process; Dr. Ramesh. K., National Head, MediAssist India, emphasised on the sustainability of health insurance and role of all the players of the ecosystem. The hospital session was yet another power packed session moderated by A. V. Rajan, Vice President, UTI Technology Services (Govt of India Company), starting off with an impressive presentation on consumer centricity in health insurance services. R. Basil, MD and CEO, Manipal Health Systems, underlined the need of health insurance from provider and patient perspective; Dr. K. Ravindranath, Chairman and MD Global Hospitals, said with a billion lives to be covered under insurance, there should be a focus on rural and micro insurance through PPPs. “There should be health schemes for people below the poverty line... Insurance services should be available on time, especially during emergencies.” Dr. Kishore Kumar, MD and CEO, The Cradle, Bangalore, gave a lively presentation and said, “There is a need for awareness and education among the public. Insurance in India is the need of the hour and not a luxury. We have to learn from other countries and protect our future generation.” July 2008
Rajeev Vasudevan, CEO, AyurVAID Hospitals, spoke about effective response to chronic illnesses, and it implications for the health insurance industry. U. K. Ananthpadmanabhan, President, Kovai Medical centre, moderated the technology session. Dr. Rahul Shukla, CEO and Co-Founder, HealthSprint, stressed on connected healthcare payer - provider network and the role HealthSprint is playing in bringing standardisation and the need to create healthcare information system services. Mohammed Hussain Naseem, Vice President (Healthcare Business), IBM, drawing parallels from the banking industry spoke about India National Health Data Network and the concept of an infrastructure backbone to facilitate efficient growth in the emerging healthcare ecosystem. Manish Gupta, Chief Information Officer, Fortis Healthcare, spoke about connected healthcare and collaborating to enable secure delivery of timely, accurate, electronic health information to authorised users across institutional boundaries. Mr. Zaheer, VP and Director of IDMsys spoke about Hospital ERP- an investment that will pay over a period of time. The attendees almost unanimously expressed that the Summit was a much-needed platform for all the players in the industry. The conference concluded with valuable learnings for participants, in addition to insightful presentations and interesting panel discussions, it served as an ideal platform for collaboration and knowledge exchange. Follow-up Key ideas/concerns/suggestions will be incorporated in the white paper which HealthSprint will bring out, alongwith UTI Technology services (Government of India Company) by June end. This will be shared with all the IRDA, Insurance Companies, TPAs, Hospitals, and all the participants. 63
The International Educational and Networking Forum for eHealth, Telemedicine and Health ICT
he Luxexpo Exhibition and Congress Centre in Luxembourg was host again to the international Med-eTel meeting held between the 16th and 18th of April 2008. In its 6th edition this year, and with a proven track record of highly efficient and effective networking, Med-e-Tel attracted once again a qualified audience of 500 Telemedicine and eHealth industry representatives, association executives, government officials, healthcare providers, payers/insurers and researchers from 54 countries around the globe. Telemedicine and eHealth are all about making healthcare delivery more efficient and effective and to cope with some of the challenges that lie ahead, such as an ageing population, the rise in chronic conditions, the shortage of healthcare professionals, and the healthcare budgets. And development Prof. Diana Schmidt and School implementation of telemedicine and ehealth tools reof Medical Informatics quire good coordination and mutual IT Faculty of Heilbronn University and understanding between all parties involved (patients/citizens, Medical Faculty of Heidelberg University care providers, government, health insurers, industry, research), so that the tools can be implemented and used in the most optimal way. Med-e-Tel â€™08 attendees agreed almost unanimously that the conference serves a great networking purpose and that it acts as a catalyst for formtion of partnerships between the different stakeholders, providing opportunities to share experiences, demonstrate technologies, and convey user needs among people with many different backgrounds and from many different places. This year, participants were welcomed in an official opening ceremony by Mars Di Bartolomeo, Luxembourg 64
Minister of Health, Prof. Dr. Michael Nerlich, President of the International Society for Telemedicine & eHealth, Pierre Gramegna, Director General of the Luxembourg Chamber of Commerce, Nick Fahy, Head of Unit, Health Information Unit, DG Health and Consumer Protection, European Commission and Prof. Giuseppe Tritto, President of the World Academy for Biomedical Technologies. Following the opening ceremony and a tour of the exhibition, a keynote session, chaired by Frank Lievens, Secretary of the International Society for Telemedicine & eHealth, featured eight opinion leaders who shared their views and experiences on a number of current issues and initiatives, several of which were discussed further in more detail throughout various sessions of the three - day conference program. Key Learnings Dr. Yunkap Kwankam, eHealth Coordinator at the World Health Organisation, also present at one of the sessions, is a strong advocate of improving productivity through technology in the traditionally inefficient healthcare sector. He observed that one of the areas where technology can contribute a lot is training and education to scale up the workforce through eLearning programs. Kwankam, in his presentation also provided examples of improvement in clinical operations and increase of healthcare HR capacity through the use of electronic medical records. Health information networks are currently being put into place to collect health data and statistics for analysis, dissemination and use to support deciwww.ehealthonline.org
Program Highlights •
2008 16-18 April 2008, Luxexpo Exhibition and Congress Centre, Luxembourg
sion making in national and regional healthcare strategies, showing once again that eHealth is an essential component of any health system reform or development plans and strategies as far as WHO is concerned. Nick Fahy of the Health and Consumer Protection Directorate-General (DG SANCO) of the European Commission shed light on the Commission’s “eHealth scenario for 2020”, a vision of what they would like to see operational in health ICT, from a public health and medical content point of view, in the EU context. The scenario is to provide helpful input for DG SANCO’s regulatory framework, financial envelopes and workplan, highlighting existing gaps and providing a clearer picture for coordination with the member states. David Whitlinger, President of the Continua Health Alliance, provided an update on Continua’s progress in recent months in the development of guidelines for device makers, that should help consumers and healthcare providers to share information more easily through common communication channels such as cell phones, PCs, TV set-top boxes, telephones, and other devices. Continua also held its Spring Summit in Luxembourg in the margin of the Mede-Tel conference and conducted a so-called plugfest for its members, to test interoperability of devices and systems, and announced the release of Device Connectivity Standards and Healthcare Records Standards, which will lead to Continua certified products and software by the end of this year. Michael Palmer, Project Officer at the ICT for Health Unit within the Information Society Directorate-General July 2008
A session on Product Interoperability Architecture presented by the Continua Health Alliance, focusing on the how and why of product interoperability in a telehealth ecosystem. Extensive focus on personal telehealth applications, experiences and research in various sessions dealing with Telehealth for Chronic Disease Management, Telehealth, Telecare and Services for the Ageing and Telehealth in Support of Self Care. A workshop on the topic of Living Labs with presentation of some existing initiatives in various European countries, user feedback, transition from ‘lab’ to ‘reality’, and roadmaps ahead. An overview of International Telemedicine & eHealth Initiatives and Developments by members of the International Society for Telemedicine & eHealth (ISfTeH), focusing on the current state of telemedicine and ehealth in a.o. Austria, Brazil, Finland, France, Georgia, Hungary, Poland, Russia, South Africa, Switzerland and Ukraine. The ISfTeH, which is now also an international NGO in Official Relation with the World Health Organization, also presented a joint exhibition stand on the Med-e-Tel expo together with several of its members. As an umbrella organization which currently already represents about 30 national Telemedicine and eHealth associations worldwide, as well as a number of educational and healthcare institutions, the ISfTeH provides excellent access to national experts and policy makers and researchers. A mini symposium on Telenursing, a growing application, offering possibilities to reduce the use of expensive healthcare services, to reduce hospital admissions or length of stay, to perform regular check-ups on patients with chronic conditions, to spread limited resources over a large population, and to increase access to nurse education. The telenursing session included an introduction to telenursing, results from a global telenursing survey, and some real life experiences from the United States. A session on Nursing Informatics: Past, Present and Future, looking at the support of nursing by information systems in delivery, documentation, administration and evaluation of patient care and prevention of diseases. A session on eHealth for Developing Countries and Low Resource Settings, presided by the World Health Organization’s eHealth Coordinator and showing ICT’s contributions to healthcare delivery and capacity building in the developing world. On a related subject, there was also a special training session on How to Develop and Implement eHealth and Telemedicine Solutions presented under the auspices of the expert group on Question 14 “Telecommunications for eHealth” within the International Telecommunication Union. The training looked at strategic planning issues for the development and implementation of eHealth services in the various areas of health sectors and the required coordination between healthcare and telecommunications authorities in the implementation of national eHealth programs (which have been recommended to all countries by the World Health Organization in its Resolution WHA58.28). A workshop on Facilitating Collaboration to Facilitate Tele-Success, focusing on effective collaboration among projects and existing technologies to create an accessible, cost-effective healthcare information system. The session zoomed in on topics such as “From the Bottom Up: Designing from the User Perspective”, “What Else Is Going On? – Building a Project Database”, “Practical Considerations: Infrastructure, Links, and Tools” and “Price-Performance via Open Source Tools”. Various sessions on Telecardiology, Health Informatics, eLearning, eHealth in Support of Routine Medical Practice, Efficiency in eHealth, Telepsychiatry, Teledermatology and Image Transfer, Mobile Health, New Trends in eHealth showed what works and what doesn’t, as well as what exists or what is under development in Telemedicine, eHealth and Health ICT systems and solutions. A regional (BeLux) seminar, endorsed by the Luxembourg Ministry of Health and the CRP-Santé (Public Institute for Research in Healthcare, Public Health and Biotechnology), about Clinical Strategy and the Use of Balanced Scorecards, showing how to create and successfully use balanced scorecards to improve clinical outcomes and overall management, taking into account the IT, medical, nursing and financial requirements and limitations. and how they can serve as an instrument to identify strengths and weaknesses in an organization and to optimise processes and outcomes, in an environment that is increasingly under financial pressure. The interactive seminar featured a look at experiences from some of the leading hospitals and organizations in Belgium, Germany, Luxembourg and Spain. 65
Nick Fahy at the Opening Session
(DG INFSO) of the European Commission gave more background information on their recently released report on lead market opportunities for eHealth that proposes actions aiming at accelerating the development of the European eHealth market, increasing economic benefits and simultaneously develop the quality of health products and services. Palmer also highlighted details of the consultation that is being planned for this year in preparation for the Commission’s communication on telemedicine for chronic disease management. Dr. Bill Crounse, Senior Director of Worldwide Health at Microsoft shared his perspectives on the growing opportunities for a new kind of medical practice based on personalised telehealth. “No longer in the sole domain of academic medical centres or large group practices, telemedicine has become a commodity technology with the promise to vastly improve the delivery of health information and medical services around the globe while reducing traditional doctor visits, saving money, and greatly increasing patient satisfaction,” he said. The presentation showed how innovative clinicians are incorporating Web 2.0 technologies into the practice of medicine and how organisations can benefit by staying ahead of the curve. Dr. Crounse also shared a “future vision” for healthcare that is more global, consumer-centric, based on cost and quality transparency, and personalised. Dr. Joseph Kvedar, Director of the Center for Connected Health at Partners HealthCare, and Associate Professor of Dermatology at Harvard Medical School talked about how telehealth in the developing world can effectively address a range of health issues, including those affecting people with chronic diseases. The use of widespread, low-cost technology, such as cell-phones, creates opportunities for improved patient education and adherence to care plans, and better access to care providers. He also discussed the vision of “connected health”, which provides opportunities for more innovative programs to address chronic disease management. Prof. Dr. Harald Korb, Medical Director at German-based telemedicine provider Vitaphone, in his presentation at the Med-e-Tel 2008 opening session, drew from experience with thousands of cardiovascular and diabetic patients, to show that a number of favourable effects can be guaranteed when modern telemedical devices with appropriate treatment pathways according to national and international guidelines are used in integrated care models. And Dr. Loretta Schlachta-Fairchild, President & CEO of 66
iTeleHealth (USA), sharing thoughts and visions for the creation of an International Telenursing Working Group within the frame of the International Society for Telemedicine & eHealth, with the goal of aligning with the International Council of Nurses (ICN), a federation of national nurses’ associations, representing nurses in more than 128 countries. “Given the worldwide nursing shortage and the global shift in demographics to ageing and chronic illness, it is paramount that nurses embrace technology as a resource multiplier”, said Schlachta-Fairchild. The envisioned working group will provide information and strategies to those interested in advancing their practice in this arena. Med-e-Tel continued with an extensive conference program which featured an additional 150 presentations and workshops on a wide variety of Telemedicine and eHealth topics. Through the variety of conference sessions, the exhibition and an extensive media corner (featuring some 35 journals, books and magazines), participants were provided with hands-on experience and an opportunity to discover and evaluate new systems and technologies and to hear about the latest eHealth and Telemedicine news, trends and developments, from companies and organisations around the world such as Aerotel Medical Systems, Agfa, Aipermon, AlcatelLucent, Center for Connected Health, Continua Health Alliance, eHIT, European Commission, GFI, Goodit, Honeywell HomMed, Intel, InterComponentWare, International Society for Telemedicine & ehealth (and about 20 of its member organisations), Management Cockpit, Microsoft, Philips, RS TechMedic, SAS, Vitalog, Vitalsys, Vitaphone Telemedicine, World Health Organization, YUSE, and many others. www.ehealthonline.org
Scoping Radiography The radiography market has been seeing great innovations of late and with each new innovation there is fresh debate on the pros and cons of the technology vis-à-vis, ease of use, accessibility and return on investment. The following expert article as well as comments from end users gives us a holistic view of the available technology.
Market Insight Healthcare Practice Frost & Sullivan
adiography is a method used for the evaluation of bony structures and soft tissues. An X-ray machine directs electromagnetic radiation, that is, X-rays upon a specified region in the body. This radiation is capable of penetrating through less dense matter like air, fat, muscle, tissues etc., but is absorbed or scattered by denser materials like bones, tumors and lungs. In film-based radiography, radiation, which passes through the patient, strikes a cassette containing a screen, which has a layer of fluorescent phosphors on it, thus exposing the X-ray film. Areas of the film which get exposed to higher amounts of radiation appear as black or grey on X-ray film depending on the extent of exposure while areas exposed to less radia68
tion will appear lighter or white. As a medical speciality, radiology can be categorised into Diagnostic Radiology and Therapeutic Radiology. Diagnostic radiology is the interpretation of images of the human body to aid in the diagnosis or prognosis of disease. It is divided into sub fields by anatomic location and application areas, some of which are as follows: Chest radiology: It is used for radiological imaging of the chest for detection of diseases. Abdominal and Pelvic radiology: This is also referred to as ‘Body Imaging’. Interventional radiology: This uses imaging to guide therapeutic and angiographic procedures. At times it is also www.ehealthonline.org
Doctor Speak referred to as Vascular and Interventional radiology. Neuro-radiology: It is a sub-specialty in the field of brain, spine, head, and neck imaging. Musculoskeletal radiology is the sub-specialty in the field of bone, joint, and muscular imaging. Pediatric radiology: used for radiological examination of neonates and children. Fluoroscopy Fluoroscopy is the specialised application of X-ray imaging, in which a fluorescent screen or image intensifier tube is connected to a closed-circuit television system, which allows real-time imaging of the anatomical structures in motion with the help of a radio-contrast agent. The radio-contrast agents are administered, which is usually swallowed or injected into the body of the patient, to delineate the skeletal system, blood vessels and the gastrointestinal tract and renal system. These radio-contrast agents absorb or scatter the radiation, thus allowing real time demonstration of dynamic processes, such as blood flow in arteries and veins. Two radio contrasts are used presently. Barium (as BaSO4) maybe administered orally or through the rectum and is generally used for the evaluation of the Gastrointestinal (GI) Tract. In some cases, iodine is also used. As Barium is known to cause complications such as tumour, cysts and inflammation. Additionally, in specific situations air can also be used as an agent for the evaluation of GI system, and carbon dioxide can be used as a contrast agent in the venous system; in these cases, the contrast agent attenuates the Xray radiation less than the surrounding tissues. Image Digitisation Technology In radiology, the digital revolution has enabled image enhancement, rapid transmission to remote locations and compact electronic storage. The simplest way to describe the basics of a digital radiography is to relate to the personal digital camera. Earlier people used cameras that had to be loaded with rolls of film, that not only were difficult to load but also cumbersome to manipulate, delete or view images immediately upon capture. The film then had to be developed using chemicals before one could view the images captured. With the introduction of digital technology images could be taken and viewed within seconds, manipulated and have the option of sharing it electronically and to be archived. All this could be done without the use of harmful and expensive chemicals. Given acceptable diagnostic quality, it makes sense to capture images digitally if those images are going to be electronically distributed and stored. The digital image can be printed on film for viewing and/or diagnosis as needed, so a digital imaging system certainly presents an intriguing opportunity to health care providers. The CR Technology In Computed Radiography (CR), the X-rays passing through the patient strike a sensitive plate, which is then read and digitised into a computer image by a separate reader. In Digital Radiography the X-rays strike a plate of X-ray sensors producing a digital computer image directly. Plain or July 2008
DDR is quite beyond the reach of individual radiologist in India, it costs in excess of a crore of Rupees, a sum not easily justified in the private sector. Of course the quality of the images are far superior and one would like the luxury of using such technology but cannot afford to. Perhaps select institutions such as the defence, AIIMS or other government hospitals may be able to invest in such technology without thought of returns but not the private sector hospitals. Dr. Rajesh Kapur Consultant Radiologist
We are currently working with CR and digital fluoro radiography (DFR). DFR uses direct images from image intensifiers and is used for interventional and (in our practice) noninterventional procedures like bariums, IVPs etc. This technology is high end and expensive compared to CR systems. DDR of course is the latest and has the highest resolution but is also the most expensive. CR systems are the easiest ones to upgrade and are most portable, apart from being least expensive. DDR is ideal for high throughput hospitals, since that’s the only way to recover investments, and is not viable in low throughput centres. Advantages of DDR include resolution, high throughput, and film-less transfer. Transition and dependence on cross sectional imaging makes CR most viable as a radiography tool. DFR and DDR with/without fluoro is ideal for high throughput hospitals. Dr. Bharat Aggarwal Consultant Radiologist & Group Director, Diwan Chand Satyapal Agarwal Imaging Research Center (DCA) 69
analogue radiography was the only imaging modality available during the first 50 years of radiology. It is still the first of the three methods to be used for the evaluation of the lungs, heart and muskuloskeletal system because of its wide availability, speed, relative low cost and small size which makes it very portable and mobile. In the last 20 years, CR technology has evolved from an experimental application into a modality with great potential, suited for portable and mobile applications. In the early 1980s, CR products were mostly installed in universities and institutions that laid emphasis on research. The emphasis in the development of CR technology today revolves around the size of the hardware and the diagnostic quality of the images. By the late 1980s, commercial CR products were available and installed in hospitals where radiologists were keen to learn this new technology which had better image quality and resolution in comparison to the old film based system. During its technological development over the last years, the CR hardware has become more and more compact. Today, the computed radiography system is seen as an effective and efficient method of delivering radiographic images in critical situations where conditions are difficult for radiologists to obtain consistent images on radiographic film. In such situations, CR systems are capable of generating images with excellent diagnostic value and superior resolution. CR systems are capable of growing further because the radiation dose used is much less when compared to the dosage used for screen or film techniques. Improvements in storage phosphor materials, image processing software, optical collecting systems and laser scanners combine to boost the sensitivity of modern CR systems. Some manufacturers are in their fourth or fifth generation of development. Image Quality of CR Systems While the radiation dose of CR systems is comparable to film-based systems, spatial resolution of the same is not comparable. The spatial resolution of a general screen/film system is 7 to 8 line pairs per millimeter whereas that of a CR system is less than half that, ranging from 2.5 to 5 line pairs per millimeter. In majority of the applications, CR does not perform well in terms of spatial resolution, but has a very high contrast resolution, which enhances the diagnostic utility of the images. The CR systems are equipped with the ability to adjust levels of brightness in images, which gives radiologists the ability to view structures that cannot be easily detected on radiographic film. With film, the contrast is determined by the composition of the film, the radiographic technique and the chemical processing. The main advantage of computed radiography is noted in it being portable and mobile, where the CR characteristics reduce the number of repeat exams required due to inaccurate technique adjustment or exposure. CR also provides the ability to provide rapid electronic image distribution. Direct Digital Radiography (DDR) Technology The direct digital radiography technology uses a direct process to convert X-ray energy to digital signal. The image 70
is directly captured on the flat plate and is then viewed in the computer. This technology uses amorphous selenium (a-Se) or an amorphous silicon (a-Si) flat plate placed in between the object to be diagnosed just as the process carried out for film-based systems. A number of components are required for direct digital image production, which includes an X-ray source, an electronic sensor, a digital interface card, a computer with an analog-to-digital converter (ADC), screen monitor software and a printer. Direct digital sensors are either a charge-coupled device (CCD) or complementary metal oxide semiconductor active pixel sensor (CMOS-APS). CCD is a solid-state detector composed of an array of X-ray sensitive pixels on a pure silicon chip. Charge coupling is a process where the number of electrons deposited in each pixel is transferred from one to another in a sequence manner so as to obtain an amplified image output on the monitor. Fiber optically coupled sensors utilise a scintillation screen coupled to a CCD. The complementary metal oxide semiconductor active pixel sensor (CMOS-APS) is the latest development in direct digital sensor technology. The CMOS sensors are identical to CCD detectors but they use an active pixel technology and are less expensive to manufacture having the same image quality as that of the CCD detectors. Some Companies Providing Radiography Equipment in India: Philips Medical || Agfa Healthcare || GE Healthcare || Siemens Medical || Carestream || Shimadzu Medical || Canon Medical || Fuji Film || Hitachi || Toshiba Medical Systems || Mitsubishi Imaging || Konica Medical || Agilent Technologies || Amicas || Barco NV
The Future of Radiology Dramatic changes are expected in radiology in the coming years, including widespread use of digital technologies. Radiology departments may apply screen/film, CR and digital radiography systems to various applications, depending on the requirement of the departments. Thin-film transistor digital radiography technology is one of the evolving technologies for radiology. In this technology, an array of transistors converts X-ray energy to an image. Electronic scanning of the transistors collects data. Unlike CR, phosphors or X-ray converting overcoats may or may not be involved, and there is no need for a laser to scan the imaging plane. This technology will have the advantage because technologists no longer will have to carry the cassettes to a processing station. Charged coupled device (CCD) technology is also an alternative for direct digital capture. Over the long term, digital radiography will likely evolve as stand-alone system for chest imaging and digital X-ray tables. Along with this, CR systems will continue to be in use for mobile X-ray applications as customers seek avenues to create the-all-digital department. The ability to digitise a film image and transmit the data to remote sites will continue to aide the CR and DR technologies to further evolve. www.ehealthonline.org
critical to tap global healthcare IT markets
In a large and diverse country like India standardisation is not an idea too easily followed. However, some International standards developing organisations have been showing the Indian IT professionals the way to a unified language to share critical care data safely and securely.
ggregated US provider and payer healthcare information technology spending was close to US$ 26 billion in 2004 and will grow to over US$ 34 billion by 2008, with a CAGR of 7%. By 2008 payer spending will amount to US$ 7.5 billion and provider spending will be at US$ 26.7 billion. (Forecast from Research & Reports) To gear up for this emerging trend, CSC made a US$ 375 million acquisition of First Consulting Group along with increasing the offshore capabilities in India. CSC, IBM, Accenture, EDS and Perot systems with billion dollar deals, spread over several years, currently corner the healthcare provider market. Indian IT firms have not been strong in the US provider market primarily due to the lack of availability of HL7 certified professionals in India. According to analysts, Syntel and TCS can capitalise on the growing healthcare provider market in US, primarily because of their extensive experience in HL7. What is HL7? Health Level Seven (HL7) is one of several American National Standards Institute (ANSI) - accredited Standards Developing Organisations (SDOs) operating in the healthcare arena. Most SDOs produce standards (sometimes called 72
Saji Salam MD, MBA Chairman, Health Level Seven India firstname.lastname@example.org
specifications or protocols) for a particular healthcare domain such as pharmacy, medical devices, imaging or insurance (claims processing) transactions. Health Level Sevenâ€™s domain is clinical and administrative data. Headquartered in Ann Arbor, Michigan, Health Level www.ehealthonline.org
drive home the message of adopting IT standards and building IT products based on HL7. Our focus then turned to creating HL7 certified professionals in India by getting the HL7 certification exams proctored in India. As founder of Health Level Seven India it gives me immense pride to note that, today India generates the most number of HL7 certified professionals in the world. Seven is like most of the other SDOs in that it is a not-forprofit volunteer organisation. Its members - providers, vendors, payers, consultants, government groups and others who have an interest in the development and advancement of clinical and administrative standards for healthcare—develop the standards. Like all ANSI-accredited SDOs, Health Level Seven adheres to a strict and well-defined set of operating procedures that ensures consensus, openness and balance of interest. A frequent misconception about Health Level Seven (and presumably about the other SDOs) is that it develops software. In reality, Health Level Seven develops specifications; the most widely used being a messaging standard that enables disparate healthcare applications to exchange key sets of clinical and administrative data. Members of Health Level Seven are known collectively as the Working Group, which is organised into technical committees and special interest groups. The technical committees are directly responsible for the content of the Standards. Special interest groups serve as a test bed for exploring new areas that may need coverage in HL7’s published standards. HL7 India is one of the thirty international affiliate countries that make up the HL7 International organisation.
HL7 International HL7 International is spread across 30 countries, across the world and most countries are involved in translating the HL7 standards or localising the standards for the healthcare systems in the respective countries. The International Committee provides a forum for the HL7 International Affiliates and other interested HL7 members to communicate and exchange views as well as discuss issues regarding the international development, adoption, application and implementation of the HL7 standard. The International Committee collates, evaluates and puts into action - for processing by other entities within HL7 any needs, issues and other inputs expressed and agreed to by the HL7 International Affiliates. The International Committee advises the Technical Steering Committee and Board of Directors on matters relating to areas of standardisation that are relevant to the International Affiliates. The HL7 Board of Directors appoints the co-chair(s) of the International Committee. The International Affiliates select the International Board Representative from among the International Affiliate members.
HL7’s mission HL7 provides standards for interoperability that improve care delivery, optimise workflow, reduce ambiguity and enhance knowledge transfer among all of our stakeholders, including healthcare providers, government agencies, the vendor community, fellow SDOs and patients. In all of our processes we exhibit timeliness, scientific rigor and technical expertise without compromising transparency, accountability, practicality, and our willingness to put the needs of our stakeholders first.
HL7 certification exam in India Certification exam for HL7 standards such as HL7 v2.5 and CDA is conducted in India. For IT/healthcare organisations with at least ten candidates who would like to take the test, examination proctors from HL7 India conduct exams at the healthcare/IT organisation’s premises. The answer sheets are then shipped to US and certificates are issued for the successful candidates by HL7 Inc USA. The fee for HL7 exam currently is INR 6000 per candidate and does not include travel expenses for the proctor. Individuals who wish to take the exam can contact HL7 India through the website www. hl7india.org
Evolution of HL7 India Eight years ago when I was with the healthcare practice of a leading IT firm in India I happened to ask the IT Project Manager why HL7 was named HL7 and not HL8 or HL9. Pat came the answer “HL7 was founded by a group of seven IT professionals and hence the name HL7”. On doing further research I realised that the “Level Seven” refers to the highest level of the International Organisation for Standardisation (ISO) communications model for Open Systems Interconnection (OSI) - the application level. Shocked by the low level of awareness on HL7 in India I took upon myself the initiative to build HL7 in India. I should say that the HL7 India organisation has been built “click by click” over the last 8 years. HL7 India organisation went on a massive education spree targeting health management schools and healthcare technology focused IT firms to
Standards based Healthcare Informatics Policy for India The switch over from proprietary information systems to standards based systems can be a costly affair. The cost of implementation of HIPAA (Health Insurance Portability and Accountability Act) standards in the US is estimated to be between US$ 20- 40 billion. At the same time the US government decided to go ahead with the standardisation process as this could result in huge savings in the coming years. As we are in the early stages of automation of healthcare facilities, India is in an advantageous position to adopt/adapt these standards and not be investing too much on proprietary systems. However this calls for meticulous planning coupled with the right leadership to put in place the right healthcare informatics policy for the country, with an emphasis on open standards.
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India has less than laboratory health worker per 10,000 population. The diagnostic and pathology market in India is around of the overall healthcare market.
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[ www.ehealthonline.org ] eHEALTH is Asia's first and only monthly magazine on healthcare ICT's, medical technologies and applications. The...