asia’s first monthly magazine on The Enterprise of Healthcare
volume 7 / issue 7 / JuLY 2012 / ` 75 / US $10 / ISSN 0973-8959
Critical Care
Diagnostics
Radiology Medical Robotics Surgical Tables & Lights
Healthcare Research & Innovations Making Quality Healthcare Affordable and Accessible
“Medical, Diagnostic & Life Sciences Equipment Special”
Life Sciences
Cardiology
www.ehealthonline.org
Neonatal Care
Emergency Care
Awards | Expo | Conferences | Workshops
15 - 16 November 2012 Hyderabad International Convention Centre, Hyderabad
For enquiries, contact Divya Chawla, divya@elets.in, +91-8860651643
www.eINDIA.net.in
volume
07
issue
07
contents
ISSN 0973-8959
10
46
Mukesh Kumar Meshram
Dr Om Manchanda
Mission Director (NRHM) Government of Uttar Pradesh
Chief Executive Officer Dr Lal PathLabs
Cardiology
20
Medical Robotics
36
Chronic Disease Management & the Role of Technology
4
july / 2012 www.ehealthonline.org
Managing Director & CEO Adiva Group of Hospitals
46
Diagnostics
52
Emergency Care
54
Life Sciences
59
Surgical Tables and Lights
62
Sleep Diagnostics
64
Critical Care
39
Dr Vivek Mahadevan, Head- Client Solutions Group, HealthFore
Neonatal Care
GS Matharoo
13
Radiology
zoom in
60
43
asia’s first monthly magazine on The Enterprise of Healthcare volume
07
issue
07
july 2012
President: Dr M P Narayanan
Partner publications
Editor-in-Chief: Dr Ravi Gupta consulting editor: Ashis Sanyal
Editorial Team
Web Development & Information Management Team
Group Editor: Anoop Verma
Sr. Executive Officer - Web: Ishvinder Singh
Health Product Manager: Divya Chawla Principal Correspondent: Dhirendra Pratap Singh Research Assistant: Shally Makin
Sr. Executive Officer – Information Management: Gaurav Srivastava
governance Manager – Partnerships & Alliances: Manjushree Reddy Assistant Editor: Rachita Jha Research Assistant: Sunil Kumar
Associate Developer: Anil Kumar Information Technology Team Dy. General Manager – IT: Mukesh Sharma Executive-IT Infrastructure: Zuber Ahmed Finance & Operations Team General Manager – Finance: Ajit Kumar
education Sr. Research Analyst: Sheena Joseph Senior Correspondent: Pragya Gupta Research Assistant: Mansi Bansal
Legal Officer: Ramesh Prasad Verma
Sales & Marketing Team Manager – Marketing: Ragini Shrivastav National Sales Manager – digitalLEARNING: Fahimul Haque Associate Manager - Business Development: Amit Kumar Pundhir Assistant Manager-Business Development: Shankar Adaviyar
Executive Officer – Accounts: Subhash Chandra Dimri
Sr. Manager – Events: Vicky Kalra Associate Manager – HR: Sushma Juyal Associate Manager – Accounts: Anubhav Rana
Subscription & Circulation Team Sr. Manager – Circulation: Jagwant Kumar, Mobile: +91-8130296484 Sr Executive - Subscription: Gunjan Singh, Mobile: +91-8860635832 Executive - Circulation: Ashok Kumar Design Team Team Lead - Graphic Design: Bishwajeet Kumar Singh Sr. Graphic Designer: Om Prakash Thakur Sr. Web Designer: Shyam Kishore Trainee Graphics: Meenakshi Rajput Editorial & Marketing Correspondence eHEALTH - Elets Technomedia Pvt Ltd Stellar IT Park, Office No: 7A/7B, 5th Floor, Annexe Tower, C-25 , Sector 62, Noida, Uttar Pradesh 201309, email: info@ehealthonline.org Phone: +91-120-4812600 Fax: +91-120-4812660 ehealth 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. ehealth is published by Elets Technomedia Pvt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS) Owner, Publisher, Printer - Ravi Gupta, Printed at Vinayak Print Media, D-320, Sector-10, Noida, UP, INDIA & published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP, Editor: Dr. Ravi Gupta © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic and mechanical, including photocopy, or any information storage or retrieval system, without publisher’s permission.
www.ehealthonline.org | www.egovonline.net | www.digitalLEARNING.in Write in your reactions to Health news, interviews, features and articles. You can either comment on the individual webpage of a story, or drop us a mail: editorial@elets.in
6
july / 2012 www.ehealthonline.org
editorial
‘Co-Creation’ Model will Drive Medical Technology Innovations Technology advancements in the last two decades have not only revolutionalised healthcare delivery, worldwide, but also aided patients and providers by enabling enhanced quality, reduced turnaround times and affordable services. However, despite the growth of the Indian medical technology market in the last few years, the industry is plagued by low penetration. The per capita spend on medical technology in India is approximately USD 2, as compared to USD 5 for China and USD 231 for Germany. The demand still is primarily coming from the urban regions and penetration in tier II and III areas remains low, owing mainly to lack of affordability, accessibility, awareness and availability. Medical technology innovation is the key to make improved care accessible, available and affordable to all as it lowers the cost of the product or delivery. Both product as well as business model innovations can benefit all stakeholders including patients, doctors, and end-users. India, however, faces serious challenges when it comes to medical technology innovations as policy and research in this field has been limited, so far. Developed countries, in contrast, have attracted wider medical technology research, resulting in medical innovations that are prevalent in all segments of this industry. United States, for instance, witnessed a 20 percent increase in medical innovations during the period 1980 – 2000. The challenge of low-penetration can only be addressed if the medical technology industry in India focuses on innovation. Innovations will help players bring down costs and create newer markets in low-income segments in tier II and III regions. Further, for fruitful innovations, it is imperative for all stakeholders including government, industry, academia and health insurance providers to collaborate and strategise for promoting innovations in any industry and the medical technology industry is no exception. This issue of eHEALTH focuses on research and development, innovations and revolutionary technologies in the medical, diagnostic and life sciences equipment space. Focused sections on Radiology, Cardiology, Critical Care, Ambulances, Diagnostics, Life Sciences, Sleep Diagnostics and Critical Care, among others provide insights into the technology innovations happening, worldwide. We hope you like the compilation!
Dr. Ravi Gupta ravi.gupta@elets.in
july / 2012 www.ehealthonline.org
7
volume
07
issue
07
july 2012
asia’s first monthly magazine on The Enterprise of Healthcare
Social Circle Medvarsity@medvarsity Gene linked to 70% of tough to treat breast cancers identified with latest technique testing multiple genes at a time http://goo.gl/PbK7m eHEALTH Magazine @ehealthonline Health IT curbs barriers to mental health http:// ehealth.eletsonline.com/2012/06/health-it-curbsbarriers-to-mental-health/ Neelesh Bhandari MD@edrneelesh Digital Medicine: Crowdsourcing Supervision of Healthcare Delivery Services in India http://vsb. li/880T4r CNN-IBN News@ibnlive HIV infection: CBI probe against Gujarat hospital http://ibnlive.in.com/news/hiv-infection-cbi-probeagainst-gujarat-hospital/268141-3.html Nicole Cummings@NicoleCummings1 Right diet, not just reduced calories, could help maintain weight loss ...: For millions of Americans on a diet,... http://bit.ly/MuaksZ Everyday Health@EverydayHealth Many #BreastCancer Patients in Their 40s Aren’t High Risk http://bit.ly/IVpgCg Dr Shreya Deshpande@DrShreya Treatment of headaches with homeopathy#headache #homeopathy http://fb.me/1TLHkpasu
Facebook Like of the Month
Dr Rajiv Kumar Jain
Dr Rajiv Kumar Jain is the Additional Chief Health Director, Hospital Administration with Indian Railways. He was previously the Director, Health & Family Welfare in Ministry of Railways
inbox Readers Speak “Congratulations and good luck to Elsevier led by Rohit Kumar. This will change the outlook of medical institutions as well students, who will now have the chance to gain knowledge in medicine and health sciences through digital learning experience.” Catakam Kumar on Gateway to Quality Medical Education “Nice article that summarizes the various technology trends in the area of healthcare! Increasing adoption of smartphones is reaching new technologies to an ever increasing set of users in a way that is easy to manage as well as highly affordable. As adoption increases, it will help users live a more natural life that is less tethered to hospices.” Atul Nene on Mobile and Connected Devices to Drive Preventive Health “The rate of a radiologist salary will vary quite significantly depending on the education a radiologist has got. The quickest is a hospital training program that takes up to a year and will provide a radiologist with a salary under USD 50,000. An associate or a bachelor degree in radiology takes more time (two and four years respectively), however, a radiologist with a bachelor’s degree may count to start his/her career with a salary over USD 70,000.” Anonymous on Interventional radiologists: Tough on liver cancer, kind to patients “We have global diseases integrated / interactive solution finding software; which can be utilized by professionals word over; overcoming human limitations / incapacitations in the way of comprehensive medical knowledge deployment; IT knowledge applications interactively shall constitute a true renaissance in this it era; but for professionals getting IT acclamatised.” Dr SC Garg on The DNA of Healthcare Organisations “This is a wonderful development that should be made easily accessible to the developing countries particularly Nigeria. I would like to volunteer to be an advocate for the use of this technology in Rivers State, Nigeria.” Sam on Sulabh’s model of sanitation impresses Bill Gates
twitter.com/ehealthonline
facebook.com/ehealthmagazine
8
july / 2012 www.ehealthonline.org
policy
ICT Requirements for
Strengthening
Primary Healthcare Through effective implementation of various schemes, Uttar Pradesh is trying to improve its healthcare delivery services. Mukesh Kumar Meshram, Mission Director (NRHM), Government of Uttar Pradesh, in this freewheeling interview with Dhirendra Pratap Singh, shares his perspectives on various healthcare issues in the state
What are the innovative programs implemented in collaboration with USAID over the years in Uttar Pradesh. How has this partnership helped in changing the health scenario in the state? Innovations in Family Planning Services (IFPS) Project was designed by USAID in collaboration with Government of India to revitalise the family planning programme in UP by introducing innovative approaches and mainstreaming successful interventions. IFPS project was started in 1992 and continued till March, 2012 having been implemented in three phases. In 1993 IFPS project created an autonomous body called the State Innovations in Family Planning Services Agency (SIFPSA) to implement IFPS project.
10
july / 2012 www.ehealthonline.org
An initiative was taken to strengthen and upgrade public healthcare facilities for provision of quality FP services. This initiative focused on strengthening various aspects of the government healthcare facilities. Up-gradation of the facilities led to improved access to quality FP services and an enabling environment was created for the service providers. Recognising it, GoI introduced the concept of first referral units (FRUs) and 24 hour functional units for providing round the clock delivery services and newborn care under the RCH II program. How do you propose to bring down the MMR, IMR and Total Fertility Rate (TFR) in the country? People in India should have access to the basic requirements of life: a balanced
diet, clean water, decent shelter, and adequate clothing. As the 21st century proceeds, it will become increasingly difficult to meet these basic needs, especially in states that have not achieved population stabilisation. Population growth is of concern regardless of where specifically it is occurring. As our numbers are rapidly increasing, environmental degradation, hunger, persistent poverty, economic stagnation, urban deterioration, and health issues will continue to challenge us in Uttar Pradesh. Currently, we have highest TFR among all states in India at 3.8, except Bihar. Although, according to the NFHS-3 report for Uttar Pradesh, TFR declined from 4.8 children per woman in 1990–92 to 3.9 in 1996–98 and to 3.8 at 2005-06, but rate of population growth is still very high at 16.16 percent.
policy
If rate of population growth continues at the same pace, Uttar Pradesh will double its populations by the year 2045 from the base of 2001 population. Many demographers consider rapid population growth of the poor to be the most urgent population problem. Various government schemes introduced in UP to address the issue to TFR, wherein sterilisation campaign is among the prominent one and implemented as part of the national programme. IEC activity addressing and sensitising the masses over the benefits of small family, delayed marriage and birth spacing was done but the outcome was not achieved as it would have been. We are still adding almost a district every year in terms of population. How do you see the involvement of Panchayati Raj Institution in healthcare delivery in Uttar Pradesh? IFPS project considered PRIs ideally suited for implementation of RCH programme and integration of services at village level and imparted training to pradhans to make them aware of various health programmes, particularly RH and FP and encouraged them to promote healthcare seeking behavior among villagers and implementation of health activities in villages. The training and orientation led to greater interest and involvement of pradhans in RCH services. PRI interventions helped to build supportive environment for RCH activities. One of the core strategies of the IFPS Project was to equip human resources in the health sector in UP, engaged in implementation of program interventions at different levels with requisite knowledge and skills, and to create an enabling environment to practice these skills leading to an improved program performance. What kind of reengineering needed for effective implementation of Information and Communication Technology (ICT) in healthcare? Presently there is a vast nationwide public healthcare infrastructure already established in our country. This infrastructure can be fortified by augmenting them with ICT technologies and services to address primary healthcare more effective-
ly. Apart from the public sector we have a large and diverse private/NGO sector addressing healthcare delivery considerably. It is pertinent and important to take this into consideration in identifying the ICT requirements for strengthening primary healthcare such that the same may be suitably adapted in different settings with minimal changes. Presently the focus on healthcare is mainly on curative medicine. It is important to take a holistic view and address promotional, preventive and curative healthcare. This needs to be further emphasised, especially in the private sector to ensure that the private/NGO sector participates more effectively in preventive and promotive healthcare for the healthcare programme to be effective. The healthcare delivery models could be different in different regions of the country based on the local factors. It is necessary to take cognizance of this factor in designing solutions. What are the challenges in deploying new technology in health sector? A set of guidelines for use of ICT for primary healthcare has to be developed which will go a long way in optimally leveraging existing technologies, while ensuring its continuity to the evolving and advancing technical innovations,
A set of standards and guidelines on ICT for primary health care have to be defined, that will help in attaining the goal of providing all people with a practically attainable standard of Healthcare
There is necessity of delivering cost effective solution for ICT based healthcare delivery at primary level and indigenous enterprise for providing software or hardware for e-health programmes. A set of standards and guidelines on ICT for primary health care have to be defined, that will help in attaining the goal of providing all people with a practically attainable standard of healthcare, which is sustainable in an integrated manner. The use of ICT in health projects will improve awareness and ensure capacity building for societal benefits. How do you see the role of clinical training to healthcare providers and strengthening of infrastructure? Clinical training needs of health staff were identified. Findings indicated that training centers lacked self-contained facilities; unavailability of training materials or equipment, outdated clinical guidelines and less attention to infection prevention practices. To strengthen the training infrastructure in a decentralised manner, divisional clinical training centers (DCTCs) were created at 10 divisional level district women hospitals. This approach reduced the work load of the medical colleges on one hand and facilitated increased participation of staff. How much public-private partnership model is workable in the health sector in Uttar Pradesh? We have started Sambhav voucher scheme in PPP model. The main objective of the voucher scheme was to provide the pre determined family planning and MCH services through voucher for BPL and poor families in accredited private health facilities for providing quality MCH and family planning services. Survey showed that ANC checkups increased from 17.5 percent to 34.3 percent, institutional deliveries increased from 22 percent to 30 percent. Similarly, Merrygold Health Network is an innovative Social Franchising Program being implemented since 2007 for private sector health service roviders for providing essential health care services including high quality maternal and child health services at affordable prices. july / 2012 www.ehealthonline.org
11
expert corner
Personalised Nano-Health Nanotechnology is truly more an evolution than a revolution, with a plethora of technological advances, processing necessity to reality
N
anotechnology (NT) is an extremely diverse new molecular level approach to developing new materials with dimensions on nano scale. It has the potential to control matter at an atomic level to revolutionise healthcare technologies. This has envisioned the manipulation of nano particles to enhance their properties. Its constituent particles are dendrimers and carbon nanotubes. The word nano is synonymous with innovations i.e. application of bio materials in medical applications in myriad uses in realms of devises. The hype of NT in medical devises, implants, reagents, biomarkers have taken us leap years ahead. These nano particles can be coated or attached to lead molecules to target specific body tissues using chemical or electronic magnetic forces on atomic levels. Nanoanalytic devices and reagents- lesser sample used, lesser reagent required, more atomic surface area allowing better diagnostic testing. Nanobiomaterials - nanofilms give better orthopedic coatings, better bio availability, and self assembly property giving targeted drug therapy. Nano drugs and nano robotics have better penetration and aids in targeting diseased tissues, better sensing of cancerous cells, better gene expression, etc. NT is not just another out of the box concept. Its intrigue is not in its conceptulisation but in its capacity to create and control nano particles. It’s truly more an evolution than a revolution, with a plethora of technological advances, processing necessity to reality. Integration of R&D with futuristic applications
12
July / 2012 www.ehealthonline.org
Dr (Prof) Sanjeev Bagai CEO, Dean and Director Radiant Life Care, Delhi
Application Domains • • • •
Targeted drug delivery Implants and prosthetics coating e.g. in Cardiac stents. Neuro Electronic Magnetic sensors, implants and devises Nano Microscopy in tunnel scanning tools
is the stepping stone for innovative high end utilities in diagnostics, therapeutic & life saving technologies. It is an endeavor with a cardinal focus to integrate science towards practical cost effective applications. Bio sensors, bioneurostimulators, non invasive surgical alternatives, self targeting neuronal implants, nanoneuroprosthetics, remote controlled monitoring devises will out strip present limitations. The stage is set for a new paradigm of disease management by continuous remote monitoring rather than repeated clinic visits. Sensors to track TPR, BP, PFT, apnoea, cardiac output, stroke volume, arrthymias, and chemical sensors
for blood sugar monitoring will augment our fairy tale on medical advancement. Fetal Antenatal diagnosis with fetal therapy, gene modification with mitigates the errors. Fiction of yester years will be facts for tomorrow. The rise of personalised medicine is the result of unprecedented advancement in ultra high tech biotechnology. Example of novel biomakers for disease detection- NGAL and IL18 identify acute kidney damage 2 days before Creatinine rises. An educated healthcare provider and an aware customer is an ideal customer. This NT and personalised health care is now a global initiative and not just a niche concern.
Cardiology
Device Based
Therapies
New innovations in healthcare lead to better monitoring of patients and thus better treatment. Dr JPS Sawhney, Chairman, Department Of Cardiology, Sir Ganga Ram Hospital, believes that technology in the field of cardiology has undergone vast improvements during the past few years
P
ercutanously implantable cardiac devices have come a long way in treating patients with serious and life threatening ailments. The number of implanted cardiac devices has dramatically increased in recent years. These devices have evolved from simple, fixedrate pacemakers to multi-programmable systems with an ever-increasing amount of information retrievable and programming options available. New innovations have better accuracy and picture quality than the ones used a decade ago. The equipments keep getting upgrading as new technology arrives on wings of the work done by innovative brains. MRI was earlier an absolute contraindication in patients with implanted pacemakers. However, MRI compatible pacemakers are now available with no ferromagnetic component. These systems enable a full 1.5T MRI scan to be performed in the patient with implanted pacemaker. Implantable cardiac defibrillators (AICD) have revolutionised manage-
ment of patients with cardiac dysfunction and rhythm abnormalities. Newer AICD successfully correct majority of ventricular tachyarrhythmias through silent antitacycardia pacing (ATP) without the need for painful shocks. Cardiac resynchronisation therapy (CRT) is increasingly being used to resynchronise and improve contractility of weak and dilated hearts by electrically stimulating the right and left chambers of the heart simultaneously.
Remote monitoring of theses devices is now available to enable wireless remote interrogation and monitoring
Newer innovations in CRT and CRT-D devices include use of multipolar pacing leads with ability to pace at multiple sites and new sensors for heart failure monitoring which are expected to make an important impact on the patient outcomes. Remote monitoring of theses devices is now available to enable wireless remote interrogation and monitoring. Reports and special alerts can be sent automatically on a daily basis. This allows physicians to respond more proactively to changes in patient or device status, to triage patient care more appropriately, and perform the postimplant ambulatory follow-ups more efficiently. From devices for monitoring patient status to those that can anticipate cases of congestive heart failure, advanes are being made in every vertical of healthcare. Now it is recognised that device-based therapies will assume an increasingly important role in treating the growing number of patients with advanced heart failure. July / 2012 www.ehealthonline.org
13
cardiology
Cardiology in Action “I consider myself lucky to be living in a world where lots of new things are happening in the field of cardiology,� says Dr JC Mohan
Dr (Prof) JC Mohan, Chairman and Head of the Department of Institute of Heart and Vascular Diseases Jaipur Golden Hospital
T
he rhythm management devices are playing a big role essentially in the management of patients who are at risk of sudden cardiac death and those people who have heart failure. Heart failure in a different subset of people who have symptomatic and asymptomatic left ventricle systolic dysfunction use cardiac rhythm management devices. Besides the use of rhythm management systems is also made in patients who have very slow heart rates like complete heart block. Basically these cardiac rhythm management devices are of three types. First is shock device, the second is called CRT (Cardiac Re-pulmonisation Therapy) and third is a combination called the combo devices. With this regard, the capacity has been increased, the limits are being refined, to bring ease to implanting a donor. So far as indications are concerned, last 5 years nothing more is coming because it is pretty much established that 1/3rd of people benefit from CRT and combination of all these devices is better for most of the patients except those who are not in heart failure. Cardiac monitors have been there for many years. Fortunately cardiac monitors are being manufactured in India also by some very reputed companies as well as we get it from multi-nationals. Cardiac monitoring devices have revolutionised the management of patients in a lot of things. It reduces our manual labour to a great extent and I think they are moving from ICUs to high dependency zones, even in the patients who are relatively stable and are in separate rooms cardiac monitoring devices are used more and more. There has been a marked expansion in the growth of cardiac treatments in the country. 30 years back people only came
14
July / 2012 www.ehealthonline.org
for diagnostic purposes, as there was a limited utility for cath labs. Now cath labs are like operation theatres. They not only diagnose the problems, they also treat the problems, in extraordinary heart disease, regular heart disease, rhythm management and so on. Every hospital is now trying to acquire a cath lab. India is a big country and has large number of heart attacks occurring, and shifting patients from far away for treatment is not a good idea. There is an exponential growth of cath labs in the entire country. Even in Delhi, there are probably more than 50 cath labs. I would say that the treatment of ST alleviation by angioplasty has really revolutionised the cardiac treatment in India. Ten years back, the number of people having angioplasty done to
l growth a i t n e n an expo ountry. There is s in the entire c ably ab rob of cath l lhi, there are p De Even in th labs a c 0 5 n a more th prevent acute heart attack was only 5000. Today it stands at 1 lakh per year. These new and innovative things have improved the quality of life of the patients and increased longevity. So I am actually very happy and content to be living in the era of modern cardiology where things are rapidly changing. The cost of treatment is also coming down in India. If we adjust for inflation, it should have been three times. But cost is exactly the same as it was 12 years back. Coronary angiography used to cost `12,000 on an average in year 2000. In year 2012 also it costs `12,000 on an average. The most important fact is that, now the societies are vigilant with web, internet and other things, people ask questions and are aware. Patients have the right to not only trust the doctor who in turn keeps us on guard, and also keeps us on right track.
cardiology
Innovation Central in Heart Care
Research, innovations and continually developing healthcare infrastructure in India is key
kind of therapy. This is a problem that can be solved by creating awareness and continuing to develop healthcare infrastructure in India.
Research There has not been enough clinical research on pacemaker technologies in India. Physicians as a result have been more dependent on the data available from the westerners, but there is a huge patient pool in India, which can be targeted for participating in clinical research – especially those who would not have had access to the technology under other circumstances. To best do this, a robust hospital infrastructure is required. Some areas of care that are currently being researched are remote patient monitoring, which is under pilot stage in India, and leadless pacemakers. A good example of technology that has been researched and now enjoys wide acceptance by the medical fraternity is the Accent MRI-compatible pacemaker.
Dr Suhas Prahlad Hardas
Consultant & Interventional Cardiologist, Ruby Hall Clinic, Pune
W
ithin the past 70 years, the study of electrophysiology has evolved significantly. In earlier times, patients with conditions such as dizziness, fainting and other ailments may not have been correctly diagnosed, and a cause of death was not always accurate. But as science evolved medical fraternity could understand the problem lay with electrical wiring of the heart. It was the identification of that very problem which led to the invention of the pacemaker. When it was first invented, pacemakers looked similar to a modern day dialysis unit and were designed to be carried externally. They had very big batteries, and short lifespans. Pacemakers have evolved much since then, in terms of their size, lifespan and sophistication. Almost one out of 150 patients who are admitted in a cardiac ICU is in need of a pacemaker but due to lack of awareness, and many a time costs, patients are often devoid of the right
Innovation One of the most important modern day innovations is MRI compatibility in modern day pacemakers. This is helping patients to be exposed to a more precise diagnostic environment, in case of current or future ailments that may require an MRI scan. Increased device longevity is also an important aspect in deciding which of the many pacemakers available is right for a patient. This quality has improved over the years and is especially critical for a young patient who may have to undergo many implants throughout his/her lifetime. Increasing device longevity can mean a possible reduction in hospitalisation cost, mental and physical trauma, among other things.
Technology Revolutions There are many technology revolutions that I look forward to. Among the most exciting are the leadless pacemakers with high longevity, which can be implanted at the target site effectively. I also look forward to further advancement in pacemaker algorithms which would help to reduce unnecessary pacing and encourage the intrinsic cardiac activity of the patient. july / 2012 www.ehealthonline.org
15
cardiology
Big Ideas, Low Cost
Dr Praveen Chandra
Our goal within each cath lab is to make procedures both effective and efficient, ensuring the best patient outcome possible
Chairman of Interventional Cardiology at Medanta - The Medicity, Gurgaon
T
he catheterisation laboratory (cath lab) is an essential cornerstone of every modern hospital performing cardiac procedures. In Medanta, more than 12000 procedures take place each year in our five labs. A number of diagnostic and therapeutic catheterisation procedures can be performed in our labs including: percutaneous coronary interventions (PCI) procedures to implant stents, fractional flow reserve (FFR) measurement procedures to measure levels of aortic stenosis, closure of congenital heart defects, and repair and replacement of heart valves that are not functioning properly. We also have a hybrid lab, where can also conduct electrophysiological (EP) studies to diagnose and treat arrhythmias. Our goal within each cath lab is to make procedures both effective and efficient, ensuring the best patient outcome possible. To do that, conducting ongoing research to discover best practices and utilising modern, best-in-class technology is paramount.
Research To optimise treatment, both conducting research and understanding the implications of the latest research from around the world is critical. Results from landmark clinical studies have influenced the way medicine is practiced. For example, recent clinical research about the impact of FFR measurement from the FAME (Fractional Flow Reserve vs. Angiography in Multivessel Evaluation) studies have clearly showed that angiography guided PCI may help optimally treat ischemic lesions. Thus, we have adopted the learning and now practice PCI using a more scientific approach to treat ischemic lesions by using FFR. Further, Medicity is involved in multiple research projects involving cutting-edge new medical devices. This includes the lat-
16
July / 2012 www.ehealthonline.org
est stent technologies, drug eluting balloons, and biovascular scaffolds, among other technologies.
Innovation One innovation that we will acquire soon is the Optical Coherence Tomography (OCT) Intravascular Imaging System with the C7 Dragonfly Imaging Catheter. OCT is a next-generation coronary imaging technology platform that helps our physicians to visualise and measure important vessel characteristics that are may not otherwise be visible. This information helps assist with stent selection using near-infrared light to create images that provide more detail than angiograms alone – thus helping create an even more effective cath lab. In terms of current industry innovation, various companies are helping take technologies used in the cath lab forward by conducting large-scale studies like FAME and FAME II. They areconstantly upgrading the technology platform to make it more accessible and user friendly. For example, the PressureWire Aeris adds wireless ability for FFR measurements and ILUMIEN integrates OCT and FFR together in one platform.
Technology Revolutions There are a lot of forthcoming revolutions that will change the way that we utilise our time in the cath lab. For example, renal denervation is going to be a revolutionary technology to treat hypertension that is resistant to drug therapy, and has shown extremely promising results in reducing systolic blood pressure. Hypertension is epidemic in India and this is a very simple procedure in which benefits can be extended to the patients. Other revolutions are looking forward to in the cath lab in the near term are biovascular scaffolds, TAVI, and PMVR.
cardiology
Aim for Excellence
R
ecently, Quadripolar technology was launched in India, and it was designed to help overcome many challenges of left ventricular (LV) placement. Using the new lead technology, which has four pacing electrodes and ten pacing vectors, it is possible to re-position the LV lead electronically, which helps in avoiding another surgery and any resulting complications.
Research Quadripolar pacing has been an important topic over the past few years, with a significant amount of research taking place in Europe and U.S. on this issue. We are planning to participate in clinical studies regarding Quadripolar pacing technology at BM Birla Heart Research Centre in the near-term.
Innovation The main difference is that for the first
time within the industry there are four electrodes, which enables up to ten pacing configurations. According to the latest research, the increased options for configurations help to reduce complications of high threshold and phrenic nerve stimulation. Quadripolar technology also has a unique design that enables basal pacing which results in about 50 percent fewer heart failure hospitalisations or deaths when compared with apical pacing. Moreover with its proven S-curve design chances of lead dislodgement is lowest.
Dr Anil Mishra
Technology Revolutions
Medical Director & Interventional Cardiologist, BM Birla Heart Research Centre
In the future, I look forward to have combination of features in the Quadripolar device including “QHR Battery Technology” and CorVue. The QHR battery packs more energy and increases the longevity of the CRT device and the CorVue feature helps monitor the fluid congestion in
lungs, which can warn the patient and physician well in advanced of clinical episode of heart failure. This allows us to alter medication and change therapy to prevent an episode of heart failure and hospitalisation.
Bandwidth of Scanning medical community. MRI scans can help physicians to better evaluate the presence of certain diseases - such as stroke, cancer, spine and neurologic diseases - that may not be adequately assessed with other imaging methods, such as Xray or ultrasound.
Research
Kaustav Banerjee
Country Manager, St. Jude Medical
A
dvanced technology based scanning is fast becoming a preferred diagnostic tool in the
It is estimated that up to 75 percent of pacemaker patients could benefit from MRI scans during the lifetime of their devices. Data from an abstract presented at the Venice Arrhythmia Congress in October 2011 demonstrated that the Accent MRI pacing system was implanted safely and with no adverse events in 129 patients.
Innovation The Accent pacemaker is the only pacemaker in India that provides coverage in
the chest and abdominal area, which is especially important to patients who may need an MRI scan in the chest and abdominal area. Further, the Accent MRI pacemaker has several features that simplify patient management. These features include AutoCapture Pacing System technology that measures the heart’s reaction to pacing beat-by-beat, and the VIP algorithm that enables the heart’s intrinsic rhythm to prevail when appropriate, thereby reducing unnecessary ventricular pacing.
Technology Revolutions I believe that MRI-compatible technology will remain an important area of focus for physicians in India and across the world. In the future, there could be new advances such as MRI-compatible implantable cardioverter defibrillators (ICDs) or other cardiac technologies. july / 2012 www.ehealthonline.org
17
expert corner
Technology that Cares Today, healthcare mostly follows a remedial rather than a preventive approach Sonal Pahwa
T
echnology has the potential to improve the quality, safety, and efficiency of healthcare, which can then be provided at a much reduced cost.The digitization of healthcare has created a foundation for a future that offers more efficient patient care and cost savings. Innovations such as M-health, Telemedicine, VoIP, multimedia collaboration tools and wireless services allow medical staff to access patient data and communications tools from any location while nanotechnology in healthcare is all set to revolutionise the entire gamut of services and the delivery thereof. The rapid rise in penetration of mobile communication devices has led to an increased access to Healthcare and health-related information. M-Health offers a real-time disease management technology, especially for chronic diseases. The program,developed using mobile phones and other digital media, is designed to collect health information, thereby motivating people to maintain good health. It enables doctors to accesspatient records instantly and take informed decisions about disease management. An online portal provides a simple & clean interface for monitoringvital medical information andspotting dangerous trends, thusleading to better lifestyle & health. It also sends customisedmedication reminders and motivational and behavioural trigger messages to patients ‘communication devices. Such programs are designed to benefit all stakeholders – patients, doctors &healthcare vendors. Patients can sub-
18
July / 2012 www.ehealthonline.org
scribe tohealth-related applications to improve lifestyle, manage chronic diseases and reduce cost of care. Doctors can use the services to improve treatment outcomes with real-time patient monitoring & counselling services. For healthcare providers, the benefits include better patient compliance, measurable outcomes, effective data management and improved customer care. As the mobile phone becomes a virtual clinic, capturing medical data and sending motivational messages for improving compliance with medication, diet & exercise regimens, patients can maintain the prescribed regime stemming fromhigher awareness levels.. Some other M-Health technologies are Patient-monitoring devices, Mobile telemedicine/telecare devices, MP3 players for M-Learning, Health vouchers, payments through mobile interface and Data collection software. The advantages offered bythese mobile communication technologies include “onthe-move” communication, irrespective of time and place.This is particularly beneficial for work in remote areas where thesecommunication devices results in improved access to information leading to better health outcomes.
Prevention Today, healthcare mostly follows a remedial rather than a preventive approach. This often results in a substantial amount of damage to the body and its functions, which are sometimes even irreparable. The future of healthcare lies largely in the
Associate Director-Healthcare, Technopak
preventive domain: identifying and stopping potential causes of disease/illness in the body before they begin to proliferate. Nanotechnology can contribute majorly to this area by preventing the occurrence of diseases.This is possible through more effective monitoring of individuals’ health (allowing diseases to be diagnosed at an early stage) and more sterile hospital environments (limiting the chance of secondary diseasescaused by bacteria, viruses and other microbes). A sterile environment can be achieved through use of antimicrobial coatings and filters, which can help minimise the ability of microbes to bind and start growing on surfaces exposed to patient body fluids. Silver and titanium dioxide nanoparticles can kill microbes directly. Silver nanoparticles have already enteredour homes in the form of coatings inside refrigerators. This anti-bacterial surface helps keepthe contents of the refrigerator fresh for a longer time. Filters with nanoscale pores also prevent viruses from entering through the surface. This technique will provide sterile surfaces by means of filtration of air and liquids that a patient is exposed to during treatment. Another domain where nanotechnology has a promising role is monitoring. This will not only aid in the treatment of existing patients but also for the routine check-up of healthy individuals. Point-ofcare (POC) and Lab-on-a-chip devices offer basic as well as advanced care at the patient’s location.
radiology
The Sound of
Serenity
The new inventions in the field of digital radiography are contributing a lot in the way of better diagnostics and imaging
T
he increase in use of advanced diagnostic imaging has almost certainly contributed to both improved patient care processes and outcomes, but there are remarkably few data to quantify the benefits of imaging. Ultrasound systems are mostly used in cardiology, radiology and gynaecology departments. But increasingly a number of other departments–critical care, emergency medicine, regional anaesthesia, operating theatres–have started showing interest in offering services for clinical applications. This is because imaging can give immediate answers to specific medical questions. Hospitals are purchasing units for different departments. Additional clinical challenges include the need for improved productivity because of staff shortages and space limitations; the need to reduce costs to enable digital imaging solutions in lower volume imaging locations, such as family practice, orthopedic, podiatric, and chiropractic settings; and the need to improve image quality and image acquisition and transmission times. Healthcare facilities around the world have unlocked the benefits of wireless DR. Installing highly productive DR suites will help the Trauma Center manage growing patient volumes using its existing xray rooms. A digital radiography system is technologically more advanced than analogue and computed radiography syste ms, which is one of the factors contributing to the growth of this market. The global digital radiography market has been witnessing the trend of film-free
20
July / 2012 www.ehealthonline.org
Dr Jignesh Thakker Secretary General, Indian Radiological & Imaging Association
A digital radiography system is technologically more advanced than analogue and computed radiography systems, which is one of the factors contributing to the growth of this market
radiology departments. However, the increasing adoption of computer radiography systems could pose a challenge to the growth of this market. The use of diagnostic imaging in the medicare population has increased significantly over the last two decades, particularly using expensive new technologies such as computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine positron emission tomography (PET). The development and improvement in these advanced diagnostic imaging technologies is widely credited with leading to earlier and more accurate diagnoses of disease using noninvasive techniques. Healthcare infrastructure is developing rapidly across India. Powered by technology, new innovations and driven by new age hospitals, Ultrasound technology has taken a giant leap forward. The new inventions in the field of ultrasound are contributing a lot in the way of better diagnostics and imaging. In post bypass patients, the physicians prefer to conduct examination through soft exposure X-Rays so as to see how wet the lungs are. The cardiac surgeon would like to have an X-Ray with a harder exposure so as to see inserted hard ware, drains, etc. In one exposure with a conventional X-ray it is difficult to achieve both. This results in one of the two being unhappy with the quality. This problem does not occur with digital X-rays as the images can be manipulated to provide a softer and harder image with the same exposure thus keeping both the physician and cardiac surgeon satisfied.
radiology
Technology
Revolutions in
Radiography
Image processing is very important in digital radiograph as it influences the way the image appears and involves noise reduction with enhanced signal-to-noise ratio
Dr TBS Buxi Head, Department of CT Scan and MRI, Sir Ganga Ram Hospital
D
igital radiography is the new age radiography with filmless technology using digital detectors and various readout techniques to make it possible to fully digitise radiographic data and use PACS for image acquisition, interpretation, distribution and storage. From the days of Kruger in 1977, when the first digital subtraction angiography was performed, to the introduction of cassette based storage phosphor image plates, it took a long time for the first DR systems to appear with CCD slot scan system. The progress was then fast with the introduction of selenium drum, then the flat panel detector systems with amorphous silicon, amorphous selenium and finally the gadolinium oxide sulphide scintillators which made it possible for digital dynamic flat panel detectors for digital fluoroscopy and angiograpy.
CR systems use storage-phosphor image plates with a separate image readout process while DR systems use systems to convert x-rays into electrical charges by a direct readout process. In a CR system, the image plate is exposed to x-rays which is stored in the detective layer. This detective plate is scanned with a laser beam; stored energy is set free and light emitted is collected by photomultipliers and converted into electrical charges. Image processing is very important in digital radiograph as it influences the way the image appears and involves noise reduction with enhanced signal- to-noise ratio. The spatial resolution determines the quality of the images and this is proportional to the pixel size, image matrix and the detector size. The smaller the pixel size, the larger the matrix and better the image. Detective quantum efficiency (DQE) refers to the efficiency of a detector in converting incident x-ray energy into an image signal. The ideal detector would have a DQE of 1. As of now, the DQE of digital detectors is limited to about 0.45 at 0.5 cycles/mm. New storage phosphors and scanning systems are being applied to revolutionise computed radiography. New phosphors have their crystals grown in a needle shape and are coated on
a glass or aluminum substrate without any binding material between the crystals for tighter phosphor packing and reduced pixel size, resulting in DQE matching those for indirect conversion flat-panel detector systems . In addition, images are scanned line by line, resulting in shorter scanning times or the line scanners could scan for longer times and produce higher signal. The new technologies can reduce the radiation exposure by up to 50 percent while preserving the image quality. The new portable devices with flat panel detector systems especially in fluoroscopy will be more flexible and might even replace CR systems. Improvement in the DQE and signal-to-noise ratio of detectors may lead to further reduction of exposure or improvement in image quality. The architecture of the readout arrays could be optimised by reducing the size of the circuit and pixels. The future of radiography is digital. With revolutionary advances digital radiography offers higher patient throughput and dose efficiency with reduction in radiation exposure, consistently reproducible images with higher diagnostic quality and interface with PACS and the world of teleradiology. (The article is co-authored by Dr Anurag Yadav who is a radiologist) July / 2012 www.ehealthonline.org
21
radiology
Innovations & Research in
MRI
Research has become relatively easy today with open source data analysis software, image analysis software and websites
Dr Harsh Mahajan, Director, Mahajan Imaging Centre
I
nnovations in MRI are many. Each radiologist is “innovating� the way they perform the MRI scan. In contrast to other imaging modalities, the MR system really allows the user to tweak the core settings of the scanning protocols with the aim of providing the best possible images and report for a particular case. This leads to a lot variability in scanning methodology and gives the radiologist the freedom to perform a tailor made scan for each patient. As far as technological innovation is concerned, new types of MRI machines are coming out and there is a trend of high-end high-field MR systems and low-field dedicated MR systems. There are systems available today which perform MRI scans of only specific parts of the body, for example joints, limbs and even breasts. On the other hand there are systems which are now enabling whole body
22
July / 2012 www.ehealthonline.org
scanning in a matter of minutes and along with many other advanced features. We have been doing MRI centric research for the last two decades and the quality and enthusiasm of researchers in our country has gone up drastically. We have been performing high-end fMRI research on brain plasticity for the last four years with one of the most reputed cognitive neuroscience departments in the world. We have also been working with some government agencies to see the effect of high altitude on cognitive capability using fMRI. We are more than willing to perform imaging for various drug trials, and have recently been participating in trials for treating multiple sclerosis, epilepsy, thalassemia, psychiatric illnesses, liver cancer and many others. We have been promoting independent research on weight-bearing MR Imaging and we hope to change the way an MRI of the spine is done all over the world. Also, in the fields of rheumatology and immunology, there is a great role that is played by dynamic contrast enhanced MR scanning, which we are trying to prove. Another innovative application of MR imaging that has recently come into mainstream is the use of MRI to perform High Intensity Focused Ultrasound Ablation of benign tumors, mostly uterine fibroids. Soon the same technology may be used for treating prostate cancer, breast cancer, Parkinson’s disease and for targeted drug therapy. Research has become relatively easy today with open source data analysis software, image analysis software and websites which enable sharing and searching of literature with the click of a button. Teleradiology software enables sharing of images across the globe and hence simplifies interaction within the scientific community at large. There is definitely great scope for both, research and innovation in MRI today and it is only when the machine developers come together with clinicians, radiologists and technologists that this can be taken to another level.
case study
Image On Display “The Barco display systems we purchased are top of the range. Consequently, they are not considered a cost but an investment that helps us serve our patients in a much better way.” Dr Bharat Agarwal, Director, DCA Imaging Research Centre
S
ince the 1930s, the DCA Imaging Research Centre, named after Dr. Diwan Chand Aggarwal, has developed a reputation as a pioneering imaging practice that is committed to introducing the latest technology in the field of radiology. With patient centricity as its core value and a ‘right diagnosis, right treatment’ philosophy, the hospital invests in highly advanced equipment. DCA has been using Coronis Fusion 6MP DL diagnostic display systems for some time now. The radiologists praise the display’s multimodality imaging capabilities. The displays ensure enhanced visual accuracy and the 30” screen gives them the flexibility to read images side by side in many configurations, thus fostering user comfort. The MDRC-2120 displays form the backbone of the CT/MRI reporting stations. The DCA Imaging Research Centre is equipped with advanced world-class diagnostic equipment, such as a 64-slice Cardiac CT, a Whole Body 1.5, a Tesla MRI and PET-CT as well as a number of mammography and digital radiography systems. The centre also offers digital fluoroscopy digital OPG, nuclear medicine and ultrasound services. When DCA was looking to upgrade its existing fleet of medical display systems, it started a thorough evaluation to find the best solution. The selection soon proved that Barco, and in particular the Coronis Fusion 6MP DL diagnostic display system, offered the perfect solution to meet the centre’s demanding imaging needs.
Enhanced workflow DCA considers the Coronis Fusion 6MP DL unique in its class. The large diagnostic display system allows simulta-
24
july / 2012 www.ehealthonline.org
neous reading of colour, grayscale and fused static and moving images. Coronal views, for instance, can now be combined with smaller MIPs and volume rendered images on the same screen, in order to facilitate faster reading and diagnostic decisions. Radiologists can quickly toggle between images from different modalities, without shifting between monitors or workstations. The integrated uniformity luminance technology (ULT) reduces non- uniformities and makes sure the display is fully compliant with DICOM GSDF, across the entire screen surface. Supported by I-Guard – a tiny embedded photometer positioned at the front of the screen, this significantly increases diagnostic precision. Dr Bharat Agarwal, Director, DCA Imaging Research Centre, mentions, “I have been using the Coronis Fusion 6MP DL for the last 3.5 years and I appreciate how it really enhances my workflow. It allows me to see CTs, MRs, ultrasound images and even PET- CTs conveniently and comfortably on one screen. The screen dimensions make it easy to compare all these images at an optimum size and resolution.”
Quality across all displays In addition to the Coronis Fusion 6MP DL, DCA installed several MDRC-2120 displays as a backbone for CT/MRI reporting. “The displays provide us with a great platform to review CT and MRI scans, which make up for the major workload of our radiology department. The great advantage is that the image quality is maintained across all displays. Contrast, brightness and a wider viewing angle are better than conventional computer monitors.” The MDRC also maintains DICOM compliance, which is vital for accurate diagnosis and review.
Quality care The Barco medical displays come, as standard, with MediCal QAWeb, a fully automated and centralised calibration and quality assurance software. MediCal QAWeb tracks, maintains and logs viewing performance, automates QA tasks, initiates display system calibration and establishes an accurate DICOM look-Up table calibration. “This really makes our life trouble free. We don’t lose time making sure we get the optimal output from each and every display, it’s all taken care of for us,” the doctor continued.
radiology
MRI Technology,
Next Ten years! T oday an MRI can perform imaging of coronary vessels of heart which was unimaginable till few years back. The most interesting development in magnet technology is the normal temperature superconducting magnets where there is no need of cooling. Already High Temperature Superconducting magnets ( HTS) are developed up to 0.5T and many firms are working a commercially viable normal temperature superconducting 1.5T MRI. If this comes true it will change the entire MRI magnet technology and that will be the biggest change in next 10 years.
Ultra fast scanning Ultrafast MRI utilises multi channel (eight or more), phase-array brain coils, which increase the speed of image gathering but does not reduce the quality of the
Som Panicker Vice President Sanrad Medical Systems images. Ultrafast MRI has been cited as a useful diagnostic tool for patients sus-
pected of suffering a stroke. Lot of MRI vendors are working in this area and ultrafast sequences will be a standard feature in coming years. This new type of MRI technology will feature all of the image collection qualities of standard 1.5 Tesla MRI systems, but with the signal-to-noise (SNR) advantages of a very high field MRI scanner. Cardiac MRI is a beneficiary of this technology .
MRI HIFU The therapeutic use of ultrasound combined with the navigation done with the help of MRI has resulted in MRgFUS or MRI HIFU (MR guided Focused ultrasound or MRI high intensity Focused ultrasound). HIFU is used presently for treating Fibroids and many forms of cancer. Lot of developments are being happening, these include the use of HIFU for treatment of brain tumour and other types of cancer cells . This technique is relatively safe and radiation free hence it attracts lot of attention in recent times.MRI HIFU could be a standard treatment mode for next 10 years. The future is certainly bright for MRI – be it in traditional diagnostic imaging, in therapy, or on a molecular level.
Innovations in Ultrasound T he field of ultrasonography is one of the fastest growing medical imaging modalities in the world today. It is the ideal combination of diagnostic accuracy and cost-effectiveness that gives the medical ultrasound an edge over almost all other modalities. At the same time, the diagnostic capability of ultrasonography is completely dependent on the skill of the ultrosonologist, especially since, unlike other modalities like X-Ray, CT and MRI, the ultrasound reporting can only be done while the scan is going on and in most cases cannot be repeated. We have recently started research to evaluate the usefulness of liver elastography by a new method. Another area research and evaluation, which we are actively pursuing, is the vast and largely
26
July / 2012 www.ehealthonline.org
Dr Prem Kumar, Senior Consultant Radiologist Mahajan Imaging Centre untapped field of contrast enhanced ultrasound. It has been found to be extremely useful for differentiating malig-
nant vs. non-malignant lesions in the liver. Other unique applications of ultrasound that we use are endoscopic ultrasound, bronchoscopic ultrasound, 3D/4D imaging, transcranial ultrasound, transcranial dopplers, carotid intimal thickness, advanced blood flow studies etc. Some vendors even aim towards “replacing� the stethoscope with an ultrasound transducer that can be connected to a mobile phone, to perform an echocardiogram of the heart! The medical ultrasound, though relatively inexpensive, both for the equipment buyer and patient, is a tool with great utility and potential, and in the right hands has the capability to transform the quality of medical care being provided to a patient. It is an ever evolving modality whose applications are increasing day by day.
RADIOLOGY
Novel Applications
Dr Suman Singhal, Senior Consultant Radiologist, Mahajan Imaging
M
ultidetector computed tomography (MDCT) has rapidly evolved from 4-detector row systems in 1998 to 256-slice and 320-detector row CT systems. With smaller detector element size and faster gantry rotation speed, spatial and temporal resolution of the 64-detector MDCT scanners has made coronary artery imaging a reliable clinical test with a high sensitivity and specificity. These emerging technical advances and novel applications will continue to change the way we study coronary artery disease beyond detecting luminal stenosis. We
are routinely performing cardiac angiography in adults and pediatric population with 64 slice CT scanners in our centres and are on our way to get the latest 256 slice CT scanner with spectral imaging in near future. 64 slice MDCT along with 3D mapping of airways and virtual bronchoscopy produces high-resolution images. CT virtual colonoscopy provides an inside view of the colon. Last but not the least, PET-CT scanning with the fusion of both PET scanning and CT scanning is becoming increasingly important in recent years for evaluation
of cancers. It provides both functional information of PET and anatomic details of CT.
Dr Venu Gangahar, Senior Consultant Radiologist, Mahajan Imaging
I
n the present century, conventional radiography has been largely replaced by CR (Computed Radiography) and more recently by DR (Digital Radiography). These modalities are essentially non-screen/non-film systems of radiography in which images are captured electromagnetically. In conventional radiography the screen combination generated and stored the image after being exposed to radiation. These newer modalities involve the use of IP (Imaging Plates) with or without cassettes in CR and DR respectively. These systems are slowly leading to omission of dark rooms from radiology
departments and are leading to workflow improvement by way of faster image viewing, easier post processing and
simplified analysis. The ability to tweak the window settings enables a single image to show both bone and tissue. With PACS systems coming into our hospitals in a big way, CR and DR systems enable real-time visualisation of X-ray images by physicians and surgeons. The level of radiation exposure to the patients also drastically decreases with the use of these technologies. Since no chemical waste or film waste is generated, these systems are more environment-friendly as well. On the other hand, relatively high cost of these systems is a limited factor as far as their utilisation en-masse is concerned.
Kamran Khan, Technical Marketing Engineer, Xilinx Technologies
T
oday the focus is on bringing doctors and healthcare to the people, wherever they are. This is made possible by two growing trends in medical devices: Miniaturisation and Portability. Medical devices, such as, Ultrasound systems are becoming smaller and more portable, enabling doctors to diagnose ill patients in the most rural places. Xilinx realised early on how important system integration and low power consumption are to medical devices, such as Ultrasound and Endoscope. This allows for unparalleled system integration.
Pulling in more functions into the device reduces the number of semiconductors dramatically, and as in case of Ultrasound, to one. Zynq’s pioneering technology that combines FPGA fabric and ARM processors enables designers the freedom to choose which architecture is best to optimise their design in. Its innovative design allows it to deliver high performance while consuming lower power, results in longer battery life. Zynq, enables tomorrow’s medical devices to be smaller and more portable, without compromising on performance. July / 2012 www.ehealthonline.org
27
Radiology
3D Advanced
Visualisation for All There is need for advanced visualisation tools with PACS and 3D capabilities
R
emember the old days when modality workstation was the only means of advanced visualisation and volumetric analysis. The so called “workstation” was perceived as the most valuable resource and was the only means by which multi-slice CT, MRI and PET/CT procedures could be efficiently interpreted and reviewed. Most CT scanners come bundled with a 3D workstation offered as part of the package, and these workstations often have good software for providing 3D interpretation support. Making advanced visualisation available to a broad enterprise poses some technological challenges. This is not like browsing the web where the processing power required is small and the data volume transferred is manageable. Modern MDCT datasets can run to gigabytes and the processing power needed to render them in real time 3D pushes the very limits of modern computing technology. As a result there is tremendous value in being able to avoid moving the large CT datasets around to multiple computers across the enterprise, and in being able to avoid reliance on the processing power of whatever computer may be available out there to do the 3D rendering itself. This effectively turns every computer in the enterprise into a 3D workstation and if the power and feature set of the server is adequate, this becomes a really elegant,
28
July / 2012 www.ehealthonline.org
Volume Rendering technique
Pranav Shah Sales Manager- India Terarecon viable and cost-effective solution for delivering advanced image processing to everyone who needs it. A truly capable enterprise solution based on a client-server solution enables multiple users to use any networked standard PC as a 3D workstation and use various clinical applications for diagnostic interpretation and review. Nowadays with software innovation together with client-server architecture, allows automatic preprocessing of datasets. PACS with 3D capabilities in the system available today enhances workflow.
The key differences between the 3D technologies in the market relate to the technology used for 3D rendering and the general architecture of the system. When the CPU of a computer is used for 3D rendering, a general purpose processor designed for Microsoft applications performs a specialised medical imaging task, often with poor efficiency and performance, even when compromises are made in image quality. The same is true for GPU rendering, as “video cards” in most computers are mainly designed for computer games. These cards deal primarily with “polygon” graphics and typically do a poor job on anatomical data, with compromises in terms of performance and image quality. As a result, such systems usually have to calculate additional information about every dataset that is received, just to prepare it for 3D rendering, which takes time, memory and CPU power, and the results must then be stored on the hard drive, consuming additional space. The alternative is to use a dedicated hardware processor specifically designed to perform medical visualisation where the slice data can simply be downloaded to the board’s memory without any delay or additional processing, with real time 3D following. Such a system can have the power and scalability to manage a true client-server deployment powerful enough for an imaging enterprise.
Need 10 workstations, but only have budget enough for one?
Trust our ... We know what you’re thinking. ™
iNtuition offers the perfect advanced visualization solution for your enterprise. Based upon our new iNtuition system architecture, iNtuition products now leverage many innovative technologies to know your preferences, pre-process your images, and present them with your needs in mind. With much of the processing already done and instant access to large CT datasets, iNtuition solutions will turn your ordinary desktop computers into powerful 3D workstations and simplified reading environments. Don’t get tied down to one workstation. Trust our iNtuition to deliver workflow that works.
Contact: Pranav Shah | Mobile: +91 98191 92754 | Email: Pranav@terarecon.com iNtuition™ and the iNtuition logo are trademarks of TeraRecon, Inc. Copyright© 2012 TeraRecon, Inc. All rights reserved. 041712AQ-A/IE[2]-A1
041712_IE_ad_2.indd 1
w w w. t e r a r e c o n . c o m
4/17/12 6:33 PM
Radiology
A Bridge to DR DR imaging technology has emerged as the leading solution for workflow, productivity and X-ray image quality. However, as facilities plan their migration to DR, there are valuable bridge solutions well able to meet their imaging need as well as provide a cost-effective path to DR in the future
Swaroop Ghosh
General Manager-Digital Radiography Carestream Health India
X
-ray technology has long been the go-to diagnostic tool for many medical procedures and exams. Ongoing advances and improvements within the technology indicate that X-ray imaging will remain a key resource for years to come in medical facilities around the world. In today’s healthcare arena, economic pressures are forcing many imaging facilities to accomplish more in the face of reduced funding—at the same time, most refuse to allow compromise of image quality or patient care. Therefore, when investing in an X-ray system it is important to avoid paying high costs for capabilities not needed today while ensuring that the new system can be costeffectively upgraded with features that may become crucial tomorrow. The trend in the market for some time now has been the movement away from
30
July / 2012 www.ehealthonline.org
film-based and Computed Radiography (CR) towards Digital Radiography (DR) systems. The reason behind this shift is Computed Radiography (the image is captured on a phosphor screen and then scanned, effectively digitising the image) and DR (which utilises direct digital capture and processing of the image) both offer robust digital imaging and advanced image processing. However, DR technology stands alone with advantages such as lower dose requirements, elevated productivity, gains in overall workflow and faster time to diagnosis. Be that as it may, there are still highperforming alternatives to the cost of a new DR suite. Facilities lacking the budget or the patient volume to make productivity an overriding concern may still find that a traditional analog x-ray system with a CR capture and digitis-
ing option to be the best solution while planning a DR migration. Making the right choices within the CR context include single cassette or multi-cassette systems, tabletop or floor stand models, and relative cassette processing speeds- all with their distinct advantages and associated price tags. Selecting a vendor that offers a broad range of analog x-ray, CR and DR solutions helps facilities begin with the optimal system, then easily bridge the gap when the time is right to retrofit the existing analog room with a wireless DR detector. This strategy delivers all the benefits of DR imaging, along with the patient positioning flexibility of a cassette-size detector, without the large capital investment in an entirely new, integrated DR room. Lastly, by purchasing all of the abovementioned x-ray equipment from the same vendor, facilities can then utilised the same detector from system to system, room to room, and even in mobile x-ray systems. This keeps that detector providing a high return on investment on a 24/7 basis. By considering all of these issues while determining a 5-year plan - and, by partnering with an x-ray imaging vendor, who provides a broad set of options and trustworthy guidance - facilities can select both an optimum solution for today, as well as a cost-effective path for DR migration in the future.
radiology
“Conventional
Radiology has Relevance” Dr Kishore Taori Chairman, Maharashtra Medical Council and Professor and Head Department of Radiodiagnosis Government Medical College, Nagpur
E
ver since the modern X-ray came into being 15-20 years ago, the industry has evolved a lot. The comprised conventional radiography for accidental emergency has become very handy, and now we have the systems for digital radiography. Basically X-Ray science is utilised only to a limited sort of methodology, but in terms of resolution, reproducibility and the quality the conventional radiology have grown up much. The dissemination of images actually, is possible now from one centre to other centres anywhere in the world.. MRI has also grown a lot with the introduction of
2T, 3T and so on. Today, 3T is prevalent in all the teaching institutes. With the advent of software, the diagnosis has become very easy and many times the invasive techniques can be avoided. The finer diagnosis and even characterisation by the spectroscopy have become very important and easy. MRI is today being increasingly used in vascular and histopathological studies. With continuous development in MR Physics and related sequences the diagnosis has become absolutely possible in good standards in many of the situations. Conventional radiology definitely has relevance. It is a sort of black box for the studies. Added to that there is computerised radiography and digital radiography that has also become a part of conventional radiology. Negative issues about the manual conventional radiology have been taken care of with computerised and digital radiography. The quality is extremely good, resolution is good, reproducibility is there and one
can have a three-dimensional sort of reconstruction; and the dissemination of the images is much easier. I strongly believe that conventional radiology has got a tremendous role to play in this era of imaging and finer imaging like MRI. Now digital radiography has become very handy, portable digital radiography kits which can be used in ICUs and the operation theatres, orthopaedic theatre and casualties. So taking the finer images somewhere, instantly transferring these images to a place is much easier. That was a science which already worked, now the thing is acceptability, and I believe that in times to come this will be in every nook and corner of the country, as it is done in the western countries. We are continuously involved in the research projects like spectroscopic evaluation of the various tumours and another area is tectography where chronological cases can be evaluated and we can suggest our neuro-surgeons for treatments accordingly.
A Culture of Innovations
O
ver the last few years, medical technology is primarily being focused on early and accurate diagnosis, faster and better treatment planning and effective follow up. maging technology is focusing on early detection and diagnosis, thus enabling higher chances of cure and correction. This also helps in using technology for preventive care rather than treatment after disease occurrence. It is now possible to detect minute lesions in the body with great precision and resolution with imaging technologies such as Ultrasound, CT, MRI, PET/CT, etc. at an early stage. For example, with Siemens PET.CT, a physician can detect a lesion as small as 2 mm anywhere in the field of view. Another example is, Acoustic Radiation Force Impulse (ARFI) technology using ultrasound, which helps in diagnosing liver ailments at a much earlier stage and without biopsies. In the field of clinical chemistry and blood analysis, technology plays a significant part. A drop of blood sample can now provide insight into an array of diseases and symptoms that might strike
a person. We have also made advancements in the area of molecular diagnosis, which can provide a profile of a patient’s genetic variation that can indicate susceptibility to a certain disease before the symptoms occur. For over 100 years, Siemens has been investing extensively in R&D. On an average, we spend close to 10 percent of D Ragavan our revenues in research and Sector Cluster Leaddevelopment. Dual Source CT South Asia scanners, Tim Technology for the Siemens Healthcare MR, DynaCT on Cathlabs, ARFI based Ultrasound are some of the prominent examples of our Innovation leadership. We will continue this tradition of focus on research and development. July / 2012 www.ehealthonline.org
31
expert corner
Integration
Technology with Healthcare of
The major challenge with modern technology is the cost and rapid changes in design and engineering, says Dr Sai P Haranath
T
echnology is like life - always changing yet constant in the certainty that ultimately all of it has a shelf life. Therein lies the beauty of innovation in technology for there is always the opportunity to make things smarter, faster, smaller, cheaper or elegant. Healthcare has often lagged behind in adopting new advances but times are changing with cross fertilisation of ideas. We now have biocompatible antimicrobial fashion scrubs alongside robotic surgical instruments. Virtual consultations are happening right next to traditional ‘touchy feely’ doctor visits. I would like to focus on three areas where I have personal experience and expertise which showcase the rapid strides that health technology is taking. The use of ultrasound is well known to diagnose myriad ailments. The latest to join this list is the use of miniaturised ultrasound probes in endoscopes to help with analysing lymph node enlargement and getting a biopsy of these internal structures. Previously only a surgical procedure could access these deep seated areas. The use of EBUS (endobronchial ultrasound) and EUS (endoscopic ultrasound) has revolutionised the management of certain cancers. In India we have a limited number of centres that offer this technology and like all great products the cost of equipment is still on the higher side but there are studies to suggest that the cost savings from avoiding surgery may be substantial. Telemedicine has come of age in many areas but in my opinion the full
32
July / 2012 www.ehealthonline.org
Dr Sai Praveen Haranath Consultant Intensivist and Pulmonologist, Apollo Hospitals, Hyderabad potential has not been explored. I am involved in providing intensive care to patients at the bedside but I also am part of a group that provides critical care to patients half a world away in the US virtually. The care we provide is of great benefit to the doctors there who can get some rest while we take care of their critically sick patients at night. The time difference and our combined critical care expertise make it an ideal situation for the US hospitals. There are a lot of regulatory and safety checks in this process and quality is a top priority. We felt that this is something that will work in India also and have floated a company (24/7 Health Vision) to start providing virtual intensive care for hospitals in India. In fact many large hospitals including Apollo Hospitals are
actively looking at entering the teleICU field since the safety and quality benefits are immense. The third example that highlights the integration of technology with medicine is, well, technical. In the intensive care unit we have patients who often have low blood pressure and often it is not clear right away why it is low. Simplifying a complex system in a few words is tough but let’s just says that the low BP could be from too little fluid or blood in the system; it may be because the heart is not pumping well or perhaps the blood vessels are too relaxed and can’t hold the fluids tight in their thousands of miles of plumbing. Infection causing septic shock is one such condition. It is now recognised that maintaining an optimal pressure and quickly treating the cause is important and one device that uses cool and advanced mathematics and algorithms is a continuous cardiac output monitor that uses something called pulse contour analysis. In tough cases it helps us figure out what the problem is. The major challenge with modern technology is the cost and rapid changes in design and engineering. Regulatory challenges, long turnaround from discovery to bedside and the unpredictable nature of human biological response to devices at times are all roadblocks to widespread adoption. My hope for the future is that the drop in cost and subsequent expansion in reach of healthcare will parallel advanced training and research and benefit the billions who suffer needlessly around the world.
medical robotics
“Da Vinci Robots are the Frontier of Precision in Surgery” Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute has set up yet another benchmark by launching Da Vinci Robotic Surgery – a cutting edge healthcare technology. Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital talks about the technology and its benefits
Dr Ram Narain Executive Director, Kokilaben Dhirubhai Ambani Hospital Why did you choose robotics technology for Kokilaben Dhirubhai Ambani Hospital? The Centre for Cancer at Kokilaben Dhirubhai Ambani Hospital is a comprehensive one stop shop for end to end treatment of cancer. Whether it be high end diagnostic tools like PET CT or genetic typing before starting chemotherapy, organ specific cancer surgeons, radiotherapy in the form of IGRT or IMRT, targeted chemotherapy or bone marrow transplant, it is all available at our hospital. Robotic surgery with its clear benefits in delivering superior outcomes in cancers of the prostate, urinary bladder, kidney, uterus was clearly the next step in expanding our scope of services. With increasing incidence of cancer and early detection due to screening, the subset of patients suitable for robotic surgery is increasing day by day. What is now available in limited centres will become a standard of care as time goes by. Tell us about your views on the potential penetration of robotic surgery in the hospitals in India. The potential is enormous in terms of penetration. One year may be too short a span of time to see a change in terms of cost and affordability. However, over a span of three years, we should be able to see a tangible decrease in costs.
36
july / 2012 www.ehealthonline.org
Which department would be early adopters of robotics? How does it help the patients and doctors vis-à-vis earlier treatment procedures? Globally UroOncology and Gynaecology are the drivers of the programme. Newer indications are emerging in head and neck, thoracic and gastrointestinal surgery. Patients are benefited in terms of less pain, less blood loss and shorter hospital stay. Doctors benefit by increased range of motion, increased dexterity and enhanced 3D visualisation. We will be expanding the range of services across specialities and set up a truly comprehensive Centre of Excellence in Robotic Surgery.
Tech Connect:
Robotic surgery is a breakthrough surgical technique. It is an effective, minimally invasive alternative to both open and laparoscopic surgery. With the robot, small incisions are made to introduce miniaturised wristed instruments and a high definition 3D camera into the body. This surgical system consists of an ergonomically designed surgeons’ console, a patient cart with four interactive robotic arms, a high performance vision system and a patented EndiWrist instrument. The surgeon can operate while being comfortably seated before a screen that displays a highly magnified 3D image of the body’s interior.
As the robotic technology is currently used for the cancer treatment, please tell us some of the highlights of this technology? Besides the benefits mentioned earlier specifically in cancer of the prostate, there is a clear decrease in the incidence of incontinence and impotence after radical prostatectomy. In cancer of the uterus and cervix a much more accurate and precise lymph node clearance is possible. At this point of time cost is a relative disadvantage in terms of capital expenditure and consumables. This will, however, over time be offset by shorter hospital stay due to lower morbidity as against laparoscopic or open surgery.
3
Power
Packed magazineS
asia’s first monthly magazine on The Enterprise of Healthcare
ASIA’S FIRST MONTHLY MAGAZINE ON e-GOVERNANCE
Asia’s First Monthly Magazine on ICT in Education
Subscribe
now
Subscription Order Card Duration (Year)
Issues Subscription USD
Newsstand Subscription Savings Price INR Price INR
1 12 100 900 2 24 150 1800 3 36 250 2700
900 -1500 `300 2000 `700
*Please make cheque/dd in favour of Elets Technomedia Pvt. Ltd., payable at New Delhi
I would like to subscribe: egov
digitalLEARNING
eHEALTH
Please fill this form in Capital Letters First Name..................................................................................... Last Name...................................................................................................... Designation/Profession .................................................................. Organisation ................................................................................................. Mailing address .................................................................................................................................................................................................... City ............................................................................................... Postal code .................................................................................................... State ............................................................................................. Country ......................................................................................................... Telephone...................................................................................... Fax ................................................................................................................ Email ............................................................................................ Website ......................................................................................................... I/We would like to subscribe for
1
2
3
Years
I am enclosing a cheque/DD No. ................................................ Drawn on ..................................................................................... (Specify Bank) Dated ............................................................................................................... in favour of Elets Technomedia Pvt. Ltd., payable at New Delhi. For `/US $ ...................................................................................................................................................................................................... only Subscription Terms & Conditions: Payments for mailed subscriptions are only accepted via cheque or demand draft • Cash payments may be made in person • Please add `50 for outstation cheque • Allow four weeks for processing of your subscription • International subscription is inclusive of postal charges.
you can subscribe online
http://www.eletsonline.com/subscriptions/
Medical Robotics
A Mechanical Arm T
Don Alvarez Director, Global Product Marketing Perfint Healthcare
38
July / 2012 www.ehealthonline.org
here are various robotic solutions being used for medical procedures ranging from mechanical devices outside the body that support surgery to so called “nanorobots� that can travel through the blood stream to find and treat diseases. There is also an enterprise level robotic systems that can more accurately and efficiently organise, distribute and record the delivery and use of drugs and medical disposables throughout an institution. There is a new type of robotic device now coming into regular use among interventional oncologists and other specialists who perform image guided, minimally invasive surgical procedures that involve the ablation of cancerous lesions and tumours. These robots help the doctor to better visualise, plan and then perform the procedures, which often entail the insertion of needles or probes deep inside the body. These robots are also proving useful in helping inexperienced doctors
train up to specialist level in minimum time. A growing number of Indian doctors are using various robotic solutions to improve medical outcomes in their patients. A good number are using robots to help them perform biopsies, ablations and precise delivery of pain medicine to the spine. The next big step in the field of robotic solutions for interventional percutaneous and ablation procedures is in the area of ultrasound guidance. The future robotic solution could be a mechanical arm that is registered with the ultrasound transducer to render real-time, three dimensional views for better planning and more exact needle guidance. Ultrasound based procedures require special visualisation skills on the part of doctors who often must train for years before they qualify for becoming expert. Robots have proven useful in dramatically reducing the time that it takes a doctor to expertly perform certain image guided procedures.
Zoom in
Chronic Disease
Management & The Role of Technology There are various diseases that are ideal candidates for chronic disease management programmes. We will have a look at one of them which has been a major contributor to both patient mortality, as well as morbidity globally, namely Diabetes Mellitus says Dr Vivek Mahadevan
A
chronic disease is one that persists for a period of three months or more. In a majority of cases improvement is slow and they do not get cured completely. Diabetes, hypertension, congestive heart failure, asthma, chronic lung disease, renal failure, liver disease, arthritis and depression are some chronic ailments with a high prevalence rate worldwide. Chronic diseases have a major impact on the lifestyle of the patients and affect their physical and mental wellbeing. They influence a patient’s daily routine as well as their patient family. They also take up scarce resources, such as specialist doctors, and other elements. In addition to the human suffering caused, these lifestyle diseases have an economic impact too, as they affect the older and experienced work force of a country. It has been proven that early screening and diagnosis of chronic diseases can significantly reduce the morbidity and decrease the need for hospitalisation. Prevention and continuous monitoring is the mantra and this is a vital ingredient of any chronic disease management programme. The management is made even more complex when a patient suffers from more than one disease. An integrated approach to healthcare delivery is required and sharing of information among healthcare professionals is of the
Dr Vivek Mahadevan, Head- Client Solutions Group, HealthFore utmost importance in order to deliver a treatment regimen to tackle these multidisease conditions.
Challenges to the Treatment of Diabetes From what we have discussed regarding the treatment of diabetes, it seems that a chronic disease management programme is the logical course to follow. So is this being followed unanimously? Well, it’s not as simple as that. Providers across the world are still using the tools of acute care in trying to fight chronic diseases. This is due to a lack of awareness even among profes-
sional care-givers. Sharing of information among providers is not happening to the extent necessary for effective collaborative care. One reason for this could be that except for the patient, there are no demonstrative benefits to the caregivers in sharing the information. Primary care physicians are wary of referring their patients to specialists as they fear losing their revenue from the patient. Patients are not adequately educated about the benefits of taking an active role in the management of their disease. They are not aware about the ways in which they themselves can reduce the morbidity and mortality of the disease. July / 2012 www.ehealthonline.org
39
Zoom In
The Role of Technology Diabetes decision support systems A diabetes advisory system can be used for the management of insulin dependant diabetes mellitus.
The aim is to support patient self-management to enable the patient to have access to information and advice at any time and in any form.
Electronic Health Records Image Analysis in Diabetic Retinopathy This is focused on automatic detection of lesions in digital retinal images for the purpose of screening for diabetic retinopathy. Algorithms have been shown to be able to detect various lesions.
Smart Bandages Smart bandages can be used to monitor wounds. The bandage contains sensors that detect the humidity, temperature and the types of bacteria present in the wound. This will help doctors to track the healing process from a remote location by analyzing the data transmitted via the net or even by phone.
Providers will use Electronic Medical Records to capture clinical information of the patient. HealthFore’s EMR has a robust disease management system that creates a series of logical workflows and alerts. Once a clinician selects a patient diagnosis; for e.g. diabetes mellitus, the system will create a treatment regimen wherein the system will prompt regular monitoring of blood indicators such as fasting and post-prandial blood sugar, HbA1c, etc. Reminders to the doctor can be generated if the patient has not done the required lab tests every three months. Alerts can be sent to nursing staff, dieticians, lab staff and across the entire continuum of care along with treatment recommendations.
Implantable Glucose Sensors Because of the limits of wearable needle-type sensors in clinical use, fully implantable glucose monitoring systems (IGMS) represent a promising alternative.
Transdermal Glucose Sampling and Detection Worn on the forearm like a watch, the GlucoWatch Biographer samples glucose through intact skin, quantitates the amount of glucose extracted, and converts that measurement to a glucoselevel value.
Tele-consultation A person suffering from diabetes for a long period of time runs the risk of getting foot ulcers and can also suffer from damage to peripheral nerves. Pictures of the affected foot can be uploaded via the net for a doctor to review.
Hand held devices The latest development in diabetes technology employs some of the latest mobile communication technologies.
40
July / 2012 www.ehealthonline.org
Health Portals HealthFore provides patient portals which the patient can access online to update their own health information. The portal will also contain education content & will provide a collaborative medium for patient-provider interactions & diabetics support groups.
Pervasive Healthcare Pervasive healthcare is all about continuously monitoring a patient by taking reg-
Early screening and diagnosis of chronic diseases can significantly reduce the morbidity and need for hospitalisation
ular readings of certain vital parameters like blood pressure, blood sugar, ECG etc. The values are cross-referenced with a list of pre-determined values and an alert is sent to the treating physician if there are variations. Blood pressure readings measured at home are more accurate as it reduces the 20-40 percent of false positives at a doctor’s clinic due to the so-called “White Coat Syndrome’.
Healthcare Blogs Blogs are also a common forum for people to exchange information. There is no dearth of good blogs dedicated to healthcare topics.
Conclusion The patient needs to take charge of his own treatment. This will lead to him taking informed decisions regarding lifestyle changes and regular monitoring of vital parameters outside the doctor’s office. It has already been demonstrated how timely management of the disease can significantly reduce both morbidity and mortality due to diabetes. The whole method of delivering healthcare revolves around the patient. Instead of confining oneself to doctorpatient interactions in the clinician’s office a patient can interact with his providers from a remote location. This increases the frequency of interactions and also provides timely advice and monitoring of a patient’s condition. We are thus talking about changing the dynamics of a typical doctor-patient relationship. This kind of patient empowerment involves providing more information to the patient, doctors, family and the community. Patients should be able to view their health information, obtain educational materials on the management of the disease and be able to communicate their concerns and queries to the physician. Physicians need to be aware of the progress in the management of chronic diseases and make adequate use of the tools available to offer better treatment to their patients.
expert Corner
The Healthcare Facilitators Evolution of India as a medical tourism hub has led to the demand for world class equipments
I
Dr Dharmendra Nagar Managing Director, Paras Hospitals
Changing Medical Technology Landscape • Faster up-gradation of existing technology and global new product innovation • Evolution of India as a medical tourism hub leading to demand for world class equipments • Growing awareness amongst providers and consumers on advancements in medical technology • Improving healthcare delivery and financing • Increasing competition with the advent of large private sector healthcare providers • Medical technology innovation: Robotic surgeries (Da Vinci S Robot Model), less invasive procedures, better clinical outcomes, shorter recovery time, Miami Brain Suite
42
July / 2012 www.ehealthonline.org
nnovative medical technology is an increasingly important driver for delivering efficiencies in healthcare systems. Despite consuming a low and relatively constant 2-5 percent of national health expenditure, between 2000 and 2008, medical technology has reduced hospital stay by an average of around 13 percent. This shift from in-patient to out-patient care provides substantial cost savings, as well as improved quality of life. Given the combination of Europe’s ageing demographic and the current economic climate, the value of these increased efficiencies cannot be overstated. Commercialisation of healthcare is definitely good for our country. Being a developing country, the advanced level of treatment methods need to be adopted which will require higher investment. Thus, there will be vision to gain profit too. As we all know that health is wealth, if one has better health then he can think of better earning. So it is directly related to our sustenance. Commercialisation means providing services for one’s own sake and benefit. And since ours is a developing country, more than 80 percent population is still in lower middle segment; so in this situation even imagination of commercialization may make ill to any poor. Now a days, it is becoming very difficult for a common man to knock the door of private hospital for his treatment. Healthcare extends beyond one person, one department, and one building. It is an active process that requires communication, collaboration, and decision-making-across care providers and care settings. At Paras Hospitals, the patient information flow among the authorised caring team-enabling better collaboration, and more informed and efficient decision-making. We offer solutions that break down barriers to help, to solve problems, to improve patient safety, to strengthen the revenue cycle, and to improve patient care. We pursue innovation in operational processes, business models, services, organizational culture and products. For example, we would have dedicated funding to projects aimed at breakthrough-level outcomes.
Neonatal care
e h t From
s ’ y s b a B B
Cradle
“Modern neonatal intensive care involves sophisticated measurement,” says Dr Neelam Kler, Hony. Senior Consultant and Chairperson Neonatology, Sir Ganga Ram Hospital
niques with smaller pressure changes are devised. Remarkable technological advances over the past two decades have brought dramatic changes to the neonatal intensive care unit. What kind of role is neonatal equipment playing in healthcare today? Newborn babies are born with immature organs which are in developing phase more so in preterm babies (born early). Hence at times sick term and preterm may need technological assistance for basic body functions like feeding, breathing and maintaining temperature. Today, there is rise in the popularity of technological advances used for special care of infants. New techniques and instruments are now playing a major role. An incubator is an apparatus used to maintain environmental conditions suitable for a neonate (newborn baby). It is used in preterm births or for some fullterm babies, who are really ill. Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity. Such healthcare equipment needs special modification for serving the cause of small babies, whose bodies are tiny and immature. Adult ventilators, for example, can damage baby’s lungs and gentler tech-
What are the innovative neonatal equipments available today in the market. A premature baby, who has not completed 37 weeks of gestation period, will be of low weight. To give them an atmosphere of a mother’s womb, and maintain body temperature, the infant is placed in specialised warm bed incubators. Many infants may have difficulty in breathing and difficulties due to the lack of biochemical agents in the lungs called surfactant, which prevent the lungs from collapsing. Treatment involves one or more of the following: supplemental oxygen (through an oxygen hood), use of a respirator (ventilator), continuous positive airway pressure, endotracheal intubation and in severe cases, doses of surfactant. The artificial respiration (ventilation) provided in severe cases can cause damage to the lungs due to high pressure and use of oxygen. A lot of sophistication has occurred in technology and methodology of ventilating these tiny babies to prevent damage to lung. Microprocessor-based mechanical ventilation
has replaced time-cycled, pressure-limited, intermittent mandatory ventilation with almost limitless options for the management of respiratory failure in the prematurely born infant. Gentler ventilation also reduces risk of brain haemorrhage in these babies which is a known risk in this subset of these babies. What are the key focus areas of modern neonatal care? Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity. Babies born at less than 34 weeks have an increased risk of bleeding in their brain. A new technology Cerebral function Monitors (bed side EEG) is also introduced. There is risk of jaundice in significant number of cases, and in severe cases this can damage the brain. Treatment involves being placed under a Bilirubin light (phototherapy). Is such sophisticated technology being used in India? In advanced centres such technologies are certainly being used. Neonatal units have also been established in district hospitals. There is a shortage of neonatologist and trained nurses in country. There is urgent need of increasing intensive neonatal beds in India. July / 2012 www.ehealthonline.org
43
Neonatal care
Caring for Newborns Due to better understanding and newer advances in neonatology these babies, now have a much better chances of survival with very few long term problems Premature babies Previously babies born early on inthe gestation period, i.e. less than 7 months have very few chances of survival. We do now have much better techniques in ventilation thereby increasing the survival rates and there are newer medicines which again aid in the maturity of the preterm lungs and also help the baby breathe better. In fact, there are newer equipment and techniques which are currently available and are conducive for totally eliminating even the most premature baby from being ventilated. This not only improves the chances of survival, but also decreases the hospital stay of the premature infant. As most premature babies have a higher caloric requirement we now have newer preterm formula feeds (for those babies where the mother does not have sufficient breast milk) which have higher amount of calories and micronutrients that are essential for the optimum growth of the baby. In those mothers who do have sufficient quantity of breast milk one can increase the nutritional value to suit the preterm infant, by adding human milk fortifiers. There are a number of sophisticated monitoring equipments that is currently being used to monitor the wellbeing of the premature baby. All the vital information about the preterm infants is continuously monitored in non invasive manner thereby preventing/decreasing invasive and often discomforting blood tests on the babies.
metabolic conditions, so that they can be detected and treated before they cause a problem to the baby. These techniques have evolved so much in the last decade that we can now screen for more than 20 – 30 conditions by just collecting 3- 4 drops of blood! Technology has been the driving force when it comes to advances in neonatology for the last two decades. Improved and newer medicines and state of the art machines have not only made neonatology less invasive, but also improved survival rates, and that too survival with much better long term outcome.
Term babies Majority of term babies born at full term do not require any form of specialised neonatal care. There are a very small proportion of babies (approximately 5 percent) who may have problems with breathing. With advancements in the field of neonatology most of these babies who conventionally had to be put on a ventilator are now being managed by non invasive respiratory support. Even the very sick babies who had infection or pneumonia, are now surviving because of a specialised ventilation technique known as High frequency ventilation. Jaundice is another common problem seen in new born babies, seen in almost 70 -80 percent. Most babies who do develop jaundice do not require treatment and the minority of babies (less than 10 percent) who do need treatment can be managed effectively by phototherapy. In fact, we now have sophisticated equipment by which this can be done at the mother’s bedside itself, as opposed to shifting the baby to the intensive care as has been done traditionally. We also do screening tests on newborns to detect certain genetic and
44
July / 2012 www.ehealthonline.org
Dr Raghuram Mallaiah
MBBS, MRCP, Director of Neonatology, Fortis La Femme Hospital, New Delhi
Diagnostics
“The R&D Unit Reinforces our Mission, Vision and Strategy� Dr Om Manchanda, Chief Executive Officer, Dr Lal PathLabs on research and development in diagnostics and more Please provide a brief background of Dr Lal Pathlabs and its reach in India and overseas? Dr Lal PathLabs was established in the year 1949 by late Dr SK Lal and over the last six years has emerged as the largest and the most reputed laboratory service provider in India. At Dr Lal PathLabs, today, we conduct over 30 million tests every year across 125 labs and over 1500 collection centers pan India. The lab also receives samples from MENASA (Middle East, North Africa and South Asia) countries, which are processed at
46
july / 2012 www.ehealthonline.org
the National Reference Lab at Rohini, New Delhi serving over 10 million patients a year. Dr Lal PathLabs has seen a rapid growth under your leadership. What are the key strategic initiatives you took that helped register this growth? The Indian diagnostic market is highly fragmented and unorganized. The non-accredited stand alone labs have low overhead costs and offer extremely low pricing. In this highly competi-
t os m e f th nt s in s o t a e ic On nific men nost sig velop diag he de D in y is t ngR& ustr utti ased c ind e of CR b us ge P lar ed lecu stics Mo gno Dia pansion was the next major initiative we undertook. The hub-and-spoke model, central to Dr Lal PathLab’s strategy, is built around company’s central laboratory in Delhi, satellite labs electronically connected with the central lab, and collection centres supplying patient samples to nearest lab. The model is perfectly synchronised with the two distinct product segments in the market—highly specialised tests and routine tests.
tive scenario, the first strategy adopted by us was to adopt an organic route and build key differentiators considering the out-of-pocket nature of spend in healthcare business. The key differentiators included Hi-Tech – provide accurate reports; Hi-Speed – provide report at the right time; Hi-Touch – provide caring environment to customers; and Hi-Spread – provide complete test menu. The second major strategy adopted was building a professional management team and formalising the organisation structure. The evolved management practices have helped Dr Lal PathLabs take a lead in this industry in terms of technology, as well as operational concerns. Scaling up and geographical ex-
Diagnostics
lies in molecular diagnostics (qualitative and quantitative), inborn errors of metabolism (IEM), new born screening (NBS), GCMS (immunosupressants), TMS, biochemistry, cytopathology (conventional and thin prep), histocompatibility and immunogenetics, hematology, immunoassay and immunohistochemistry, flowcytometry and cytogenetics. In all these segments, we aim to cover a vast variety of diseases and disorders. What directions would you like the diagnostics industry to take? The diagnostics industry must develop technologies/processes to provide diagnostic services for mass population screening for NCDs at very affordable costs and partner with the state and central governments for PPP models (Dr Lal Pathlabs is in fact already successfully running PPP models with state governments of Tripura and Gujarat).
What is your outlook on the research and innovations in diagnostic industry? Which in your opinion are the most significant developments in research in the diagnostic industry today? At Dr Lal PathLabs, the R&D unit reinforces our mission, vision and strategy of continually applying contemporary knowledge and technologies to achieve tangible improvements in the health of our customers. One of the most significant developments in R&D in diagnostics industry is the use of cutting-edge PCR (Polymerase Chain Reaction) based Molecular Diagnostics, to develop accurate tests for variety of diseases and also make them available to all sections of society at and affordable cost in the shortest possible time.
What is the average technology spend in your company and which areas would you prioritise for future investments in research and innovations? Our average technology spend on R&D is about one percent of the total turnover. The areas that the organisation prioritises for future R&D and innovations include Molecular Diagnostics for improved and highly accurate test results in communicable and non-communicable diseases (diabetes, CVD, cancers, etc); state-ofart laboratory information management services (LIMS) to empower the customers (doctors, patients and clients); highly automated and computer controlled ‘hands off’ testing services; and latest web-enabled technologies for remote registration and report downloads to cut down on processing and testing time and further improve TAT.
Which are the major areas that Dr Lal Pathlabs is focusing on in the diagnostics segment? Keeping in mind the company’s vision – committed to be the undisputed leader in providing world class diagnostic services maintaining the highest ethical standards and quality, the major focus
What is the future growth model of the company? The future growth model will be in terms of geographic market expansion, new related businesses, M&A, and innovation to serve new needs of our existing customers. We are engaged in evaluating various initiatives that will enable this vision. july / 2012 www.ehealthonline.org
47
Diagnostics
Marking the Biomarkers In order to truly reap the benefits in clinical practice and shorten the warm-up period, education and awareness are most essential
Dr BR Das President – Research & Innovation Mentor - Molecular Pathology & Clinical Research Services Super Religare Laboratories
What is your view of the level of adoption in India of innovative technologies for diagnosing various diseases? Over last decade globally there has been an unprecedented development and growth in lab medicine area with adoption of newer and innovative technologies for diagnosis and monitoring of diseases. Pathological market leaders as well as medium and small labs are critically assessing the innovative and emerging technologies for a quicker adoption in clinical practice. The brightest example is adoption of Molecular Diagnostic technologies in India, particularly for screening, diagnosis and monitoring of major health threats such as TB, HIV and various types of Cancer. For years, DNA or RNA targets that can diagnose an infectious disease, identify specific gene variants that affect drug metabolism, or test for genes associated with diseases such as cancer. At the heart of such tests lie amplification technologies such as real-time quantitative polymerase chain reaction (PCR), transcription-mediated amplifica-
48
July / 2012 www.ehealthonline.org
tion (TMA), target amplification, and signal amplification. Apart from these the gold standard Sanger sequencing and DNA fragment analysis or sizing applications using capillary electrophoresis more popularly known as DNA Sequencing are also key technologies crucial for diagnosis of complex genetic disorders and other advanced applications such as Predictive or Preventi Medicine. Brief us about the plans of research d partment studying the role of right medical technology equipment in a hospital. In the healthcare sector, the focus now is shifting from treatment to prevention as a way of improving patient outcomes and to contain costs. Two important growth drivers in the clinical setting include the
to earlier and more reliable diagnosis, even when there are no symptoms, which in turn leads to earlier treatment and improved patient outcomes. In fact, our R&D has expanded role in nurturing the implemented technologies through education and awareness building activities for clinicians and hospitals, who are the key drivers in making these technologies effective in efficient patient care and management. How are such innovations benefitting the masses? Mainly in the field of Molecular Diagnostics (MDx), the advanced technologies and tests have enabled physicians to track disease course and progression on molecular level. These applications
st of the o m n i s nologie aboratories h c e t e r l The co gnostic a i d stems r y a s l u n c o e l g mo focusin ific target n e e b e c hav ct a spe e t e d h whic
need for new biomarker assays as well as for technologies that lower the cost per test, and which improve accuracy, sensitivity, specificity,and quick turnaround. Besides robust scientific evaluations for establishing validity of these technologies in Indian clinical settings and hospitals, the commercial feasibility aspects are also critically evaluated. The economic argument is simple: more accurate diagnostic technologies lead
aid in accurately pinpointing disease states and recommend therapies that are tailored to a person’s unique genetic makeup or “molecular signature.” Incertain scenarios, MDx do more help than physicians diagnose illnesses; they indicate prognosis as well as course of treatment. Due to its explicit sensitivity, specificity, accuracy and rapidity, MDx couldalso eventually explode the number of patients coming to labs as we transition from reactionary to more prospective healthcare.
diagnostics
From a Biomarker Perspective
W
hat will the future be for Invitro Diagnostics (IVD)? Will IVD products only diagnose or prognose a disease condition. How will it further help in patient care management? What will the future be for IVD? The most commonly used cardiac marker was CK, and CK MB with some customers looking at doing some more esoteric tests. Today we have newer markers like Myoglobin, Troponins, NT Pro BNP, Copeptin etc. The most commonly used inflammatory and sepsis marker, fifteen years back we had CRP and we used to look at other basic assays. Today we have the likes of procalcitonin, endotoxin and even a molecular diagnostics sepsis panel available. Procalcitonin is even used as both a diagnostics and prognostic tool. The most commonly used nephrology marker were the Biochemistry parameters of creatinine and urea. Today we have newer markers like Cystatin C and yet another Prognostic and Diagnostic marker called NGAL. The most common marker for rheumatoid arthritis was Serum RF IgG and IgM. Today we have newer markers called Anti CCP, MCV, etc. For the routine ANA Diagnostics we used to do a screen by Human Epithelial cells and confirma-
Suresh Chandrasekaran
Business Unit Head – Immuno & Molecular Diagnostics CPC Diagnostics tion with a six antigen ANA Profile. Today we are looking at a 15 antigen ANA Profile apart from the ANA Screen. Even for specialised assays like Downs Syndrome diagnosis, we were doing only second trimester screening, which was able to detect only around 68 percent risk assessment a decade ago. Today we have been able to evolve new biomarkers for first trimester in the form of PAPP-A and Free Beta HCG along with measurement of nuchal translucency to
facilitate the laboratories to assess close to 92 percent detection rate of the risk of foetus developing Downs Syndrome. The above are just some of the instances of how we have advanced with regard to Clinical Diagnostics. We are certainly moving into the era of Biomarkers, where newer technologies, newer techniques and newer markers will rule the roost. Coming back to the present, this is the era where in we can be able to do multiplexing using the complex bead based array like Luminex or do Microarray based on either fluidics, as seen in affymetrix platform, or a biochip based microarray, as seen in quite a few other instances. Further we will have newer technologies like proteomics, metabolomics and companion diagnostics gaining significance in the coming years. We have seen evolution of Invitro Diagnostics from routine parameters to the Specialised Biomarkers in the key areas. The Biomarkers will continue to evolve as a key tool in not only diagnosis but also in prognosis. Majority of the new Biomarkers may not be the ‘magic bullets,’ but they will certainly facilitate being associated as a Navigational tool towards diagnosis and prognosis of the specific disease conditions.
Access
magazine on iPhone and Android
july / 2012 www.ehealthonline.org
49
Diagnostics
Upstreaming Innovation “Point of care testing makes monitoring and management of chronic ailments easy,” says Ameera Shah
H
ealthcare is an ever evolving field with technological revolutions in various arenas like patient care, biotechnology, virtual consultations etc. It has been presumed that over the coming decade, as much as 50 percent of healthcare will shift from hospitals and clinic to the patient’s home or work area. New technologies will drive in-home care and at-workplace care. This will in turn help in improving prevention and detection, and will lead to faster clinical aid becoming accessible to the patients. It has been observed that wide range of personal health technologies are coming into their own, as the consumerisation of medical and consumer devices are taking healthcare to the next level. With point of care testing monitoring and management of chronic ailments lik, hypertension and diabetes can be easily done from the patient’s home. The advent of devices like smart phones, tablets, notebooks, have made it possible for us to have virtual consultation with doctors, online booking of appointments, and generate reports at the click of a button. This has in many ways simplified health wherein interaction with your doctor happens within seconds. It doesn’t require a personal visit this cuts down the waiting time at the clinic. Recent times have seen rapid advances happening in the diagnostic sector. Large numbers of devices are now able to conduct real-time monitoring. Sensors will look for changes in how we move to detect neurological risk. Tiny
50
July / 2012 www.ehealthonline.org
implantable devices can analyse blood chemistry in real time and let a doctor know if our drugs are not being metabolized correctly. By using simple devices integrated in everyday objects, a range of measurements can be taken. For example, there can be an integration of a thermometer into your mobile phone or a hydration monitor into your PC mouse. By interfacing the data with a remote management centre, through an internet portal, the consumer can be advised to test, and specific test requirements can be sent by mail whenever needed. Using complex data analysis, trends can be assembled and disease states spotted before they become untreatable. Traditional sampling methods can be painful and intrusive, often resulting in users either avoiding the test or testing irregularly. Today there has been a sea change in sample collection from the patients, so as to make the phlebotomy a pain free experience. Test specifications now require a very low blood sample volume or indirect measurement which enables increased compliance. Alternative sources of sample are available for testing, like saliva, sweat and urine. Indeed direct measurement may also be possible, all of which can be used to improve compliance. At Metropolis we have built in many patient friendly options to make blood collection a pleasant experience. Heel prick technology adopted by us makes blood collection of infants and toddlers a near pain free experience since low volume of blood is required. Sample is
Ameera Shah CEO, Metropolis Healthcare
drawn by pricking the heel of the baby and collection is done through specialised pediatric vacutainers backed by a well trained staff. Painless blood collection is available for sensitive adults or geriatric population through a gel, which is applied few minutes before sample is collected. Vein detector, a new innovation, helps in locating the vein before collection. This reduces the chances of second prick. Technological revolution has now become focussed on making healthcare a pleasurable experience. In times to come we can expect a healthcare that is as tasty as ice-cream in summers.
Diagnostics
Emerging
Wellness Marker Ensure that laboratories are providing accurate testing results in vitamin D testing methodology
W
hen I look back into my 45 years of medical practice, I find that we were made to understand that in our country with plenty of sunshine there is hardly any vitamin D deficiency. Vitamin D deficiency was associated with rickets in childhood and with osteoporosis in old age. There was no routine test available for Vitamin D estimation. The Vitamin D deficiency was assessed by estimation of calcium and alkaline phosphates and radiological findings. As a matter of fact, not very long ago, we did not have Vitamin D estimation as a routine investigation, it was only a research tool, nor was Dexa scan to assess the strength of bone, we were giving Vitamin D and calcium supplement to vulnerable people empirically or clinically or based on our Ca, Po4 and alkaline Phosphorus, but deficiency of Vitamin D was prevalent worldwide, osteoporosis came to notice when elderly people get fracture with minimal or no trauma. For some strange reason we under estimated Vitamin D deficiency. Now Vitamin D status is that of an emerging wellness marker. Vitamin D is now recognised not only for its importance in promoting bone health in children and adults but also for other health benefits, including reducing the risk of chronic diseases such as autoimmune diseases, common cancer, and cardiovascular disease. Vitamin D testing is increasing worldwide. Recently several diagnostic manufacturers have launched automated
Dr JS Suri, Director-Dr Suri Lab
25-hydroxy vitamin D (25OH-D) immunoassays. In last decade we have reliable and automated immunoassay platform for estimation of Vitamin D. We find that Vitamin d deficiency is far more prevalent than hitherto known. Globally, over one billion people are vitamin D deficient, and in the United States 77 percent of U.S. adults have insufficient levels of Vitamin D. Increases in vitamin D testing can be attributed to a growing global deficiency due to limited sun exposure and increasing links between Vitamin D deficiency levels and health conditions. In order to ensure that laboratories are providing accurate testing results, it’s important their vitamin D testing methodology measures total vitamin D (25(OH) vitamin D2 and D3), is traceable to LC-MS/ MS, and has acceptable precision. The recent dramatic increase in vitamin D testing is primarily due to two causes. First, there has been a marked increase in vitamin D deficiency in the U.S. and throughout the world. It is estimated that one seventh of the world’s Population is vitamin D deficient, and a recent study shows that nearly 80 percent of the U.S. population is insufficient. Many of the insufficiencies in the developed countries are due to people limiting their exposure to the sun to reduce their risk of skin cancer. Vitamin D deficiency is found in these regions when individuals limit their exposure to direct sun by using clothing or sun block. Unfortunately, the amount of vitamin D consumed in diets will not
compensate for the reduction of vitamin D caused by the use of clothing and/or sun block. The second reason for the increase in vitamin D testing is due to its use as a general health marker and the link between vitamin D deficiency and several diseases. The diseases that have been statistically linked to vitamin D deficiencies are various cancers, diabetes, multiple sclerosis, and cardiovascular and autoimmune diseases. There was and probably is considerable confusion on the reference range. Earlier reference range were based on population studies and the lower limit of normal was considered 8ng / ml. there was flaw in population based reference range as majority of population had deficient or insufficient Vitamin D levels. So health based reference range is being used now in evaluating Vitamin D deficiency and that is the right approach. As per health based reference range, 30 to 70 ng/ ml is considered normal and 20 to 30 ng/ml is considered insufficient and less than 20 ng/ ml is considered deficient. Pregnant women should receive 4,000 IU of daily vitamin D supplementation. Breast-feeding women should receive 6,000 IU of daily vitamin D supplementation. Vitamin D, not 25(OH) D3, crosses into the breast milk, and daily doses are preferred over weekly doses. Avoid supplementing the infant and instead supplement the breast-feeding mother directly. If the infant is bottle-fed, supplement with 400-800 IU/day. July / 2012 www.ehealthonline.org
51
Emergency Care
Story of the
Platinum Minutes It is a well known fact that the first hour, known as the golden hour, and the first couple of minutes, known as platinum minutes, after an injury or illness of critical nature, are vital for providing necessary medical intervention and can be highly crucial in saving a life or a limb Jashvant Prajapati, COO, GVK EMRI, Gujarat
B
efore the start of the era of Emergency Medical Services (EMS) in India, ambulances were merely white painted transport vehicles with a sign of red cross and very few healthcare facilities had well equipped medical ambulances. With the start of GVK EMRI 108 Services in India in the year 2005, a whole new chapter of EMS with well equipped ambulances and global standard pre-hospital care had evolved and that journey is still continuing. After the miraculous work of 108 in 12 states and 2 union territories, most of the people now understand that ambulances are not merely transport vehicles. s on today, we have saved more than 4.30 lac lives in critical cases and the maternal and infant mortality rates have been dropped considerably in the states where we are operating. There are other avenues where an ambulance can play a major role like a specially designed 4X4 wheel drive difficult terrain ambulances for hilly areas, boat ambulances for areas predominantly having water fronts, air ambulances for
52
July / 2012 www.ehealthonline.org
reaching areas inaccessible by road and small four or two wheeler first responder vehicles where reaching the location of emergency is still a challenge due to inaccessibility and traffic delay. Ambulance for a special purpose like neonatal ambulance or a high-tech ICU on wheels with specially trained staff can be very helpful. Ambulance can be converted to a Mobile Medical Unit to bring the primary healthcare facilities at the doorsteps of the citizens especially in rural areas. Ambulance can also be converted in to a Disaster Response Vehicle or Hazmat Vehicle and on this front much work is yet to be done. All 108 ambulances are equipped with all the necessary medical equipments and extrication tools and there are continuous efforts with a focus on further improvement and advancement in this front. All our ambulances will be equipped with Automatic Vehicle Location Tracking System (AVLTS) very soon. This equipment has various applications both in non-medical and medical like vehicle location on GIS maps and
navigation by GPS, bio-attendance of EMS staff, two-way video conferences between the paramedic and hospital/ doctor, transmitting patient/victims vital measurements and ECG recordings to hospital/doctor, etc. We can also exactly map all the important locations like hospitals, police stations, fire stations, disaster management centers, etc. with this and can prepare Geo Maps later on which can be very useful in responding to disasters of mass scale. Electronic version of Pre-hospital Care Record (PCR) is under development right now where the paramedic can enter the details/data about the case in a hand held touch pad and transmit it electronically to the center. Automatic CPR machine, rapid fluid infusion machine, neonatal transport, incubator, among others are the new avenues to be explored in the future. Government of India has also taken an initiative to chart out and implement a National Ambulance Code and in the near future all the ambulances operating in the country have to comply with the standards laid out in it.
Emergency Care
Wheels of Fortune
Lot of innovations have been done to make mobile medical units an authentic health delivery system
A
Dr HN Sahay Director Smile Foundation
pproximately two decades ago, Mobile Medical Units were being used only for emergency services for transporting patients to for special care at hospitals. Mobile Medical units as authentic health delivery system parallel to static mode of health delivery system. Smile Foundation, a national level development organization known for its innovative mobile hospital programme called “Smile on Wheels” launched in 2006. Smile on Wheels is a national level multi- centric project initiated by Smile Foundation with an objective of providing a comprehensive range of health care services to under-privileged community in outreach, remote rural areas and slums through an equipped mobile medical van. The programme focuses on providing wide range of
promotive, preventive and curative health services to the beneficiaries. Smile on Wheels address the problem of affordability, availability and accessibility of health care services. Smile on Wheels is equipped with all the facility to provide wide range of primary health care services e.g. advanced laboratory (semi auto analyzer and other equipments), x-ray machine with advance facility of auto film development (processor), ECG, minor surgery, OPD, pharmacy, life support system, TV, DVD, PA System, refrigerator, Power back up with digitalised distribution system and air-conditioned vehicle with all the advance facility in the van. Smile on Wheels is also equipped with Global Positioning system to monitor the vehicle under digitalization of monitoring mechanism.
Subsidised Emergency Services “Necessity is truly the mother of invention,” says Sweta Mangal, CEO, Ziqitza Healthcare
T
hose having undergone the traumatic experience of dealing with an accident or emergency health situation will easily understand how life threatening the crippled emergency service infrastructure in India can be. Today Ziquitza Healthcare limited (ZHL) runs 860 ambulances all over in India and has served more than 1.6 million people. To ensure high quality, the cardiac ambulances have life-saving equipment and medication, and are fitted with global positioning and radio systems. We do not just transport patients. We provide high quality in-transport medical care to
our customers by bringing together the best technologies like GPS and stateof-the-art call centres, advanced medical devices and well trained emergency medical staff on-board. Scaling up to increase equipment base and investment in state of the art technology are key to making a sustainable business Partnering with the Health Ministry of India through the NRHM project, ZHL now has strong presence through the 108 emergency services in Rajasthan, Punjab, Bihar and Kerala. The company, with the support of the government is now able to service the poorest of the poor at no cost to them and has successfully handled in-ambulance deliveries and medical complications with the help of trained medical staff. Rapid growth necessitates more robust IT systems and need to invest more in state of the art call-and-dispatch centres and ambulance tracking devices. july / 2012 www.ehealthonline.org
53
Life Sciences
Hospitals need precise ventilation Airflow control solutions can be installed and commissioned in an existing healthcare facility with as much ease as in a new upcoming facility
C
ritical environments like hospitals need precision airflow control. Without it, there will be higher energy costs and unsafe conditions for staff and patients. Precision airflow control achieves required environment service levels such as temperature, humidity, ACPH (Air Changes Per Hour), polarity/direction of airflow. It is mandatory to have accurate and repeatable control of airflow to reduce spread of airborne pathogens. Airflow can be categorised broadly as constant air volume (CAV) and variable air volume (VAV). Precision airflow control solutions are available for CAV and VAV applications. CAV applications are those wherein a fixed quantity of air is required at all times to meet the prescribed service levels. These are commonly applications wherein polarity / direction of airflow or ACPH is/are priority. Variable air volume applications allow for varying quantity of airflow to ensure service levels. These are common applications wherein temperature, ACPH (based on occupied/unoccupied status), is/are central to the requirement.
The technical features of the system allow it to be retrofit in existing ducting layouts and even at bends and transitions without requiring straight lengths of ducting. The TAB (testing, adjustments and balancing) / commissioning of the solution is immediate since the equipment is custom designed and calibrated/ configured for the application, prior to shipment of the equipment. Facilities with a need for critical environment control, as a basic first, can install the venturi valves at the supply and exhaust of demand side applications such as isolation rooms, operating rooms, in-hospital pharmacies, and patient rooms in order to ensure precise service levels such as temperature, humidity, ACPH (Air Changes Per Hour), polarity / direction of airflow. Additional equipment can be installed to upgrade the solution to include the entire facility. Venturi valve based airflow control solutions are accurate, repeatable, maintenance-free and energy efficient; they provide reliable space pressurisation, and lead to improvements in infection control and are insensitive to down-
Key facts linking healthcare to precision airflow/ventilation
• Infection Control – Better control of airflow/ventilation means better control of airborne pathogens • Energy Consumption – Hospitals run 24x7 and therefore properly controlled ventilation in unoccupied spaces contributes directly to energy savings. • Environmental Comfort – Improved climate control ensures comfort of medical staff during surgery • Pandemic Influenza and Emergency Preparedness –Patient rooms, intensive care units and emergency departments should be designed to convert to isolation or protective environments as needed • Profitability – Regulations place a great burden on hospital performance and profitability
54
July / 2012 www.ehealthonline.org
Prateek Vohra CEO Technocrat
stream and upstream disturbances that often upset service levels in a facility. It can incorporate low-leakage shut-off valves thus permitting gaseous decontamination or HVAC isolation procedures in virtually any space, should the need arise. It caters to the dynamics of a demanding hospital environment, irrespective of the, often encountered, poor levels of maintenance of the air delivery system. These valves should control air volume and directional airflow in the critical spaces of healthcare facilities, such as isolation rooms (switchable protective environment or airborne infection isolation), operating rooms, in-hospital pharmacies, and patient rooms designed for pandemic events. Venturi valve solutions meet all national/international healthcare engineering regulatory requirements set forth by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) and Centre for Disease Control (CDC). This makes it simpler for hospitals to gain accreditation like NABH, JCI, LEED.
If you are a Hospital a Wet Chemistry / Bio-containment Laboratory a Life Sciences Clean Room Facility
and your goal is to provide enhanced Safety Infection Control Energy Saving Comfort
Precision Airflow Control Solutions is your answer Talk to us +91 40 40198091 / 66333205 Write to us info@technocratsindia.co.in
www.technocratsindia.co.in
Life Sciences
Optimum Solutions G
rowing trends in the health sector from nucleic acid based rapid detection in clinical diagnostics to the need for Intra Cytoplasmic Sperm Injection (ICSI) technique in the IVF sector has allowed to position our liquid, sample and cell handling portfolio in a much better perspective. The new purity grades of eppendorf consumables are also setting highest standards in this segment. Addition of new pipettes to the existing range and NABL accreditation of our Pipette Calibration facility at Chennai have strengthened our capabilities in supporting and fulfilling customer needs in liquid handling arena. Aerosol tight centrifuge rotors with IVD conform certification are introduced to minimise the risk for lab personnel towards accidental exposure of samples in the diagnostic facilities. Sample prep
equipment like the MixMate and Thermomixer Comfort can comfortably handle low volume sample preparations in multiple formats. For most labs, running a 24x7 Ultralow temperature freezer (-860C) to store precious samples can be the most recurrent expense and we have introduced the High Efficiency Freezer (HEF) from our New Brunswick range which is energy efficient up to 40 percent compared to the regular models available in the market. Ultimately for labs interested in stem cell work our latest additions are the Galaxy CO2 incubators with gas control and complementing tissue culture consumables. Knowing that the priority of healthcare industry is quality products and after sale service, we at Eppendorf strongly believe that the solution is with us.
Dr D Muruganand Vice President, Marketing Eppendorf
Diagnostics- At All Time High
D
Dr Ravi Kumar Founder XCyton Diagnostics
56
July / 2012 www.ehealthonline.org
iagnostics in India is perceived as a high volume - low profit, cash strapped industry and thus unattractive for investment by venture capitalists. XCyton’s vision was to cater to the unmet need of medical diagnosis of causative agent in cases of critical infections (read as life threatening or causing disabilities) on the day of admission to any ICU. Fastest and the most sensitive way to detect the direct presence of the infectious agent is to look for the genetic materials of the pathogens. Logically we arrived at the development of a molecular diagnostic tool that can detect the presence of the pathogens directly in the clinical specimen. XCyton’s Syndrome Evaluation System (SES for short) was developed to simultaneously detect all the probable pathogens in a single sample, in a single test, with just seven hours of process time. Research of SES involved judiciously mixing a compli-
cated science of genomics with available knowledge of pathogenesis of the infections; blending the knowledge of nucleic acid chemistry to arrive at an easy to use test procedure; designing a test ultimately answers the needs of the clinicians at war with the infections. Today we believe that we have revolutionised the way neurologists manage infections. Timely use of this test can prevent blindness when eyes are infected after cataract surgeries. Neonatal sepsis the major killer of new born babies in this country is no more a desperate situation for neonatologists. This revolution would not have been possible but for the technology development loan we received from CSIR, Govt of India, in collaboration with NIMHANS, Bangalore; Sankarnetralaya, Chennai; LVPEI, Hyderabad; CCMB, Hyderabad; St John’s Medical college Bangalore and AIIMS, New Delhi.
life sciences
Personalised
Medicine Affordability is the reason that we today are turning to personalised medicine Dr Dinesh Pendharkar Cancer Specialist, Asian Institute of Oncology SL Raheja- Fortis Hospital
How do you think India has adopted innovative technologies for diagnosing cancer? In India we are absolutely in tune with international research as well as diagnosis of cancer. In cancer diagnosis the basic test required is the histopathology and a tissue biopsy and the processing of that biopsy. To diagnose it, we need to investigate how far the cancer has spread. So far the best diagnostic tests are readily available in the country. So as far as diagnosis is concerned all pathological tests can be done and all radiological investigations can be done to find out the type of cancer and the extent of cancer. How do medical oncologists react to the innovative technology available in the market today? How do you think the equipments or the diagnostic laboratory actually helps the cancer patients today? As far as medical oncologists are concerned, they are absolutely user friendly and they adopt new technologies very fast. So if a new tool becomes available, we are right their to accept it. Diagnostic Laboratories help in a big way. The basic analysis with the cancer diagnosis test is that these tests actually help us in identifying a particular patient, for instance, if
a patient has a breast cancer there are multiple drugs available. So the doctor needs to know which drug is suitable for this particular patient. Patient can get a drug which acts exclusively on these receptors in the cancerous cells. So these diagnostics will help us in modifying the treatment for cancer patients and using them for best results, so that the patient gets the maximum benefit out of the available drug. At the same time there is a cost saving. If the test is negative in a patient, the use of a particular drug may cost huge money. So the cost is saved because we perform this test and we know that this drug is not active for this particular patient. The test helps in modifying the treatment in various levels. Do you think that personalised medicine is a good approach to take up in the future? Affordability is the reason that we today are turning to personalised medicine. Personalised medicine is a treatment that has been personalised according to the type of cancer the patient is suffering from. That particular cancer will be treated by a particular type of receptor according to the particular property it has. Each kind of drug can target exclusively the property of that cancer.
Can you name a few technologies that you think can actually revolutionise the way cancer can be diagnosed? The best technologies which will really help us in diagnosis will be genomic technology, which is also known as micro array technology. And the second most important technology is the PCR technology. These micro array and genetic technologies can actually detect the genes which are defective, they can select and check multiple gene. These two three technologies will find out some genetic defects in a cell and can personalise the type of cancer with type of gene affecting the cells. The genomic and micro array technologies could be of great help. I wish to develop a term which is personalised adaptive treatment, which means I should be able to adopt this treatment towards patients as a whole, not only to the cancer patients. If the patient is receptor positive I know this drug is working but may be this patient is so lean that he cannot take up this pressure, and then I have to adopt treating. May be today he cannot take it, but tomorrow he can take it. The bottom line is that that the system of treatment also needs to be personalised. july / 2012 www.ehealthonline.org
57
expert Corner
Technology for Improved Care Dr Shivani Sachdev Gour, Director, SCI Healthcare and ISIS Hospital
T
he role of medical technology in healthcare can be imagined like that stethoscope without which a doctor’s picture is incomplete. Be it a small thermometer or a big MRI machine, medical technology is ubiquitous in health sector and with the remarkable progress in technology over the last century, the benefits have been miraculous. Medical technology inherits exceptional possibilities to improve the quality, safety, and productivity of healthcare. Owing to technology enhancements, treatment procedures are available at reasonable price
with better outcome and guarantee a quick recovery and lesser pain. It has reduced errors in medications and improved the efficiency of diagnoses, which earlier led to many deaths. Moreover, a quick and exact diagnose can cure fatal diseases. Medical technology has improved life expectancy, reduced IMR and MMR, alleviated handicap, cured the deadly diseases and has controlled epidemics. Considering its vital role, it would not be pretentious statement to make that medical technology industry has given us nature’s best gift—‘life’.
Dr Abhimanyu Bishnu, Senior Manager- Medical Operations & Quality, Aditya Birla Hospital The hospital has deployed advanced medical technology and IT resources. It has several innovations to its credit. Some of the major innovations that the hospital has introduced include full-time medical consultant concept. In community health education area we have started the Arogyadoot programme, which is aimed at creating health workers in the community to provide basic life support, mental health support, diet and nutrition and preventive measures for chronic illness.
In medication management audit system area we have introduced medication audit system at prescription, transcription, dispensing and administration stages. Some of the technological aspects in which the hospital has excelled, are High tech Hill-Rom beds, which have
been provided in all critical care areas, In-vitro Fertilization (IVF) Centre with foetal medicine specialty, 13 Hi-end Operation Theatres with guided air flow systems, 1.5 Tesla MRI with total imaging matrix and compatible ventilator for critical patients, Advanced NICU with neonatal ambulatory ventilators, Pneumatic chute system for transportation of samples and reports and hydrotherapy unit for treatment of occupational disorders. The hospital has achieved ISO certification and is aiming for NABH and JCI certification.
Dr Diptimala Agarwal, Consulting Anaesthesiologist and Intensivist, Pushpanjali Hospital Domiciliary Equipment usage has revolutionised patient care. Glucometer regulates blood sugar, blood pressure measurer at home helps in monitoring BP closely; CPAP (Continuous Positive Airway Pressure) machine has proved to be a boon to COPD patients and sleep apnea syndrome patients. This minimises the hospital stay and patients can use it at home on a daily basis. Likewise home dialysis is done for cases of Chronic Renal Failure (CRF) and Patient Controlled Analgesia (PCA) makes life quite comfortable for the patients suffering from chronic pain. Use of Automated External Defibrilators (AED) can save a life in the situation of a sudden cardiac arrest.
58
July / 2012 www.ehealthonline.org
Surgeries increased in both number and complexity, creating a need for new medical devices. Such devices included a variety of surgical instruments, catheters, and intravenous infusion equipment, as well as an array of peripheral healthcare products, including sterile surgical caps, gowns, masks, and gloves. Further growth in the overall medical device industry was spurred by the proliferation of community hospitals, which have become the primary market for medical equipment. There is dramatic room for improvement in healthcare delivery. The urgency to reduce the high level of preventable
medical errors, reduce liability issues, control infection and provide home healthcare services will focus our attention and resources as never before.
surgical tables & lights
Healthy Environment T he new Dräger “advanced workplace design” for ceiling supply units is made of components that make the daily working routine of medical staff easier. The “advanced workplace design” includes, among other things, a new lighting concept, the volume indicator “Noise Display” and an additional support arm for lifting a patient. Dräger will continue to develop this system over the next few years.
ent colour temperatures and moods. Sudden changes in brightness and the interference of monotonous lighting can effect the biorhythm and may delay the recovery of the patient. Factors such as the concentration levels of the staff can also be affected. During the night, the navigation light on the top side of the arms of the ceiling supply unit and the bottom side of the media column allow nursing staff to move around safely without bothering sleeping patients.
Lighting concept: Efficiency meets comfort
Noise Display: More peace in the hospital room
An ideal lighting concept is designed to allow examinations and treatment in the room while keeping the patient comfortable. One option in the new Dräger lighting concept simulates natural daylight over a course of twelve hours by modifying the lighting conditions and can create differ-
Noise Display is a volume indicator that emits an optical warning signal if hospital staff or visitors exceed previously defined limits for the room sound volume. With an additional support arm at the ceiling connection, Dräger now offers the option of adding a Guldmann patient lifter to the
ceiling supply unit. The patient lifter can be adjusted electrically for back-friendly lifting and transferring of patients. It helps to relieve clinical staff and increase patient comfort. The patient lifter is designed for a weight of up to 350 kg.
(Draeger Medical India Pvt Ltd, Ground Floor, Goldline Business Centre, Linkway Industrial Estate Link Road, Malad (West) Mumbai 400064, India, Tel: +91 22 4084 3825, Fax: +91 22 4084 3898, Mo: +91 9987538722, aditya.prakash@draeger.com, www.draeger.com)
Safe Patient
Handling
Girish V.Golani, Product Manager, South Asia, ARJOHUNTLEIGH
I
ndia is witnessing a paradigm shift in patient handling techniques with widespread introduction of patient lifters available worldwide, which are making foray into the Indian market. Patient lifters are electronically battery operated equipments, which are mobile and ensure safe lifting and transfer of patients from their bed to another desired area of transfer. An average caregiver (nurse) should not lift weight beyond 23 kgs as per international standards. Manual lifting is predominantly a cheap and widely available resource in India and often causes injury to caregivers, safety hazards for patients and cost implications to hospital. Passive floor lifters usually involve actuators, which drive the unit to lift the sup-
plement the efforts of patient lifters by minimising manual labor right from patient admission to transfer till discharge – a total safe and advanced way of handling patients. However, in India even due to absence of this legislation, there is no major acceptance by doctors and caregivers in intensive care units to enable safe and effective patient transfers. JCI accreditation plays a pivotal role in usage of these lifters in more and more corporate hospital chains across the country since these lifters also help to weigh the patient in addition to safe transfers. Ceiling lifters, which is a relatively new technology in India offers innovative transfers with the help of ceiling tracks and cassettes providing tailored medical solutions for the healthcare industry. July / 2012 www.ehealthonline.org
59
CEO corner
“Our OTs are
Equipped with Latest Equipment” GS Matharoo has taken Adiva Hospitals to greater heights by installing the latest and most cuttingedge equipment and adopting strategic management decisions. In this interview, he talks about the innovative equipment and technologies being used at Adiva As CEO of Adiva Hospitals, what is your vision and strategy for growth? In past, there has been a huge vacuum of organised chains of specialised nursing homes. We realised that and stepped into healthcare with the aim of filling this vacuum. These big set ups have a holistic approach but are focused on providing all kinds of services and tackling all medical needs. The big set-ups are losing on specific needs of the patient–they are not being able to give personal attention to customer’s needs. On the other hand the small nursing homes are ‘person/doctor’ based and not organisation based. More precisely they do not have the capacity to become an organisation or chain of nursing homes or professionally handle big business. Thus, with a combination of professional care of highest degree, the most experienced doctors, the latest technology and equipments along with personalised care, we plan to open 50-60 bedded super-speciality nursing homes all over. What role is technology playing in hospitals? Along with advancement, IT has played an important role in the definition of advancement of machines. Our operation theatre has advance care station, which is a clinically inspired, compact, integrated anesthesia care station that combines highly advanced anesthesia delivery, the very best in anesthesia patient monitoring, and information management. By combining these care elements with our supplies and services, we deliver an essential component of the integrated perioperative solution, anesthesia ventilation, electronic gas mixing, advanced breathing system (ABS), patient monitors, integrated solutions designed to enhance patient care and information at the point of need through web network.
GS Matharoo Managing Director & CEO, Adiva Group of Hospitals
60
july / 2012 www.ehealthonline.org
What are the various technologies and facilities provided in the operation theatres of Adiva? The OTs are equipped with latest equipments specific to each specialisation. OT complex is designed as per European stand-
CEO corner
ards with maintenance of air ventilation. The OT is equipped with electro hydraulic operating table and LED lights with modular OTs. It has a logic 200 probes ultrasound machine for ovum pick up and anaesthesia machine from Datex Ohmeda. The OT and the embryology lab and cryology room are made up of granite stone so that dust particles and micro organisms can be easily cleaned. The IVF equipment is of world class standard that include the K-system from Denmark. The K-system has inbuilt filters and a laminar flow to purify the air. The table can be heated up to 370C to maintain the temperature of the oocytes and embryo. Similarly, Endoscopy OT is designed to do all Laproscopic and Hysteroscopic procedures, both diagnostic and therapeutic. It has a TRICAM 3 chip camera with 19inch medical monitor from KARL STORZ with electro mechanical G1 Morcellator Rotocut. Hysteroscopy equipment includes Endomat for advanced hysteroscopic procedure and TCRE procedure. Electro surgical generator (Diathermy) force Fx from valley lab state of the art cautery machine. Anaesthesia is given by highly effective 7100 ventilator by AESTIVA 5 compact machine by DATEX OHMEDA. OTs have attached recovery room with Philips monitors on individual beds. The Gynae OT has been designed by MGI specialist, OT makers of international standard. The OT is equipped with Hepa filters and laminar airflow with plan air ceiling. It has a control panel controlling ceiling lights, humidity and temperature, clock and telephone anesthesia pendant. There are remote controlled electro hydraulic OT tables with sliding top designed for C-arm image intensifier. What are the innovative and new systems provided by the hospital? With its comprehensive list of standard features, including the latest modes of ventilation, 72 hour trending of all settings and monitored patient data, loops with freeze and overlay capability, respiratory mechanics (static and dynamic), programmable nebulizer and built in SPO2, the iVent is the most versatile eICU class ventilator in the market. A com-
pact electro-cardiograph which can be configured to patient‘s needs for faster, more confident cardiac assessment and better patient care. Patients with acute, life-threatening conditions need the best possible care. The PROCARE Monitor B20 provides a continuous flow of quality information to enhance clinical decisionmaking in acuity care areas. The B20 monitor is designed with advanced clinical measurement technologies for accurate and reliable patient monitoring. In the operating room, the right illumination is essential for success. The latest newly designed Polaris 200/200 LED surgical illumination systems provide cool, shadow-free light during surgery. The st-
To diagnose this and any malformations we use Logix 200 portable Ultra sound equipment. Draeger Babylog Ventilators are being used to support babies with breathing difficulty. Fischer and Paykel Bubble C-PAP for minor breathing difficulties we use C-PAP which is a gentler and better mode of ventilation is specific conditions. Bed side X-ray facility in the nursery gets the X-rays of the babies without any untoward delay. How do you plan to use IT to integrate all these systems to manage and support the hospital? We use GE Wipro CARESCAPE Mobile Viewers, which display patients’ clinical
OTs have attached recovery room with Philips monitors on individual beds. There are remote controlled electro hydraulic OT tables with sliding top designed for C-arm image intensifier eris OT lights complement this system. This is an Advanced Electro Surgical unit with Advanced Vessel Sealing capability. It is characterised by advanced energy based platform, minimum blood loss during surgery, least possible surgical time frame, safer and faster procedures and US FDA approved. How do you keep yourself updated when it comes to neonatal Equipment? The Phoenix Open Care System unit has two Warmers with in-built temperature control and oxygen delivery system for preterm babies. B Braun Syringe and Infusion Pumps are used because of poor swallowing capability and immature gastrointestinal functions, the small preterm and sick babies are not able to tolerate oral feeds well and require intravenous nutrition in form of fats and proteins. We have been using intravenous nutrition in our unit. Premature babies are prone to have intraventricular hemorrhage (brain hemorrhage) especially in first week of life.
information in near real-time, enabling doctors and nurses to make informed decisions from virtually anywhere, anytime. Current waveform and numeric trend information is saved in an electronic format to provide a paperless workflow for management of arrhythmia data. The hospital has a HIS to achieve the best possible support of ‘patient care and outcome’ and administration by presenting data where needed and acquiring data when generated. It is especially beneficial at ambulatory (out-patient) point, hence enhancing continuity of care. Internet-based access improves the ability to remotely access such data. Decision support system for the hospital authorities for developing comprehensive health care policies is set up. This leads to the reduction of adverse drug interactions while promoting more appropriate pharmaceutical utilisation. Enhanced information integrity, reduced transcription errors, and reduced duplication of information entries is observed. Telemedicine is an exclusive feature implemented for consultation from various specialists. july / 2012 www.ehealthonline.org
61
Sleep Diagnostics
Awakening Senses T
echnology is revolutionising the way treatments are carried out. Sleep disorders were diagnosed pretty late, yet today we have a range of technological systems to unwind the sleep matrix.
Decoding the sleep matrix Innovations in last five years, in terms of therapy have seen the growth of sleep lab machines. Sleep labs are more functional and they are seen as a better treatment modality. New methods of adoptive technology constitute of sleep sensors with pressure control, and the pressure varies when the patient is sleeping. All the senses are connected to the machine and the readings are recorded and downloaded to interpret the sleep and brain functioning. Basically sleep labs comprise of a com-
Dr Animesh Arya Senior Chest Physician, Specialist in Allergy, Sleep and Critical Care, Centre for Sleep, New Delhi prehensive group of equipments brought together to diagnose disorder. A recording device, inbuilt with software, is able to sense variations and body positions and is able to generate lot of information. Di-
agnosis of sleep disorders is based on a combination of history and physical examination, monitoring of the sleep/wake pattern, and physiologic testing. Phillips is the only player in most of the hospitals for diagnosing sleep disorder. The most common sleep study is overnight polysomnography (PSG), the monitoring of multiple physiologic parameters during sleep. Improvements in portable monitoring technology have made home sleep testing more feasible. While this may reduce the cost per study and improve some patients’ tolerance of sleep testing, there is also the potential for more widespread testing and increased overall cost. The search continues for more effective and better-tolerated therapies. But that is the case with all verticals of healthcare.
Measuring Quality Sleep
Dr Manvir Bhatia Director Neurology and Sleep Centre New Delhi
T 62
echnology has an important role to play in helping us diagnose various types of sleep disorJuly / 2012 www.ehealthonline.org
ders. The most common disorder diagnosed is obstructive sleep apnea. To evaluate this condition, we need to talk to our patients, get information on their symptoms and carry out a confirmatory test known as, sleep study. Sleep study is done through a monitor which takes account of factors like brain activity, muscle, storing, breathing, oxygen etc, over a period of few nights. We also have some gadgets and tools which are used to measure the quality of sleep recorded for five days, for one week for two weeks. During sleep, a positive pressure is reported which is recorded by a device. Technology is helping the patient for treatments in all aspects The latest in the sleep diagnostics area is the system for home monitoring, which is much cheaper. The regulators in USA were resistant to approving such monitoring initially, but now they have allowed it. The insurance com-
panies are now taking this illness seriously and providing cover for them in their health plans. Similarly for chronic treatment, sleep labs are always effective and have shown a lot of improvement in therapy. There has been a considerable improvement in the masks, improvement in the machine especially for patients who have a heart problem with sleep disorders, lung problem along with sleep disorders. They require a different kind of machine. Sleep labs are both hospital based and clinic based. They are equipped with a range of devices to monitor sleep during the whole night. It records brain activity, muscle activity, breathing, snoring, movement etc. throughout the night and there is a technician on duty the whole night to observe and record the data. People are now aware of such disorders and regular check- ups are also being recommended to patients to help them diagnose.
MASTEL
MASTEL PRIMA-XL
MASTEL PRIMA Start Tlee : 09:59 Current Time : 03/14/2007 10::01:22 HR ECG
BED OFFLINE 11
MASTEL
PRIMA-MINI
83 116 93 76 98 80
S
111
N
NIBP
10:01 ADULT nnHg NARMAL
D
15.4/10.1(12.1)
STOP.
TIME HR S D 10:00 80 0959 83 110
77
TIME
M 90
VOLUME PRIMIER
STOP PR 98 80 97 81 DOLOF
RR
T1 T2 17 35.5 36.5 17 35.5 36.5
STANDERD
MODE
EXTEND
RESP RR
PR
TEMP
19
hpn
T1 T2
o
C
35.5 36.5
RETURN
Multi-Param
eter Patient
Monitor
MASTEL PRIMA-ECO
critical care
Sophistication Matters!
“Over the years ventilators have evolved to be sophisticated, automated platforms, which adapt to the patient rather than just work as pumps,” says Dr Vikram Khatri Monitoring
Dr Vikram Khatri Consultant – Intensive Care Unit Moolchand Medcity
We have had a tremendous increase in the ability of the ventilators. They help the physician in measuring lung dynamics, pressures, autopeep, and inspiratory and expiratory holds. Also, newer ventilators have incorporated VCO2 and EtCO2. This new technology helps monitor the adequacy of ventilation, which is critical in some situations like those common in neurosurgery and avoids frequent blood gas measuring in the others.
Newer methods
V
entilator technology is a strong pillar of modern medicine. These machines are critical for the modern doctors to help their patients. It used be as a sure sign of terminal illness and impending death, but is now used prophylactically and are critical in providing a secure, reliable and efficient respiratory support to the patients in variety of clinical settings. They are used in stabilising patients with respiratory disease and to provide support in other medical conditions until they get resolve. Essentially ventilators are machines with the ability to deliver oxygen, pressure and volume to the lungs.
Synchrony with the patient Newer ventilators are very sensitive to patients’ breathing effort and terminate breath or deliver or cease support with almost no lag. This reduces the need for sedation in a ventilated patient.
64
July / 2012 www.ehealthonline.org
Pressure and flow regulation Newer challenges such as harm associated with high pressures have been controlled with the limitation of pressure applied to the lungs, at the same time ensuring the delivery of the appropriate volume with active changes in the flow patterns. Technologies like Autoflow, PRVC, volume guarantee, among others have emerged and matured.
Adaptive support Previously it took a physician/clinician to decide clinically, the appropriateness of the support and change it accordingly, now the ventilators have been designed to adapt to the patients increasing and decreasing demands. The newer machines do this by sensing the flow pattern and the pressure gradients generated by the patient. Algorithms like MMV, adaptive support ventilation, smart care etc are popular now.
Acute respiratory distress syndrome and other such conditions in which the traditional modes of ventilation failed now have some chance, thanks to modes like APRV and unique ventilation technology namely high frequency oscillation. They differ from the traditional mode of blowing oxygen mix in the lungs. APRV keeps the lungs at a fixed volume and releases the pressure periodically. High frequency oscillating technology oscillates the lungs and achieves oxygenation and ventilation. Initially popular in children it is now gaining foothold in the adult world of medicine. Finally weaning or as it is called liberation from the ventilators is increasingly being automated and a lot of research is taking place in this sphere. The ventilator automatically switches on the weaning mode and assess the patients’ ability to survive without it or otherwise. It then displays the test results to the physician. The ventilator is smart enough to realise a failing trial and increases the support, not stressing the patient and preventing decompensation.
Critical Care
“Anesthesia is now being Monitored” Dr Subhash C Sahu Vice President, Indian Society of Anethesiologists
C
heap and safe anesthetic agents like ether and equipments like EMO and spinal
analgesia have become outdated due to availability of safer and better drugs and technologies. But these sophisticated drugs and technologies are costly and beyond reach of common people. Patients do not get the benefit of cheap but efficient analgesic drugs like morphine and fentanyl. Further, highly priced corporate hospitals make all above drugs and equipments and their services beyond reach of the poor and the common public. Anesthesia Work Station with inbuilt ventilator, multi-modal monitor, ETCO2, gas with agents provides good quality of anesthesia. Cerebral function monitoring, BIS, TCA, PCA/PECA is utilised widely for day care anesthesia, moni-
toring awareness and patient controlled analgesia have also been developed. Neuromuscular blocker (ToF-4) assists in providing adequate motor relaxation. ABG for intra-operative use provides adequate monitoring of Metabolic Function. TEE determines better cardiac function results. Availability of LMA, flexible fibre optic laryngoscope, igel, etc. have revolutionised airway management. Availability of Sevoflurane has seen better days of day care and paediatric anesthesia. Drugs like rocuronium for reversal, propofol for quick induction and recovery, renifentanyl and alfentanyl as very short analgesic, which have changed morbidity status of patients under anesthesia.
Reversible Loss of Consciousness Innovations in Anaesthetic Equipment There has been tremendous growth in anaesthetic agents and anaesthetic techniques. Lot of work has been done for coming up with new innovations that can make anaesthetic experience a safer. One of these innovations is Ultrasound guided centra-neuraxial blocks and vascular cannulations. This technique offers greater safety and predictability in performing these interventions. The second one is airway accessing tools which are very simple to use from peripheral places to highly advanced territories namely Laryngeal Mask Airways and I-Gels that have revolutionised the concept of airway safety in difficult circumstances.
Revolutionary Technology Both fluoroscopy and ultrasound imaging techniques have made a difference
ings in anaesthetic equipments and their role. It can be enhanced by more awareness at not only the tertiary care centre, but at peripheral health centres. This we can achieve by e-learning modules especially for senior anaesthesiologists who are at the helm of affairs at these learning centres.
Future of these innovative techniques Dr Muralidhar Joshi Director, Department of Anaesthesia & Pain Management Kamineni Hospitals in acute and chronic pain issues. These innovations are being acknowledged as they can bring precision and predictability in results. The healthcare situation in India has come to a full circle. There is greater awareness on the latest happen-
To make the anaesthetic practice a safe and accessible, the innovations have to be simpler, cost effective and time tested. The industry should think towards more non-invasive options than invasive tools to make the equipments user friendly and cost effective. I would like to quote the slogan of World Health Organisation (WHO) in 1990’s “Think Globally, Act Locally.” With that spirit the newer and innovative anaesthetic equipments can make a difference. July / 2012 www.ehealthonline.org
65
Index of People and Organisations Featured in this issue...
People Ameera Shah, CEO, Metropolis Healthcare 50 Barco 24 D Ragavan, Sector Cluster Lead-South Asia ,Siemens Healthcare 31 Don Alvarez, Director, Global Product Marketing Perfint Healthcare 38 Dr Abhimanyu Bishnu, Senior ManagerMedical Operations & Quality, Aditya Birla Hospital 58 Dr Anil Mishra, Medical Director & Interventional Cardiologist, BM Birla Heart Research Centre 17 Dr Animesh Arya,Senior Chest Physician, Specialist in Allergy, Sleep and Critical Care, Centre for Sleep 62 Dr BR Das, President – Research & Innovation, Mentor - Molecular Pathology & Clinical Research Services, Super Religare Laboratories 48 Dr D Muruganand, Vice President, Marketing , Eppendorf Dr Dharmendra Nagar, Managing Director, Paras Hospitals
56 42
Dr Dinesh Pendharkar, Cancer Specialist, Asian Institute of Oncology, SL RahejaFortis Hospital 57 Dr Diptimala Agarwal, Consulting Anaesthesiologist and Intensivist, Pushpanjali Hospital
58
Dr Harsh Mahajan, Director, Mahajan Imaging Centre 22
Dr Prem Kumar, Senior Consultant Radiologist Mahajan Imaging Centre 26 Dr Raghuram Mallaiah, MBBS, MRCP, Director of Neonatology, Fortis La Femme Hospital, New Delhi 44 Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital
36
Swaroop Ghosh, General Manager-Digital Radiography, Carestream Health India 30 Sweta Mangal, CEO, Ziqitza Healthcare 53
Organisations Aditya Birla Hospital
58
Adiva Group of Hospitals
60
Apollo Hospitals, Hyderabad
32
ARJOHUNTLEIGH 59
Dr Ravi Kumar, Founder, XCyton Diagnostics 56
Barco 24 BM Birla Heart Research Centre
17
Dr Sai Praveen Haranath, Consultant Intensivist and Pulmonologist, Apollo Hospitals, Hyderabad 32
Carestream Health India
30
Centre for Sleep
62
CPC Diagnostics
49
Dr Shivani Sachdev Gour, Director, SCI Healthcare and ISIS Hospital 58
Dr Lal Path Labs
46
Dr Subhash C Sahu, Vice President, Indian Society of Anethesiologists
Dr Suri Lab
23
Draeger Medical India
59
65
Dr Suhas Prahlad Hardas, Consultant & Interventional Cardiologist, Ruby Hall Clinic Pune 15
Eppendorf 56 Fortis La Femme Hospital, New Delhi 44 Government Medical College
31
Dr Suman Singhal, Senior Consultant Radiologist, Mahajan Imaging 27
GVK EMRI
52
Dr TBS Buxi, Head, Department of CT scan and MRI, Sir Ganga Ram Hospital 21
Indian Radiological & Imaging Association 20
Dr Venu Gangahar, Senior Consultant Radiologist, Mahajan Imaging 27
Indian Society of Anethesiologists
Dr Vikram Khatri, Consultant – Intensive Care Unit, Moolchand Medcity 64
Jaipur Golden Hospital
14
Kamineni Hospitals
65
Draeger Medical India
Kokilaben Dhirubhai Ambani Hospital 36
59
HealthFore 39
65
Intel 34
Girish V.Golani, Product Manager, South Asia, ARJOHUNTLEIGH 59
Mahajan Imaging Centre Medanta - The Medicity
16
Dr JC Mohan, Chairman and Head of the Department of Institute of Heart and Vasculsr Diseases, Jaipur Golden Hospital 14
GS Matharoo,Managing Director & CEO, Adiva Group of Hospitals 60
Metropolis Healthcare
50
Dr Vivek Mahadevan, Head- Client Solutions Group, HealthFore
Moolchand Medcity
64
Neurology and Sleep Centre
62
Dr Jignesh Thakker, Secretary General, Indian Radiological & Imaging Association 20
Jashvant Prajapati, COO, GVK EMRI, Gujarat 52
Paras Hospitals
42
Perfint Healthcare
38
Pushpanjali Hospital
58
Ruby Hall Clinic Pune
15
Kaustav Banerjee, Country Manager, St. Jude Medical 17
Sanrad Medical Systems
26
SCI Healthcare and ISIS Hospital
58
Mukesh Kumar Meshram, Mission Director (NRHM), Government of Uttar Pradesh
Siemens Healthcare
31
Dr HN Sahay, Director, Smile Foundation 53
Dr JPS Sawhney, Chairman, Department Of Cardiology, Sir Ganga Ram Hospital 13 Dr JS Suri, Director-Dr Suri Lab
23
Dr Kishore Taori, Chairman, Maharashtra Medical Council and Professor and Head Department of Radiodiagnosis Government Medical College, Nagpur 31 Dr Manvir Bhatia,Director, Neurology and Sleep Centre 62 Dr Muralidhar Joshi, Director, Department of Anaesthesia & Pain Management, Kamineni Hospitals 65 Dr Neelam Kler, Hony. Senior Consultant and Chairperson Neonatology, Sir Ganga Ram Hospital 43 Dr Om Manchanda, Chief Executive Officer, Dr Lal PathLabs
66
Dr Praveen Chandra, Chairman of Interventional Cardiology at Medanta The Medicity, Gurgaon 16
july / 2012 www.ehealthonline.org
46
Kamran Khan, Technical Marketing Engineer, Xilinx Technologies
39
27
Sir Ganga Ram Hospital 10
Pranav Shah, Sales Manager-India, Terarecon
28
Prateek Vohra, CEO, Technocrat
54
Som Panicker,Vice President, Sanrad Medical Systems 26 Sonal Pahwa, Associate DirectorHealthcare, Technopak
18
Suresh Chandrasekaran, Business Unit Head – Immuno & Molecular Diagnostics, CPC Diagnostics 49
22,26,27
13,21,43
SL Raheja- Fortis Hospital
57
Smile Foundation
53
St. Jude Medical
17
Super Religare Laboratories
48
Technocrat 54 Technopak
18
Terarecon
28
XCyton Diagnostics
56
Xilinx Technologies
27
Ziqitza Healthcare
53
+91 98400 80008