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VOLUME 4 | I S S U E 2 | F E B RUARY 2 0 0 9

ISSN 0973-8959

Wave Medical’s CDSS now on mobile platform

Philips announces the acquisition of Traxtal

A Monthly Magazine on Healthcare ICTs, Technologies & Applications Vo l u m e 4 | I s s u e 6 | J U N E 2 0 0 9 | I N R 7 5 / U S D 1 0

COVER STORY Asking ‘IT’ eHEALTH PAGE 8

EXPERT CORNER Advances in Detection of Breast Cancer Dr. K. L. Chakraborti, Head, Department of Radiological Imaging Institure of Nuclear Medicine & Allied Science PAGE 22

PERSPECTIVE EHR and EMR in India fantasy or reality? Inderjith Davalur, CEO, Aosta Software Technologies PAGE 26

Asking ‘IT’

IN CONVERSATION Eyeing Opportunities beyond Metros... Dr. Pradeep Bhardwaj, COO, Ojjus Medicare Group PAGE 28

Out-of-the-box quezzing of some of the globally renowned health IT experts who promise to redefine healthcare automation.

TECH TRENDS On the go… Ramesh Sundararaman, Head - Mobile Computing Business, Symbol Technologies, Motorola Enterprise Mobility PAGE 30

INDUSTRY SPEAK

www.eheal t honl in e . o r g

John McCormick InterSystems

Gary Cohen iSoft

Ramesh Raghavan TCS

Matt Campbell Microsoft

Vishal Gupta Cisco

Dr. Pankaj Gupta Infosys


CONTENTS w w w . e h e a l t h o n l i n e . o r g | volume 4 | issue 6 | June 2009

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COVER STORY

EHR and EMR in India fantasy or reality?

Asking ‘IT’

Inderjith Davalur, CEO, Aosta Software Technologies

Exclusive interviews of some globally renowned health IT leaders who promise to redifine healthcare industry forever.

COVER STORY: INDUSTRY SPEAK

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PERSPECTIVE

28

Asian market is more comfortable with buying projects over products

IN CONVERSATION

Eyeing Opportunities beyond Metros... Dr. Pradeep Bhardwaj, COO, Ojjus Medicare Group

John McCormick, COO, InterSystems

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We are now in a unique position Gary Cohen, Executive Chairman & CEO, iSOFT

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TECH TRENDS

On the go… 14

Enterprise mobility solutions from Motorola Ramesh Sundararaman, Head - Mobile Computing Business, Symbol Technologies, Motorola Enterprise Mobility

Healthcare has no room for error Ramesh Raghavan, Global Head-Healthcare Practice, TCS

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Taking a long term view in our approach Matt Campbell, Director - Healthcare Solutions Group (APAC), Microsoft

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BOOK REVIEW

Strategic Management of Information Systems in Healthcare By Dr. Sanjeev Sood

The human (health) network effect Vishal Gupta, Senior Director-Healthcare Practice (APAC & Emerging Markets)

39 20

An exciting time for healthcare transformation Dr Pankaj Gupta, Principal-eHealth and Clinical Practice (New Markets),Infosys

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TELE MEDICINE

Data Connectivity Challenges in Telemedicine Lieutenant Colonel Salil Garg & Squadron Leader Mudit Mathur

REGULAR SECTIONS EXPERT CORNER

Advances in Detection of Breast Cancer

News Numbers

34 44

Dr. K. L. Chakraborti, Head, Department of Radiological Imaging Institure of Nuclear Medicine & Allied Science

Corrigendum: Kindly note that pictures and graphics used in the article titled, ‘Latest in Haematology Analyzers: Fluorescence Flow Cytometry’, page 30-31, May ’09 issue are attributed to Sysmex (business partner of Transasia Bio-medicals Ltd. for Haematology & Coagulation range of analyzers). Absence of proper acknowledgement captions is deeply regretted by the editorial team of eHEALTH.

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www.ehealthonline.org Now a CAREER section specifically for professionals in eHealth, Health IT, Bio-medical Engineering, Medical Technologies, Medical Electronics, Telemedicine, Tele-health, Healthcare Operations and Administration. Employers can now give specific details for the positions available & Job Seekers too can finally get a clearer picture of what jobs are on offer for them. Get a clutter-free picture of the healthcare job market!!!

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

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

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

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

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EDITORIAL Volume 4 | Issue 6 | June 2009

Health IT czars – on a platter! PRESIDENT

Dr. M P Narayanan EDITOR-IN-CHIEF

Dr. Ravi Gupta PRODUCT MANAGER

Dipanjan Banerjee mobile: +91-9968251626 email: dipanjan@ehealthonline.org SR. CORRESPONDENT

Harsha Chawla email: harsha@ehealthonline.org SALES & MARKETING

Arpan Dasgupta Executive Officer - Business Development mobile: +91-9911960753, +91-9818644022 email: arpan@ehealthonline.org Bharat Kumar Jaiswal Sr. Executive - Business Development mobile: +91-9971047550 email: bharat@ehealthonline.org SR GRAPHIC DESIGNER

Bishwajeet Kumar Singh GRAPHIC D ESIGNER

In every issue we try to give our readers something interesting and informative to read. Our aim has been to cover every aspect of the emerging healthcare IT market in India, Asia and across the world. In this issue, we bring you a set of exclusive interviews with senior executives from some of the top-notch IT companies of the world who are taking healthcare automation to a new level. The objective is to provide an insight into the present and future of IT in healthcare - engaging specialised health IT companies, along with solution providers and service integrators with footprints in healthcare. Interviewees have put in their perspective about both domestic and western countries. They also talked about their challenges, opportunities, growth strategies and the overall evolution of healthcare technology in the coming days. Catch’em all in the cover story of this issue. Healthcare IT deals with a very niche domain of healthcare. The penetration of technology in health care in India is still very low. The management of most hospitals still see IT spending as a ‘cost’ rather than an ‘investment’. Consequently, we often find ourselves in a tight spot due to the lack of very successful case studies on IT implementation in Indian hospitals. Yet, we try to come up with something absorbing for you from both domestic and international fronts - check out the ‘Tech Trends’ section in this issue, focusing on Motorola’s mobility solutions for healthcare organisations.

Om Prakash Thakur WEB

Zia Salahuddin SUBSCRIPTIONS & CIRCULATION

Manoj Kumar (+91- 9891752931) manoj@ehealthonline.org EDITORIAL CORRESPONDENCE

As many healthcare groups are in an expansion mode, we try never to miss any of them in our magazine. This time we have covered one such venture that is making inroads into some of the emerging cities of northern and central India. Look into the ‘In Conversation’ section to get a low down. I hope we keep you updated with the most cutting edge and contemporary in healthcare.

eHEALTH G-4 Sector 39, NOIDA 201301, India tel: +91-120-2502180-85 fax: +91-120-2500060 email: info@ehealthonline.org 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. 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 Print Explorer 553, Udyog Vihar, Phase-V, Gurgaon, Haryana, INDIA and published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP Editor: Dr. Ravi Gupta

Dr. Ravi Gupta Ravi.Gupta@ehealthonline.org

June 2009

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COVER STORY

Asking ‘IT’ Out-of-the-box quezzing of some of the globally renowned health IT experts who promise to redefine healthcare automation.

The world of health IT is moving at a phenomenal pace ! According some analysts, healthcare will emerge as the ‘next-big-thing’ for IT in this new millennium. Indications are strong enough, and indeed so. While there are quite a few specialised health IT companies who have a clear leadership in this domain, mainstream solution providers and service integrators are not leaving them uncontested. In following few pages, catch up with the senior leadership in some of the most reputed IT companies of world, and how they perceive the unique challenges and opportunities in this domain and its growth in the coming days.

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COVER STORY: INDUSTRY SPEAK

“Asian market is more comfortable with buying projects over products” Recognised as world’s leading vendor of database and integration technologies for healthcare applications, InterSystems Corporation has set itself as a class-apart in the global health IT industry. With an impressive product portfolio comprising InterSystems CACHÉ®, Ensemble® and HealthShare™, and the relatively recent introduction of InterSystems DeepSee™, the company is well poised to hold its leadership position in times to come. In the sidelines of HIMSS AsiaPac 09 held in Kuala Lumpur, eHEALTH caught up with John McCormick, COO, InterSystems to get a full view of his company’s philosophy and business strategy, and look into the future of health IT in Asia vis-à-vis the world. Excerpts from the interview.

Take us through the journey of InterSystems and how it became global leader in healthcare IT? InterSystems’ history can be traced from its growth over the past three decades since its inception in 1978. Terry Ragon, CEO & Founder of InterSystems led the company through its early days and made it a reputed name in the global IT industry, especially, for healthcare – nearly 80% of our business has always been from the healthcare sector. We started off with the implementation of public domain standard database and application development technology, developed at MIT. Since it was a public domain standard, initially there were multiple implementers. In 1990, we did a consolidation by acquiring other implementers that gave us the famous ‘CACHE’. Interestingly, it was a time when the whole world suddenly got interested in healthcare systems in general. We witnessed a terrific growth through our partners like GE Healthcare, iSoft and Siemens, who used our technology to develop advanced healthcare IT systems and applications. However, we were striving for more

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recognition, since we always remained hidden behind our partners. About two years ago we acquired TrakHealth and made it a part of InterSystems. That’s how we ensured a pretty big presence in the application side as well.

Is it that after acquiring TrackHealth your focus would shift more towards solutions? Not at all. 75% of our business comes from our application partners. Hence, they have been a very important part of our past and will remain so in the future. Not only do we have the technology for healthcare, we also have access to all the solutions of our partners. Together, it gives us tremendous footprint in the healthcare. Thus, the last thing we would want to do is walk away from the technology and loose the support of our partners.

InterSystems’ Ensemble is regarded as one of the best integration platforms of the world. What has been the real success with Ensemble so far? InterSystems most valuable product Ensemble is a high-performance software platform and advanced

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messaging engine that is used to develop and integrate mission-critical applications, leverage previous software investments through composite applications, and establish an enterprise service bus or SOA infrastructure. Ensemble-based projects are deployed in healthcare, commercial and government organizations worldwide to solve many demanding HL7 integration problems and as part of some of the world’s most visible initiatives to develop national electronic health records.

How do you think the newly released InterSystems’ DeepSee BI platform can value-add healthcare applications? DeepSee has a very high value-add business intelligence functionality when embedded in an application. It is incredibly useful, as it increases the value of all our partners’ applications. The goal of DeepSee is to give our partners the power to add superior BI capacity in their existing applications and help them make it more saleable to both new and existing customers. Considering current environment, the possible space where one can


COVER STORY: INDUSTRY SPEAK make the most sales existing customers.

is

among

What form of market leadership has InterSystems acquired in the Asian region? What will be your comments on this? In terms of numbers and size I can’t comment, but I can guarantee that ours is a product against which all other products are being compared. I think the Asian market is more comfortable with buying projects over products, especially from some of the big, powerful companies in Asia. Many of these companies build almost whatever they want, install them and run them for 5 years, and thereafter, replace them all over with new ones. But we need to understand that healthcare is different - if somebody puts in a fully patient-centric integrated hospital information system, it is once in a lifetime investment and one should not go through it again. For instance, we still have those partners and customers who were there with us since our inception in 1978.

What does a IT buyer need to understand about the difference between buying a product over a project? What are the challenges in this regard? I guess it is easier to comprehend this once we get used to the idea that we have a product and that there is a cost of having it. To make the whole process work out, one has to appreciate that there will be ongoing expenses to support the application, whereas on our side, we have an ongoing obligation to stay close to the customer to make sure that he gets the advantage of new releases - because otherwise, he won’t get the full benefit. It is surely a challenge for us to educate the market that a project is quintessentially different from a product. But, the nice thing about the healthcare industry is that stakeholders share their experiences all over the world, so ignorance doesn’t last long. Thus, when people start comparing, it doesn’t take long to realise the benefits of buying products. Products are usually perceived to be of low cost, but then turn out to have high cost in the long term. It is a true that whatever one spends to get

to the first 90% of the results will be almost same for getting just the last 10% - since the last leg is most detailed. However, a customer, while buying the better of it all, doesn’t understand this in the beginning. It’s understood only after one has used a product for a while and put in a couple of new releases into it.

Do you think the growth of health IT market in countries like India is primarily driven by inorganic factors such as medical tourism, rather than by organic factors like industry maturity or public policy interventions? I think one cannot possibly pinpoint the factors that have boosted the growth of health IT in countries like India. In the revenue model of all hospital chains in India, medical tourism is playing

“If somebody puts in a fully patientcentric integrated hospital information system, it is once in a lifetime investment and one should not go through it again” an important part. Already, there is a trickle-down effect and everybody wants to cash in on it. Consequently, the quality of hardware, software and medical facilities have improved over time. Numbers of corporate hospitals are coming up in Indian cities, many doctors have achieved star status and salaries of healthcare professionals have gone up exponentially. Medical tourism for sure is very important for a country like India as a few highpriced patients in a hospital make a huge difference to an average person. Moreover, India has got a tremendous

source of hardworking and brilliant people, and we need to take them out of traditional low-paid jobs. Overall, I think medical tourism along with several others factors have contributed to the growth of the health IT market.

What are your viewpoints about President Obama’s multi-billion dollar program for healthcare IT modernisation in US? If we remember, George Bush had earlier put up a program in which a doctor would be entitled for a slightly higher compensation from the government if he/she were using electronic medical records. In perspective, I think that program was actually pretty good. President Obama is definitely throwing a lot of money for transforming healthcare, but getting the doctors to actually adopt EMRs will be the biggest challenge and a crucial determinant of success. The change in healthcare is brought through evolution, and not through revolution. I think too much of money thrown is a matter of concern. The argument, at least in the US media is that, if you use an EMR it means you are seeing fewer patients because it slows you down. The standard I would like to put on things if I can build an EMR would be the one which allows the doctor see more patients and which gives you a huge amount of adoptions. If it is efficient but has a high cost, people would still go for it as nobody wants to compromise on their personal time.

Has the recent economic downturn affected business revenues of InterSystems? Under present scenario, it’s very difficult to predict the economy in the coming months. Thankfully, till now we haven’t seen a drop and one of the reasons the downturn hasn’t affected us till now is that 80% of our business is in healthcare and in the government sector. We have no debts and the company is in a good shape. This has resulted from our culture of doing quality business that contributes to the long-term recurring revenues, rather than focusing on short term profits. June 2009

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COVER STORY: INDUSTRY SPEAK

“we are now in a unique position” iSOFT is one of the world’s largest providers of healthcare IT solutions. iSOFT designs, builds and delivers industry-leading software systems that serve the entire health sector. At present, over 13,000 provider organisations in 38 countries across five continents use iSOFT solutions. iSOFT, headquartered in UK, became part of the IBA Health Group in Australia through a merger in 2007. eHEALTH caught up with Gary Cohen, Executive Chairman & CEO, iSOFT, in the sidelines of HIMSS AsiaPac ‘09 held in Kuala Lumpur, Malaysia. Excerpts from the interview.

What has been the global performance of iSoft in past few years? It has been a fantastic growth story for us in last couple of years. Our business has grown by almost 20% year-on-year, with strong growth on both revenue and profit side. We have also seen a strong growth in most of our global markets. Currently, 85% of our revenues come from the UK and European markets and Asia accounts for 5% of our total business. However, opportunities in Asia are expected increase significantly in future. Last year our total revenue was AUSD 500 million with profits of around AUSD 68 million.

What are the strategic advantages of the merger between iSoft and IBA Health Group? iSoft became part of the IBA Health Group following a merger completed in October 2007, and subsequently, retaining the name iSoft for the merged entity, primarily due to its global recognition and brand value. We are now among the top four companies in the world that specialise in Health Information Systems and also the largest health IT company outside US. There are several advantages of being on the top and the most obvious

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of them is that we are seen as the right channel by smaller companies to introduce their products in the market by combining them with our products. Thus, it gives us tremendous opportunities to get a lot of value from our global footprint. It also brings with it a very substantial portion of recurring revenues. Currently, more than 60% of our revenue comes from this recurring channel. There are a few technology companies in the world who have a good visibility and are prominent from the customers as well as the investor point of view. We have a solid business which has a very strong cash flow as well as a very strong visibility to future earnings. This merger has not only given us the positioning and goodwill in the market, but also given us access to world-class technology which was built for a national program – the UK NHS. Most companies who create such products do not have a strong customer base, or even if they do have customers, they have to invest substantial amount on marketing and sales for new products. For us, our large customer base across the world often helps us underwrite the development and enables us to redevelop and redeploy

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solutions and also make them saleable in the global market. This means we are now in a unique position to take the benefit of the technology on a global scale without fearing of failure.

Are you looking forward to more mergers or partnership opportunities in the near future? We have been looking at a number of things. In the present scenario, the global financial crisis is making it very difficult for companies with great technology or customers to grow, primarily because they cannot get access to credit or capital market. There are many companies including many American companies who have had very bad quarters. Most of the American companies haven’t done very well because the American software market is private enterprise oriented, and thereby, have suffered badly. Today, we are in the top 200 listed companies in Australia, and therefore, we would try to use our strengthened position and look at opportunities to potentially acquire or partner with other companies.

iSoft’s Lorenzo promises to bring the next-generation solution for global healthcare industry. What had been


COVER STORY: INDUSTRY SPEAK its genesis and what are its winning attributes? Lorenzo is a unique solution that will revolutionise the way healthcare is delivered around the individual. Lorenzo is a key value element of IBA’s growth strategy. Lorenzo was first conceived in 2003 and was chosen in 2004 as the key solution for the UK National Programme for IT of UK NHS. Following several years of development and successful testing in early adopter sites in UK and Continental Europe, Lorenzo is getting rolled out in the industry. Built on a service-orientedarchitecture (SOA), Lorenzo enables healthcare providers to manage their processes while at the same time giving secure authorised access to patient information to those who need it, anywhere and at any time. One of the major features of Lorenzo is that it incorporates iSoft’s many years of clinical expertise in several thousand care activities, designed to support clinical decisions, improved patient safety and evidence-based medical practice. These care activities

within Lorenzo, with its plug and play capability, are designed to maximise the retention of existing healthcare IT investments, thereby avoiding the need for a costly and risky implementation often associated with other systems. Lorenzo is designed to adapt to existing healthcare IT systems for all points of need – from hospital to community and clinic settings. Customised for each customer’s specific needs, it also provides the flexibility to quickly respond to changing operational, legal or business requirements. It puts the patient at the centre of the healthcare journey by managing and orchestrating the information around them, at the same time protecting the patient’s unique identity through this journey. In addition, in the event that mistakes are made, the system will help provide guidance or alerts – making the delivery of healthcare safer.

What is your strategy for American, European and Asian markets? Our strategy for America, Europe and

Asia is very different. We are a big provider in the European market, so we are using Lorenzo to build relationships with many of our customers out there. We are enabling our customers to use it on top of their existing products, so that they don’t have to throw away their pre-invested technologies. Asia being an emerging market, it is easier for them to leapfrog to nextgeneration technologies such as that of Lorenzo. America being a very complex market requires significant investment in marketing. Our strategy in America is not to compete with American companies head-to-head, but instead, use our expertise by partnering with companies that have products but don’t have the architecture. Hence, out there we would like to provide the Lorenzo’s architecture or the tools set, and not push for Lorenzo’s application. Thus, in America, we want to partner with technology vendors or healthcare corporations with large IT department or health IT vendors who have lots of product but do not really have a way of bridging the solution.

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COVER STORY: INDUSTRY SPEAK

“healthcare has no room for error” TCS - the global name in software solutions and services is also one of the leading IT providers for healthcare & life sciences industry across the world. Its advanced hospital management system – ‘Tata HMS’, integrated with Oracle e-business suite of applications is capable of addressing automation needs of any healthcare organisation. Apart from delivering solutions for the healthcare industry, TCS also provides consulting services to healthcare institutions worldwide. In a recent interview with eHEALTH, Ramesh Raghavan, Global HeadHealthcare Practice, TCS, talks about various facets of technology, industry and business. Excerpts from the interview.

In what ways health IT solutions are distinct in terms of their design, development and implementation? Healthcare applications are extremely unique. Take for instance, the TCS Hospital Management System - we have one version of HMS which is specifically meant for public sector/government hospitals, and another, which caters to the very discerning private hospitals. In doing so, we take into consideration ground realities in each of these places. In government hospitals a doctor sees about 150 patients in three hours, and therefore, expecting them to feed detailed diagnostic data is quite impractical. To address this problem, we develop solutions for them that are less complex, can quickly capture data and have features that help patients to remember their IDs.

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Such problems don’t exist in private hospitals - primarily due to their better doctor-to-patient ratio and availability of IT trained manpower. However, there exists a difference in requirements among private hospitals in terms of documentation and information management needs. Thankfully, this distinction is gradually getting blurred, as more and more hospitals are adopting to standards based practices. At TCS, our aim is to create intelligent solutions that are easy to run and are most user-friendly. We are also developing feature-rich products that can fulfill the regulatory (HIPAA, JCI, etc.), clinical and administrative requirements of a broad range of hospitals with minimum customisation. On the implementation front, we are creating solutions which can be

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installed in any hospital of the world.

How do healthcare applications contrast with those of other industry verticals? There are a number of aspects in this regard. Primarily, healthcare deals with human health and well-being, and hence, there is no room for error. Secondly, people don’t want to divulge information about their health conditions, especially critical ailments, hence privacy is of paramount importance. Lastly, in healthcare, we always go through more than one source to ensure that a uniform process is followed in order to get to the truth. It is also a domain where new innovations are of great importance, as they significantly impact our lives and our well-being.


COVER STORY: INDUSTRY SPEAK What is your view about the difference in IT appreciation capacity and value-chain capability of healthcare organisations in advanced and emerging markets? Having examined the HMS solution installed in various hospitals in US, Canada and India, I can certainly say that I haven’t noticed any significant difference except the way we manage information. What makes us different from those in the West is the way they capture and utilise data. I guess there is one big advantage that we have over western countries – that of absence of legacy. Here, we can directly leapfrog into the most futuristic technology, without getting stuck in existing systems. Also, innovation is now taking place much rapidly in India and at our customers in developing countries, which makes our technological advancements at par with global standards. Additionally, TCS continues to collaborate with its alliance partners in the development of solutions that move their customers up the value chain of information management.

What are your competitive advantages and USPs? What is the current portfolio of healthcare solutions offered by TCS? TCS healthcare practice has exhaustive domain expertise. We have been investing heavily on R&D for over two decades now, and the top management is extremely passionate of the future of healthcare offerings from TCS. Presently, we have a dedicated team of many doctors and specialists in the healthcare division. All this has helped us to take our innovations to the domestic and international markets. Today, TCS solutions are successfully running in many hospitals in India and abroad. We have HMS for large and mid-sized hospitals that can improve patient care, administration and clinical support activities. We are also developing specialty EMRs - solutions for oncology, ophthalmology and special rehab are currently available and development of EMRs for diabetes management is underway. We have developed an ambulatory ECG device for assessing cardiac patients on site or on the move, while transmitting information wirelessly to doctors and enabling them

to decide immediate course of action. In addition, it can also send diagnostic alerts to a hospital through mobile phone interface. We also have an end-to end clinical trial management solution that addresses all four phases of clinical trials. Our telemedicine portal – WebHealthCenter.com is another important initiative towards providing an array of services including free online medical consultation, health and medical record archiving, directory listing, news updates and many more.

What is the current footprint of TCS among public and private providers in India? Could you tell us about some of your notable installations and initiatives in the country? At present, we have about 40 installations in private hospitals and 200 in government hospitals across

“Very soon we are going live with our HMS solution at Apollo Hospital in Hyderabad. Subsequently, we will implement in all the four Apollo Hospitals based in metro cities and eventually in all Apollo Hospitals in India” India. In the private sector, Medical Trust Hospital in Cochin, Tata Memorial Hospital in Kolkata and Sankara Nethralaya in Chennai are some of the better-known hospitals where our HMS solutions are running successfully. Very soon we are going live with our HMS solution at Apollo Hospital in Hyderabad. Subsequently, we will implement HMS in all the four Apollo Hospitals based in metro cities and eventually in all Apollo Hospitals in India.

In what ways can health IT policies and standards leverage technology investments of individual organisations? How do you think the ‘payer-providerpatient’ community can benefit from such initiatives? What I believe in is that for a developing country like India, which has a lot of pressing problems to be addressed in the healthcare system, setting up Health IT guidelines wouldn’t lead to any big change. What is more important today is to enable healthcare facilities for the entire spectrum of population. We should be more focused towards the quality of patient care than being transaction oriented. For instance, we definitely cannot neglect the benefits of EMRs, especially when we have already lost enormous amount of data. At the same time, it is also important not to make it difficult for a person who is capturing data by putting him under pressure through national guidelines. A common man is aware enough to know what drives the market, so let the money that the patient pays for the service dictate the quality of service. What can work best for India in the current scenario is to have a broadbased, generic health IT guideline to begin with and slowly develop on it as the system matures over time. At the same time, we are also involved in the creation of standards for the emerging payer markets. This is an exciting opportunity and we find that we are taking on existing global standards, leveraging newer technologies and leap-froging ahead since we are not burdened with legacy. We see the emergence of these standards as the next wave that will be accepted globally by payers. The current committee working on these standards is comprised of insurers, technology vendors and hospital administrators and so we are seeing the realisable emergence of interoperability which is a much abused term in the advanced markets. Once comprehensive standards are established and implemented – we see a significant increase in patient safety that will emerge due to expanded use of computerised physician order entry systems and their effective deployment. June 2009

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COVER STORY: INDUSTRY SPEAK

“taking a long term view in our approach” Despite being the world’s most powerful IT company, Microsoft has been rather a late entrant into mainstream health IT domain. However, over last few years, it has substantially enhanced its capabilities for the healthcare industry and steadily emerging as a dominant player through focused approach and some strategic acquisitions. Matt Campbell, Director - Healthcare Solutions Group (APAC), Microsoft, provided a deep insight into the technological prowess and growth strategy of the company in a candid interview with eHEALTH in the sidelines of HIMSS Asiapac 09 in Kuala Lumpur.

Currently, healthcare industry across the region seems to be in a race to catch up with IT uptake and technology adoption. What has been your observation in this regard and what do you think are the reasons behind this lag? Transforming healthcare is a complex problem with no easy answer and certainly no quick-fix solution. With the Asia Pacific region experiencing increasing challenges and escalating healthcare costs, healthcare organizations are continually threatened by an insufficient allocation of technology, resources, and capabilities for their efforts. Technology has a very real and proven ability to drive transformation— arming healthcare workers, plan administrators—and most importantly, consumers, with the best knowledge for real-time collaboration and decision making. We believe this will chart the path to better, more efficient healthcare outcomes. At Microsoft, we firmly believe in software’s ability to make a positive impact on the healthcare ecosystem worldwide. However, no one company can solve it alone. We are taking the long view in our approach to enabling transformation across the healthcare

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June 2009

system - it will be a marathon vs. a sprint.

Microsoft’s acquisition of Global Care Solutions is supposed to substantially expand healthcare capabilities for the company and create superior customer value. What are your comments on this? The acquisition of GCS complements Microsoft’s already strong portfolio of health solutions and will provide hospitals across international markets with a new alternative to achieve improved workflow and patient safety through information technology. GCS’s impressive state-of-theart health information system has enabled complex facilities such as the Bumrungrad International hospital in Bangkok achieve amazing outcomes related to improved workflow and patient safety. The fully integrated nature of GCS solutions, and the fact that it is built from the ground up on scalable Microsoft technology, makes this a great addition to our portfolio of health enterprise products as we look to power developing and emerging hospital systems around the globe. Our solution has allowed the Bumrungrad facility manage scheduling demands, multiple languages and medical

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records so efficiently that the average waiting time to see a doctor is only 17 minutes.

Till now, Bumrungrad InternationalBangkok was the most widely known success story of Microsoft in Asian region. How do you foresee your business prospects in near future? The success of Bumrungrad is a sterling example that we foresee other hospitals and medical facilities modeling their technology deployments on. The synergies between GCS solutions and Microsoft’s health solution portfolio and the future innovations will further strengthen the product offering to new and existing customers globally. After acquiring GCS our success story also extend to 6 other customers in Asia outside of Bumrungrad International. We have HIS systems installed at FrancoVietnamese Hospital in Vietnam, Asian Hospital in the Philippines, Assunta Hospital in Malaysia and recently, the Temerloh Hospital in Thailand. In addition to this, we have been very successful in the Singapore market with Changi General, KK Women and Children’s and Singapore General Hospital with a combination of PACS systems, medical records document imaging, and image distribution for


COVER STORY: INDUSTRY SPEAK the SingHealth cluster of hospitals and polyclinics covering 49% of Singapore healthcare.

The recent launch of Microsoft Amalga promises a new beginning in enterprise healthcare solution. What technological and functional specialties are builtin Amalga, and how does it bring in a differential advantage over other solutions? Microsoft Amalga Family of Health Enterprise Systems consists of a portfolio of enterprise-class health solutions that provides rich integration, giving clinicians and executives quick access to valuable, up-to-the-minute information across their health enterprise. The clear winners are doctors, administrators, and patients. Microsoft Amalga provides a powerful, truly seamless system that can deliver quick, high-quality data to any department, which, in turn, can help hospitals increase patient turnaround time and enhance the patient experience. Integration also improves data integrity between different systems, can reduce

transcription errors and duplication of data entry, and optimises report turnaround. The system fully supports paperless, integrated workflows and facilitates easy access to patient medical information and order, scheduling, and study information. The Amalga family is built on widely used and supported Microsoft products to deliver important benefits, including security, high availability, scalability and full audit capabilities. Amalga also offers simplified deployment and improved supportability through streamlined administration, configuration and self-service tools for users.

The major bottleneck for mass adoption of Health IT is the ‘technology averseness’ of doctors. Does Microsoft have plans to increase technology friendliness of doctors through education programs? One major reason for the bottleneck is the healthcare industry’s own conservative attitude and reluctance to change. For example, it currently takes 17 years for a new drug to be

fully approved. It does not help that the advancement in healthcare is often inextricably tied to a government’s agenda, which puts additional consideration in areas like political sensitivity, employment issues and so on, giving greater reason for highly conservative attitude. At Microsoft, we believe that we are in a unique position to deliver solutions that span from the hospital to the physician’s office to the patient’s home. Our willingness to partner with other leading industry vendors further expands the reach of the Microsoft platform in health IT. With a friendly, consistent user experience and rich set of services, we believe that doctors will more readily accept Microsoft-based healthcare solutions than older, legacy products. As mentioned before, we are taking a long term view in our approach and it will require significant effort to inform and educate healthcare providers about our solutions. Our participation in events such as HIMSS are an example of the kind of outreach that we will engage in over the next several years.

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COVER STORY: INDUSTRY SPEAK

“the human (health) network effect”

Considered as the global leader in IT network solutions and products, Cisco has developed an array of innovative and futuristic solutions that promises to transform the way healthcare is delivered and received. Vishal Gupta, Senior Director-Healthcare Practice (APAC & Emerging Markets), gives a sneak peek into some of these possibilities in a tete-a-tete with eHEALTH.

What is the current portfolio of your solutions for healthcare sector? Cisco healthcare solutions comprise of Cisco Medical Grade Network, Cisco Connected Imaging, Cisco Healthcare Context Aware Solution and Cisco HealthPresence. Apart from these healthcare solutions, Cisco technology products like Cisco Unified Communications, Security, Wireless and Mobility Solutions are very helpful in addressing some of the healthcare business challenges. Cisco Medical Grade Network provides scalable, robust, secure, and highly available network infrastructure to support the business critical requirements of hospitals. Cisco Health Presence provides a secure, reliable, and user-friendly telemedicine solution to enable remote healthcare delivery to patients located in remote areas. It also helps doctors consult other specialists in relation to complicated cases for second opinion. Cisco Connected Imaging addresses the issue of lack of collaboration among radiologists and physicians and also the issue of PACS performance management by integrating Cisco

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Unified Communications into the existing PACS solution. Cisco Context Aware Healthcare enables real time tracking of critical human and non-human assets such as mobile X-ray machines, Ultrasound machines, Intravenous pumps, etc. within a healthcare facility to streamline clinical and non-clinical business processes facilitating the provision of high-quality care.

What is the essence of your ‘Connected Healthcare’ concept? How is it meant to benefit the overall ‘provider-patientpayer’ community? Healthcare need to move towards a new vision—one that seamlessly connects all parts of the healthcare world to networked resources of data, information, knowledge and processes in order to reduce costs, increase access to care and improve quality of care. That vision is Connected Health. Connected Health creates collaborative relationships among all healthcare stakeholders to deliver safe, affordable and accessible health services. Cisco enables a Connected Health community through the ‘Human

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Network’ effect that includes interoperable processes, technology, and people to provide critical health information at any time from any location. Cisco addresses key healthcare challenges by enabling collaboration, virtualisation and convergence Collaboration: Technology needs to integrate patients, providers, payers, and the community across the care continuum through the efficient use of data, voice, and video so that the various stakeholders can communicate and collaborate in real time. Cisco’s portfolio of products and solutions leverage the network and provide innovative solutions using technologies like Unified Communications, Wireless, and Web 2.0 solutions. Virtualization: The reality of the healthcare industry is that there are no standardized applications across the healthcare continuum. In order to improve patient care we need to enable faster access to critical information at the point of care. Cisco’s Medical Grade Network enables the healthcare entities to have a virtualized infrastructure that can dramatically speed up the


COVER STORY: INDUSTRY SPEAK processes and bring down the Total Cost of Ownership. Convergence: Traditional networks have separate channels for data, voice, and video. This infrastructure is difficult to use and expensive to maintain. Hence this technology is giving way to the IP platform, which convergence voice, video, and data onto a single platform, which is scalable, easier to use and maintain. Cisco’s Connected Care vision enables this convergence on a single unified platform.

What is the extent of your success in the Indian healthcare industry? What are your primary targets and expectations from this market in near future? The penetration rate of ICT in the Indian healthcare industry is still low compared to more matured markets like North America and Europe. Within the Indian industry, it is relatively higher in the corporate and private hospital segment. However, of late, we are seeing increasing interest from both public and private hospitals to implement ICT. Many government

agencies are planning initiatives like remote care delivery (rural telemedicine) and modernisation of healthcare IT infrastructure, which bodes well for Cisco.

What are some of the futuristic and emerging solutions that you are working on at present? How do they promise to further transform healthcare? Cisco feels that the next wave of healthcare IT adoption is in the area of remote healthcare delivery models and in collaborative care. Cisco is working on developing innovative solutions around Rural Telemedicine and Collaborative Disease Management that will transform the way Healthcare is delivered today and will make the care better while reducing its cost. Getting specialised and high quality healthcare is a problem for far-flung rural areas. Remote delivery of healthcare to patients can help address this challenge. Specifically, Cisco’s HealthPresence solution leverages Unified Communications in an effective way to deliver healthcare

from urban centers to rural areas. Doctors and specialists in urban hospitals can consult with patients in remote centers. To put into perspective, up to 20% of the population suffers from chronic illnesses and accounts for more than 70% of healthcare costs and over US$150 billion is spent annually in treating chronic diseases*. Effective chronic disease management prevents disease progression, slows the natural history of disease, and prevents/delays complications. Cisco’s Chronic Disease Management solution helps to assist the healthcare providers and patients to continuously monitor and manage chronic diseases. This solution has the ability to both reduce cost and improve care for chronic diseases like Diabetes and Heart Disease, while transforming the way patients, primary care givers, hospitals and even the payers interact in the delivery of care for chronic diseases. (*Source: Second annual Almanac of Chronic Disease, released by the Partnership to Fight Chronic Disease (PFCD) - http://www.fightchronicdisease.org)

June 2009

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COVER STORY: INDUSTRY SPEAK

“an exciting time for healthcare transformation” Known for its prowess in the global IT industry, Infosys has slowly and steadily developed a strong practice and a full range of solutions and services for catering to healthcare organisations. Dr Pankaj Gupta, Principal-eHealth and Clinical Practice (New Markets), Infosys, in a candid interview with eHEALTH.

What are the most common IT challenges faced by healthcare industry? IT challenges faced by healthcare industry are identified as in the following 1. Lack of EMR adoption by physicians: This is the single largest IT challenge faced by healthcare organisations at present. Changing physician’s approach towards using technology is a key focus for most CIO’s. 2. Extreme heterogeneity of IT environments: Data lives in silos separated by individual systems or paper based processes. Managing, integrating and optimising these data sources, whether through updating technologies or implementing and managing interoperability platforms is a nightmare. E.g. doctors don’t think in terms of per disease episode, rather they treat the entire patient; therefore they want a comprehensive longitudinal record. Payers administering disease management programmes for preventive and wellness support, also need comprehensive medical records thus requiring smooth integration between multiple information silos 3. Improving operational efficiency

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4.

5.

6.

and optimizing organizational performance: Finding out what to measure in order to optimise processes and improve outcomes is a challenge because a hospital is one of the most complex enterprises that anyone can imagine. Administrative processes are so tightly linked to clinical processes such that clinical knowledge is a pre-requisite in managing hospital administration in a patient centered manner. However, most clinicians do not have sufficient administrative experience or the time and inclination to design corrective measures. Lack of health IT experts and professionals: Shortage of trained and experienced IT manpower in healthcare result in inefficient, delayed and aborted IT projects, resulting in a high degree of distrust and loss of credibility for use of IT in hospitals. Demonstrating a quantifiable ROI: This has always been a difficult question for healthcare CIOs and is often the basic source of conflict at the management level discussions on healthcare IT. Increasingly sophisticated functional demands on claims processing and claims adjudication

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systems: With a large number of legacy systems in place, payer CIOs are struggling to keep pace with the need to enhance/modify/ replace these systems to manage areas like fraud detection, disease management and potentially competing with upcoming government insurance plans.

What range of solutions and services do you offer in the healthcare domain? Infosys has a wide range of healthcare specific vertical solutions and services, as well as, horizontal technologies and platforms that can be used extremely effectively in the healthcare industry. These offerings include: 1. HIS/EMR Centre of Excellence – Implementation and maintenance of HIS and EMR for physicians and hospitals. Infosys has alliances with HIS/EMR product vendors globally, including India. 2. Infosys EHRS - to integrate various health IT applications for building a longitudinal medical record. Performance 3. Healthcare Management Platform – Prebuilt solutions around Clinical Quality Management, Capacity Management and Revenue leakage management combining business process management, predictive


COVER STORY: INDUSTRY SPEAK

4.

5.

6.

7.

8.

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modeling, data analytics, reporting and actionable real time KPI-Dashboards for process management and optimization Healthcare Modernization Solution - for improving claims processing by payers. Health Plan eConnect Solution - to help payers build physician and patient portals. Healthcare consulting for business problems in payers, providers and pharma companies, where we suggest solutions and help them realize the ROI on their investments. iTransform™ product suite a comprehensive tool kit, geared towards semi-automated remediation associated with HIPAA 5010 and ICD10 adoption in the health industry Enterprise Applications Implementation, Maintenance and Support. Complete IT Application Maintenance and BPO Management

Which are some of the landmark healthcare projects of Infosys across geographies? Infosys has been doing business consulting, application development, maintenance, testing, IT support and a whole range of IT operations for health insurance companies, pharma and life sciences organisations. Recently, we have started entering the healthcare provider segment as well. Some of these engagements are multi-year, multimillion dollar deals spread across many geographies including North-America,

Europe and APAC. Our India unit has been recently setup to focus on special needs of the Indian market.

How do analyse emerging opportunities in US, in wake of the government’s ambitious eHealth investment plans? US is going through very exciting times in terms of healthcare transformation. 1. The Physician practices suddenly have become a very large Healthcare-IT market in USA! The power base has shifted. I remember the book ‘Power Shift’ by Alvin Toffler. 2. Obama has put life back into Public Sector Health plans - Medicare and Medicaid! So what is expected to change: 1. Pharma co: Physician’s reliance on pharma companies for drug education updates will reduce because they will get direct access to latest version of electronic drug databases in the EMR. Many EMR will have CPOE and Medication Management built into it, which will guard against unnecessary/ incorrect prescriptions. Crossselling and Up-selling of drugs will get minimized. However the drug compliance will go up in chronic disease management. 2. Insurance: Private sector Health Plans will have to compete with Public sector Health Plans for their bread-and-butter. US has a fairly large population that can fall under public health plans – uninsured, underprivileged, and aged. 3. Hospitals: Will have to figure

out how they can increase their practice on public health plans Medicare and Medicaid. They will also have to depend more on Physicians that already have a greater mix of Medicare and Medicaid practice. 4. CDC: Public Health initiatives and Disease Surveillance will gain power because they will start getting valuable Public Health data through public health plans such as Medicare and Medicaid. So far private enterprises have been reluctant to share disease, prevalence and outcomes data. 5. Healthcare Economics: will shift towards measuring clinical outcomes rather than business value. Public Health, Disease Management and Preventive Medicine will gain. 6. M&A: New business models and major consolidations should be expected. I can see Pharma companies and Insurance companies buying out EMR/EHRS, Healthcare-IT companies [which one, I keep guessing..]. Infosys is watching the emerging changes and is prepared to offer solutions and services tailored for physicians, hospitals and payers, especially 1. EMR implementation and support, 2. Integration of EMR to enable record sharing (as and where appropriate) 3. Analytics and reporting for enabling meaningful use of EMR.

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IN FOCUS

Advances in Detection of Breast Cancer Advances in diagnostic imaging, like Infrared Thermography, which helps in detecting signs of cancer at an extremely early stage is improving survival rates.

B

reast care presents a challenge to the entire health care delivery system, payor and provider alike. Its relative importance extends far beyond its cost in that one in eight women in the US will become a victim of breast cancer during her life time and virtually every women has a relative or close acquaintance who has had breast cancer. Breast cancer is the second most common cancer in Indian women. According to the National Cancer Registry project report about 52,000 women develop breast cancer in India per year. This gives breast cancer a high emotional, political and media profile.

Dr. K. L. Chakraborti Head, Department of Radiological Imaging Institute of Nuclear Medicine & Allied Sciences, Delhi

“Each time the breasts are exposed to an X-ray, the breast cancer risk increases by 2%. The pre-menopausal breast is highly sensitive to radiation Each 1-rad exposure increasing breast cancer risk by about 1% with a cumulative 10% increased risk for each breast over a decade. Mammography compresses breasts painfully and can lead to spread of cancer cells.�

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An early accurate diagnosis of breast cancer has a favourable prognosis than that of late detection and even at times totally curable. Most often women are referred for multiple diagnostic tests which can include X-ray mammography, galactography, ultrasound, colour Doppler Ultrasound study, CT Scan, MRI, PET/CT Scanning, fine needle aspiration, and in some cases open surgical biopsy. X-ray Mammography is considered as gold standard. But it involves ionising Radiation. Each time the breasts are exposed to an X-ray, the breast cancer risk increases by 2%. The pre-menopausal breast is highly sensitive to radiation. Each 1-rad exposure increasing breast cancer risk by about 1% with a cumulative 10% increased risk for each breast over a decade. Mammography compresses breasts painfully and can lead to spread of cancer cells. Low specificity of current screening and diagnostic modalities appear to be responsible for such unnecessary testing of benign symptoms and results in anxiety to patients and excessive health care expenditure. Thus there is need for a cost effective means of safety, reducing the number of diagnostic procedures undergone by these women. Moreover, the existing technologies detect only structural changes. It may take up to 8 to 10 years for tumour to grow to a sufficient size to be detectable. By this time the tumour may have achieved more than 25 doubling of malignant cell colony & may have already metastasized.


IN FOCUS The application of noninvasive, non-ionising and radiation free, cost effective technique for breast diagnostics aimed at early tumour detection is a challenging task of current interest for biomedical electronics research. Noninvasive infrared (IR) is a promising application for such detection. IR comprises wavelengths of 1mm to longest wavelength of visible light from 5-6 microns to 14 microns wavelength. This range also known as radiant heat, discovered by English Astronomer Sir William Hershel in 1800. Normal human body temperature is 98.6 F. Most of our body heat is typically radiated away as far infrared at 8-10 micron wavelength. As it is more penetrating than visible light, such radiation is being used in many practical applications like infrared thermography. IR thermography is a physiological study. In order for Solid mass cancer tumours to grow, the circulation near the tumour becomes abnormal. These changes are such that the central nervous system loses control of the heating & cooling. These abnormal temperatures are detectable with highly advanced infrared cameras. Digital infrared sensing camera and high speed computer are used to measure the heat radiated from breast and adjacent areas. The fact that the physiological changes preceed anatomical mammographic detection, allows us to react early in preventive mode in early stages of development of cancer itself. This is a surprising fact that though medical thermography has been in the use since early 1970’s and the modality was approved by the FDA in 1982 for breast cancer detection and risk assessment as an adjunct to mammography, the women population in India and even majority of the woman in Europe are unaware/unfamiliar with the breast thermography.

countries as a first line screening procedure to assess breast health. Clinical Digital Thermography (DITI) is unique in it’s capability to detect physiological changes and metabolic processes. The IR Thermography instrument is compact and consists of a scanning system and IR detector. The detectors mainly used are InSb or HgCdTe in case of cameras where liquid nitrogen is used for cooling whereas HgCdTe is mainly used for thermoelectric cooling. InSb detector size is about 9.6 x 7.2 cm2. The latest thermal camera has a highest resolution of 640 x 512 pixels. It can pick up a difference of 25 mK temperature difference. Addition of a G3 microscope lens provides a working distance of 35 mm (3.5 cm). The IR thermography of the breast is performed before and after the cold challenge. A highly skilled

June 2009

IR thermography is very cost effective, risk free and provides instant images. The resolution of the equipment has improved tremendously. In Europe, IR thermography fees for breast screening are $ 175 for the initial scan, $ 175 for the 3 month follow up & whole body scan is $ 400. In India effort should be taken up by the Govt, either to import a large number of machines & introduce in the Rural Primary Health Centre level or to procure the core elements (sensors) from manufacturers abroad and develop the system in India. Introduction of this cost effective, first line screening technique in early detection of breast cancer will prove to be a great boon to the Indian health care system.

Major benefits of thermography

Timeliness : early detection provides the best outcomes in improved survival rates Inclusive : examines the full body including whole chest and armpit areas Good for all breast types: young, dense, fibrocystic, women on HRT, etc. Pregnant & teen-age women can be examined. The method is precise, has no risk, no pain & it is a complementary first line detection modality.

Presently breast thermography is extensively used in US and European

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thermo logy reader analyses the before and after cold challenge scans in order to prepare a thermography report.

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PERSPECTIVE

EHR and EMR in India fantasy or reality?

in the private and government sector to share medical charts electronically (within strict guidelines for maintaining privacy of patient records). The whole idea behind the EHR philosophy is to allow the chart to be portable between hospitals allowing greater flexibility for patients and doctors. Having served on committees in the US on architecture and logistics of such a system, along with designing and implementing a system for integrating 11 hospitals across 3 states to provide reports to the top management, I can fully appreciate the advantage of such a system.

INDERJITH DAVALUR CEO, Aosta Software Technologies

A

Medicine has been generous with its estimate of about 10% for hospitals and 17% for doctors - in reality it is even lower, but growing.

I could not agree more with the Editor’s observations about the benefits of electronic health records (EHR) and interoperable systems across platforms. As far as compliance on EHR in the US goes, the New England Journal of

What is the reality in India? Firstly, a distinction between EHR and EMR – while both refer electronic version of records, EMR is limited to a specific institution or a group of institutions, while EHR relates to a common platform that would allow disparate institutions

recent column in the Editorial that appeared in The Hindu (Friday, April 3, 2009) titled “IT for Health” drew my interest in writing a few of my own thoughts.

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Where does that bring us in terms of electronic charts in India? I am unaware of any formal study that has been conducted about the prevalence of EHR or the number of doctors who actually use it, if it is available in their institution. My observation is that, at present, only a miniscule portion of doctors are enthusiastic about embracing this technology. Given the volume of patients they see in a day, it is hard to imagine physicians taking time to make notes directly into the system. There is also a stigma attached to doctors typing their own notes. But, like any other technology or practice, EHR will not gain a foothold unless there are some incentives and/or some penalties in the healthcare system.


PERSPECTIVE

There are several software packages currently available in the Indian market that offer EMR along with HIS (Hospital Information System), but unfortunately, there are only few takers for the EMR. Unless there is a serious effort at educating the medical community in India about benefits of an electronic system, we will miss out on this marvelous revolution. Selling HIS or EMR packages to hospitals should not be the goal but a by-product. Software companies should first invest time and effort to educate the customer. Then they need to sell the appropriate package if it is the right fit. We should rather not make a sale if it is not the right fit for the customer and keep his respect for ourselves and our company, than do otherwise and not be able to look him in the eye. I personally consider that a large portion of the responsibility in advancing this electronic revolution in India rests upon

the software community. Journalism in the IT sector and especially healthcare has come a long way in providing

“We should rather not make a sale if it is not the right fit for the customer and keep his respect for ourselves and our company�

to the needs of the medical community and gearing up to meet them. They can also share their knowledge with the medical community about all the marvelous things that are possible through software solutions. After all, if we can provide some of the top talent in software technology to the world should we not learn to benefit from that for our own advancement as well? What we really need is another Sam Pitroda to do the same for healthcare industry, what he did for telecommunications industry in India.

(The author, Inderjith Davalur, is currently the CEO of Aosta Software Technologies based in Coimbatore, India. He did his MBA and MS in healthcare

an excellent platform for those with experience to share their views and knowledge. Software companies can do a lot for the community they serve and for themselves by paying more attention

administration from University of Massachusetts, USA and has worked for over 20 years in US since 1986. His background has exclusively been in healthcare IT and has served on patient privacy and electronic health record committees in the US.)

June 2009

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IN CONVERSATION

Eyeing Opportunities beyond Metros...

Ojjus Medicare Group has recently unveiled plans to open five hospitals and two medical colleges across non-metros cities like Noida, Faridabad, Jaipur, Bhopal and Ranchi. The group presently has the 220-bed multi super-speciality hospital in Noida, and an upcoming 300-bed oncology and 200-bed rehabilitation centre in Faridabad with post treatment co-ordination and follow-up centres across the country. In an interview with Dr. Pradeep Bhardwaj, COO, Ojjus Medicare Group, talks about the ambitious plans of Ojjus Medicare and about the growth of healthcare administration in India. Q. You have been awarded as the ‘Youngest Medical Superintendent’ in India, and recently you were selected for the prestigious ‘Rashtriya Rattan Awards 2009’. In retrospect, what were the important milestones in your career which helped you in achieving your goals? A. I consider this prestigious award a token of my hard work. For the first time this award has been given in the area of healthcare management, so I hope it will give a fresh impetus

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to the profession of hospital administration and management in India. I started working towards my goals when I joined the Indian Spinal Injuries Centre in 2001 and later moved on to Fortis Healthcare and Sir Gangaram Hospital, Delhi. My zeal towards work keeps me going and motivates me to do complete justice to my work. I always try to do things which are often overlooked by others and to an extent it reflects in all the work I do. One of my aims

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is to raise the profession of hospital administration and management to a status it’s worthy of and to change the role of healthcare administration in India. For that to happen it’s important to change the doctorcentric model of Indian healthcare management industry. Today, a great number of hospitals in USA and almost all the hospitals in UK are headed by the non-medicos trained in hospital administration. In practice, it was found that a nonmedico brought more success to a hospital, as he has a better business acumen than a doctor.

Q. What are your future plans for your hospital? A. Ojjus Medicare has spread itself far and wide in the country. Ojjus Medicare’s comprehensive 700-bed Oncology Centre is coming up in a sprawling 9 acre plot in Faridabad, which has been designed to cater to the needs of the domestic as well as international patients. We are renovating the Goodwill Hospital and Research Centre Ltd., Noida, comprehensively by adding 220 new beds. Ojjus Medicare is upgradating the overall facilities at its Noida facility. The expansion plans for the Noida Hospital include upgradation of investigation facilities by installation of an MRI 1.5 Tesla system and replacement of spiral CT with the state-of-the-art 64 slices CT, establishment of superspecialty cardiac and neurosurgery


IN CONVERSATION

departments having dedicated modular surgeries for complex cardiac and neurosurgical procedures, increase in ICU bed strength to 30 beds, and a fully equipped world-class CCU. Ojjus Medicare is coming up with 3 more hospitals in Jaipur, Bhopal & Ranchi apart from Noida and Faridabad, and 2 medical colleges at Jaipur and Bhopal. Rachi will have 150 beds and Jaipur and Bhopal each 850 beds. The reason why we are coming up only in second tier cities is that the quality healthcare in these cities is lacking. And, there is an urgent need to cater to such cities so that people don’t have to travel to metropolitan cities for medical treatment. All our hospitals would be super-specialty hospitals, as at the present there are already many multi-specialty hospitals. For instance, Noida has lots of multi-specialty hospitals, but not a single super-specialty hospital for neurology or cardiology. And, looking at the increasing shortage of healthcare professionals we have decided to come up with two medical colleges too, because we strongly believe that in the coming years only hospitals with their own medical colleges will be able to survive. At the Noida facility, Paramedical courses affiliated by Noida Medical Council have already started.

Q. Which areas/specialties of healthcare hold the maximum growth potential and supply gap at present? How does Ojjus group aspire to cater to such segments? A. The major growth areas are Oncology, Neurology, Cardiac, Rehabilitation (Physical and Occupational) of people affected by drugs/polio/accidents in industry/agriculture sector and chest diseases. To cater to international patients we are thinking of adding facilities like IVF, plastic and reconstructive surgeries, life-style related problems and joint replacements etc. Presently, we are helping the Artemis Hospital, Gurgaon, in medical tourism by referring our international patients to them and also with our service apartments in Gurgaon. We are also planning to come up with service apartments for our Noida facility.

Q. How important is IT and automation technologies for delivering high quality healthcare and bringing cost efficiencies? What are your plans in terms of adoption and investment in IT of Ojjus hospital? A. Healthcare systems are extremely complex. They operate in a mixed environment of public and private services that make the design, implementation and operation of integrated healthcare systems both difficult and expensive. Patients have to deal with several departments that have no commonality in the way they work. Every department operates in a different fashion - controlling information flow and its access. Various stake holders who have their own methods e.g.-service recipient and provider, materials/service providers, finance providers, hospital (and Health) managements, Databases etc. can come together on a single platform provided by automation technologies/IT leading which would save money, increase efficiency and customer satisfaction by better quality control. Ojjus Medicare has decided to fully automate its Noida facility and all the four hospitals coming up in Faridabad, Jaipur, Bhopal and Ranchi. Our vendor, Protech IT Solutions, is given charge to digitize all our five hospitals. We have already placed an order of Rs. 1.4 million for the Noida facility.

Q. In the present economic environment, what are some of the biggest challenges for Indian healthcare industry? What

is your wish-list from the government to make this sector more vibrant and viable? A. The healthcare industry has become highly competitive with increased awareness, quality consciousness among public, and compulsions of the trade. Further, the rapid advances in the technology dictates continuous upgradation of the services, facilities and the infrastructure. In the coming years medical insurance will be indispensable rather than just a need. Majority of our population lives in rural India, so the thrust must be maximum there. In India, 80% of the healthcare expenditure is borne by the patients and 12 % by the government. The expenditure covered by insurance claims is 3%. As a result, the price sensitivity is quite high and quality healthcare facilities are out of the reach of the common man. The government should consider higher depreciation on infrastructure; lower taxation on the hospital industry; insurance companies/ TPAs be made more responsive to the problems faced by hospital; increase the budget for public healthcare for preventive measures and for upgradation of infrastructure at village/taluk/district; involve the alternative medicine practitioners at the block/taluk/district levels to make up for the shortage of allopathic doctors; to formulate council for healthcare administrators; and to formulate common reporting formats in pathology, radiology across the country. June 2009

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TECH TRENDS

On the go… A new series of mobile computing device launched by Motorola is all set to revolutionise the way enterprises work and do business. While these new devices, launched recently in the Asian market, are offering a wide variety of mobility solutions across industry verticals, healthcare organisations that are looking to create a sophisticated enterprise-level mobile work environment has much in store from this.

eHEALTH caught up with Ramesh Sundaraman, Head-Mobile Computing Business, Motorola to get a low down on potential application of these devices for healthcare industry.

What are the potential applications of Motorola FR series mobile computing devices in hospitals and healthcare enterprises? Over the last one year we have been doing pilot projects with our new FR series devices in several hospitals. We have learnt from our experience in deploying mobility solutions there are about 24 different areas where a hospital can potentially mobilise its operations, such as - bedside monitoring of patients, pharmacy inventory, medicine administration, blood bank, operations and telemedicine. We have already done significant deployments in Thailand and Hong Kong where we have put together Enterprise Wireless LAN for building highly secured and efficient networks. One of the main areas where such deployments are made is ‘asset management’. To being with, hospitals were somewhat reluctant about deploying mobility solutions for clinical operations; however, they later adopted the same, after realising its true value in bringing superior work efficiency and improving service quality.

How do you go about marketing your solutions? Is it only through IT vendors 30

June 2009

and SIs or do you also approach hospitals on your own? If a hospital already has an IT setup, we would try to work with the vendor who deployed the solution at the first place. The reason being they are the ones who would best understand the hospital’s requirements. Our role is to extend their IT infrastructure to offer mobility solutions. However, in an absolutely new setup everything has to be done from the scratch. For the value addition that we do, we try and understand the needs of our client; however, for actual installation and operationalising the solution we do seek help of the IT partners. We also approach hospitals independently to understand their problems and sometimes to explain them the benefits of our solution. We also update them on latest technologies. For instance, many understand wireless technology and barcode scanning, but very few understand enterprise mobility.

Do you evaluate applications of HMS vendors to ascertain workability and compatibility of your devices/ solutions? If a hospital is already having an IT

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vendor then not much work is required in this respect. It would just be an issue to check for technical compatibility. However, if the customer is installing HMS for the first time then there is lot to be done. In such cases, we do validate the software from all generic requirements to ensure that it works well with all our devices.

With so many solution providers, health IT market today seems to be highly fragmented. What are your comments? It is indeed a big challenge for us because almost every hospital is deploying a different package. Nowadays, even different branches of the same hospital group would have different HMS packages. At our end, we try to enroll those partners who are engaged with us, but we also try to enroll some big players offering solutions. For instance, IBM is our worldwide partner and Wipro is our Indian partner who provides solutions not just in health care but across many other verticals. I hope we all would gradually evolve in the process.

What will be your comments in terms of long term cost advantage for hospitals for using mobility solutions?


TECH TRENDS There are two aspects to it - one is the return-on-investment, and other is the total-cost-of-ownership. As regards the former, it can be readily realised as the enterprise spends sometime working on the mobile platform. The work efficiency, performance and

About Motorola FR68 & FR6000

service quality can be dramatically improved over a relatively short period of time. In terms of the later, we have the same architecture across our product line which ensures the availability of all products. It’s a very important aspect because ours

are consumer-based devices which can’t be phased out, as enterprises make a long-term investment on them. We also ensure stability of the platform and its reliability by providing superior services to our customers.

CASE STUDY: The Sir Run Run Shaw Hospital in China Saves More Lives with Motorola Mobility Solution The Sir Run Run Shaw Hospital is a modern hospital ranked amongst the best in China and co-managed by the Medical Centre at Loma Linda University in California. Realising the fact that a hospital’s information system is what allows them to deliver the highest level of service, it undertook the task of upgrading and modernising its IT infrastructure by deploying Motorola’s high-performance wireless medical system that can integrate its existing information systems and bring seamless, real-time connectivity across the organisation.

The Solution The solution includes WS5100 wireless switches, AP300 network antennae and MC50 handheld mobile terminals. The WS5100 provides powerful, centralised intelligence and management capabilities and the MC50 is an enterprise digital assistant combined with barcode scanning capabilities. It features advanced data capture, flexible voice and data communication capabilities.

The Benefits

Motorola’s FR68 Enterprise Digital Assistant (EDA) and the FR6000 rugged handheld computers (currently available only in the Asia-Pacific markets) are full-function 3.5G HSDPA/ WAN network mobile computers that offer simultaneous voice and highspeed data connectivity, and GPS navigation. The devices also offer expanded levels of enterprise-class features in a highly compact form factor and ergonomics best suited to the needs of Asian users. Additional functionalities include high resolution 3.2 mega pixel auto-focus color camera, and optical character recognition (OCR) functionality in the FR68, and 1D laser scanner, plus additional connectivity through wireless LAN (WLAN), Bluetooth® and IrDA. Powerful computing capabilities enabled through the Marvell XScale PXA312 624MHz processor and Microsoft® Windows® Mobile 6.1 operating system in the devices ensure ease of integration with existing enterprise infrastructure, enhanced security features, a flexible development platform and improved mobile messaging – all in a single device.

With wireless LAN covering the entire hospital the medical staff can now access the information system from anywhere in the building. Doctors and nurses just need to scan a patient’s barcode wristband with the MC50 which identifies them immediately and retrieves their medical history automatically. The medical and nursing staff can now work beside the patient’s bedside, giving them more attention while at the same time ensuring safe and accurate treatment. Doctors can now verify patient’s medical information real time, right by the patients’ bedside and take prompt decisions based on patient’s immediate needs. Interestingly, some of these decisions were actually life-saving. In addition, it helps hospital staff to achieve true mobility - drug management, sample collection, blood transfusion tests, asset and material management, remote patient monitoring and nurse calls can be deployed wirelessly, increasing the efficiency rate of many common activities. From a patient’s point of view, once the admission procedures have been completed the system notifies the relevant doctor in real time, allowing for the efficient scheduling of consultations or surgery. If additional consultations are required, the wireless medical system provides an extremely convenient way of fixing the appointment. The MC50 mobile terminal instantaneously sends the information to the relevant administrative office, which will arrange for the appointment via the wireless network. In comparison to the conventional handwritten consultation slip, the electronic consultation slip greatly improves the efficiency of hospital staff.

ROI & User Feedback “A cutting edge management model and modern information management system have greatly augmented the competitiveness of the hospital. The patient satisfaction level has reached 97%. Amongst similar hospitals in China, Sir Run Run Shaw Hospital has the highest bed turnover rate and the lowest antibiotic usage rate. The average number of hospitalisation days is now only 8.95” Said He Chao. June 2009

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BOOK REVIEW

Strategic Management of Information Systems in Healthcare

Reviewer:

Dr. Sanjeev Sood, Senior Medical Officer and Aviation Medicine Specialist in Indian Air Force

Authors:

Gordon D Brown, Tmara T Stone, and Timothy B Patrick Publisher: Prentice-Hall India Pvt. Ltd., New Delhi-110001 Year of Publication: 2006 Pages: 310; Soft Bound Price: INR 275.00 (Original US Edition-INR 4136.00) ISBN Code: ISBN-81-203-3000-5

T

his book explores how healthcare organisations can utilise advanced information technology to achieve high levels of operational performance and strengthen their market position. It considers health information systems from an organisation perspective, integrating the science of IT, medicine and nursing practice within the context of complex adaptive systems. The book provides a conceptual framework for considering how IT can be used to redesign

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clinical work processes and integrate the clinical and business functions to achieve a coherent organisation strategy. The frame work draws on a body of organisational and systems theory and incorporates evidence from information and clinical sciences. The book takes an application approach, drawing on current operational and policy issues, supported with rapidly growing body of evidence on how IT can be used to transform health systems function and improve clinical and business performance. The book is divided into four parts. Each chapter begins with chapter outline, learning objectives, overview; key terms used and end up with conclusion, questions for discussion, references and further reading. This format makes the understanding of the subject easier, while giving more stimulus for further exploration for those interested. The book has been amply illustrated with case studies by drawing on actual situations to introduce and apply the concepts. These chapters also include a problem solving scenario that draws on the case and thereafter applies and integrates material from the chapter. Part-I focuses on both business and clinical strategies and then considers them as an integrated organisational strategy. Part-II focuses on information strategy relating to enterprise strategy, and how organisations use information to position themselves in a competitive market and respond to environmental changes. Specific strategies are selected and discussed in some detail, including knowledge management as an organisational strategy, consumer informatics, role of e-health and web-based technologies, and the impact of genomic medicine on health behaviour and service delivery. Part-III focuses on managing information recourses. The editors feel it is necessary to provide a detailed discussion of IT from the perspectives of operations management in Part-I and strategic management in Part-II before addressing the specifics of managing information resources. The section includes chapters on effective management of information resources, IT investments, IT structure and staffing and information security and ethics. Part-IV provides a broader context for thinking about how IT might affect health systems in the future. It is policy oriented and includes a comparative analysis drawing on how information has been applied in other service industries and health systems in other countries. It considers how IT in health might spawn fundamentally new ways of thinking about the industry. Included in the discussion is an assessment of current U.S. policy initiatives to develop a national health information infrastructure.


BOOK REVIEW IT is recognised as an important and one of the latest technologies to be brought into health systems. This recognition has given rise to many clinical and business applications and is reported in the literature. Information, however, is more than just latest technology to affect health systems. It is one of the few resources that increase in volume and value as it is used. Its value is its use, as with any resource, but by its use adds to resources. Traditional models to explain the economics and strategy of investing in a technology do not fit in information technology. This book explores IT within a new paradigm applied to health organisations and systems. Historically, the application of IT in health institutions has been considered primarily from a technical perspective. The technology has been applied to existing decisions, work processes and system structures. Complexities of clinical and business processes have posed major technical challenges that have taken time to resolve. Part of the challenge has also been the difficultly of changing clinical processes because

of conflicts between traditional professional roles. The technical focus of early IT applications primarily included nursing and medical professionals. This book builds on the foundation work in medical informatics to explore how IT can be used to transform work processes and systems. The science and complexity of tasks are explained to include how information can be used to facilitate change in complex systems and individual behaviours. Information enables organisations to restructure their work processes and systems. It also enables them to develop new strategic initiatives, some of which are based on information as an enterprise strategy. Such profound change draws on the fields of medicine and nursing, informatics, systems theory, organisational psychology, organisational strategy and structure, economics and finance, law and ethics. These are disciplines from which this book draws to understand the potential of this new technology. The book has been authored by professionals in the faculty of the department of health management

and informatics at the University of Missouri-Columbia. It primarily discusses the subject in the context of highly decentralised and privatised hospital centric healthcare system of USA. Because of its grounding in theory and research evidence, the book is well designed for use in graduate courses in health management, medical informatics, eHealth, medicine and nursing and in general all those interested in applications of ICT in healthcare. Practicing health professionals can use the book effectively as well, either as general reference or by focusing on the conceptual and applied material as a framework for solving strategy development. With increasing adoption of ICT applications in Indian hospitals for safe, efficient, patient centric and cost effective delivery of healthcare, the book shall provide a useful study material. Further, healthcare organisations running chain of hospitals and interested in giving a strategic direction to their enterprise through adoption of technology shall find this book as an invaluable accompaniment.

June 2009

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NEWS REVIEW

GE plans to invest $6 billion on healthcare GE Healthcare, the $17-billion healthcare arm of General Electric launched new, low cost products, aimed at developing markets such as India, as the company seeks to spend around $6 billion on its global strategy to grow its revenues from emerging markets. As part of its ‘Healthymagination’ initiative, GE will spend $3 billion over the next six years on research and development, provide $2 billion of financing over the next six years to drive healthcare information technology and health in rural and underserved areas, and invest $1 billion in partnerships, content and services. GE has also demonstrated a hand-held ultrasound machine and a bassinet with an overhead heater among products to be manufactured as part of the company’s strategy to shift its focus to lower cost products in Washington.

Philips announces the acquisition of Traxtal

Ranbaxy looks to rebuild its US business

Royal Philips Electronics announced that it has acquired Canada-based Traxtal Inc., an innovative medical technology company in the field of minimally-invasive instruments and software for image-guided intervention and therapy. Traxtal’s navigation solution functions as a GPS for medical instruments, designed to make interventional radiology procedures more accurate while aiming to reduce contrast, radiation dose and interventional time. Coupled with Philips’ strong position in medical imaging, this acquisition enables Philips to become one of the leading healthcare solutions providers for image guided procedures. Traxtal complements Philips’ offering in the area of minimally-invasive procedures. Traxtal’s navigation solution displays, during the procedure, the instrument’s position, orientation, and trajectory on medical images such as Ultrasound or CT. An example is the radiofrequency ablation of liver tumors during this procedure Traxtal’s PercuNav system helps guide and monitor the positioning of the ablation needle towards the center of the lesion.

After facing massive losses coupled with regulatory hurdles in the American market, Ranbaxy Laboratories Ltd has chalked out plans to revamp its US business. For the year, 2009, Ranbaxy has a clear strategy to harness its growth potential in the emerging markets, rebuild the US business through a series of actions on products and facilities. For the quarter ended March 31, 2009, Ranbaxy reported a loss of 153 million dollars, while it posted a 14 per cent decline in its US business at 68 million dollars. The company is taking various actions for minimising its losses. It is also working to increase the capacity of its US-based subsidiary Ohm Laboratories. In September last year, US health regulator Food and Drug Administration had banned the import of 30 generic medicines manufactured at Ranbaxy’s two plants -- Paonta Sahib and Dewas - in India. Ranbaxy had indicated that it is looking for acquiring FDA approved manufacturing facilities to shift its products from Paonta Sahib and Dewas.

iSOFT wins US$ 3.54m deal in England for a HMS iSOFT, an IBA Health Group Company announced that it has won a contract for a hospital information system with a National Health Service (NHS) trust in southern England worth US$3.54m over five years. The contract with Heatherwood and Wexham Park Hospitals NHS Foundation Trust is for iSOFT’s i.Patient Manager (i.PM) PAS and a technical refresh of an existing iSOFT clinical solution, i.Clinical Manager (i.CM). i.PM is replacing an outdated third-party system. The trust elected to contract directly with iSOFT for a replacement PAS instead of waiting for a solution under England’s National Programme for IT. This is one of the first major deals in the Southern Cluster, which was formerly serviced by Fujitsu.

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Merge Healthcare partners with China’s health IT provider Merge Healthcare, medical imaging solutions provider has partnered with Shanghai Kingstar Winning Co., a healthcare IT leader in China. The Merge Healthcare China office will make available clinical imaging solutions and professional services to Kingstar Winning for use by more than 800 hospitals in its install base, as well as future Kingstar Winning customers. The strategic partnership between Merge Healthcare and Kingstar Winning comes at an excellent time for healthcare in China. The Chinese government has announced a new healthcare reform plan, similar to the American Recovery and Reinvestment Act of 2009, which allocates almost $20 billion for health IT. The plan outlines $125 billion (USD) in spending over the next three years, including a sizeable investment in rural health technology and infrastructure. Together, Merge and Kingstar Winning will provide cost-effective, quality solutions into more rural areas, leading to better patient care for these communities and contributing to the success of the reform plan.


NEWS REVIEW

Slovenia rolls out e-health insurance card system The Health Insurance Institute of Slovenia (HIIS) has decided to roll out a new electronic health insurance card project to streamline the patients’ claims processing system. The new system enables healthcare providers to instantly and accurately check a patient’s health insurance status and allows for health claims to be processed online. The system enables healthcare providers to accurately check a patient’s health insurance status and allows them to instantly process health claims. The decision to implement the new electronic health insurance system nationwide comes after the successful completion of a pilot program at Dr Franc Derganc General Hospital in the Nova Gorica region of Slovenia. The new system is based on an IBM integrated IT infrastructure solution that links healthcare providers to both public and private health insurance organisations. The company has provided the hardware, software and services in order to create the central IT infrastructure for the project. The solution is based on IBM System z10 hardware that runs on its WebSphere and DB2 software. The main software components include modules for identifying, authenticating and authorising health professionals to ensure a secure communication channel between the healthcare provider and insurer.

Airtel offers health services on mobile

Cadila Pharmaceuticals ties up with TAKE Solutions Cadila Pharmaceuticals recently selected TAKE Solutions for their PharmaReady eCTD, SPL and PPM software for regulatory submissions management. Considered to be a major win, the project came in less than twelve months since TAKE Solutions launched the product in India. Speaking on this occassion, Ramesh L, VP-Sales, Life Sciences APAC, said, “Cadila is a valuable addition to our growing list of Indian customers. The association with a brand like Cadila proves the reliability of our products for top notch companies.

HID Global introduces e-Health LAN card reader

Airtel users in Karnataka will now have access to two new health care services via their mobile phones. The services: Virtual Blood Bank Service and VacciDate service are being offered to subscribers free of cost. Airtel claims that in an emergency, its subscribers can rely on its service to call for the Virtual Blood Bank Service when in need of blood. This service aims to bridge the gap between blood banks, donors and recipients of blood. Subscribers will need to dial the toll free number 51514 from their Airtel mobiles to access this service. This IVR based emergency helpline number will assist and guide the Airtel customer till the time his/ her requirement of blood is addressed. VacciDate service is a vaccination alert system on mobiles for Airtel subscribers. The service is aimed at parents so they can keep a track of their child’s vaccination dates. This free service also has a special alert feature for POLIO Sundays organised by the Government of India. Lastly, users can also query the system to check their kids’ next vaccination date. Airtel customers need to SMS VACC (Date of Birth in DD MM YYYY Format) to 52225.

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HID Global, a leading access and ID management solution provider, is introducing the OMNIKEY 8751 e-Health LAN card reader terminal on the market. The device has already been in use in German clinics, pharmacies and medical practices since 2007 in the scope of the test regions for the new health card. The network-compatible card reader terminal has Gematik’s e-health BCS approval and supports all current requirements for multifunctional card terminals (MCT/BCS). The OMNIKEY 8751 e-Health LAN reads current medical insurance cards as well as the new electronic health cards, and is thus equipped for all future functions in German health care. In addition to having a serial port, the reader can also be integrated into a network as an MCT/BCS terminal and has an RFID interface for the planned convenience signature. What’s more, the firmware upgrade required for the online expansion of the nationwide e-health telematics infrastructure is provided free of charge. The OMNIKEY 8751 e-Health LAN card reader terminal is one of the first reader devices to receive Gematik’s e-health BCS approval. This means that it has been approved for the general rollout as of August 2009 and is refundable in the scope of the financing agreement. TheOMNIKEY 8751 e-Health LAN can be used by conventional means via serial interface or can also be put to use immediately in existing practices by using what’s known as a CT-API.


NEWS REVIEW

Philippines urged to adopt telemedicine Senator Joseph Emilio A. Abaya of the first district of the Cavite province stressed the need for the country to have a law pushing for a telemedicine bill that will facilitate collaboration between public and private institutions, and government and non-government offices. The call was made during the e-Health and Telemedicine 2009 Conference and Exhibition on 9 May in Quezon City, where the congressman noted how the rapid development of ICT has provided a window of opportunity for the health sector to expand its reach. According to 2007 data from the National Statistics Office (NSO), there are only 2955 medical doctors in public hospitals; and this is a paltry number in relation to our burgeoning population (90 million), especially in the provincial areas where people rely on government facilities for their health and medical needs.

Hetero bags Government’s anti-flu drug deal

Health care village in Kerala

Hyderabad-based Hetero Drugs has bagged the government’s 10-million anti-flu drug order. The company will supply nine million capsules of Oseltamivir, the generic version of Roche’s Tamiflu, to the government. Industry officials estimate Hetero Drugs would earn INR30-35 crore from the order. The pharma company has the licence from Swiss drug major Roche to develop and sell the generic version of Tamiflu. Hetero Drugs pips bigger rivals, such as Cipla, Ranbaxy, Roche India and Natco, who also sent quotations to supply their drugs. The remaining order will be completed by mid-June. The company is expecting to bag additional drug orders worth at least $10 million (Rs 50 crore) from foreign governments. It is in talks with about 40-50 countries, which include Argentina, Columbia, Venezuela, Honduras, Thailand, the Philippines, Egypt, Saudi Arabia and over 10 countries in Africa. Following the global outbreak of H1N1 Influenza Flu, governments across the world are stockpiling Oseltamivir to combat the disease.

A multi-disciplinary health care village has been proposed on 40 hectares of land in Kozhikode as part of providing integrated treatment facilities from all scientific streams of medicine. Conceived by Infrastructures Kerala Limited (InKEL), the village, to be completed in four years, is estimated to cost Rs.417 crore. The project, being implemented in association with the State government, is expected to bring in another Rs.1,583 crore from the private sector in setting up other facilities. The village is aimed at promoting medical tourism in the State, setting up wellness, preventive and alternative medicine centres, a medical college and a hospital with state-of-the-art health-care infrastructure. A 500-bed multi-specialty hospital is to be set up in the first phase. The village will ultimately have a 2,000-bed facility. A medical college, a super-specialty hospital, a dental college, a nursing college and a paramedical institution will be part of the village. An exclusive Ayurvedic centre offering traditional treatment, along with a wellness centre, has been proposed. A medical education and training wing will come up on 10 hectares of land with the School of Medicine as the nucleus around which other institutions will function. The school will offer courses in multiple streams of traditional and modern medicine. Each stream will offer postgraduate and doctoral programmes in medicine.

Wave Medical’s clinical decision support now in hand Health professionals need to look no further than their iPhone to support them at the point of care. Wave Medical, who provides clinical decision support applications to general practitioners, nurses, emergency doctors and medical students has expanded its mobile platform offering to include the iPhone and iPod Touch. Now all healthcare professionals can easily access any of Wave Medical’s specialty-focused clinical decision support applications through iPhone’s innovative platform. With thousands of international drug names, dosing and medical calculators, disease profiles, illustrations and a powerful drug interactions generator, Wave Medical’s fully integrated content enables quick navigation through the clinical decision process. Heavy textbooks are no longer the only reference physicians consult in their daily clinical decision routine. Now the most up to date clinical decision support content is available on their iPhone, in hand and right at their fingertips.

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The super-specialty hospital will come up in the medical services wing on another 10 hectares. The proposed recuperation centre is aimed at attracting NRI and medical tourists. Facilities such as helicopter evacuation, tele-diagnostics and telemedicine will be on offer for the needy.


TELEMEDICINE

Data Connectivity Challenges in Telemedicine (This is the fourth insert in a series of six articles to be contributed by the authors)

Lieutenant Colonel Salil Garg Cardiologist, Command Hospital, Pune

Squadron Leader Mudit Mathur Indian Air Force

INTRODUCTION We live in a divided world: between rich and poor, healthy and sick, literate and ignorant, democratic and authoritarian, and between empowered and deprived. All the technologies and policies that we developed in the past for harnessing human development have not wiped out these glaring disparities. While many categorisations of countries have been developed (such as developed, developing, emerging and transition economies etc.), a new label—a sign of the times—is the ‘digital divide’, which describes the

development of countries (and groups within countries) in terms of their capacity to harness the power of ICTs. Whether we can overcome the digital divide and provide basic and advanced medical care to even the most destitute of people is a question that remains unaddressed! Of late, people are taking active interest in the development of telemedicine infrastructure. This is because medical services have become very expensive and costs are spiraling out beyond the means of the common man. In such a scenario, will telemedicine be able to provide a solution by enabling transfer of highquality images and data at economical rates and bring down the cost of service? Is telemedicine is going remain to hallowed portals of high tech medicine or will it be able to provide succor to the man on the street? Marrying the two ends is where the future of telemedicine may lie!

Transfer of Data Wireless telemedicine: In today’s world, how does telemedicine work? As we have already brought out in our previous articles, there are three particular aspects - patients dealing with doctors, doctors dealing with other experts from remote locations and data sharing between various doctors/ experts. All three require different levels of technological adaptations.

The first level is possible either through telephony (voice-based) or through Internet (transfer of data and images). The remotely located doctor analyses the oral/verbal/image-based data and gives a reasonable treatment advice that maybe sufficient in itself or may help in tiding over the crisis and the patient may seek further help at a more convenient time. Even at the second level, where doctors and paramedical staff working in remote locations need to consult with experts in other locations, a simple access to a telephone or an internet connection maybe a great achievement. Any transmission of data and any response from the other end are more than welcome. At the pinnacle of telemedicine practice, is the contact between various high end hospitals and specialists, who maybe discussing and dealing with very sophisticated decision making and management practices just at the click of a button. We need technologies that can make slow connections a history and through which doctors and patients will be able to communicate with each other easily. The earliest of these are nearing implementation in the form of 3G telecom technologies, which is going to be followed in next few years by 4G, 5G and 6G technologies. In telemedicine, data transfer involves transmission of select, June 2009

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TELEMEDICINE usually quantifiable, biochemical and physiological parameters of organ or system function to a central point for storage, analysis and immediate feedback instructions to the patient concerning treatment. Transtelephonic assessment of cardiac pacemaker signals is also a form of data transfer. Data transfer may be direct, accomplished by automated measurements and periodic downloading through a special device, such as a biosensor or specially designed palmtop. Conversely, data transfer may be indirect, with manual measurements being performed by the patient and then communicated via telephone or Internet to a central receiver. Indirect data transfer demands thorough patient or caregiver training to avoid errors that could lead to wrong diagnosis.

A Telemedicine System over Internet A modern patient oriented web-based telemedicine system to promote the idea of e-medicine should have the following features: • Provide the efficient and convenient methods for patients and doctors to communicate with each other through the Internet and to fundamentally alter the personal face-to face relationship that has been the model for medical care for generations. • Design less expensive and more realistic methods for testing the effectiveness of alternative clinical practice. • Provide a circumstance for “Case Diagnosis” and “Case Consultation” on the remote situation. • Build computer-based patient records and other electronic information systems that provide relatively easy and fast access to large databases and that permit the application of powerful statistical methods for analyzing and displaying those data. • Allows patients to see doctor specialist in web and send their medical data/image by Internet. • Formulate strategies for proving information to patients, clinicians, and others in ways that promote informed decisions and stimulate

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• •

desired changes in behaviors and outcomes. Potentially allows easier access to more information about a patient that the user either requests or needs. Automatically produce a payment including types of telemedicine services and would be divided into professional and facility components. Providing secure web payment. Authentication procedures to ensure that messages are received from the stated source exactly as they were sent. Should be able to maintain patient confidentiality, medical ethics and be covered on medicolegal issues.

Wireless Communication in Healthcare systems Limitations of technologies The advantages of using wireless technologies far outweigh their disadvantages. However, handheld devices and wireless technologies have some issues which would pose a challenge in the healthcare industry and its applications. Some of these potential threats are:

Small Screens2 Due to small screen sizes health professionals cannot view large tables / electronic health records in a single screen. However, this may change in the future with wider screens, more availability of wireless connections and ability to connect to bigger screens for better viewing.

Insufficient Memory3 To minimise costs handheld devices and mobile devices come with very small memory footprints and the processing speeds of these devices are slow compared to personal computers or laptops. This aspect is again likely to be rectified by technology.

Less Bandwidth4 Bandwidth plays a vital role here as the pervasive and QoS related issues

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are very high in terms of serving patients who are in need for immediate healthcare service. This is the most important limitation and if we can circumvent it, it will ensure a quantum leap in our telemedicine abilities.

Slow Data Entry5 Handheld devices are small in size and therefore, data entry becomes a tough process especially while on the run. It becomes a very time consuming process if long notes are required to be taken.

Security issues6 Handheld devices can be easily hacked, lost or stolen. Hence, some form of security like biometric entry and usage must be built into the devices. The other potential threat would be the entry of remote users into the hospital’s expert system or mainframe computer. This poses as a threat to patient’s privacy and well being. As we all know the transition from the present day technology to 3G and onto 6G is going to be a long drawn and a tedious process. Though it may take time, it is bound to happen and we have to be there when it does, because if we miss the bus, we may not get another chance.

The Limitations Today, doctors and the patients are limited by technology. The entire data cannot be transmitted and the transmitted data may not be accessed at the place of reception. Let us take a few examples Suppose a patient presents himself with chest pain. The doctor requires to know the symptoms - the same may be transmitted by telephony or the patient may be seen by videophony (though a 3-D image maybe more preferable).


TELEMEDICINE The ECG requires to be transmitted. If transmitted on a mobile phone it may not be large enough for the doctor to analyse and a larger screen may require connection with a computer which may not be possible at the time. A similar limitation maybe there with X-ray images. During coronary angiography, in case advice from another expert is needed, and this may require split second decisions, it may not be available. The angiographic images are heavy radiological images and it is still very difficult to transmit them. Similarly, in cases of stroke, it maybe very difficult to transmit CT scan images or MRI images to the neurophysician. Not only they take long time to upload, they may not be even clear to the viewer on small screens. At present, very few ICU’s or radiology laboratories are equipped with data transmission facilities.

3G Technology 3G is the third generation of telecommunication hardware standards and general technology for mobile networking, superseding 2.5G. It is based on ITU family of standards under the IMT-2000. 3G networks enable network operators to offer users a wide range of advanced services including wide-area wireless voice telephony, video calls and broadband wireless data, all in a mobile environment. Additional features also include HSPA data transmission capabilities to deliver speeds up to 14.4 Mbit/s on the downlink and 5.8 Mbit/s on the uplink.

4G Technology 4G (also known as Beyond 3G), an abbreviation for Fourth-Generation, is a term used to describe the next complete evolution in wireless communications. A 4G system will be a complete replacement for current networks and be able to provide a comprehensive and secure IP solution where voice, data and streamed multimedia can be given to users on an “Anytime, Anywhere” basis, and at much higher data rates than previous generations. A vital requirement for telemedicine procedures is the reliable, uninterrupted delivery of information. Heterogeneous 4G networks will allow users to access a wide range

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of location dependent services like increased data rates and streaming media. Consider an ambulance equipped with wireless telemedicine devices and initially under the coverage area of an Wireless LAN hotspot with data rates up to 54 Mbps. Under the coverage area of the hotspot, the ambulance will transmit the telemedicine traffic streams at the available data rates. However, on the move the device will handoff to the next best available network (e.g. GPRS), which offers data rates only up to 13.4 Kbps. Thus the connection could be maintained albeit at lower data rates. Furthermore, if the ambulance travels into areas that do not fall under GPRS coverage, the device can handoff to the wide-area satellite network. Even though it may not be possible to transmit highquality multimedia streams at all times, 4G networks offer more reliability by allowing healthcare professionals to roam freely between urban and rural areas, and still remain connected to the main site through the best available network service7. However, successful implementation of 4G involves resolving a number of issues. The convergence of networks with disparate characteristics results in many complexities at both the application and network level, particularly during conditions like vertical handovers. Although the channel quality improves during a downward vertical handover, (when the MH moves from a macro cell to a micro cell) it can degrade considerably during an upward vertical handover, which may result in connection loss. To maintain an acceptable level of Quality of Service (QoS), it is vital to hide these complexities from applications while roaming among networks. Apart from this, maintenance of a balanced flow of multi-class traffic across a wireless channel under varying network conditions and reconfigurability of terminal devices and network elements for dynamic selection of

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best available service are a few among the numerous issues that researchers are striving to discover optimum solutions for and form a truly ubiquitous heterogeneous 4G network. Yet, despite the numerous challenges involved in the development of a ubiquitous heterogeneous network, the fascinating idea of seamless connectivity anytime, anywhere makes it an attractive field of research. 4G is being developed to accommodate the quality of service (QoS) and rate requirements set by forthcoming applications like wireless broadband access, Multimedia Messaging Service (MMS), video chat, mobile TV, HDTV content, Digital Video Broadcasting (DVB), minimal service like voice and data, and other streaming services for “anytime-anywhere” objectives of the 4G wireless communication standard8:

5G (Real wireless world) (completed WWWW: World Wide Wireless Web): The idea of WWWW, World Wide Wireless Web, started with 4G technologies. The following evolution will be based on 4G and will be completed by forming a ‘real’ wireless world. 5G should be a more intelligent technology that interconnects the entire world without limits. The differences between 3G and 4G are with respect to data rate (speeds) and services, for example - global roaming, interface with wire-line Internet, QoS and security. 4G will be supported by IPv6, OFDM, MC-CDMA, LAS-CDMA, UWB and Network-LMDS. They can be arranged in different zone size. IPv6 can be designed for running in the widest


TELEMEDICINE

zone, called World cell. OFDM, MCCDMA and LAS-CDMA can be designed for running in the wide area, called Macro cell. Network-LMDS is in Micro cell, and UWB is in Pico cell. In the 4G wireless networks, each node will be assigned a 4G-IP address (based on IPv6, 128 bits), which will be formed by a permanent ‘home’; IP address (32 bits) and a dynamic ‘care-of’ address (32 bits) that represents its actual location. The care-of address will be informed to other devices by directory server for directly transmit purpose using mobile IP interface with wire-line network and wireless network. 5G will be the completed version of WWWW, World Wide Wireless Web, to form a real wireless world with no more limitation with access and zone issue.

STOPPING POINT In spite of the security issues in wireless technologies, incorporating wired and wireless technologies in healthcare systems proves to be a viable and last mile solution for serving the needs of the patients at the shortest possible time. Applying wireless technologies into healthcare benefits not only the healthcare professionals but also the patients. Considering the coverage, performance and service factors, as discussed above, an effective wireless technology can be designed. Thus, properly designed and developed wireless technologies may ensure smooth communication between the patients and healthcare professionals, by providing coverage, performance and service, thus helping the healthcare professionals to serve the patients effectively. Expert systems should be used in healthcare combined with Artificial Intelligence

to ensure faster communication between the healthcare professionals and the patients. The following diagram gives an expected schedule for meeting with our objectives. And if we are not there on schedule some doubting Thomas may certainly be able to say “Doing it right is no excuse for not meeting the schedule.” (Plant Manager, Delco Corporation) The challenge is how to make newer technologies to overcome the present limitations. A seamless transmission of data and images as in the cases of transmission of X-rays, angiographic films or CT scan images and MR images would result in the same images being reviewed by experts in real time with the ability to advice corrective measures. Maybe the holographic projection of images will be able to solve the problem of viewing images in proper size and a 3- D perspective. As our medical services and living conditions improve our life expectancy will go up. The future may have a higher geriatric population. There will be more patients with metabolic and lifestyle diseases and more people will be alive and living with these diseases. So, you may have a 90 year old gentleman with all the diseases including arthritis who may still be enjoying his golf and who needs to consult once in three months. This he may do via telemedicine, thus saving transportation charges and other difficulties including a visit to the doctor who himself maybe 90 year old. Maybe

doing it right and doing it on schedule maybe the answer. (This work provides the overview of the field of Telemedicine practices done by various experts and institutes. Author(s) take no claim in either designing the models or its concepts, however, direct integration of isolated works in the field of Telemedicine practices has been done in this article. Suitable cross references are marked.)

References : 1.

2.

3.

4.

5.

6.

7.

8.

Applying Mobile Wireless ADHOC Technologies and Expert systems in Healthcare Reid J. A Telemedicine Primer: Understanding the issues, Billings, Mt.: Innovative Medical Communications; 1996. Moving mountains with mobile computing, 2004, ‘Wireless Technologies in Healthcare’, Healthcare Informatics – Special Advertising Section http://www. healthcare-informatics.com/reports/ industry8.pdf Lewis.C, “Emerging Trends in Medical Device Technology: Home Is Where the Heart Monitor Is”, Food and Drug Administration, May 2001 Last Accessed: 3 April 2004 http://www.pueblo.gsa.gov/cic_text/ health/med-device/mdt.html Bibbi Thome, Anna-Karin Dykes, Ingalill Rahm Hallbert, ‘Home care with regard to definition, care recipients, content and outcome: systematic literature review’, Journal of Clinical Nursing 2003; 12: 860–872 Jean-Pierre Dan, Jean Luprano, Homecare : A Telemedical Application, Medical Device Technology. Chester: Dec 2003. Vol. 14, Iss. 10; p. 25 (4 pages) Next Generation Internet in Europe; InfoWin Thematic Issue: Next Generation Internet 19.07.1999 Smart Bundle Management Layer for Optimum Management of Co-existing Telemedicine Traffic Streams under Varying Channel Conditions in Heterogeneous Networks ; F.Shaikh, A. Lasebae and G.Mapp; School of Computing Science, Middlesex University, White Hart Lane ,London. N11 1BA, United Kingdom. June 2009

43


Approximately US$14 billion is being spent across the Gulf on new hospital and healthcare facilities in ‘08-’09.

Government fund allocation for Indian medical research in ‘08-’09 budget stands at INR 5.32 billion.

Mobility applications for enterprises can reduce manual errors by at least 31%.

Healthcare spend of US Govt is estimated to exceed 25% of GNP by 2015.

The Indian X-ray market is expected to reach US$ 45 million by 2011. 44

June 2009

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