asia’s first monthly magazine on The Enterprise of Healthcare
eHealth Magazine
volume 9 / issue 03 / march 2014 / ` 75 / US $10 / ISSN 0973-8959
Dr Girdhar Gyani, Director General, AHPI
Dr Narender Saini, General Secretary, IMA
Dr KK Kalra, CEO, NABH
Dr Purshottam Lal, Chairman, Metro Group
Reaching the
Unreached From Policy to Action
Dr. Vikram Singh Raghuvanshi, CEOHealthcare, Jaypee Hospital
Dr Ravindra V Karanjekar, CEO, Global Hospitals
Vibhu Talwar, MD, Moolchand Medcity
Avinash Ojha, CEO, RG Stone Urology and Laprascopy, Hospitals
ehealth.eletsonline.com
Dr Sameer Khan, CEO, Rockland Hospital Group
volume
09
issue
03
ISSN 0973-8959
Contents 56- Bringing Change to our lives Vasukumar Nair, Director, 21st Century Informatics
58- HMIS: In its Developing
Stage Prabhakar Annaswamy, CTO, Idea Object Software Pvt. Ltd
cover story
28- Rural Posting, 2600 PHC’s Against 50,000 Doctors Dr Narender Saini, General Secretary, IMA
30- Policy Regulation Need of the Hour Dr K K Kalra, CEO, NABH
32- Building Capacity into
Indian Healthcare Dr Girdhar Gyani, Director General, AHPI
36- Healthcare at International Standards for all Dr Purshottam Lal, Chairman, Metro Group
38- Cutting Edge Healthcare at Tertiary Level Vibhu Talwar, MD, Moolchand Medcity
40- Healthcare at the Best
Practices Dr Sameer Khan, CEO, Rockland Hospital Group
42- Single Specialty can be a Game Changer Avinash Ojha, CEO, RG Stone Urology and Laprascopy, Hospitals
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44- Promoting Excellence: A
Framework for Healthcare Dr Vikram Singh Raghuvanshi, Chief Executive-Healthcare, Jaypee Hospital
46- In a move to Provide Best
of Quality Dr Ravindra V Karanjekar, CEO, Executive Director, Medical Services and Quality, Global Hospitals,Mumbai
Tech Trend
50- Moving Towards Error Free Medication
52- Focus On Healthcare
Products Naeem Ahmad, Manager Business Development, Akhil Systems
60- Application to speed up Things for the Patients Sachin Chougle, Co-Founder and Director, Design Tech Systems
62- Transforming Healthcare Treatments M Vennimalai, CEO, Aavanor Systems
Specialty
64- Cardiac Transplant Patients Living Longer
Dr Sujad Shad, Senior Consultant and Co-Chairman Department, Cradiac Surgery, SGRH
68- Accurate Effective and Efficient
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asia’s first monthly magazine on The Enterprise of Healthcare volume
09
issue
03
march 2014
President: Dr M P Narayanan
Partner publications
Editor-in-Chief: Dr Ravi Gupta group editor: Anoop Verma
Editorial Team
WEB DEVELOPMENT & IT INFRASTRUCTURE
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ehealth does not neccesarily subscribe to the views expressed in this publication. All views expressed in the magazine are those of the contributors. The magazine is not responsible or accountable for any loss incurred, directly or indirectly as a result of the information provided. ehealth is published by Elets Technomedia Pvt. Ltd in technical collaboration with Centre for Science, Development and Media Studies (CSDMS) Owner, Publisher, Printer - Ravi Gupta, Printed at Vinayak Print Media A-29, Sector-8, Noida, UP, INDIA & published from 710 Vasto Mahagun Manor, F-30, Sector - 50, Noida, UP, Editor: Dr. Ravi Gupta © All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic and mechanical, including photocopy, or any information storage or retrieval system, without publisher’s permission.
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editorial
When Bloom becomes a Boon! The current issue of eHealth focuses on world class hospitals that have emerged as epitome of health care and let the patient stay at one place and allow the specialties come to him under one roof. Today super multi specialty hospitals in India have come of age and are quite capable of delivering medical treatments that are at par with the best in the world. Now Indians are not going abroad for treatment but patients from overseas are pouring in as they have accepted and acknowledged Indian hospitals as viable option and alternative by way of quality and money. Considering rapid growth, potential and opportunity, large business houses continue to invest money in super specialty hospitals. This has resulted in state-of-the-art hospitals fused with cutting edge healthcare. Single specialty hospitals are winding up or paving way to incorporate the multi specialty. The assurance of quality comes from National Accreditation Board that enforces creation and maintenance of `Quality of Care’ across all departments, both clinical and non-clinical. Most of the hospital have optimised their IT infrastructure and are fast catching up with digital technology. The assurance of quality comes from National Accreditation Board that enforces creation and maintenance of ‘Quality of Care’ across all departments, both clinical and non-clinical. Most of the hospital have optimised their IT infrastructure and are fast catching up with digital technology. Nudged by necessity, cardiac surgery has come a long way- from transplants to artificial hearts. We speak to some of the pioneers in heart transplants who have undertaken major surgical procedures like Coronary Bypasses, HOCM, Aortic Surgery, and Mitral Valve repairs and replacements to name just a few. We also touched the diagnostic dilemmas of renal transplant, which is exposed to high risk of infections and complications due to immune compromised state. India retains the unfortunate distinction of having the largest number of people with visual impairment globally. Glaucoma is the third leading cause of blindness in India affecting 12 million people. During the World Glaucoma Week, we discuss the sneaky eye disease with experts.
Dr Ravi Gupta ravi.gupta@elets.in
march / 2014 ehealth.eletsonline.com
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news
Creation of Chair in the School of Tropical Medicine The creation of a chair in the School of Tropical Medicine (STM) to post humously honor Subhas Mukherjee has been suggested by West Bengal Chief Minister Mamata Banerjee. The former was a Kolkata-based physician credited with India’s first test-tube baby. According to her there should be an award and chair instituted in the memory of Subhas Mukherjee as he created the world’s second and India’s first baby (named Durga) using the in-vitro fertilisation (IVF) procedure October 3, 1978.
GE Healthcare Announces Collaboration to Accelerate Innovation for a Healthier India GE Healthcare, the US$18 billion healthcare business of General Electric Company (NYSE: GE) and Healthcare Technology Innovation Centre (HTIC), a multi-disciplinary R&D center of IIT Madras announced a three-year collaborative research and development agreement for innovating a range of disruptive and affordable healthcare solutions. Commenting on the partnership, Terri Bresenham, President & CEO, GE Healthcare, South Asia, said, “We at GE Healthcare are at work for a healthier India through development of innovative and affordable technology solutions. Accelerating innovation for affordable healthcare requires an ecosystem of partners and collaborative efforts by all stakeholders. We firmly believe that the ideas and innovations developed by the next generation of researchers will be an added benefit to the healthcare ecosystem. This collaboration between HTIC and GE Healthcare will bring together start-up dynamism and corporate scalability to healthcare innovations while putting the unserved customer at the centre of healthcare innovation”.
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More MBBS Seats to be Created in Country Minister for Health and Family Welfare, Ghulam Nabi Azad said that as per a high-level expert group report which has been presented to Planning Commission, an additional 187 medical colleges are required in under-served districts during the 12th and 13th Plans. “The current doctor-population ratio in the country is approximately 1:1,700, yielding a density of 0.5 doctors per thousand people, which is not adequate,” he said in a statement. The Union government has approved three centrally sponsored schemes aimed at, among others, upgrading 58 district hospitals into medical colleges and increasing undergraduate and postgraduate seats at government medical colleges.
Union Health Minister Lays Foundation Stone for New Facilities in AIIMS Union Health Minister, Ghulam Nabi Azad recently laid the foundation stone of two blocks at the AIIMS that will add facilities of 600 beds and 24 operating theatres at a total cost of `255 crores. The surgical block, will be spread over an area of 17000 sq meters and will have three basements and nine floors. It will have 200 beds, 12 operation theatres, a national endoscopy centre, a high dependency unit and transplant facilities. The facilities would be constructed at an estimated cost of ` 55 crores approximately and is expected to be ready by April 2015.
Patents on Next-Generation Drugs in India The United States voiced concern over protection of patents on safer and more effective next-generation medicines in India amid fears that authorities are considering, allowing more Indian firms to make new varieties of cheap generic drugs still on patent. In 2012, India issued its first-ever compulsory license to domestic drugmaker Natco Pharma Ltd on a kidney and liver cancer drug, Nexavar, patented by Germany’s Bayer AG.
Government to Track Mother and Child Health The Mother Child Tracking System (MCTS) is a web-based service that records details of pregnant women and children up to five years and also tracks delivery of due services to them. The aim of MCTS is to ensure that every woman gets complete and quality pre-andpost-natal care and every child receives a full range of immunisation services, Health Minister Ghulam Nabi Azad said while launching the service.
Good Healthcare is a Sign of a Developed Country, says President A healthcare system resting on the trinity of availability, quality and affordability is the sign of a developed country, President Pranab Mukherjee said at the foundation day celebrations of the Post-Graduate Institute of Medical Education and Research (PGIMER) of the Ram Manohar Lohia (RML) Hospital. “In 2005, the National Rural Health Mission was started to take healthcare to the doorstep of the rural population through a network of sub-centres, primary health centres and community health centres. Better infrastructure, trained manpower, effective drugs and modern equipments have improved service delivery. This mission has now been extended to the urban areas,” he said. In healthcare, technological applications have brought about a silent revolution. The telemedicine project using satellite technology has helped establish linkages between health centers in remote areas and super-specialty hospitals in urban areas, and facilitated expert healthcare consultation reaching the needy and under-served.
Victory over Polio Indian leaders marked the celebration of the eradication of polio, marking one of the country’s biggest public health success stories which were once thought impossible to achieve. President Pranab Mukherjee, Prime Minister Manmohan Singh as well as the health minister and the head of the World Health Organisation were all gathered at New Delhi stadium to celebrate India’s victory over polio.
Health expenditure, 3.7 percent of the GDP
The muchawaited global Conference, “The Future of Healthcare: A Collective Vision,” happened in the city on 3 and 4 March, providing a powerful platform to industry stakeholders to brainstorm unique solutions and innovative strategies to help lead humanity towards a healthier future. Montek Singh Ahluwalia,Deputy Chairman, Planning Commission of India while addressing the conference said that the next decade can be the period when India manages to improve its health infrastructure. According to Health Secretary Luv Verma, India’s total health expenditure is 3.7 percent of the GDP which is ‘woeful’. “The quality of healthcare services suffers as there are doctors who are not adequately trained,” he said.
Health Ministry got `5.97 billion for research personnel The Cabinet Committee on Economic Affairs (CCEA) approved the proposal of the Health Ministry for the scheme at an estimated cost of `5.97 billion, an official release said. The scheme intends to create a pool of talented health research personnel in the country by upgrading the skills of faculty of medical colleges, mid-career scientists and medical students through specialized training. The scheme provides for grant of 2,585 fellowships for training in India and abroad and development of 1,694 research projects by the trainees during the 12th plan period.
MARCH / 2014 ehealth.eletsonline.com
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news
Dr Mohan Thomas Becomes the First Indian to be Elected to American Academy of Cosmetic Surgery Leading cosmetic surgeon Dr Mohan Thomas has become the first Indian to be elected to the board of trustees of the prestigious American Academy of Cosmetic Surgery (AACS). Speaking about the development Dr Thomas said, “I am thrilled and honored to be associated with an institution such as AACS which is known for its commitment towards the development of the field of cosmetic surgery as a continuously advancing multispecialty discipline that delivers the safest patient outcomes through evidence-based information.”
Second Generation Health Reforms launched by CM Presently, the state government is working on a project of big data analysis which will have a comprehensive database of disease’s outbreak. It will provide proper analysis of any disease besides research for preventive measures. This was announced by CM Nitish Kumar recently, during the launch of second generation health reforms. He said the government, under the second generation health reforms, has made at least one primary health centre in all 534 blocks operational round-the-clock and facilities, including MRI and CT Scan, have been made available to patients on the model of public private partnership (PPP). Physiotherapy units have been established in all district hospitals and patient welfare committees (PWC) will monitor the functioning of the units. The CM also inaugurated a computerized system for operating physiotherapy centres, registration for outdoor patients’ department (OPD), medicine distribution and pathology diagnostics in all sadar hospitals across the state and an online information system portal. Transasia Bio‐Medicals Ltd. offers External Quality Assurance (EQA) programme
Space Promises to Treat Cancer Space exploration has more to offer people on Earth. Scientist have learned that research on cells in space can help us understand and treat malignant tumours on the ground. Some tumours which are aggressive on Earth are considerably less aggressive in microgravity, shows research. By understanding the genetic and cellular processes that occur in space, scientists may be able to develop treatments that accomplish the same thing on earth.
Stroke Epidemic Hits India
Quality control is the most efficient tool to cross check laboratory’s performance. Quality control programmes focus on accuracy and precision of each parameter at micro level. Presently, laboratories are heading towards External Quality Assurance (EQA) programme followed by performing traditional internal QC checks.
Transasia Bio-Medicals Ltd. offers External Quality Assurance (EQA) programme
Changing habits and sedentary lifestyles have made the incidence of strokes more prevalent among Indians, and can induce permanent disability or prove fatal, even as preventive measures are at hand, doctors maintain. According to them, an aggravation of intracranial atherosclerosis (ICAD), the hardening of the arteries that supply oxygen to the brain, can impede blood flow by narrowing and obstruction of blood vessels and result in strokes.
Transasia Bio‐Medicals Ltd. offers External Quality Assurance (EQA) programme ie. EMQAS (ERBA Mannheim Quality Assurance System) which provides inter‐laboratory comparison and peer group statistics. It enables the laboratory to monitor analyte’s performance by method and instrument specific
Quality control is the most efficient tool to cross check laboratory’s performance. Quality control programmes focus on accuracy and precision of each parameter at micro level. Presently, laboratories are heading towards External Quality Assurance (EQA) programme followed peer group comparison. by performing traditional internal QC checks. Transasia Bio-Medicals Ltd. offers External Quality Assurance (EQA) programme ie. EMQAS (ERBA Mannheim Quality Assurance System) which provides inter-laboratory comparison and peer group statistics. It enables the laboratory to monitor analyte’s performance by method and instrument specific peer group comparison.
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health watch
Tracking New Options
to Treat Glaucoma Blindness from glaucoma is irreversible. By the time the first visual loss occurs, it’s too late to improve that vision. Dr Devindra Sood, Director & Head, Glaucoma Services & Dean of Academics, Eye-Q Institute of Glaucoma, discusses the sneaky eye disease with Shahid Akhter, ENN India retains the unfortunate distinction of having the largest number of people with visual impairment globally. Please comment on the factors leading to such a scenario? Your suggestive solutions ? In India, it is estimated that glaucoma affects 12 million people and by 2020, this is expected to be 16 million. Statistics say that one in eight persons above the age of 40 years in India are afflicted by glaucoma which is also the second leading cause of blindness after cataracts. However, if we look at irreversible blindness, glaucoma is the leading cause worldwide. Glaucoma causes 12.8 per cent of the total blindness in the country. In India, more than 90 per cent of the glaucoma in the community is undiagnosed. The risk of developing glaucoma increases by five times if a parent has glaucoma, and by almost nine times if a sibling has glaucoma. Also, hypertension and diabetes are the other risk factors. People under high risk category should must go for eye check up every year after turning 40.
Glaucoma affects about 70 million people worldwide, of whom about 10 per cent are believed to be bilaterally blind. It is estimated that by the year 2020, this number would rise to around 79.6 million 12
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What causes glaucoma? Glaucoma is the name given to many different diseases, characterized by a typical damage to the optic nerve. In most cases there is an accumulation of fluid within the front part of the eye which exerts a pressure on the back of the eye. The increased back pressure reduces the blood supply to the optic nerve. The health of the optic nerve then begins to get compromised. Damage to the optic nerve is a hallmark of glaucoma. As damage to the optic nerve progresses, part of what we see around us is lost. First the edges of the picture blur and disappear. As the damage spreads, the view of the world becomes narrower and narrower, in effect producing tunnel vision. If the entire nerve is destroyed, blindness results.
Any precise reason for escalation of glaucoma in the India ? Glaucoma is essentially a disease of the aging population. With increasing life spans we are seeing a large number of geriatric diseases. Glaucoma is one such disease. However blindness from glaucoma is irreversible and occurs usually because of a raised eye pressure. Damage to the optic nerve can also occur in the absence of a raised eye pressure. The other concern in diagnosing glaucoma is that the common forms of glaucoma usually have no symptoms in the early stages of the disease. Also when symptoms develop, they mimic other conditions. Example: Blurred vision can happen with cataract and also with advanced glaucoma. The vision loss from cataract can be restored by surgical removal of the opaque lens. However, vision loss from glaucoma cannot be reversed. Again, glaucoma as a disease is diagnosed by signs and not from symptoms. Symptoms of glaucoma when they appear do so when the disease
is advanced. Since the damage from glaucoma is irreversible, the emphasis is on early diagnosis of glaucoma. Also the textbook description of symptoms for glaucoma are usually absent amongst us Indians.
Precisely, which aspect of glaucoma afflicts India ? All aspects of glaucoma affect us in India. Essentially glaucoma has no classical symptoms and when they do occur they mimic other diseases. In fact just because you can read this piece of information or drive independently does not rule out glaucoma for
T stands for Tonometry where the eye pressure is measured, preferably with an instrument which uses blue light. It is important to know that the eye pressure should be checked at every visit. O stands for Ophthalmoloscopy where damage to the optic nerve is assessed (structural damage). The optic nerve is the end organ of damage in glaucoma which results in a gradual painless loss of vision which is irreversible. Examining the way the optic nerve looks is very important to diagnose glaucoma. P stands for Perimetry and is a
“In India, glaucomas present differently. The open type of glaucoma presents in the advanced stages with blurred vision similar to cataract. The closed type does not show the typical features described in the text book” you. If lack of awareness prevents us from getting an eye check up, so does our busy lifestyle. Also of the 12,000 eye doctors in India, most are in cities, thus leaving a large part of India inaccessible to eye care.
How is glaucoma diagnosed ? Any preventive measures that you may suggest? Blindness from glaucoma is irreversible. The key to prevention lies in early detection. Today science and technology has progressed to a level where we can prevent further damage but we cannot reverse the damage. Hence detection in the early stages with appropriate treatment can prevent the blindness from glaucoma. The diagnosis of glaucoma is made by the TOPG test.
measure of one’s field of vision. Field of vision is the part of space we can see with one eye closed. The field of vision is irreversibly reduced in glaucoma (functional damage). Assessing one’s field of vision is essential for diagnosing glaucoma as structural damage to the optic nerve is currently documented as a functional loss on perimetry. G stands for Gonioscopy and involves assessment of the angle outflow structures. Gonioscopy is the single test which determines the kind of glaucoma one has. Amongst the common types of glaucomas, the open type and the closed type are treated differently. The open type is treated first with medication failing which one looks at other alternatives including surgery. The close type is treated
march / 2014 ehealth.eletsonline.com
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health watch
To facilitate early detection and help preserve vision in glaucoma individuals at risk age over 40 years of age glaucoma in the family those with diabetes/ thyroid disease / hypertension have received steroid containing preparations : tablets/ drops/ ointments/ puffs/ injections see rainbow coloured rings around bright light have a rapid change of glasses take medication for sleep/ anxiety / depression / asthma/ parkinsonism have had an injury to the face / eye myopia Have headaches
with a laser iridotomy first followed by medications. Surgery for glaucoma is always a last resort.
What are the problems associated with the various stages of angle closure in pigmented eyes? In India, glaucomas present differently. The open type of glaucoma presents in the advanced stages with blurred vision similar to cataract. The closed type does not show the typical features described in the text book – headache, coloured haloes and redness. Also the presentation in the closed type mimicks the open type of glaucoma. However the dif-
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ferentiation is important because treatment for different glaucomas is different. The open variety is treated with eye drops failing which surgery needs to be considered. The closed type is treated with a laser iridotomy first and combined with medication the aim is to keep surgery as a last resort. The problem in the closed type is essentially the difficulty in diagnosis.
With more than 18 years of experience in glaucoma care, can you please suggest the way out. How do you salvage the situation? For any blinding disease to be detected, we need to create an awareness about it. Since blindness from glaucoma is economic blindness we need to strengthen our health care systems. Most patients are dependent on out of pocket expenses to take care of themselves. The need for medication, frequent checkups and investigations can create havoc with ones budgeting. Remember other diseases like diabetes, hypertension and possibly others are going to add to the burden. As ophthalmologists we must hone our skills in the context of diagnosing and managing glaucomas in the Indian perspective.
Any particular programme that you have implemented for mass awareness and routine check up for all, particularly the elderly ? Net worked glaucoma care at Eye Q Super Specialty Eye Hospitals ensures that its apex centre Eye Q Institute of Glaucoma co ordinates, implements and audits glaucoma care at all its 33 centres in India. Quality at affordable costs with the judicious use of technology is our focus.
With technological advancements shaping up modern treatments, what does one expect in
glaucoma detection and treatment ? What to expect at Eye Q Super Speciality Eye Hospital ? We provide quality glaucoma care to all, for life. The Eye Q Institute of Glaucoma deals exclusively with glaucoma to provide increased awareness about its diagnosis and management. Our main focus is the care and treatment of patients with glaucoma, from the common types to the rare forms of glaucoma which require treatment not available elsewhere in India. We follow world class management practices in glaucoma, customized to us Indians, in a cost effective manner, employing advanced sight saving medical and surgical techniques. From the initial examination to treatment and management of complex situations, the entire range of glaucoma care is covered. The Next Generation of Glaucoma Care (NGGC) represents an amalgamation of validated newer technology, a gamut of new thought processes in glaucoma management and the implementation of these processes for the best possible outcome for our patients. We treat people at our main hospital at Shalimar Bagh, New Delhi and several other locations in and around the capital, enabling us to provide expert treatment closer to our patient’s homes.
How well equipped is your centre to deal with high risk cases with advanced glaucoma or failed glaucoma filtering surgeries? We are the first standalone Glaucoma Institute in the country. Thanks to our team of glaucoma specialists who have been trained at leading institutions in India and the world we are equipped to manage all forms of adult and paediatric glaucomas, advanced glaucomas, high risk and refractory glaucomas. Our focus is on quality glaucoma care to all in the Indian perspective.
health watch
Viral Hepatitis, Act Now
Before It Is Too Late
Medical experts around the country have expressed concern at the increasing prevalence of viral hepatitis cases in India, suggesting that it be declared a public health issue
A
s many as 12 million people may be chronically infected in India and most are unaware of it. According to experts, lack of awareness about the disease and its treatment coupled with the fact that it has no visible symptoms in its early stages have contributed to its spread. Dr Bobby John, Executive Director of Global Health Advocates, India says, “The situation seems alarming, even with the currently known numbers of people with the disease- which are estimated between 25 and 40 million people living with Hepatitis B and C. This is far higher than the prevalence of HIV or any cancer.”According to him, with a coordinated mix of prevention, treatment and awareness programs, the growing burden of viral hepatitis could be effectively tackled. GHA is a non-governmental organization that focuses on engaging all sections of society to fight diseases,
Dr Bobby John
Executive Director of Global Health Advocates
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Dr Ajit Sood
and aid in formulation and implementation of effective public policies. “These diseases being silent killers with long gestation periods have so far not attracted the attention of the policy makers. What is required today is to draw the attention of our policy makers and draw up a comprehensive policy towards addressing the issue,” says Dr Samir Shah, the Founder Trustee of National Liver Foundation (NLF) and Head of the Department of Hepatology, Global Hospitals, Mumbai. Leading gastroenterologist Dr Sudhanshu Patwari, who is the convener of the Gujarat state chapter of National Liver Foundation, says, “Hepatitis is a silent killer, and is far more easily transmitted than HIV. There is an urgent need to formulate effective screening, prevention and control strategies.” Unlike Hepatitis A, Hepatitis B
Gastroenterologist at the Dayanand Medical College and Hospital
March / 2014 ehealth.eletsonline.com
Dr Praveen Malhotra HOD, Gastroenterology, PGIMS), Rohtak
and C remain silent and keep affecting the liver for a long period of time before showing any signs. During this silent phase, the person carrying the virus can potentially be a source of infection for others,” he says. It is estimated that liver diseases are among the 10 ten killer diseases in India, causing lakhs of deaths every year. Besides, there are those who suffer from chronic liver problems, needing recurrent hospitalization and prolonged medical attention, which leaves them and their families physically, mentally, emotionally and financially devastated. Medical experts are of the opinion that studies so far have indicated that some liver related diseases like Hepatitis B and Hepatitis C virus could burgeon into an epidemic much larger in scale than HIV. “More epidemiological studies are required to fully assess the scale and extent of the viral hepatitis epidemic
Dr Samir Shah
Founder Trustee of National Liver Foundation (NLF) & HOD of Hepatology, Global Hospitals, Mumbai
Dr Sudhanshu Patwari
Convener of Gujarat State Chapter of National Liver Foundation
What is
viral hepatitis? Hepatitis is the inflammation of the liver, which can be caused by toxins, certain drugs, heavy alcohol use and bacterial or viral infections. Viral Hepatitis is the liver inflammation caused by one of the five hepatitis viruses, referred to as types A, B, C, D and E. Hepatitis A virus (HAV) is usually transmitted by the faecal-oral route, either through person-to-person contact or ingestion of contaminated food or water. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Hepatitis B virus (HBV) is transmitted through exposure to infectious blood, semen and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth, or from family members to infants in early childhood. Transmission may also occur through unsafe sexual intercourse, transfusions of HBVinfected blood and blood products, contaminated injections, and sharing of needles and syringes among injecting drug users. HBV also poses a risk to healthcare workers who sustain accidental needle-stick injuries while caring for HBV-infected people. A safe and effective vaccine is available to prevent HBV infection. Hepatitis C virus (HCV) is mostly transmitted through exposure to infected blood. This may happen through transfusions of HCVinfected blood and blood products, contaminated injections during medical procedures, and sharing of
needles and syringes among injecting drug users. Sexual or interfamilial transmission is also possible, but is much less common. There is no vaccine against HCV. Both HBV and HCV can cause cancer to humans. Antiviral agents against HBV and HCV exist. Treatment of HBV infection has been shown to reduce the risk of developing liver cancer and death. HCV is generally considered to be a curable disease but for many people this is not the reality. Access to treatment remains a constraint in many parts of the world. Hepatitis D virus (HDV) infections occur exclusively in persons infected with HBV. The dual infection of HDV and HBV can result in more serious disease. The hepatitis B vaccine provides protection from HDV infection. Hepatitis E virus (HEV), like HAV, is transmitted through consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in the developing world and is increasingly recognized as an important cause of disease. HEV infection is associated with increased morbidity and mortality in pregnant women and newborns. From the Hepatitis family of viral infections, the most common and serious is HBV and HCV. Hepatitis B and C spread through unsafe injection practices, unprotected sex and transfusion of infected blood. The infection may also spread from mother to baby at birth.Sharing a razor or toothbrush with a hepatitis infected person, getting body piercing or tattoo done with infected tools, sharing needles, or even the use of unsterilized instruments during a dental procedure spread the infection.
in India,� says Dr Parveen Malhotra, Head of Department, Gastroenterology, at Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak. Most people who were infected long ago with HBV or HCV are unaware of their chronic infection or their high risk of developing severe chronic liver disease. Unknowingly they transmit the infection to other people. Hence, today, we are experiencing a silent epidemic. Additionally, the HCV being asymptomatic does not help detect it at an early stage. According to medical experts, awareness about Hepatitis is inexplicably low and the majority of those infected are still unaware. Inadequate education and awareness about the disease conditions often results into millions of hepatitis diseases cases going either unreported or reported at an advanced stage,� Dr Shah says. Dr Ajit Sood, a gastroenterologist at the Dayanand Medical College and Hospital, Ludhiana, says, “While most Hepatitis transmissions have resulted from IDU and syringe reuse, blood transfusions remain a significant risk factor as well. The total number of infected persons needs to be confirmed to understand the Hepatitis disease burden. This requires a political commitment to address viral hepatitis.� Dr John, on this issue, says, “Besides lack of awareness among the general public, absence of proper epidemiology data at the national and state levels is hindering the framing of a national hepatitis campaign.� We also need to work on clinical guidelines and awareness among primary medical care providers about Viral Hepatitis, and strengthen mechanism to encourage screening of individuals,� he says. Doctors suggested that affordable measures, such as vaccination, safe blood supply, safe injections, and safe food can reduce the transmission of viral hepatitis infections.
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health watch
Infectious Complications after
Renal Transplant Transplant recipients are at extremely high risk of infectious complications because of their immune-compromised state. These patients tolerate infection poorly with high morbidity and mortality. Dr Vikas Jain, Assistant Professor & Head, Renal Transplant and Urology, Institute of Liver and Biliary Sciences, in conversation with Shahid Akhter, ENN discusses the issues in management of infectious complications after renal transplant
Transplantation of organs and tissues is increasing. How do you identify and eliminate donor derived infections that come with risks associated with transplantation? How stringent are the screenings? Infections derived from donor tissues are the most important exposures in renal transplantation. Some of these are latent infections, such as tuberculosis, which may become activated many years after the exposure, whereas others are the result of the occurrence of active infection in the donor at the time of procurement. Living donors undergo an extensive screening program to prevent transmission of such infections to the recipient however donor screening is limited by the time available within Transplant is the best treatment for a patient with End-stage Renal Disease (ESRD). It is a lifelong commitment. The risks of having a kidney transplant include:
Rejection of the transplanted kidney Infectious complications Surgical problems like ureteric leak/stenosis requiring auxiliary procedures Stenosis of main artery supplying the kidney Late complications like increased risk of various malignancies
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which the organs from brain-dead donors must be used. It is reasonable to avoid donation from individuals with unexplained fever, rash, or infectious syndromes, in this setting.
Once the tissues or organs have been harvested and stored, how do you ensure that they remain free from any infection during storage? Living donation is the major source of organs in India. Storage and transmission of infection during this stage is never an issue in living donation, as the organ is transplanted immediately after harvesting. The safe storage is an issue in organs harvested from deceased donors. An easy and convenient way is to cool the organ. Most commonly used now a days is the static cold storage technique, which includes a rapid vascular flush and washout with removal of blood with subsequent storage in a preservation solution at 0 to 40C. This procedure virtually eliminates of risk of infection during storage.
Cytomegalovirus (CMV) is the single most important infectious agent affecting recipients of organ transplants, with at least two-thirds of these patients having CMV infection 1–4 months after transplantation. Please comment on the Indian scenario. Screening for CMV is an integral part of donor evaluation as CMV greatly impacts the course of renal transplant recipient. Transmission of CMV in the transplant recipient depends on the CMV serostatus of the recipient and donor at the time of the transplantation. Seronegative recipients who receive organs from seropositive donors (D+/R–) have a 40–50% chance of developing the disease. Endogenous reactivation leading to CMV disease occurs in 10–15% of seropositive recipients (D+/–R+). The figure may be higher in those who receive anti-lymphocyte therapy. The risk is negligible in D–R– transplants. As for
as Indian scenario is concerned, I would like to quote the paper from CMC Vellore published in Journal of Nephrology and Renal Transplantation in 2009. In their series, more than 90% of patients and donors tested,were found to be infected with cytomegalovirus (CMV). CMV disease occurred in 20% of patients, and 6% have tissue-invasive disease, mostly of the gut and the lungs, causing considerable morbidity and mortality.
but the incidence is still not zero. In addition, majority of post-transplant protocols include routine prophylaxis against various infections for e.g. trimethoprim/sulfamethoxazole for Pneumocystis carinii and antifungals.
Viral, bacterial, and fungal infections have been transmitted via transplantation of organs and tissue allografts. What preventive measures are used to keep such infections at bay?
Parasitic infections are usually recipient derived exposures or community derived exposures. They are rarely transmitted during transplants. These include foodborne and waterborne infections. Dietary habits, including use of boiled water and hygienic freshly cooked food and some other lifestyle
Transplant recipient can contract four different types of infections-- donor-de-
Several types of protozoan and even worm parasites have been transferred via organ transplants. How do you address this issue?
The main issue in the management of infectious complications after transplant is diagnostic dilemma, as patients manifest diminished signs and symptoms of infections and they may develop systemic signs in response to noninfectious processes like rejection rived infections, recipient-derived infections, community-derived exposures, and nosocomial exposures. Extensive screening protocols are in place to prevent the transmission of donor-derived and recipient-derived infections. In living donor transplants, a complete detailed evaluation is possible and all the infections are treated before the surgery. The crucial feature in screening of deceased donors is time limitation. However, all the efforts are made to complete all the microbiologic assessments. Major infections are excluded, and appropriate cultures and samples are obtained for future reference. Such strategies have significantly reduced the risk of transmission of infection
changes play a major role in the prevention of this category of infections.
Organs cannot be subjected to sterilization process. How do you eliminate or minimize the risk of infectious disease transmission? It is true that organs cannot be subjected to various sterilization process but they still remain sterile because they are harvested in a sterile fashion, stored in a sterile preservation solution and then transplanted in a sterile manner. Strict sterility is maintained at each step and by every individual involved in the transplantation. This makes a sort of sterile “chain” and there is actually no need to sterilize the organ.
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policy
IAPCON 2014 Active in Alleviating Pain 21st International Conference of Palliative Care, held in Bhubaneswar from Feb 13-16, 2014, focused on evidence based palliative medicine. The conference witnessed the participation of more than 600 delegates which included over hundred representations and guests from 15 countries By Siddharth Kundu
W
ay back in 2002, WHO had notified that the fundamental responsibility of health profession to ease the suffering of patients cannot be fulfilled unless palliative care has priority status within public health and disease control programme; it is not an optional extra. Though it took a dozen years since then, on 23 January 2014, the executive board of the WHO passed a resolution for integration of palliative care into health care. This did not just happen; it took years of sustained advocacy by a lot of committed people. “Advances in medical Science, breakthrough in technology and increasing consciousness of civil right are some of the factors which have contributed to the thought that the people who need palliative care deserve a better quality of life. As we are aware, the physical, psychological and spiritual aspect of patient care are best looked after by a partnership of different kind of health professionals, community volunteers and family members,” said Keshab Desiraju, Secretary, Department of Health & FW, Ministry of Health & FW, Government of India. According to Dr M.R. Rajagopal, Chairman, Pallium India, Director, WHO Collaborating centre for training and policy on access to pain re-
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Professor Jan Stjernsward
WHO Emeritus Director, Cancer & Palliative care, Switzerland
lief, Trivandrum, “among all our successes and failures in the last quarter century of palliative care in India, it seems to me that our biggest success has been that the Government of In-
dia has, in the last few years, finally accepted this responsibility of the health care system, at least to some extent. Out biggest failure is that we have not got the common man aware.
Today, palliative care is something that we dish out to people when we want to; it is not something that they feel they have a right to claim. Advocacy is the key, and that is not where the palliative care processional’s skill lies. It is a responsibility that we have to accept and a skill that we have to acquire if the burden of disease-induced suffering in the country is to be reduced.â€? Professor Jan Stjernsward, WHO Emeritus Director, Cancer & palliative care, from Switzerland applauded the new generation of Palliative care workers coming to IAPCON 2014. He stated that “The new generation of Indian palliative care workers coming to the IAPCON 2014 Conference should become rightly proud by knowing the history and achievements of their Indian leaders –past and present – second to none! – something I will exemplify. Having worked in India since close to early 1980’s, I am indebted to my Indian colleagues. Much of WHO public health approach, policies and strategies were done and influenced in close collaboration with Indian colleagues, who made me learn a lot, something reflected in the “WHO Pain Ladderâ€?, still the global standard for a method able to cover all, WHO global public health policies and guidelines for its implementation, for national cancer control and palliative care programs and official recommendation to all WHO member states, all common sense and evidence based. India has thereafter taken global leadership for a great part of the world for relevant solutions in palliative care‌â€? There were 12 plenary lectures by eminent palliative care experts from abroad. 72 faculties delivered their lectures in 18 different sessions. There were 54 free research presentations by palliative care 2 enthusiasts and 30 poster presentations. Three separate workshops were conducted for Doctors, Nurses and Volunteers held at AIIMS, Bhubaneswar and the main conference was held at KIMS.
CANCER CAPITAL Approx. 70-80% cancer pts. are diagnosed late when treatment is less efficient, 60% of them don’t have access to quality cancer treatment, Out of 300 plus cancer centre in India, 40% are not adequately equipped with advance cancer care equipment, This study further suggests India will need 600 additional cancer care centre to meet the req by 2020 (Boston Consulting Group Study, India)
A total of 80 abstracts in different areas of Palliative Medicine were received and in order to motivate the younger generation, they will be published in Indian Journal of Palliative Care.
There was a major panel discussion on the topic Corporate Social Responsibility and Role of Industry, coordinated by Dr Sukhdev Nayak (Organizing Chairperson IAPCON, Professor & HOD Department. of Anaesthesiology AIIMS, BBSR) and Dr Sushma Bhatnagar (Chair Scientific Program, IAPCON, Professor & HOD of Anaesthesiology, Pain and Palliative Care, AIIMS) with esteemed panel participants like Dr G K Rath (Chief of B.R.A.I.C.H., AIIMS), Dr Paul Sebastin (Director- RCC Trivandrum), Dr NibeditaPani (Professor & HOD of Anaesthesiology, Cuttack Medical College & Hospital) and A K Goyal (Senior General Manager & an Industry expert) and panel was concluded by Professor Jan Stjernsward (WHO Emeritus Director, Cancer & Palliative care, Switzerland) with a consensus of more academic & industry interface with a major emphasis on Geriatric Palliative care & facilities in India.�
Morphine to be Accessible The recent passing of the much awaited, Narcotic Drugs and Psychotropic Substances (NDPS) Act Amendment Bill by the Parliament will ensure that morphine, the essential medicine for pain relief, becomes more accessible to those suffering from chronic pain. It is certainly a welcome step in the right direction, though it is too little and too late. The simplified regulation will ensure that the barriers that prevented the needy from accessing morphine were being removed. However, hurdles and barriers continue to be there. Imagine the plight of Indian doctors being ignorant about the usage of morphine tablet for two generation ! They not only lack the experience, most of them may not have even seen a morphine tablet !! Creating awareness, sensitising the medical fraternity, teaching medical undergraduates about pain and palliative care; and training them to put their knowledge into practice will take the toll of time. Regulations have been simplified but it will not translate into overnight increase in morphine demand. During 2013, about 300 kg of morphine was consumed for pain relief, while the actual annual requirement was around 36,000 kg. Moreover, the amendment will come into force only when the President of India signs the bill.
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health watch
Prevent TB Transforming
to Drug Resistant TB By Dr Kailash Nath Gupta, Chest & Critical Care Specialist (ICU) and Interventional Pulmonologist at Columbia Asia Hospital, Gurgaon
T
uberculosis(TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis which affects the lung but it can also spread to other organs including the lymph nodes, gastro intestinal tract, genito-urinary tract, brain, bones, joints, skin, eyes or almost any other organ in the body. TB is spread through the air when people with an active pulmonary tuberculosis infection cough, sneeze, shouts or spit. Severe cough for three weeks or more, discolored sputum, blood in the
Dr Kailash Nath Gupta, Chest & Critical Care Specialist (ICU)
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sputum, night sweats, mild fever, evening rise of temperature, fatigue, weakness, pain in the chest while breathing, loss of appetite and pain during coughing or breathing are the symptoms of patients suffering from TB. The symptoms of TB are quiet similar to pneumonia, hence patient needs advise and treatment by pulmonologist. For the vast majority of patients, TB diagnosis depends primarily on sputum smear microscopy, along with chest X -ray. If X- rays are inconclusive, then CT scan of the chest and in some cases higher tests like Bronchoscopy are done. In few cases when there is high suspicion of TB then based on the symptoms, the doctor treats the patient with empirical treatment for 3-4 weeks under medical supervision. The infected person should follow the medication regime properly, by discontinuing or by taking the medication irregularly there are chances of developing resistance to anti-TB drugs resulting in deadly form of TB called MDR-TB (multi-drug resistant TB). As per the Global Tuberculosis report 2013 by World Health Organisations , India has the highest multidrug resistant tuberculosis patients partly due to poor disease management by the healthcare system. TB can be prevented in childhood by vaccination and by maintaining high levels of hygiene. Patients suffering with MDR-TB do not respond to, or respond extremely
poorly to first-line anti-TB drugs. A person is said to have MDR-TB when he is resistant to two of the important first –line anti-TB drugs i.e. Isoniazid and Rifampicin. The WHO’s global tuberculosis report for 2013, estimated that India accounted for 63,000 cases of MDR-TB among notified patients with pulmonary (lung) tuberculosis. China and Russia follow with 59,000 and 46,000 cases. As per the key findings of the report, about 3.7 percent of TB patients in the world have MDR-TB. Levels are much higher by about 20 percent in those previously treated. About 9 percent of MDR-TB cases also have resistance to other anti TB drugs, which is called extensively drug resistant TB(XDR-TB). The term Total drug Resistance ( TDR-TB) is being actively debated for cases that are resistant to all anti TB drugs. Treatment: The treatment of MDR TB and XDR TB is expensive , prolonged and final outcomes are not very promising. The number of pills and injections are much higher in treating resistant TB as compared to non resistant cases. Treatment is mainly the combination of first line and second line drugs. The drugs are chosen based on the culture and sensitivity report, their effectiveness, safety, and cost. To effectively treat MDR TB as per WHO the treatment period is prolonged up to 20 months.
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Innovative products form the foundation of profitable and sustainable growth, enabling Maquet to serve as a market leader in an ever-changing international health market–pioneering therapeutic approach
Maquet Celebrates 175 Years of
Innovation in Healthcare
W
ith 175 years history, Maquet is one of the most established and dynamic medical technology company in the world. The company designs, develops and distributes innovative therapy solutions and infrastructure capabilities for high-acuity areas within the hospital including the operating room (OR), hybrid OR /cath lab and intensive care unit (ICU) as well as intra and inter hospital patient transport. A long and trusted partner of many hospitals and doctors worldwide over many years, the company is global leader in supply of medical systems that meet the highest requirements for medically challenging interventions. At the same time, these systems exceed the expectations of the hospital teams that are responsible for the care of patients. Maquet designs, develops and sells innovative treatment solutions and infrastructure functions for extremely demand-
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ing hospital departments, including operating rooms, hybrid operating rooms, catheter laboratories and intensive care units as well as intra and inter-hospital patient transportation.
History of leadership Since its foundation 1838 in Heidelberg, Germany clinics all over the world have trusted in Maquet products and its solutions. In collaboration with medical and science experts, Maquet has advanced clinical standards while developing innovative therapy approaches and products. One of the oldest medical technology companies in the world, Maquet began as a manufacturer of padded hospital chairs and patient care products. In 1840, it introduced the first operating table made from wood and in 1889 introduced the first operating table made of steel. As medicine evolved over the years- so did Maquet, from a mid-sized OR table manufacturer to a
world-leading provider of comprehensive therapeutic solutions.
It’s all about the hospital New and changing health markets as well as increasing budgetary concerns in hospitals pose challenges which require long-term and sustainable solutions across the globe. Today, a product is no longer just evaluated according to its clinical relevance, but also according to the return on investment. Operating rooms and the processes associated with them are an essential return factor for hospitals. Increasingly complex procedures and time pressures confront surgeons and clinical personnel. Surgical suites are often fitted with a wide variety of devices from various manufacturers. The handling of single devices costs time, is sometimes intricate and represents a potential risk for patient safety. Process-optimization and solutions with integrated systems are gaining
in importance. Every reduction of the surgery time and every element that streamlines processes is not just a benefit for the patients; it also makes economic sense for the hospital as resources areused more effectively. A simplified workflow that is coordinated to match real work processes combined with ergonomic OR equipment sets new standards in process optimization, reducing the stress factors for both surgeons and patients. The implementation of entire projects minimizes expenditure and budgets, ensure a one point of contact from planning to implementation and beyond. Thus Maquet meets these clinical and economic requirements in an optimum fashion.
Highest standard for customers Maquet customers save lives on a daily basis and shoulder great responsibilities. The company supports them with products and services which offer the greatest possible therapeutic benefits in the day-to-day workings of a clinic. In the endeavor to continue to be recognized as a reference market maker by customers Maquet has always followed a clear strategy to develop and enhance the quality of their products and solutions. The maintenance of the greatest of safety and quality standards as well as absolute reliability and competent consulting on a level with the customer are the primary focal points. In collaboration with medical science as well as other fields of science the Maquet claim is to create the most widely accepted practice within clinical environment. In doing so, the claim that Maquet makes for them is of a very high standard and refers not only to the quality of the therapy solutions and products, but also to the quality of daily life in all departments.
Simplifying complex hospital projects The operating room generates essential revenue for the hospital. Optimized
its footprint and market position in the areas of critical care, surgical workplaces and cardiovascular. The trust and support of its partners have been the building blocks of growth in the country and continue to be an integral part of the company.
Innovation is the basis for success
The company supports clinicians with products and services which offer the greatest possible therapeutic benefits in the day-to-day workings of a clinic. processes and minimized downtimes are the main elements of efficient utilization. The core competencies of Maquet are overall solutions for operating rooms, intensive care and recovery areas, as well as the central sterilization and other sensitive areas of a hospital. As a pioneer in the implementation of complex projects, Maquet supports clinics in the realization of tailored solutions, from consulting to design, planning, production and installation, as well as initial operation. The concept has drawn considerable attention worldwide.
Maquet India
In 2004, Maquet started its local subsidiary, Maquet Medical India after its acquisition of the Siemens Life Support Systems Division. Over a decade in action, the company has expanded
Innovations form the foundation for profitable and sustainable growth in international health markets. Approximately 600 staff members are employed in eight globally distributed development centers. Around eight percent of the turnover is re-invested in innovation projects. Medical and technical innovations play an increasingly larger role in the international health system. But in times of limited budgets, particular focus is placed on the economic sustainability of investment and therapies. Hospitals are no longer interested in clinical relevance only, but they are also focused on the influence that the product has on the return on investment. The company has positioned itself as trendsetters and experts for both aspects.
Long-Term Success For all that has changed within the past 175 years, basic things have remained constant. Maquet was – and still is – focused on improving the quality of patients’ lives while ensuring maximum convenience and comfort for clinical staff.The winning Maquet formula for steady progress from a manufacturerof medical technology devices to a partner for integrated concepts is the perfect combination of quality, reliability, innovative power, and flexibility and superlative employees. At the same time values entrepreneurial skill above all. Their executive managers lead Maquet as though it is their own company, with passion and accountability, acting with foresight andresponsibility. These leaders play a key role in the company’s long-term success and have paved the way for the future.
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cover story
ory ital lat gu Hosp e R s: ion t die rat en Bo Ope gem a n Ma
No Point in being Rigid Aman Gupta, Health Policy Analyst, elaborates about how Indian pharmaceuticals companies evolves as the true pharmacy of the world Aman Gupta Health Policy Analyst
T
he Indian pharmaceutical industry has beenwitness to some high level regulatory issues in recent times. Whether, it is the heightened activity of the USFDA that started last year, with Ranbaxy agreeing to pay a fine of $500 million after pleading guilty to felony charges relating to the manufacturing and distribution of “adulterated drugs”,tothe growing concerns voiced by the US Chambers of Commerce on the existing Intellectual Property environment or lack of policies for clinical trials, the reputation of the Indian pharmaceutical sector, referred to as the Pharmacy of the World, has only taken a beating. While the issue will continue to be
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a high-pitched deliberation for some time in the future, what is important and needs to be understood is that the industry and its regulatory systems needs an overhaul, taking into consideration the current realities, and the road ahead. The US Food and Drug Administration (USFDA) Commissioner Margaret Hamburg, during her recent 10-day visit to India, not only stressed on the need for Indian drug makers to comply to the global standards, but also announced co-operation from the administration in this regard. Ms Hamburg may be right in her own wayswhen she said that there is an increasing need for a global coalition of regulators with the Indian
side actively participating in global forums. While not everyone here in India may agree to Ms Hamburg’s suggestion, one aspect that emerges clearly is the need for the Indian drug makers, the regulator and various other stakeholders to align themselves with global systems and approaches and build an ecosystem that ensures a shift from ‘Access to Medicines’ to ‘Access to Healthcare’. This may be easier said that done, but here a few baby steps that can be initiated: * Increased spend by Indian government for health and building of healthcare infrastructure * Innovative offerings by the health insurance industry considering the spending capabilities of the diverse Indian population * Delink innovation with access to healthcare * Greater thrust on awareness and disease prevention * Collaborative approach between different stakeholder groups It is high time that we all realize that ‘Access to Healthcare’ is not just a function of the health ministry. What’s required today is a futuristic yet realistic blueprint that is able to transform this into reality. As for the Indian pharmaceutical industry, the players need to evolve from just being a manufacturer of generics drugs to a contributor towards ensuring global health. As is the case with all other sectors, it is time that effective steps are taken, not just to move up the value chain, but also focus on the need for innovation to address future needs.
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cover story
ory ital lat gu Hosp e R s: ion t die rat en Bo Ope gem a n Ma
Rural posting, 2600 PHC’s
Against 50,000 Doctors Dr Narender Saini, General Secretary of Indian Medical Association, who earlier served as the President of Delhi Medical Association, with his focus on “health for all” at affordable cost, in an interaction with Ekta Srivastava, ENN, speaks about the role of IMA in forwarding the healthcare issues to the Government ‘Healthcare for all’ was your mission while you joined as General Secretary. How has been you journey so far? Indian Medical Association (IMA) is a body which creates awareness into the system to self regulate ourselves and creates awareness among people. We don’t have the power, which the government has. So, we can apprise the government, where the lacuna is in the government system. Now, on these two facts we have been quite successful but we still lag in creating dent in the government system. First and foremost for making affordable and accessible healthcare, the government has to increase the GDP, which unfortunately we have not been able to get it raised, which is still around .9 percent to 1 percent and very low in comparison to other countries. Even the neighboring countries like Sri Lanka and Bangladesh are spending more than 2 percent of their GDP. In our many efforts we met the Parliament, Planning Commission and Standing Committee on health, with a hope that one day we might see our targets achieved and make the health as the primary agenda in the forthcoming election.
Recently, in the interim budget there is no any mention of
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Dr Narender Saini General Secretary of Indian Medical Association
health, not even the leading newspapers have given it any preference? That is very unfortunate because the whole world and especially in the developed world, elections are based on health politics but in India it has never been given the same impor-
tance. We are making efforts to create awareness among the public that they should consider health as a primary agenda. We have said that ‘Right to Health’ should be the agenda of every political party. For the same, we come up with the white paper and forwarded it to every political party.
In your opinion,where do you think the government has failed in providing better healthcare? The foremost is not giving importance to healthcare. Since your focus is not health, you will not spend on health. Secondly, we have this tendency of spending more on treatment than on prevention. We create diseases first and then we spend the whole of the budget in treating those patients. Hygiene is such an important thing. If you create awareness about hygiene then most of the communicable diseases can be prevented but unfortunately the focus is not there in prevention. The other important thing is accountability. How much the money has been allocated, where it is used, there is no any proper record. Then is the data collection, for whom we are making policies, what are the diseases, how many have been infected, there is no statistics and without proper data one cannot have proper policy. So, I think these are four or five things where the government has failed.
While doctors and medical students are opposing to have rural posting, How then healthcare facilities will reach them? We are not against doctors going to rural areas. We are for it that doctors should go to rural areas. But how they should do it? That is a question. Government says that they should do one year rural posting. The two of us are saying the same thing but at a different time. The government says that they should do their rural posting besides doing their internships, before doing their PG exam they have to go for a rural posting, which means one year extra. If you see any professional courses, this is the longest duration course that too at undergrad level. Rather we should try to think that if we make it shorter than it would be better, more practical. So what we are saying is that make the rural internship for six months and during the three year post
graduation in any of this year’s you can post the students in rural areas for six months. This is more practical. Now, to make rural posting of these 50,000 doctors, which are passing out every year you need the same amount of vacancies. For this we file an RTI and got to know that there are just 2600 seats vacant in rural areas in various primary healthcare sectors’ (PHC’s). How you will accommodate that many people, when you don’t have that kind of infrastructure. For putting up this infrastructure, I am not talking about money, but you need at least a nurse and a compounder for that you need a minimum of Rs 10,000 crore every year and your
are saying is that India lacks 5 lakhs doctors, that is a presumption but it might be more as our data is very weak. If you accumulate this for a 5-year term then 1.5 lakh is getting wasted every year into just sitting in the room and reading. We have written to the ministries several times to increase the seats. In USA they have just 18,000 seats for medical graduate but they have 30,000 seats for post graduate. Rather we have given a proposal to MCI to give them a 6-years course out of this six years, 3-years should be basic sciences and in the next three years he will choose his specialization so that he does not come out as a
We are more of paper tiger, make policies, speak beautifully on those policies but when we make execution I don’t know where our vision goes! budget is 30,000 crore only. Well, what we have said is that make this posting during the course or make compulsory six months during the internship of one year. Simultaneously, it will become the responsibility of the respective college to provide the rural posting. Then we can have add-on increment for the medical officers who are deployed for rural areas, can have mobile van dispensaries. Another thing which I want to say on rural posting is that there are so many Ayush, Ayurveda and Homeopathic people, where they had spend their time and government has invested their infrastructure. So they can also be used in rural areas provided the basic facilities.
There are 50,000 students every year who clear MBBS but there are only 20,000 seats in PG. How is the Government planning to accommodate these left 30,000 students, is IMA raising voice against this? We have already raised that. What we
plain MBBS like in the USA and other countries he comes as a specialist and out of this 3-years, one year will stand in a rural posting. Plus his clinical can start from the first year only.
What do you think about the quackery happening in medical education? Quackery is of two kinds in this country, first quackery is when they do not have any educational background in medicine but they behave like medical professional. The other kinds of quacks are those who are qualified in one specialty but start prescribing for other. This is something which needs a greater attention because many people are losing their lives in their hands. The third of quacks are chemist they dispose all kinds of medicine and fourth kind of quacks I would say are some people in our community who do not prescribe any medicine or call themselves a doctor, but advise all sorts of medicines without any knowledge.
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Policy Regulation
Need of the Hour
National Accreditation Board for Hopspital (NABH) is the hallmark of quality care in hospitals in India. Dr K K Kalra,CEO, NABH, in conversation with Ekta Srivastava, ENN, speaks on the importance of getting NABH accreditation countrywide
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ccreditation benefits all stake holders and getting accreditation for any hospital either private or government is both difficult and hard to sustain its policies. Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated. “As of today, there are just 200 NABH accreditated hospitals. It requires a lot of commitment and continuous improvement. Just getting an accreditation is not enough. Sustaining it is very difficult as the board keeps a serious surveillance on those accreditated for renewal. In the first go, accreditation is given for just three years,” said Dr K K Kalra, NABH CEO. The staff in an accredited health care organisation are a satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes.
Accreditation Important for Patients Patients are the biggest beneficiaries of the accredited hospitals.Accreditation to a health care organisation stimulates continuous improvement. It enables the organisation in demonstrating commitment to quality care. It raises community confidence in the
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he informed. NABH accreditation was not mandatory yet but it was also not an easy affair. The process involved many pre-assessment procedures and inspections but was mainly patient centric. “It is aimed at providing the best possible care to patients. Beginning from small things like hand washing to post operative care, everything has a definite protocol monitored extensively. We conduct even surprise inspections,” said Dr Kalra. Patient safety and care were the biggest pillars of certification process, he added.
Wake up Call!
Dr K K Kalra CEO, NABH services provided by the health care organisation. It also provides opportunity to healthcare unit to benchmark with the best. Dr Kalra said the biggest beneficiaries of accreditation were patients as the certification ensured best quality services to them. Although there are 19 major criteria to be followed by any hospital seeking accreditation, there are 150 minor objectives that the unit should fulfill,
There was a time when people were not exactly aware of the functioning of the hospitals, neither in the government section nor in the private, which ultimately ended them with empty pockets and huge debt. In regard to the role of NABH as waking up the patients and passing on the awareness , Dr Kalra said, ‘When I studied the whole market and discussed with various people, there was awareness among the communities as well as with the hospital administrator also. There was a need to little motivate them and we had come out with some other solutions. It was said that quality was ducting there was no limitations to the improvement. Even in a full accredited hospital, there is still a chance for further growth in excellence. Quality is a journey, we had in-
troduced two more stages. Hospitals which had and which wanted to come here due to legal or regulatory problem or some other reasons, straight away could apply there, i.e, pre- entry level. So that oncesome basic culture of the quality sets here then they would enjoy this level and can progress to higher levels. Today, there are just 200 hospitals accredited out of 50-60 000, be due to this some will get motivated and come forward’’.
are coming up with new programme of Nursing Excellence, we improve the nursing care the whole scenario will change. Major role is the nursing care; outcome depends upon the nursing care. What kind of nursing care is in the hospital is very important. So hospitals which otherwise are not fully complied cannot go for this at different level of this start. There is A improvement in the hospital gradually’’.
New Certificates
Government’s loopholes
Further he added that beside that they had introduced two new systems Safe I certificate and Nursing Excellence. The certificate was awarded under the NABH Safe-I hospital infection control programme, which acts as the first stepping-stone towards NABH accreditation for those hospitals that lack the resources and managerial bandwidth to achieve the full NABH accreditation. Under the Safe-I programme, NABH recommends safe injection and infusion practices, biomedical waste management, healthcare workers safety, and sterilization and disinfection. NABH and BD had signed an agreement in August 2011 to support hospitals in attaining quality-ofcare standards for infection control in three phases. During Phase One, initial workshops were carried out across hospitals in India to ensure the Safe-I programme is adopted by hospitals as a stepping-stone towards achieving quality. The second phase will offer Centres of Excellence and Health Economic models to be developed for the benefit of Indian healthcare after dissemination of Safe-I programme. The last phase will augment national capability of standards dissemination by developing additional Centres of Excellence. On speaking about the second certification Dr Kalra mentioned, ‘’we
In India, there are many states which are deprived of facilities including healthcare including healthcare.
on health sector. in the world .In India there is just one percent, now they have targeted for three but I am not able to see any priority here. Out of the pocket expenses in the world India is having maximum, which is around 71 percent. Health insurance today is aprox 10-12 percent, who will then afford to go to the private hospital. Though there is some awakening but still for the poor people they have to sell their every property to afford even the cheapest health facility. Today government is not bothered about anything, everything is on paper. There was a time when government hospitals are trusted with closed eyes
“There is a need for increased awareness among the healthcare facilities so that more healthcare organisations start participating in quality initiatives� Though there is a huge budget that goes across from the central government, the state government lacks in providing all the basic facilities to the people. As Dr Kalra said, ‘’Everybody says that health is a priority, but there is always minimum three to four percent of gross domestic product (GDP)
Future Awareness Programmes Accrediation for Dental ealth Crae Service Providers (DHSP) Medical Imaging Services Accreditation Continual Quality Improvement: Tools and Techniques NABH Blood Bank Standards Education/ InteractiveManagement of Medication and Patient Safety
but now government itself is discouraging them by not providing any infrastructure or facility.’’ NABH is a constituent board of the Quality Council of India under the ministry of commerce set up to establish and operate accreditation programme for healthcare organizations. The International Society for Quality in Healthcare ( ISQua) had accreditated the ‘standards for hospitals’ laid down by NABH India which meant that the standards were at par with internationals norms, Dr Kalra said. Blood banks, pathology laboratories, dental hospitals and single specialty hospitals were added to NABH only in the last few years. Finally, accreditation provides an objective system of empanelment by insurance and other third parties. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.
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Building Capacity
into Indian Healthcare Dr Girdhar J Gyani, Director General, Association of Healthcare Providers (India) (AHPI), discusses about the plans to be implemented and role of government in promoting healthcare in India. In Conversation with Ekta Srivastava, Elets News Network (ENN) Tell us the motive behind the launch of the Association of Healthcare Providers of India (AHPI). The Association of Healthcare Providers (India) is a recent initiative. It was founded in November 2012. Basically, the idea behind AHPI is that the hospitals did not have a pan-India organisation, which can work together and with the government. We wanted to work with the government on the universal health coverage and to build capacity into the Indian health systems. So, with this motive, this association has been formed and today we have more than 10,000 hospitals as its members.
Recently, IHI (Institute for Healthcare Improvement) entered into an agreement with AHPI. What benefits do you foresee? The Institute for Healthcare Improvement, USA is a premium institute in healthcare quality. They keep conferences all over the world but they have an open school programme which is delivered online. Anybody can register there, but the fee is ex-
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orbitant− ranging from $70 to $90 which a person has to pay to undergo that programme. This programme has got 16 modules and covers legal, patient’s safety, facility management and all sorts of things. So, we entered into an agreement with a lot of deliberations to offer this programme to Indians here by just paying `3,000 and the person can complete these 16 modules in one year’s time. Ideally speaking, it can just be covered in two to three months’ time, but we thought we would be able to provide world-class modules to our Indian professionals. This is what we have started now and we are going to start the first batch with 50 students, for which we have got 50 passwords from IHI already that will be given to the individuals who will register with us.
healthcare. Have you seen any new district hospitals in the past 30 years? Same is the case with tertiary level of healthcare except some seven to eight AIIMs which have been announced but the figure is very small. The whole secondary and tertiary level is with the private sector. In 1947, private sector had 8 per cent of the market, however, today they have captured 70 per cent in terms of patient’s workload and in terms of IPD it is 60 per cent. The private has a large share of investment in healthcare... The government and the private sector should be treated together. Both are healthcare providers, but in terms of taxation the hospital owners pay electricity tariffs what the government charges from malls and cinema halls. Of four categories,
What is the total worth of healthcare market in India at present and how fast is it growing?
“Advocacy is the major issue. To ensure that we are allowed to function to deliver universal health coverage, regulations should be objective, taxation should be reasonable and other conditions like lands, should be in such a way that they are able to meet objective of both our and government”
The worth keeps changing. If you talk to Mc Kinsey, they will give you one figure and if you talk to KPMG, they will give you another. In fact, healthcare business would be the largest segment in terms of generating employment. This sector was never aware of its own potential. First, we are the largest employment generation body, secondly, in terms of social aspect, we employ maximum number of females. We have a higher ratio than paramedics and doctor communities combined. The spending on healthcare by the private sector is 80%. The rural areas still have big untapped market, while some corporate are going inside.
What are the major factors that the government needs to know to improve the sector significantly? The government is not investing in secondary and tertiary level of
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agriculture, domestic, industries and commercial, we are bracketed under commercial. On the one hand, the government wants us to do noble cause by providing treatment to the patients and on the other hand there is taxation. We have taken up the matter with various state governments, and luckily Karnataka is the first state to drop down the tariff by 15 per cent. Haryana and Madhya Pradesh have also initiated the process. Secondly, we do not have the technology for biomedical treatment, we have to import since there is no manufacturing done here. There is a 12 per cent duty on this. Government needs to provide social security cover related to healthcare. Schemes like Aarogyasri of Andhra Pradesh should be made available across the entire country. This is working because government is buying healthcare services from the private players and serving to poor patients under PPP model. Drastic measures are needed to bring in simple and objective regulatory framework for the industry. Similarly, in the breakup of taxation on buildings, we have calculated that 40 per cent goes to government taxation. In terms of land, 12 acres of land in Dwarka was announced for auction Two years back, the cost of which was `300 crores. It will take five years’ time if you build a hospital at that cost, which is very discouraging factor for the private sector. Secondly, patient’s safety is important to everyone. If I have to do a procedure in a 10-bed hospital being run in a residential area, where operation theatre’s size is just 7 by 4 feet and if the same procedure is done in say Vedanta, obviously it will cost more. I think every citizen has to realize this and has to start budgeting for healthcare. We need to spread awareness these safety and quality healthcare are going to cost more and can’t be free.
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What are your views on the rise of multi-speciality hospitals? Why you need multi-speciality hospitals. Suppose you are doing a bypass surgery there you develop a neurological problem, which was not earlier known. If a multi speciality hospital is there then under one roof you can betaken care of, while a single speciality hospital has of course its own advantages but people are preferring multi specialities. The issue perhaps worth raising is whether you need secondary level or tertiary level. Here again AIIMS is the highest level of tertiary level hospital in the country but it is mostly used as a primary ailments. And there a patient has to roam everywhere to get a single test done; even sometime they are referred to other hospital like Safdarjung hospital or RML. Go to AIIMS any time there is a huge line coming from villages without knowing whether they need a tertiary hospital or not. We have not been able to create a referral system correctly. A good example of this will be Sanjay Gandhi Hospital in Lucknow, they will not admit a secondary level patient there, we can do it here too provided we have to plan to do it.
Why corporate are not reaching in the rural areas and how can they increase their reach? There were two super speciality hospitals opened in Delhi by the government last year and wanted to do PPP. They put a condition that 60 per cent of the patients have to be treated at CGHS rates. Secondly, doctors avoid rural postings because of the lack of infrastructure, safety, schools, etc. Some of the medical colleges that have been opened by the private sector are far in rural areas and even the government encourages them to open medical colleges there. Medical colleges should be in a proper district when they are tertiary level health centres. Nobody is against the setting up of an infrastructure in
rural areas. Agro industries, some coal-based fire plants should be set up so that the rural population get employment there. The government has to find a practical solution. People from rural areas come to metro cities to give their children better lifestyles and we are asking doctors to go and serve in rural areas.
Pirated medicines are very much common. What do you think why there are not enough laws to put them in place? Regulations are always an issue in this country. Drug controller is supposed to regulate the issues. They may not have enough man power.
ted detailed proposal to the government to reduce the import duty on life saving medical equipment. We are working with our member hospitals, especially with smaller nursing homes to implement patient safety protocols. We have prepared two level standard on ‘Patient Safety’ to provide guidance to these nursing homes. We are also going to launch series of value added training programs to improve on safety and affordability.
What is you road map ahead? We have to be realistic about the cost of healthcare, which means the cost of safe healthcare. Secondly, the government must bring effective and objective
“Patient Safety has become one of the most important factors in the healthcare and concerns equally to all the stakeholders. Patient safety requires open communication between physicians, hospital staff, patients and their families They may not have enough technologies to do the surveillance, or they are not willing to do so. . In order to control this, there has to be right kind of people, right kind of technology and transparent system.
How the organisation is working on to benefit common man? The motto of AHPI is ‘Advocating and Educating for Well Being of Common Man”. We have close to 10,000 hospitals as our members. We have taken series of advocacy issues with the government, which should help in providing safe and affordable healthcare. For example we have taken up the matter to reduce electricity tariff for hospitals, which is presently at par with Cinema Halls. We have submit-
regulation, whereby no hospitals are allowed to function unless they adhere to minimum critical protocols for patient’s safety. According to me, these are the two important things. Rest, the existing primary health centres should be handed over to the private sector. Our association can play a role there− you give us the primary centre, you give us the budget and we will invest too as a part of our corporate social responsibility. The government is buying the entire healthcare from us for all the schemes. We have the hospitals, they have the patients for whom they only pay, and this is one example of PPP. Another PPP can be, they give us the land and we can run a hospital on that. They can also charge 4 percent from us from the gross revenue.
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Healthcare
at International Standards for all With the aim of providing healthcare to all at par with international standard Padmashree, Padma Bhushan, Padma Vibhushan, Dr Purshottam Lal, Chairman, Metro Group of Hospitals, in conversation with Ekta Srivastava elaborates more on the technological development for patient’s betterment What are the technological advancements your hospitals have introduced lately in different verticals? We strongly believe that technological advancements are almost always for betterment of patient care. For a patient the most important thing is the best of the equipment, best of the doctor and best of the quality. If you can provide these three things to a patient, there is nothing else which a patient
need. We provide an additional thing; we respect the price of the human life. In a country where a large number of population are common people or a low middle class people, who cannot afford the major of the advance technology and where you work on it, we work on it, we make sure that we make a very minimal profit to keep the things going on. Now as regards, the technology in different verticals, like cardiology, we have anything and everything
Dr Purshottam Lal Chairman, Metro Group of Hospitals
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which a cardiac department or the cardiac hospital can have in the world. We have cath labs from GE and Siemens. In addition, our hospital has a niche that patient do not have to undergo bypass surgery though we do all complex cases. We have most advanced electrophysiology department manned by fully trained electro-physiologist. The reason is a lot of foreign visitors come and watch our procedures. In Radiology, we have advanced 500 sliced CT scan, and we have been told by the GE Company, so that far it is the best in the North India. Our Pulmonary Department is very advanced, special ultrasound called Intravascular Ultrasonic (IVUS), wherein the vessel wall and blockage can be visualized from within leading to precise stent deployment and thereby reducing potential complication of stent deployment such as acute or sub acute blockage of the stent following clot formation within it. We have also introduced bio-absorbable stents where the stent dissolves completely in about two years time thereby leaving no metal mass within the vessel. We have also started nonsurgical replacement of narrow aortic valve wherein an artificial valve is deployed across the original and natural diseased valve thus ob-
viating the need for traumatic open heart surgery with its attendant morbidity and likely death. We are also in the process of starting nonsurgical repair of leaking mitral valves by transcatheter and non-surgical means. In addition, we also do outpatient coronary angiography, which we call metro coronary clinic, where we have done 27,000 cases. Today, we have fully operational 12 hospitals, where one is completely dedicated to cancer.
Do you think multi-specialty hospitals are gaining popularity these days? Multi-specialty hospital are the need of the day, where you can provide a good team care. Today, people are getting very health conscious and they want a place where everything is easy accessible. In any multi-specialty hospital different departments and specialties are located under one roof as a result of which a patient can consult different doctors of different specialties easily. Another advantage is that a doctor from a particular specialty is readily available should a complication arise during the course of treatment of a particular illness. This particularly holds true while treating patients from abroad who would be scared of visiting different hospitals for different complaints.
What kind of emergency services do you have? Our hospital is well equipped to handle all sorts of cardiac emergencies such as acute heart attack, acute onset of severe breathing difficulty (acute heart failure) which may be due to acute heart attack or due to some serious problem in one of the heart valve. We also get patients with severe breathing difficulty due to blockage of one of the vessel to the lung secondary to migration of blood clot from within one of the veins in the leg. Occasionally we get patients with severe chest pain secondary to tear-
ing of inner wall of the aorta i.e. major blood vessel arising from the heart.
Kindly update us on any of your landmark initiative on healing a critical disease. We had the privilege of treating a 74 -year-old patient with severe and inoperable blockages in his heart vessels which was associated with severe weakening of heart pump with resultant low blood pressure and extremely poor overall condition. This patient was treated on ‘left arterial-femoral artery’ bypass support, wherein oxygen rich blood was withdrawn from within the heart by using a roller
Future Plans and Initiations Open a tertiary care hospital in different parts of the state which would cater to a vast majority of the local population and provide them international standards heart care at the most affordable cost. I also wish to ensure that my super specialist doctors visit different strata of the society and provide them quality care.
pump and sending this blood back to the body through the groin artery; this ensured complete rest to left ventricle i.e. pump of the heart which sends oxygen rich blood to different parts of the body. While on ‘pump’, his blockages in heart vessels were treated by ballooning and stenting there by providing complete rest to heart. The patient withstood the procedure well and discharged 5 days later in a stable condition. While, two years back, we have treated a 14 year old child who suffered from high cholesterol and had angina. When we did the angiography his left main valve was block, which was the first case in the medical literature where we have put the stent
and cured him making him the youngest patient to get treated. Similarly, we have treated the oldest patient of 104 year with the same problem.
What are the achievements witnessed by the institute so far? We have the distinction of performing a large number of angioplasty (procedure of opening blocks in heart vessels) which is one of the highest in the country. We have also closed heart holes in children and young adults by different techniques. On 12th July, 2004, our centre had the unique distinction of performing nonsurgical replacement of aortic valve using core valve for the first time in the world. We have also treated a critically ill patient with a heart hole, narrowing of pulmonary valve and severe blockages in all heart vessels by non-surgical means. We have also introduced the technique of performing angiography and angioplasty through arteries of the hand, namely radial or brachial arteries, a technique which minimizes discomfort to the patient and also drastically reduces the volume of contrast agent used during the procedure. In addition, we treat patients from economically poorer sections of the society.
How are you planning to give a sustainable quality healthcare? My mission is to provide latest advancements in cardiology and cardiac surgery to patients admitted in this hospital at an affordable cost. The overheads and expenses in running a super specialty hospital like ours is steadily increasing which do not necessarily reflect in the money we charge from our patients. This shrinks our profit margin but at the end of the day we have the satisfaction of doing our bit for welfare of the society in general. And while setting up this hospital, I had a dream that even a rickshaw puller can have courage to enter the premises without any hesitation and I had achieved that.
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Cutting Edge Healthcare
at Tertiary Level One of India’s foremost names in healthcare, Moolchand has been setting standards for excellence in healthcare for the past half century. Vibhu Talwar, Managing Director, Moolchand Medcity, believes that redefining the healthcare system can bring more quality and excellence towards the patients. In conversation with Ekta Srivastava, ENN What are the key achievements of the Moolchand Hospital so far? Moolchand began with a legacy of philanthropic endeavors has spanned more than 80 years. Moolchand Trust was created in 1928 at Lahore, present day Pakistan and was started with an initial endowment of Rs. 4 million. Last year, Moolchand expands its footprints with an intention to bring the best of healthcare services available in Delhi to Agra and Western Uttar Pradesh. Moolchand’s quality, service and innovation mindset has always been recognized and the hospital has received prestigious awards like the IMC Ramkrishna Bajaj National Quality Award. Moolchand group hospitals have multiple accreditations including NABH, NABL and JCI amongst others.
How the group is planning to provide comprehensive tertiary care? Moolchand is recognized to be a leader in healthcare and is recognized for excellence in Women’s Health, Orthopaedics, Emergency Medicine and Critical Care among other areas. Last year we launched Moolchand Medcity, Agra that intends to offer comprehensive
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Vibhu Talwar Managing Director, Moolchand Medcity
tertiary care services including high-end diagnostics, emergency and critical care services. It is the intention of Moolchand to bring cutting-edge healthcare to Agra so that patients do not have to travel to Delhi for the treatment. Initially the focus specialties will include Cardiology, Critical Care Medicine, Dental, Dermatology, Emergency & Urgent Care, Endocrinology, ENT, Faciomaxillary Surgery, Gastroenterology, Internal Medicine, Nephrology, Neurology, Obstetrics & Gynaecology, Orthopedics, Ophthalmology, Pathology, Urology and Radiology amongst other areas. In Phase 2, the hospital is intended to launch a Cancer hospital and have already purchased the land adjacent to Moolchand Medcity Agra.
What are the latest trends in the Healthcare in India? With respect to the current trends in Indian healthcare, I would broadly classify the trends in five buckets i.e. Increased flow of Private Equity investment: Private equity firms have played a pivotal role over the past decade in scaling up organization across various segments such as hospitals, and diagnostics chains. As a result, we have seen the emergence of national and regional chains. In addition, venture capitalists have incubated new models and have helped establish successful and profitable new healthcare businesses in cancer care and eye care. Private equity player have made good to excellent returns in this sector. As a result, increasingly larger amounts of capital will continue to be deployed behind established ideas like national and regional hospital chains, pathology chains and eye care chains. This funding will be towards new firms as well as further funding of market leaders. In addition, there will be continued focus on funding potential new businesses of tomorrow like daycare, dental, dialysis, and in-vitro fertilization. Consolidation in healthcare sector: M & A has been a thrust area for many healthcare institutions as it helps to optimize costs and bring efficiencies in process and procurement. The healthcare sector is going to see further consolidation. Focusing towards tier II cities: With the growth of India’s economy over the past decade, the disposable income in tier II cities have increased manifold and people have a propensity to spend on quality healthcare services. Significant land price escalation in key metros has increasingly made new projects in these cities less viable. Hence, large healthcare chains find these markets attractive given the latent demand-supply gap, the relatively low cost of land, and lower competitive intensity for quality and higher end
We aspire to be the lifelong healthcare partner of our customers by delivering on their healthcare wishlist: superb physicians, cuttingedge technology, compassionate care, integrity and affordable excellence
services. In addition, larger players are aggressively scaling their networks by venturing into multiple untapped markets simultaneously. Emergence of new single-specialty businesses: In the past few years, there have been success stories of single-specialty chains in diagnostics and eye care, which have demonstrated the attractiveness of these spaces versus the hospital provider space in terms of simplicity of business model, rapid scalability, relatively lowcapital intensity, shorter breakevens and extremely attractive operating economics. In the next 3-5 years, we would see the emergence of such single-specialty businesses. Increasing collaboration across companies: Increasingly, key firms in the sector will collaborate at various levels to compete effectively. A bias to do everything will increasingly shift towards companies focusing on areas of their core competency and relative advantage. In addition, they will increasingly try to maximize returns on their existing assets by partnering to deliver existing services more effectively or to introduce new services. We are already witnessing this change. Leading hospitals are form-
ing alliances with single speciality chains such as pathology and radiology chains, IVF centres, eye clinics, physiotherapy centres, cancer chains, etc., to effectively deliver services and jointly unlock more value. In addition, daycare firms have partnered with hospital groups for select markets as equity partners.
What kind of emergency services do you have? Moolchand’s Centre for Emergency and Urgent Care provide comprehensive emergency services benchmarked on international protocols. Our Emergency Department (ED) is staffed with a team of 20 emergency doctors experienced in caring over a period of 24 hours. We have a dedicated resuscitation bay, fully equipped operation theater and emergency procedure rooms for trauma and surgical emergencies. We have dedicated observation area for intensive monitoring, advance cardiac life support ambulance services. Moolchand in partnership with the Ronald Reagan Institute of Emergency Medicine at George Washington University, USA to offer 3-year Post Graduate Program in Emergency Medicine. Our emergency staff is hired by physicians, who are board certified in emergency services and trained registered nurses.
What is your road map ahead? We have committed 500 crores to our expansion plan in the next 3 to 4 years. Add to our existing bed capacity in Delhi, by adding another 400 beds in the next 2-3 years. We will expand our group presence through acquisitions. Today people are willing to pay in the healthcare sector. They now don’t hesitate in spending big hospitals if they are getting better facilities then government hospitals. So, we are planning more to open up in tier 2 and tier 3 cities, which is an excellent opportunity. Hope more big players will start moving to it.
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Best Practices for
Best Healthcare Dr Sameer Ahmed Khan, CEO, Rockland Hospitals Group ,with his hands-on experience in process-driven, large healthcare organisations, coupled with his strong operations, business acumen and leadership skills is expected to help Rockland to enhance its leadership position in the industry. In conversation with Ekta Srivastava, ENN
Tell us about the inspiration behind the launch of Rockland Hospital. The planning of Rockland Hospitals started almost 10 years back with a firm belief of providing healthcare to people at the best practices being followed all across the world. The prime objective was to take healthcare to the masses so as to detect & diagnose the disease and reduce the suffering to the minimum.
How do you plan to provide affordable healthcare to all? We follow the basic principle of creating a process and monitoring it vigorously. By doing this we keep a tap on our expansion and try to pass on the benefits to the patients. In addition to this, we intend to be as close as possible so that the cost and discomfort to the patient is within limits. The Rockland healthcare delivery mechanism is capable of supporting the doctors located in remote areas by creating facilities for door-to-door collection for lab tests, pharmacy support and ensuring imaging facilities close their location. The imaging facilities are connected through an IT interface with a remotely located centralized reporting center. This will translate into lower costs for the patients and higher volumes for the doctors and ultimately results in creating cost efficiency and transparency for the insurance companies, empanelled organizations and other payers. Rockland has begun the process of reaching nearer to the patients. In the first phase, five primary care centers have already been opened in Delhi/NCR and many more are in the pipeline.
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In setting up of hospitals what are the challenges that you have faced and how did you overcome them? The biggest challenge all hospitals face is to finish the hospital within stipulated time, in addition to the ongoing shortage of skilled manpower. We have monitored the project stage very vigorously and have invested in training the manpower as well. We also utilized our existing trained manpower to set the systems and processes in new hospitals so that we follow the same processes in all hospitals and take benefits from the economic fiscal. One of the challenges in implementing the Rockland’s five layered healthcare delivery model in the past was non availability of affordable and proven technology solution which is now available and is being used across the industries. The healthcare industry too can use these technology solutions now. It was realized early in the business by the Rockland Hospitals team that the investment in tertiary care hospitals has a huge project cost and the secondary and primary care levels have a major challenge in managing operations due to the unorganized nature of the domain. The challenge was to create a healthcare delivery model that would ensure that the patients are provided quality treatment at the right place, at the right time. This challenge itself was the main inspiration and driving force that led to the creation of three tertiary care hospitals with one more hospital of 500 beds in the pipeline for which land has already been acquired.
What are the objectives of this hospital? The objectives of these hospitals are to provide affordable healthcare to the masses. We intend to create a continuum of healthcare where the patient (as his family) has faith in our system & doctor.
Please tell us more on the emergency services of your hospital. We have a very well equipped & mannered emergency services of ACLS/ BLS ambulance available 24/7. We are equipped to handle all emergencies at any point in time and our teams of doctors and paramedics are always ready to be available to take care of patients within and outside the hospitals.
What technological advancements are you planning in your hospital? We are planning to invest in IT in a big way. The idea is to convert the small hospitals and GP around our hospitals so that the patients can avail themselves of our facilities seamlessly. In addition to this, we are also investing
tals with tertiary care hospitals in a seamless manner through an IT and Telecom interface. Rockland plans to empower the doctors in providing quality healthcare solutions by leveraging its state-of-the-art diagnostics services, emergency and well equipped OTs for secondary level surgeries and treatment
How Rockland hospital will cater the need of the patients differently from other multispecialty hospitals? I think passion and dedication will be to provide cost-effective healthcare as close to the patient as possible. The All India Institute of Medical Sciences, the premier medical institute in India had recently invited the Rockland team to share their five-layered
“We follow the basic principle of creating a process & monitoring it vigorously with a firm belief of providing healthcare to people at the best practices being followed all across the world” in linking all our ICU’s and ER so that monitoring can be better and at the right time. We can also invest in a highend oncology centre in Manesar which will be one of the best in the country. The next step is to build a chain of emergency, secondary and tertiary care support to doctors operating out of clinics, nursing homes and small hospitals. Such a mechanism exists in the market but in a much disorganised manner, in bits and pieces. The Rockland Hospitals team has created and tested a unique model to match the needs of the doctors and patients through a five-layered healthcare delivery mechanism. This network model connects the patients with the clinics, nursing homes, small hospi-
delivery mechanism as a solution to the challenges faced by the healthcare industry with the who is who of the healthcare industry in India and a large number of doctors. This was a rare honour as well as an acknowledgement of the Rockland model of healthcare delivery.
What advantages does multispecialty hospitals caters? The rise of multispecialty hospitals is a more in the right direction for the wealth in the country. The patient gets everything under the same roof which is helpful in treating all the co-morbid conditions as well. Even the treating doctors get the right support for them colleagues in other specialties.
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Single Specialty can be a Game Changer RG Stone, plans to scale up its portfolio from 16 hospitals to 30 by 2016 and will invest around `140 crore ($26 million) for the same. Avinash Ojha, Chief Executive Officer, RG Stone Urology & Laparoscopy, Hospital, in an interaction with Ekta Srivastava, ENN, elaborates more on the hospital expansion Tell me the objective behind the launch of RG Stone Hospital? Founded by Dr. Bhim Sen Bansal in 1986, the journey of RG Stone Urology & Laparoscopy Hospital began with a single clinic in Mumbai and since then it has established itself as nationwide chain of 15 numbers of hospitals offering Urology and Laparoscopy treatments. Today RG Stone Urology & Laparoscopy Hospital is India’s only chain of super-specialty Urology & Laparoscopy hospitals and the leader in Lithotripsy & Holmium Laser treatment in India, fully equipped with state-of-the-art, U.S. FDA approved international standard equipment. Dr Bansal, after a careful and detailed analysis, realised that most of the hospitals focused on best treatments in the areas of Heart, Orthopedic, Gynecology etc., but there was a gap when it came to superior treatment for urology cases which were on a rise. After identifying the need for super specialty hospital for Urology and with intent to provide world-class treatments in India, Dr. Bansal, brought “Siemens Lithotripsy” device in India in the year 1986. During that time, the treatment of urology cases through laser technology was a pioneering technology internationally and RG Stone became the first hospital to start the treatment in India. But the Lithotripsy treatment had limitations as it could not treat stones bigger than 3 cms in size and
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the treatment could not be provided for duration beyond 45 minutes. After identifying this limitation, RG Stone started Endoscopy, a minimal invasive surgery for the treatment and from here onwards, RG Stone became a complete Urology Care Center.
Avinash Ojha Chief Executive Officer, RG Stone Urology & Laparoscopy, Hospitals
After this successful introduction of international technology for Urology treatment in India and mastering the technique of urinary stone management without surgery, RG Stone progressed further on the growth path and brought the first “100-watts Ho-
lomium Laser” from Coherent USA in the year 1999 which is the best in class technology so far for treating critical urology cases like heart, BP patients with urology condition. Along with specialty treatment, the hospital chain provides added support with in-house dialysis, Diagnostic department, ICU, Post op Recovery Room, Nephrology and Cardiology department for monitoring etc. for treating critical cases. The equipment was inaugurated in a live workshop at RG Stone, Mumbai in association with West Zone Chapter of Urology Society of India by Dr. D. Bagley and Dr. Akhil Das, professor at New York Medical College.
What are the medical specialty services that you offer? We offer Urology and Laparoscopy services. In Urology, we do everything except kidney transplant. We have highly qualified doctors and the second advantage of the institute is that all the doctors work full time. Otherwise you will find most of the institutes have consultants who come for a couple of hours. We do Laparoscopic surgeries which used to be again open surgery for gall bladder, hernia etc. We do these surgeries without any cut and discharge the patient the next day. Further, we have Lithotripsy, Holmium Laser, Laparoscopic Urology, Laparoscopic GI Surgery ,Endourology Procedures, Andrology, Uro-oncology, Surgery for Urinary Incontinence, Reconstructive Urology
What technological advancements have shaped your hospitals? We are supported by an array of stateof-the-art equipments to offer services that are unique & far superior to anything presently available. The Institute is well equipped to meet every possible healthcare need in urology, to ensure seamless operations. The inception of India’s first Siemens Lithostar, started a new era in the field of urology that
‘Increasing trend of single-specialty hospitals’ During the last year itself, the sector saw an increase of approx. 20% in PE investment as compared to the year 2012). This is due to various factors including Lower set-up costs, high margins, high ROI for investors and inclination from the patients to opt for specialty hospital given the superior therapeutic performance - as compared to multi-specialty. Also while the capital expenditure cost in single specialty is as low as 2 crores as compared to large multi-specialty
Single Specialty Year
Investment (in $mn)
2011 2012 2013
90 127.3 155
Number of Number of Investors transactions who invested
9 8 12
7 10 11
hospital where it is approx. 40 crores, the exit time for investors is lesser in single-specialty which is about 2-3 years as compared to multi-specialty where the investors can get any returns only in 6-8 years’ time.
“The usual size of kidney is less 10 cm, and we operated a stone that was13cm long and that too without open surgery. For this achievement we were named in the Guinness Book of World Records changed the face of urinary stone management across the country. R G updates itself regularly with the newer techniques in order to treat complicated cases with ease and perfection Equipments like HoLEP Flexible Ureteroscope & Flexible Nephroscope are a few to mention. Holmium Laser Enucleation of Prostate (HoLEP) is now completely replacing the standard TURP and has become a basic tool for urologists. We are in constant touch with all the latest technological innovations in urology; whenever it comes in we get an update.
Tell us about the key achievements which the hospital has witnessed so far? Today RG Stone has 15 branches across India with an investment of approx 100 crores. With over 27 years of experience in the field, 40 full time dedicated senior faculty, it is the most sought-after hospitals for treatment
for all urology related diseases with a capacity of over 450 beds. RG Stone received funding of 41 crores in the year 2010 from ICICI Ventures which was bought back in the year 2011, through promoters fund, family and friends. Later in the year 2011, the chain of hospital received a funding of Rs. 95 crores of Primary and Secondary from India Equity Partner (IEP) for expansion across other parts of the country. It has been certified by Guinness Book of World Records for treating the largest kidney stone (13 cm) in the world. Taking in view, RG Stone’s international standard success rate many public sector undertakings, multinationals, insurance companies and Ministry of Health and Family Welfare empanelled them for the treatment of their employees and their dependents. Recently, RG was awarded “Best single specialty hospital for Urology” by CNBC TV18 Healthcare awards for 2013.
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Promoting Excellence
A Framework for Healthcare Tell us about the inspiration behind the launch of Jaypee Hospital? Our Founder Chairman Shri Jai Prakash Gaur’s vision is the inspiration behind the Jaypee Hospital, Noida – more than a million square feet of international quality infrastructure and technology. Shri Jai Prakash Gaur founded the Jaypee Group more than five decades ago from humble beginnings, creating international quality infrastructure in Power, Cement, Hotels, Expressways and Real Estate, the scale and quality of which can match the best in the world and are benchmarks in their respective sectors. Jaypee Group is setting up a world-class township, Jaypee Wish Town in Sector 128, Noida (UP), 8 KM from South Delhi, as a part of the Yamuna Expressway Project. Jaypee Wish Town incorporates the finest infrastructure providing all the amenities required by the people who would be residing in and around the township including the Hospital, Hotels, Commercial Developments, Golf Courses, Clubs, Schools, Colleges, etc. Even prior to the Jaypee Hospital project, the group has been providing quality medical care to all its employees and population in adjoining areas at all its project sites across the country. The Jaypee Hospital is part of our Founder Chairman’s vision to create model healthcare delivery institutes across the country which would become benchmarks in the healthcare industry.
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How do you plan to provide affordable healthcare to all?
Jaypee Group, an infrastructure conglomerate, is all set to launch its Flagship 1200 Bedded Hospital in Noida (with 525 beds operational in Phase I) with the vision of promoting affordable and world-class Healthcare. Dr Vikram Singh Raghuvanshi, Chief Executive-Healthcare, Jaypee Hospital, in conversation with Ekta Srivastava, ENN
We are committed to serve a large section of population with affordable healthcare. Given our expertise in construction, we have ensured that cost of creation of infrastructure is reasonable without any compromise on quality. Also, our costs are lower than industry norms and we have decided to pass this benefit to our patients. As an organization, we are extremely sensitive to quality and cost. Our team at Jaypee Hospital has worked intensively to define optimum clinical pathways for majority of ailments which ensures only the necessary investigations and selection of right materials along with zero tolerance for infection. All this contributes in reduction of cost of care which finally benefits patients.
In setting up of hospitals what are the challenges that you have faced and how did you overcome them? Any new venture has its share of challenges. We are fortunate that the Jaypee Group has over five decades of experience in the creation and operation of world-class infrastructure. We believe that we have an experienced and capable in-house team that has been assisted by HURON, one of the world’s leading healthcare consulting firms and specialized hospital architects from Bangkok & Singapore. Furthermore, we have involved over 200 doctors, nurses, equipment suppliers and service providers
(food service, laundry, IT) to ensure proper planning. This helped us in efficient and timely implementation of the project. We look forward to commencing operations in April 2014.
What are your thoughts on the rise of multi-specialty hospitals? What are the advantages it caters? A multi-specialty approach is always good for consumers as it provides comprehensive care. It is also important to note that healthcare delivery is a multidisciplinary team approach which can be implemented optimally in a hospital where all services are available under one roof. This results in better clinical outcomes at optimum cost. I strongly believe that in the interest of patients as well as caregivers, it is always better to create a multi-specialty unit.
What technological advancements are you planning in your hospital? We are committed to create centres of excellence in Oncology, Cardiac Care, Neurosciences & Orthopaedics, Critical Care, Ophthalmology, IVF, Solid Organ Transplant, Kidney disease, Key-hole surgery, Mother & Child and Rehabilitation. In order to achieve this, we have adopted cutting-edge technology like Bi-plane Cath Lab with Clarity platform for Neuro Intervention and Pediatric Cardiology, Hybrid OT (Operating room with Cath Lab) for advance coronary work like TAVI, advance OT and ICU for Pediatric Cardiac Surgery , Liver Transplant, LINAC Trubeam STx with HD MLC, 6D Robotic Couch & 4D-CBCT for most precise radiotherapy treatment, India’s most advance PET CT with Flow Motion technology, Imaging department having 3.0 Tesla MRI, CT Scan with spectral imaging Dexa Scan, Digital Mammography, Digital X-ray with PACS, 4D Ultrasound. Our hospital has also catered for Endoscopic Bronchial Ultrasound (EBUS), Extra Corporeal Membrane Oxygenation (ECMO), ID-NAT Laboratory for blood donor
Planned 2.6 million square feet area of hospital with 1 million developed in Phase I spread over 25 acres Conceptualized with inputs from world renowned healthcare consultants Amongst highest investment per bed in technology to provide advanced medical care testing, Neuro Navigation System, Intraoperative spinal cord monitoring, Video EEG Monitoring, Trans-cranial Doppler, Femtosecond Laser for eye surgery, Robotic System, latest Lithotripter for kidney stone.
How Jaypee Hospital will cater to the need of the patients in a different way in the cadre of multi-specialty hospitals? We are not creating just one more hospital. In fact, we are in the process of creating a healthcare institute which in due course of time will be known and respected for: • Innovation in healthcare delivery • Ethical values • Zero tolerance for error • Quality – that will become benchmark for the rest In order to achieve this, we have ensured highly skilled Doctors & Nurses, equipments which are best in their category and well-defined clinical pathway for each possible ailment. As we are absolutely strict on eth-
ics, our patients can be assured of correct line of treatment. Today, a poor patient runs from door to door to have an answer to their queries such as “should I go for a bypass or angioplasty�, “does this really require a surgery�, “will it really benefit�, etc. At Jaypee, our patient will not experience this as our system is so defined with absolute transparency. We are extremely sensitive to cost. I am sure our patients will see clear difference in the cost of care offered at our unit versus other similar hospitals. I can assure you, in due course of time Jaypee Hospital will be in league of Harvard Medical Systems, Cleveland Clinic & AIIMS.
What are the objectives of this hospital? Our objective is to create a world-class healthcare organization that is recognized and respected for providing affordable healthcare across specialties, for its skillful Caregivers (Doctor’s/ Nurses/ Technicians) and for our commitment to ethics.
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With three values, dedication to the cause, curiosity to learn, and the mindset to share knowledge, wealth and time, Dr Ravindra V Karanjekar, CEO, Executive Director, Medical Services & Quality, Global Hospitals Mumbai, has spent around 38 years in working and excelling as hospital administrator. In an interaction with Veena Kurup, ENN Brief us over the technological advancements introduced by Global hospitals to cater different verticals? Mumbai is a recent addition to our Global Hospitals Group and in a short span of time we have succeeded in equipping the latest and advanced technologies in our hospitals. In our Radiology department, we have with us the 500 slice CT which probably nobody in the country could match with. We are equipped with the latest 3 Tesla MRI, which are utilized for the liver diagnosis. The technology enables to diagnose the disease at a much earlier stage; and in India we are the only hospital having this technology. We are also having the HLA lab for matching the tissue donors and have the latest ICUs for distinct specialty treatments. We are the only hospital in Mumbai, which has the dedicated eight-bed liver transplant ICU and six-bedded kidney transplant ICU. Apart from that we also have advanced distinct facilities like medical ICU, surgical ICU, cardiac surgery ICU etc. Secondly being a multi-organ transplant hospital, we focus on delivering the finest services through our
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In a move to
Provide Best of Quality
Operation Theatres. Global Hospitals has the unique Single-Shell Operation Theatres made up of Dupont’s Corian material. Our Operation Theatres are also equipped with Robotic Surgery Technology and are Computer Assisted. We also offer the most advanced technologies available for facilities like mammography. Today, Global Hospitals is the only hospital in Mumbai offering the laparoscopic donor kidney removal surgery. This enables the donor to get discharged within two-three days after the surgery. Furthermore, we have now applied for heart-adrenal transplant. We will be utilizing our skilled
Chennai and Mumbai team to execute such heart-transplants. Once we have gained approval for this transplant surgery, Global Hospitals will emerge as a full-fledged organ transplant hospital in Mumbai. With the help of efficient and advanced technologies we are able to provide and deliver the best treatments and services to our patients.
Can you throw some light upon the Single Shell Operation Theatre and its benefits? The Dupont’s Corian material utilized for making our Single Shell Operation Theatres (OT), makes our OT antifungal, anti-bacterial and without any
joints. In a surface like this there is no place for bacteria to settle, unless the OTs made up of joints wherein cleaning becomes a difficult task. In addition, these Single Shell OTs helps in reducing infections. These qualities enable us to gain an added advantage over the modular Operation Theatres that has joints. Most of the advanced hospitals in our country utilize such modular Operation Theatres. We have 15 such OTs in our Mumbai Centre and we will be soon trying to set up similar OTs in Kolkata, Chennai and Hyderabad also.
What is your outlook upon the growing popularity of multispecialty hospitals in our country? Multi-specialty hospitals are gaining popularity, as a patient is able to get distinct specialty treatments under one umbrella. Such kind of hospitals is increasingly becoming more common in urban areas. These multi-specialty hospitals enable to gain treatment in a better and more coordinated manner. Hospitals need to focus on delivering such distinct facilities and be able in delivering treatments to the patient as a whole. Furthermore, corporate and insuring agencies or companies now prefer such single umbrella entity hospitals, wherein distinct treatments are offered under one roof. Such facilities help in better co-ordination.
List down the kind of emergency services which the hospital have? We at Global Hospitals Mumbai don’t consider emergency as casualty. Rather we ensure that the required treatments are being delivered to the patient to the patient within the first one hour. Activities like taking the ECG readings, setting up the ventilator, analyzing the requirements for ultrasound facilities, stabilizing the patient etc are taken care of in the first hour itself. The prime concern has to be upon stabilizing the patient. Post that, within the next two hours, the patient is put forth to further
observation and respective treatments. Emergency by itself is a department and requires its own set of specialists’ skillsets. This requirement yet needs to be adopted and implemented in India.
Share us about any landmark initiative you have put forth for eradication of any critical disease? Global Hospitals is the pioneer in performing Donor Laparotomy surgery in India. We have a strong base in liver transplants. Our Chennai centre has already proved and emerged as the leaders in the country and one amongst the best in the world for Pediatric Liver Transplants. We have now equipped the same skill-set of doctors and technologies in our Mumbai centre. In addition, Liver Transplant ICU is a new
involves monitoring air and water samples. These monitoring reports are submitted and analyzed on a day-to-day basis. We have almost 1000 protocols in the hospital on each respective monitoring service, like for example OT Cleaning Services, Patient Satisfaction etc. International Patient Safety Goals are adopted for training our workforce. This helps in gaining an edge over delivering qualitative and sustainable healthcare services to the patients.
How do you see the role of technology in healthcare facilities? Technology plays a phenomenal role. However, taking cost as a parameter, the technical condition is pathetic in several regions, barring urban areas. Because of the laparoscope, kidney
Expansion Plan Within 2014-15, we will have four satellite centers in and around Mumbai and will gradually expand centers in other cities. initiative which we have started. We also offer the most advanced machineries for CT and Cardiac CT services. In Neurosurgery, we will be soon introducing an Integrated Stroke Unit, which can be considered as a need of the hour. We will integrate this facility within the 10km radius in an hour, thereby saving the patient from going into a paralytic stage. This is one of our new initiatives. We have already received equipments for Neurosurgery and plan to implement this facility, most probably by next month. We are also one among the most preferred private hospitals on integrated surgeries for Epilepsy.
How do you plan to give us a sustainable quality of healthcare? Quality is being considered from the patients’ safety perspective. We have sixty-four indicators and from day one they are being monitored, which even
transplantations have become an easy task, earlier it was considered as a major challenge. This technology has not been percolated to the B-Graded or CGraded cities and remote areas. Many of them are still dependent on assured technology. In urban cities, people owing to their constantly rising technical knowledge have an evolving demand. Besides, the pay-capacity of cities in metros and urban areas are much more than the ones in tier-II and tierIII regions. Another advancement that our group would be doing is the tele-radiology and tele-medicine. Both these facets are making phenomenal advancements in Chennai and other places, particularly in aiding people dwelling in the remote areas. Such facilities enable to gain knowledge about the health issue beforehand and in approaching for apt treatments at specialty hospitals.
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zoom in
Creating a Niche
in e-Medical Education
Rohit Kumar, MD - South Asia, Health Science Division, Reed Elsevier India Pvt. Ltd is previously the President of Association of Publishers of India (API) and Co-Chair of (FICCI) Committee on Publishing. In Conversation with Ekta Srivastava, ENN
Please tell us something about Elsevier Science Olympiad? Elsevier India, medical information solution provider to health professionals believes that the basic sciences subjects’ need special attention because they play a vital role in developing skills of future medicos. Medical students must be hence, encouraged to strengthen their subject expertise and skills in these areas. With precisely this thought, they had launched Elsevier Finale Sciences Olympiad in February. With top three winners from the country Pakistan, Nepal and India, more than 15,000 students taking the quiz and 180 medical colleges participating, this quiz provides a great platform for MBBS students to showcase their talent and test their academic merit. Designed specifically for the Professional course undergraduate medical students across South Asia, it is one of the most ambitious and extensive quiz campaign by Elsevier, helping the students develop their skills and gain a hands-on learning experience . It doesn’t only tests students’ knowledge in basic sciences subjects, but also provides them an opportunity to meet and interact with their fellow participants from across the south Asia. Moreover, each participant gets a fair chance to join the elite academic “hall of fame”. The top 3 winners of this quiz had win a total cash prize of INR 50,000/- and lots of laurels!
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How you are planning to take the evnt forward next year? Next year, we are going to take this contest apart from medicine to other departments like dental, nursing, pharmacy, so we become the true partners for the students for their quest for the Knowledge. Elsevier is basically in education and research, helping practicing doctors with e-reading and books but now we have developed some software as well, which some of the colleges has also started subscribing too. Then we have some of the leading journals in the world and almost every college in the country is having some sort of subscription from the organization.
What is your seslection procedure for the authors? Though we too look for the authors from our end, there are some who come up with their own ideas. We look for their credentials, quality of the work they have done and most important the quality of their idea. If idea is good and the person is good we just go ahead. In addition, we are planning more books with the Indian authors.
Paper reading to e–reading, How you think the technology has changed? At the moment, everyone wants to read from the book. When they get the pdf downloaded they will go and get it
Rohit Kumar MD - South Asia, Health Science Division, Reed Elsevier India Pvt Ltd print on papers because they are used too of this and they preferred to read in print. I think in the medical education in next ten or five years, we will not see a dramatic shift in that habit but something that complements will be coming as app. Like any app in mobile phones, though sitting in the mobile or laptop then in the library will take a little more time for the adaptation.
TECH TREND
Moving Towards
Error Free Medication Access to the right information and the automation of complex tasks and workflow is the key focus of the HMIS, freeing the staff to spend more time on caring for patients and extending the reach of services By Japneet Sabharwal, Elets News Network (ENN)
H
ospitals are extremely complex institutions with large departments and units that coordinate care for patients. Hospitals these days are becoming more reliant on the ability of hospital information system to assist in the diagnosis, management and education for better and improved services and practices. Hospital information systems (HIS) or Hospital management information systems (HMIS) are increasingly becoming an emerging tool in health care arena to efficiently deliver high quality health services. HIS/ HMIS is one of the most widely used computer systems support health care services. A Hospital management information system is a comprehensive, integrated information system designed
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to manage all the aspects of a hospital operation, such as medical, administrative, financial, legal and the corresponding service processing. HMIS can be defined as massive, integrated systems that support the comprehensive information requirements of hospitals, including patient, clinical, ancillary and financial management. HMIS features unparalleled flexibility & scalability, comprehensive report types, easy customization, intuitive visuals and interactive graphics that simplify complex data, dashboards support quality initiatives and comprehensive drill-down capabilities.
Healthcare and the Effect of Technology: Developments, Challenges and Advancements Healthcare is significantly affected
by technological advancements, as technology both shapes and changes health systems locally and globally. As areas of computer science, information technology, and healthcare merge, it is important to understand the current and future implications of health informatics. Technology in healthcare can improve efficiency, make patient records more accessible, increase professional communication, create global health networking, and increase access to healthcare. However, it is important to consider the ethical, confidential, and cultural implications technology in healthcare may impose. Most work positions for HMIS are currently resident types. Mobile computing began with wheeled PC stands. Now tablet computers and smartphone applications are used.
Highlights of HMIS Easy access to doctor’s data to generate varied records, including classification based on demographic, gender, age, and so on. It helps as a decision support system for the hospital authorities for developing comprehensive health care policies. Efficient and accurate administration of finance, diet of patient, engineering, and distribution of medical aid. Enhances information integrity, reduces transcription errors, and reduces duplication of information entries. New technology computer systems give perfect performance to pull up information from server or cloud servers.
The HMIS is a province-wide initiative designed to improve access to patient information through a central electronic information system. HIS’s goal is to streamline patient information flow and its accessibility for doctors and other health care providers. These changes in service will improve patient care quality and patient safety over time. The patient carries system record patient information, patient laboratory test results, and patient’s doctor information. Doctors can easily access a person’s information, test results, and previous prescriptions. Patient schedule organization and early warning systems can be provided by related systems. Hospital information systems provide a common source of information about a patient’s health history. The
Access to information are becoming a vital part of today’s healthcare. Patient-centered approach as patient can take care of his own health and can analyze himself the seriousness of his illness and whether he needs to visit doctor or not. User-friendly, easy-to-use and web-enabled applications. Security and privacy (authentication, authorization, privacy policy). Data consistency. Transparency. Clinical pathways mapped to the system improve diagnoses and treatments offered.
IT systems facilitates decision making and provides 24x7 assistance anytime, anywhere.
It provides doctors and hospital staff with the decision support system that they require for delivering patient care.
systems keep the data secure and control who can access the data in certain circumstances. These systems enhance the ability of health care professionals to coordinate care by providing a patient’s health information and visit history at the place and time that it is needed. Patient’s laboratory test information including visual results such as X-ray are available to the professionals. HMIS provides internal and external communication among health care providers. HMIS can be composed of one or several software components with specialty-specific extensions, as well as of a large variety of sub-systems in medical specialties, for example Laboratory Information System (LIS), Policy and Procedure Management System (PPMS), Radiology Information System (RIS) or Picture Archiving
and Communication System (PACS). Hospital information systems main demands are correct data storage, reliable usage, fast to reach data, secure to keep data on storage and lower cost of usage. Additionally, the HMIS provides a host of direct benefits such as easier patient record management, reduced paperwork, faster information flow between various departments, greater organizational flexibility, reliable and timely information, minimal inventory levels, reduced wastage, reduced waiting time at the counters for patients and reduced registration time for patients. HMIS is a next-generation MIS that is powerful, flexible and easy to use and has been designed & developed to deliver real conceivable benefits to hospitals and patients.
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tech trend
Focus On Healthcare Products
Naeem Ahmad, Manager-Business Development, Akhil Systems Pvt. Ltd., interacts with Japneet Sabharwal, ENN, regarding healthcare products for different segments on web based platform
How do you perceive the market for HIS & HMIS in India? In this competitive era HIS providers must be updated about the latest technology, and it should be made available in market. This will improve the product and enhance user experience. Providers should be always active in research and development of the software to get updated with the latest technology and current market demand. Akhil Systems since last 20 years developed its product from DOS- based system to cloud- based systems as per market demand.
What are the unique HIS/HMIS solutions you have designed for Indian healthcare? MIRACLE HIS: It’s a web-based, comprehensive and complete solution designed for automation of front office, back office and administrative services for a single and group of hospitals & satellite clinics. MIRACLE Express & MIRACLE Premium HIS: This product is offered to a small and medium hospital for automation of their various departments. MIRACLE EMR: This is a web-based solution designed for complete automation of a single clinic with single specialty, multispecialty polyclinic and chain of clinics. Patient Clinical Information is also available on Patient Portal, which can be accessed by the patient or doctor from anywhere anytime. This can be integrated with
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tech trend
Hospital Information System also if required by any of the hospital. It has inbuilt templates for over 50 specialties. CareLIS/RIS: Designed for complete automations single lab and chain of laboratories & radiology centers. The application will also offer interfaces with lab machines, bar-code, and PACS for online viewing of radiology images on the doctors computers. It can generate various statistical reports and Turn-around Time (TAT) report. It has user-defined result templates. CarePIS: Designed for warehouse, chain of pharmacy retail outlets with CIMS database integration. PACS: We provide PACS and miniPACS from our partners as well.
On the technology front, what are the new developments that have come up in this field? n One of the latest emerging solution is web based HIS to manage hospital operations. It can be hosted on the cloud. The benefit of web based HIS is that it allows the application to run on multiple servers and at various locations suitable for chains of hospitals, clinics, diagnostic centers and pharmacy. n EHR system is the one piece of health technology that has received more attention than any other over the past several years. Various renowned hospitals like Apollo Hospitals (Dhaka, Bangladesh), Lagoon Group of Hospitals (Nigeria), Saket City Hospital (New Delhi), Paras Group of Hospitals (Gurgaon), Shanti hospital (Bangalore), BL Kapur Hospital (Delhi), Frontier life line hospital (Chennai), RenaiMedicity (Cohchin) etc. are already using EHR developed by Akhil Systems and we receive enquires regarding EHR almost every day. n Over the past several years, the omnipresence of smartphones, tablets and their applications has been one of the biggest cultural shifts in the hospital setting, as well as society at large. The iPad, which has almost become a
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default tablet, has countless popular apps for physicians and executives, ranging from medical calculators and medical terminology to clinical presentations and actual EHRs. n Patient Portals is an online tool for patients is also one of the latest technologies now available in market. Through this, patients can get online test results, access their clinical records etc.
Through patient portal, patient can be able to see online test results, schedule appointment, access online patient clinical records etc. What are the advantages, the solutions offered to the hospital caregivers? These solutions benefits in several ways to the hospital like it automates hospital operations, improves workflow and easy access to information, reduces medical and billing errors, provides more satisfaction and a better hospital visit experience to patients, creates analytical reports for management and decision makers, save time with auto-appointment reminder, patient questions can be addressed at the staff’s convenience, save time per patient visit and generate better documentation to support billing, increase patient convenience and satisfaction, generate additional revenue etc. Through patient portal, patient can be able to see online test results, schedule appointment, access online patient clinical records etc. Also SMS to be sent to patient & doc-
tors for appointments, lab results etc.
With over decades of exposure and experience in healthcare, how do you visualize and evaluate the IT transformation? The Indian healthcare segment is highly fragmented in nature, and has relatively low exposure to IT. As compared to other countries, the percentage of IT spending on healthcare with respect to GDP is quite low. Hence, the potential to transform existing processes using IT is huge in Indian healthcare.
IT illiteracy and lack of awareness often act as initial obstacles for health IT players. Did you face similar challenges? Our HIS is so user friendly that it covers maximum customization as and when required. Akhil Systems is focused on healthcare domain for past 20 years. Over these years we have faced many challenges in India. Among these, IT illiteracy majorly contributes as a challenging obstacle, especially in some hospitals. Due to lack of IT expertise, user training can be challenging as they resist adopting the changes. Also, due to IT illiteracy there is lack of standardization in implementing as user want function as per their convenience all the time which may or may not technically feasible with HIS sometimes. We try to overcome this challenge by offering customization wherever possible but it increases cost of the projects.
Security is an integral aspect of Health IT Infrastructure. What’s your take on this? Any attempt to introduce computerized health-care information systems should guarantee adequate protection of the confidentiality and integrity of patient information. Akhil systems has recently got ISO 27000:2005 to comply with Information Security Management Systems standard for our product.
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Tech Trend
Bringing Change
to our Lives
Vasukumar Nair, Director, 21st Century Informatics, in conversation with Japneet Sabharwal, ENN, about the growing role of technology in HMIS
How do you perceive the market for HIS & HMIS in India? The Indian healthcare industry is growing rapidly with an annual growth rate of 18 to 20%. Our research shows there is a big market for ICT applications. If one side the driver is due to growing population and a need for healthcare, the other end is
Vasukumar Nair Director, 21st Century Informatics
less penetration and standardization of ICT systems. We also see, there is huge opportunity for training and implementation of ICT systems on how physicians, nurses, pharmacists and other care personnel of hospitals are trained in ICT. There is also a need for a centralized Electronic Health Record (EHR). Lack of EHR prevents
the development of speed, accuracy and transparency throughout the healthcare system. We see the market is dynamic and promising. Now, we find that both government and private are in the race to provide better facilities, though there are administrative delays. We have experience; the transformation in certain pockets of the country such as tier-I cities and technology are bringing change to our lives in a big way. There is a huge opportunity in the semi-urban and rural areas that can undergo the same transformation through ICT and this will lead to deep impacts in these areas in the field of medicine.
What are the unique HIS/HMIS solutions you have designed for Indian healthcare? 21stCentury Informatics is a Dutchpromoted company with a global delivery centre in India. Our contribution to the healthcare industry has been consistent over the years. Our Dutch experience has helped us offer a global perspective to the Indian healthcare industry with respect to healthcare ICT applications. The BENLUX region in Europe is a frontrunner in applying advanced healthcare ICT applications. Our endeavor is to apply the knowledge and successful process applications from our company’s European experience to the emerging market. Our focus is on innovation and on adapting our product to the Indian healthcare industry.
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Presently we service more than 500 sites; our contribution to the healthcare industry has been consistent over the years. Our flagship product Apex enterprise HIS is a healthcare platform that comprises various plugin components. The end users can configure their required systems as per their requirements without coding and no hassles.
On the technology front, what are the new developments that have come up in this field? We find a mix of new technologies that is being used or are in development. In Indian scenario, the revenue cycle management is still in the initial stages. Once health insurance comes into our landscape, there will be major changes in the IT systems towards global health insurance standards. Now in some areas, our customers are investing in automation of clinical processes. We find that there is a good acceptance of the implementation of EMR with Clinical Decision Support Systems in some countries. With respect to technology penetration, market response is good for cloud computing, healthcare analytics and BOYD. In the Indian scenario, we offer technology solutions and support with the usage of gadgets and devices and performance dashboard through mobile computing for the top management. Our team is constantly innovating to provide new features and functionality to our users. We have come out with a new platform that enables rapid expansion of functionality during IT product implementation. It is supported by advancement in cloud computing technology and emergence of the SaaS model. A few of our customers have tested this platform and we are currently in the process of taking it to the market.
What are the advantages the solution offers to the hospital caregivers? Our flagship product Apex enterprise
HIS is an integrated enterprise-wide application with respect to hospital management, electronic medical records and clinical intelligence with analytics. Most of the HIMS applications have a rigid business logic flow and it is very difficult to change application behavior. With this platform our end users can change the process based on business dynamics. Typically, internal IT staff cannot change the application to map changes in business dynamics – they need to contact the software company or implementer to get the application reconfigured. We have changed that situation by empowering the ICT staff even to build new systems and process.
“With respect to technology penetration, market response is good for cloud computing, healthcare analytics and BOYD With over decades of exposure and experience in healthcare, how do you visualize and evaluate the IT transformation? India’s healthcare system faces considerable challenges, such as dearth of right staff, low doctorpatient ratio, quality of care, rising costs in services and medicines, major divide between urban and rural facilities, etc. However, if you look closely at certain hospitals and hospital corporates, they have focused significantly on IT whether for management control or for bringing clinical excellence. The telecom revolution and IT have provided a huge opportunity to care providers
to transform their service delivery models and there are many success stories in private and public system with respect to the use of right technologies such as HIS, mobile health, tele-medicine, EHR and also automation of government hospitals by transforming health care.
IT illiteracy and lack of awareness often act as initial obstacles for health IT players. Did you face similar challenges? We don’t find IT iliteracy as the main challenge. However adoption of new systems and process is sometimes difffult for stakeholders. Although there is some standardization in the clinical care areas, with respect to other processes, this field still lacks guidelines and standardization and there is less control over variance.
Security is an integral aspect of Health IT Infrastructure. What’s your take on this? With healthcare information being exchanged within the hospital and extending beyond hospitals to other labs and clinics, the confidentiality of patient data, hospital business records and other revenue data becomes topmost priority. Providers must think beyond the conventional antivirus and firewall combination for safety and security. Now, with the Bring Your Own Device (BOYD), security and compliance aspects have become the primary concern,internal and external breach, regulatory compliance, and inadequate deployment of right technology are the key factors that top management looks at while assessing solution providers like us. We have made sure that we comply with global standards in messaging and data exchange. Our solutions meet the regulatory requirements and can manage security threats. Our team is constantly focusing its effort to come out with innovative features that tighten privacy, security and safety.
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Tech Trend
Prabhakar Annaswamy, CTO, Idea Object Software Pvt Ltd., talks to Japneet Sabharwal, Elets News Network (ENN) about the positive changes in HMIS sector
HMIS, in its
Developing Stage
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How do you perceive the market for HIS/HMIS in India? The market for HIS in India is in its developing stage. More and more hospitals are moving from locally customized billing software to standard HIS product based solutions. The hospitals are starting to have a strategy and team for IT and HIS plays a central role in it apart from other applications such as ERP, HRMS, etc. India is a very large market for HIS and we are focusing on the corporate hospitals who want IT as an enabler for their success and who can invest on the IT infrastructure and teams.
What are the unique HIS/HMIS solutions you have designed for Indian healthcare? The workflows and requirements of Indian hospitals are very similar to the hospitals in rest of the Asian
“Indian healthcare is transforming very fast to match the international standards of IT infrastructure and implementation” countries and Middle East. So we have developed a single product that we are targeting for India and abroad. In addition, to suit the internet & infrastructure availability in India, we have developed synchronization services which can enable remote locations to use HIS in an offline model.
On the technology front, what are the new developments that have come up in this field? Mobile and tablet devices will be the
key point of care devices in the near future and we are enabling our HIS to be available on these platforms. Technologies have evolved to support cloud -based HIS deployments and SaaSbased offerings. Codification of data using standard coding system such as SNOMED are available now and the data analytics and BI tools are getting deployed in hospitals today for management and decision making.
How much investment is required for procuring HIS/ HMIS solution for a hospital infrastructure? The investment will be in terms of software licenses for the product and professional service charges for the implementation. The extent of investment will vary based on the size of the hospital, concurrent users, and the modules that they need. We also support SaaS based offering where the hospital can pay a small recurring monthly fee and use the HIS Software hosted on our cloud.
What are the advantages the solution offers to the hospital caregivers? Our product HealthObject addresses all the PAS (administrative) and EMR (clinical) requirements of the hospital, in addition to technological advancements such as multi location access, single patient record, integration with external systems, mobile and tablet access, etc. The major advantage is that it supports the standards based protocols (SOPs / Care pathways) which will help the caregivers in upgrading their processes to proven and international standards.
With decades of exposure and experience in healthcare, how do you visualize and evaluate the IT transformation? The IT or IT enabled transformation is happening at various levels in the
healthcare ecosystem, both in terms of hardware / devices and software. The acute care segment is more ITenabled today compared to the primary care segment. The diagnostics segment such as labs and radiology already depend a lot on IT automation for their day to day operations. Similarly, IT transformation is happening more at Tier I & II Cities and private hospitals compared to public hospitals. But Indian healthcare is transforming very fast to match the international standards of IT infrastructure and implementation.
IT illiteracy and lack of awareness often act as initial obstacles for health IT players. Did you face similar challenges? In the major cities in India and abroad, we don’t see IT illiteracy in hospitals, rather we see that the users are familiar with IT usage and are fast learners of the new system. The caregivers are generally busy with their work and getting their time and attention for requirements study and training has been an obstacle that needs to be managed carefully for successful implementation of the system.
Security is an integral aspect of Health IT Infrastructure. However, a majority of healthcare organisations haven’t yet woken up to its significance. What’s your take on this? The scenario is changing in India and has changed long time back in many other countries abroad. Almost all the hospitals abroad and the Tier I hospitals in India do specify security as an essential non functional requirement. Our product, HealthObject has security implemented across all the layers of the architecture. We support anonymization of patient records and confidentiality of patient records such as investigation results to ensure that security is maintained throughout the application.
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Tech Trend
Transforming
Healthcare Treatments “Computerised tools that assist in prescribing and treatment only enhance the outcomes for physicians’’ says M Vennimalai, CEO, Aavanor Systems in conversation with Japneet Sabharwal, ENN
How do you perceive the market for HIS & HMIS in India? With a number of state government hospitals commencing work on creating electronic medical records, there is increased pressure on private providers to utilise IT effectively in healthcare. The real game changer might however be mobile applications in the healthcare space which draw both patients and care givers into the usage of IT in healthcare. For mobile applications to move from the fringes (small apps for specific ailments or concerns) into comprehensive and effective health management, they will have to work off an integrated EHR and this will probably speed up in-depth adoption of HIS and EHR in healthcare.
What are the unique HIS/HMIS solutions you have designed for Indian healthcare? Doc99 - a Patient Portal on a Mobile – This is a comprehensive yet simple tool for the population to manage their clinical visits. It allows for l Scheduling / paying for appointments from the phone. l Completing pre-visit forms. l Viewing Doctor’s prescription on your mobile. l Receiving medication reminders and recording compliance with medication. l Viewing lab results on your mobile.
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l Completing
forms monitoring health improvement and response to treatment. l Tele-consultations with Doctors, via text and voice messages aided by pictures and video. l Re-ordering of medicines online. l On-line payment for services, teleconsultations and medicines. Patent- pending ‘Paper View EMR’ -It uses eBook technology to dynamically create medical records that look just like the paper records currently used in hospitals. Medical records captured through various forms in a computer application for medical facilities, are collected and published in a usable and familiar format. The caregiver is able to see the complete patient medical record, up-to-date with all information recorded at multiple places in the medical facility. q…less Money- An innovative technology that allows a patient to request and pay for services using his/her mobile phone. Allows for cashless transactions in the hospital and allows system interaction to be centred on the patient rather than the transaction or department. Patients deposit money into their account and use it for all transactions such as pharmacy payments, consultation charges, lab charges, etc. Business Intelligence –Easy to use dashboards and dials help Management and other users keep track of the operations and to monitor Key
M Vennimalai CEO, Aavanor Systems
The 2014 market will demand analytic solutions that can be combined with powerful EHRs and are capable of extracting data from multiple repositories Performance Indicators vital to the health of the hospital.
On the technology front, what are the new developments that have come up in this field? The major development has been mobile centric technology, where every solution is now designed around a mobile experience. Analytics and Executive Dashboards (Big Data)- In the past, analytics and benchmarking was mostly reacting to prior month’s data manually compiled
by department leaders. Compiling the data was labor intensive. The 2014 market will demand analytic solutions that can be combined with powerful EHRs and are capable of extracting data from multiple repositories. Population Health Management (PHM): The definition of accountable care is basically a group of providers collectively working together managing a population of patients to improve outcomes and lower costs. Because EHRs were never built as care coor-
PHM, the HIE is typically structured as a solution that manages the exchange of data behind the EHRs and PHMs. Rarely will the end user interact directly with the HIE. Stage 2 of meaningful use will require a connection to an HIE.
month. Apart from the low entry costs, users do not have to worry about servers, maintenance, etc.
How much investment is required for procuring HIS/HMIS solution for a hospital infrastructure?
The clear and long term benefit is that the caregiver is immediately able to take a holistic view of the patient’s health by viewing their entire record, rather than treating the episode purely in a crisis handling mode. Good HMIS systems offer numerous tools to caregivers to enhance the level of care. Computerised tools that assist in prescribing and treatment only enhance the outcomes for physicians. These tools will grow in importance in the years to come.
Entry costs in purchase of software can be as low as `10 lakhs for a small hospital wanting to setup an EMR, and
What are the advantages the solution offers to the hospital caregivers?
With over decades of exposure and experience in healthcare, how do you visualize and evaluate the IT transformation? I believe that the smart phone and tablet revolution that is sweeping our country will help achieve deep adoption within the country. What was perceived as an intrusive technology by physicians is now becoming easier to use and people are more accepting of display devices being a part of a conversation. These subtle but significant changes are pushing IT adoption toward the tipping point in Indian healthcare. dination tools, there is now a market for PHMs, which will manage the consumer side of accountable care. PHM solutions will act as large repositories storing information from various EHRs and health information exchanges to enable care coordination between providers and the population of patients for which they are responsible. Health Information Exchanges (HIEs): HIE and PHM sometimes get confused as they both provide ways to share data across multiple caregivers and healthcare stakeholder. Unlike the
may go up to a few crores of rupees for the large facilities. Training costs for systems that are designed to be understandable and simple are lower than first generation systems that tend to be cumbersome and intimidating to users. Our design philosophy has always factored this into account and therefore the tag line – ‘Intelligently simple, Simply intelligent’. But the cloud has brought about remarkable affordability for the EMR and users can start using our system on the cloud for as little as Rs.2000 per
How much do you think mHealth will contribute to healthcare? The ease of use and convenience that mobile devices including smart phones and tablets provide, make it convenient, for the first time, to use IT in a care delivery setting. By sharing the responsibility of care with the patient using their smart phone, patients will take a greater role in managing their own health, again contributing to the improved efficacy of healthcare. There is no doubt that mHealth will revolutionize healthcare.
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Tech Trend
Application to Speed
Up Things for the Patients Sachin Chougule, Co-founder and Director, DesignTech Systems Ltd., talks to Japneet Sabharwal, ENN, highlighting the need of applications to throw up lot of information to caregivers How do you perceive the market for HIS & HMIS in India? The overall investments in the Healthcare sector are growing by more than 15 percent/annum as compared to investments in Healthcare IT products which are currently less than 10 percent/annum. The major drivers for growth for healthcare IT product usage are as follows: • Current market size as per Gartner Group report in to the tune of `5000 crores and is growing at the rate of 7 percent/annum. • Rising awareness and demand for higher level of healthcare need use or EMR. • The requirement of cashless payments or insurance and speedy settlements of claims need IT enablement. • Increase in medical tourism is making hospitals invest in state of art IT setup to attract patients from abroad.
Sachin Chougule Co-founder and Director DesignTech Systems Ltd
What are the unique HIS/HMIS solutions you have designed for Indian healthcare? DesignTech Systems offer four different products for the following market segments. Asclepius Clinic for clinics and practitioners, Asclepius Lite or Professional for small or medium size hospitals and Asclepius Enterprise for large hospitals. Our ERP caters for Patient Management, Billing, LIS, RIS and Inventory Management
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and seamlessly integrates all the allied services of the hospital. The unique and “The Next Big Thing” concept of Workflow Management Framework enable hospitals to reduce overall time to process transactions. Building applications that are user-friendly are a passé. The need today is to build the HIS applications
that will enable caregivers to deliver services in the nick of time. One of the major grievances coming from patients is wait time and time spent in queues. Applications with Workflow Management Systems can significantly reduce the wait time. Workflows give caregivers advance information about the service and care due to the pa-
tient, and enable them to prepare in advance. Work orders provide information to respective departments and caregivers through workflows. We have already seen hospitals managing more number of patients in lesser OPD time as compared to while user earlier versions of HIS solutions.
On the technology front, what are the new developments that have come up in this field?
without making them wait at all. Work orders processed by workflow management give caregivers advance information about the patient and the services to be provided to them. Applications need to throw up lot of information to caregivers. Applications must be able to refresh this information and make it presentable to users at all time, whether as pop ups, live lists and drag and drop.
As mentioned above we have invested in building our application on the .NET Workflow Foundation. Work orders based on workflows allow applications to speed up services in various departments in the hospital. The other most crucial aspect is to make information available real time. This is pushing vendors to make the application portable on the cloud. Having the application hosted on a cloud will enable pushing data on various types of devices such as mobiles, tablets etc.
With over decades of exposure and experience in healthcare, how do you visualize and evaluate the IT transformation?
How much investment is required for procuring HIS/ HMIS solution for a hospital infrastructure?
IT transformation is fast paced phenomena in India too. India also has a foot print of the west. Indian hospitals have invested in multiple applications to address multiple needs of the organization. Hospitals have made investments in HIS, LIS, RIS, EMR etc. Each of them bring value addition to the organization. The challenge is integrating all such systems, and make the data inter portable and seamlessly available to the user. Healthcare data can be huge and complex, and at the same time is always changing. Data is also sensitive and must be protected for manipulation, make need for state of art storage solutions.
Like other industries such as automobiles, manufacturing, tourism etc, hospitals need to budget out a certain percentage of their turnover for IT spend. The IT spend should include capital expenditure, infrastructure, hardware and software, running costs in terms of annual subscriptions etc. and personnel. Hospitals must plan and fix the IT budget on priority. IT budget spend can be recovered in less than 18 months, in many cases.
What are the advantages the solution offers to the hospital caregivers? As we have started stressing that it is not important to make the application user friendly but it is important the application can speed up things for the patients. Applications must enable caregivers to attend to patients
change the application to meet their requirements. The seriousness to accept IT as a real differentiating and enabling tool, willingness to invest in it and leveraging as competitive advantage is generally lacking in the top management/ owners of our healthcare organizations. Compare this with the services and manufacturing industry of the mid 90s when IT use was restricted to mainly EDP functionality which today has changed to the strategic CIO role making them globally competitive. With international medical tourism opportunities, globalization and in-
“Our ERP caters for Patient Management, Billing, LIS, RIS and Inventory Management and seamlessly integrates all the allied services of the hospital”
IT illiteracy and lack of awareness often act as initial obstacles for health IT players. Did you face similar challenges? Yes, but only sometimes. The major challenge is lack of common processes. Hospitals often force vendors to
creasing regulatory pressure healthcare organizations will also have to accept strategic role of IT tools soon.
Security is an integral aspect of Health IT Infrastructure. However, a majority of healthcare organisations haven’t yet woken up to its significance. What’s your take on this? Security of data is vital, and especially when it comes to clinical data. As mentioned earlier data in healthcare is exchanged from one system to another and hence need to be secured at all time. Unlike the West, India lacks laws and proper regulations in this regard. US and many other countries have laws that bind on hospitals and HIS vendors to safeguard clinical and patient data. Security is not only a part of software, but also hardware and networking systems. A proper security system is built from the combination of all the above.
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Specialty
Cardiac Transplant
Patients Living longer Heart transplantation continues to be the “gold standard� treatment for end-stage heart failure. Dr Sujay Shad, Senior Consultant and Co-Chairman Department of Cardiac Surgery, Director Cardiac Transplant, Sir Ganga Ram Hospital shares his views with Shahid Akhter, ENN about his pioneering interventions
You were the first to transplant a heart in Delhi? How do you recall this most memorable moment? Once I had decided that Sir Ganga Ram Hospital would be a Cardiac Transplant Centre, I spent a considerable amount of time and effort to train all my surgical, anaesthetic, nursing, and paramedical staff. We were not just lucky, we had prepared for this day over a period of 18 months; so when the day arrived when we had a perfectly matching recepient (who was suffering from incurable heart failure) and a brain dead donor, we were prepared. I deliberately had to tone down the excitement in my department, and instead had everyone to focus on the task at hand. After 10 hours of operating; first the donor and then the recepient, I came out of the operating theatre very satisfied; with the heart functioning beautifully in perfect harmony and normal body function. 15 days later, we held a press conference that was very well received. I came to know later that while my department was busy treating this patient, a large number of seniors at Ganga Ram faculty and lots of our nurses were quietly praying for this patient to recover. That was a deeply satisfying and gratifying
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moment, and it was good to know my work was being appreciated.
What initially attracted you to cardiac surgery ? Did someone inspire you? It was a brief visit to an operating session at AIIMS while I was a surgery resident, when I saw the chest open. It is all very magical for the uninitiated. I was extremely lucky to land up at the world famous Harefield Hospital in the UK. A few days into my training, I stayed up all night to accompany a surgical team that went to retreive a heart from a brain dead donor; and then subsequently drove like mad through the streets of London to get back to Harefield. Once back in the hospital, the heart was swiftly prepared and implanted into a terminal heart failure patient by the legend himself, Professor Sir Magdi Yacoub. A giant amongst Cardiac Surgeons, inventor of multiple specialist cardiac operations, doyen of heart, heart-lung, lung transplants; artificial hearts and so on and so forth. In the world of cardiac surgery, he is royalty. I was deeply influenced by his methods and techniques. One could say that I was charmed into the specialty by Professors Sir Magdi Yacoub, Robert Bonser and Gilles Dreyfuss. I hold these men in the highest regard.
How far have we advanced in heart transplant, technologically? How do you perceive the future ? Technically the operation remains the same as was described in late 60’s with a few minor improvements. It is by no means a simple operation, however in my practice it is not the most complicated operation either. Surgery is only part of the process, which remains complex. The Achilles Heel of any transplant surgery remains immunosuppression, which is essential for the implanted organ if not rejected by the recepients body; too little and
the organ gets rejected, too much and one is susceptible to multiple infections. Maintaining balance is crucial and requires precise regulation and follow up.
How far have we progressed by way of organ donation, precisely heart ? How good is our awareness in organ donation and what needs to be done? Multi-organ donation is now finally becoming accepted in the country, some states notably Tamil Nadu and Andhra Pradesh have tweaked the rules and regulations governing this
one can now choose the most appropriate device for a particular patient. These devices are expensive and can easily cost `1 Crore. The long term results of the newest and best devices in the field now comes close to the results of heart transplantation. The upside is the lack of need of immunosuppresion; the downside with these ventricular assist devices, is the need to carry around battery packs to power the device, not to mention the wires that protrude from the body.
A recent finding published in the Lancet suggests that blood transfusions are overused during
Longest-surviving heart transplant A British grandfather has entered the record books as the world’s longestsurviving heart transplant patient. John McCafferty, 71, has now beaten the previous record of 30 years, 11 months and 10 days, set by American Tony Huesman, who died in 2009.
“I would not be surprised to find myself implanting hearts grown and cultured from the native tissues of my patients and remarkably improved the availability of organs. The shocking reality is that today we have surplus of donated hearts that go waste because of lack of potential recepients. Heart failure patients who can’t breathe properly and require repeated hospitalisation for water retention, really need to seek treatment from specialists in heart failure surgery and heart failure cardiology.
How far does the artificial heart help? Your inputs on the scenario in India? We have various devices that can be used for short term (days to weeks), medium term (weeks to months) and long term heart support and replacement. Depending upon the indication
common heart surgery. Can’t we limit this without causing any harm to the patient ? Blood transfusions are not just trivial replacements of blood. We know that patients who do not receive blood transfusions during surgery fare better than those who end up needing them. Transfusions have potent effects on lung function, immune function, and there is a linkage of subfertility amongst young ladies who have received multiple blood transfusions. It is possible to reduce and eliminate blood use in the majority of cardiac surgery patients by improved surgical techniques, and cell salvage during surgery. At my last audit we found we were using an average of 0.6 units of blood per patient.
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With technological advancements in diagnosis of heart diseases becoming easier, faster and accurate, please tell us about the most exciting tools that have brought about this change ? Broadly, there are two types of tests: the ones that define the structure and those that define the function of the heart. It is combination of the two that gives the most valuable results. Now a days we use a battery of tests to provide us the requisite information. We often use ultrasound (Echocardiogram) to give us valuable structural information, however, a well performed echo provides very accurate information about the function of the heart as well. CT scans have recently come in vogue to define the structure of coronary arteries. Scans have become very fast, use much lower doses of radiation and are very accurate to define structure. However, very limited functional information can be gained from these scans. Cardiac MRI is now the gold standard for functional assessment of cardiac function; a lot of information about valves and walls of the heart can be gained but it fails to provide any useful information about coronary arteries. PET scans as well as Cardiac MRI provide valuable information about recovery of cardiac function after surgery. None of these information systems were available 15 years ago barring echocardiogram, today we have these techniques and also have the knowledge to interpret the results, and then apply them to clinical situations for the benefit of patients. Nowadays we certainly have much better information about a patient’s heart before an operation.
Please tell us about your patents in valve mechanics ? It is a very simple device infact. So simple that I was able to explain it to my son when he was eight, he ripped out a part of his toys and said, so this is what part of his toys and said,’so this is what
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Factors deciding the heart transplant ? End-stage heart failure, ischemic heart disease, cardiomyopathy, or congenital heart disease. Low chance of living as long as 1 year without a heart transplant. No other serious conditions that would compromise his expectancy. Heart transplant will increase survival and improve the person’s quality of life. you meant?’. I try to keep the development work going, we have received a grant from the DBT and in association with the IIT Delhi we are slowly moving forward. Essentially it is a specifically designed ring that holds and improves the hemodynamic characteristics of existing artificial valve.
How do you decide that a patient requires a heart valve repair or replacement surgery? Any diseased heart valve causes distinct alterations in valve function, as well as a structural change in the walls of the heart. Once the two coexist, the diagnosis and severity of the valve dysfunction is not in doubt. That is generally the time when a valve should be operated upon especially if the patient presents with classic symptoms. Mitral and tricuspid valves are amenable to repair and unless they are very badly deformed and damaged, the primary surgical aim is to repair these valves. Aortic valves on the other hand can only be repaired if they are leaking, the techniques of repairing a narrow aortic valve are still being developed.
Do we have national guidelines for the management of valve disease and other prostheses? We don’t have national guidelines and
I personally don’t believe that we need them. Patients and their hearts are the same across national borders. The treatment algorithms needn’t change between one country and another. Today we use the same knowledge, same investigations, same techniques of surgery, and the same medications as the rest of the world.
Minimally invasive open heart and bypass surgeries with robotic assistance are becoming a reality. Will robots take over surgeries in India today and tomorrow ? I would separate minimally invasive cardiac surgery (MICS) and the robots. We have joined the MICS bandwagon, because we can see certain advantages for the patients today and also because we are a major training institute for Cardiac Surgery in India. As for Robotic surgery, it is a major healthcare aberration. Remember that these devices were invented for use aboard ships and in battlefields; so that a skilled surgeon could sit on a console in Washington and operate upon a patient on a frigate in the Pacific. Since that couldn’t accrue, the target audience was altered to the most flamboyant of surgeries, i.e. cardiac surgery. The company failed to make a mark in its quest for robotic cardiac surgery; it managed to survive by the skin of its teeth when urological applications were confirmed. In fact a recent BMJ paper discussed how there isn’t much evidence that robotic surgery is better than conventional laparoscopic surgery, despite an over 20 times cost inflation. I am 100 percent sure that robotic surgery is the future; but definitely not in it’s current avatar. The current crop of machines are neither intuitive, nor provide a great leap in surgical technique. I expect to see some major developments in this field within the next decade or so.
specialty
Accurate Effective
and Efficient
State of the art radiology department at Hinduja Healthcare Surgical, Khar, has put preventive care and world-class diagnosis at patients’ doorstep New trends in radiology and imaging Radiology is undergoing a major shift in how it is practiced. In this rapidly changing healthcare environment, radiologists need to closely watch the emerging trends that are influencing their field. In radiology, there is significant variance in clinical protocols and contextual measurement of quality.Healthcare costs across our nation are frequently described as unsustainably high and advanced imaging tests and radiologists have been targeted as contributing to the problem. With ever-increasing concerns about radiation dose and the appropriate use of diagnostic imaging tests, doctors are continuously looking for ways to better image their patients. Advances in ultrasound are making technology appear more attractive for certain clinical applications, from breast health to cardiology, thanks to their non-invasiveness, cost-effectiveness and lack of radiation.“We have Siemens 128 slice Somatom Definition AS Plus, one of the fastest single source CT scanner in the world which provides accurate speedy diagnosis and also incorporates dose
reduction tools. We have with us the best standard tools that are required including ArtisCath Lab from Siemens, Kodak CR/DR system, high end Colour Doppler USG from Philips amongst others,” says Dr Zena Patel, Department of Radiology, Hinduja Healthcare Surgical. From patient compliance point of view there are now faster CT scanners, improvisation in scanning techniques and better contrast media. All of these have a direct impact on the image quality, making it advantageous for the radiologist as well. Advanced technology has streamlined workflow and has replaced film reporting with direct reporting on PACS workstations. Advanced IT integration with HIS, PACS, speech recognition software for direct dictation of reports are all advanced tools which streamline workflow and reduce turnaround time.
Safety First The newer remote viewing systems allow access via e-mail or the Internet to images and reports through modules for a PACS, third-party standalone systems or linked to the facility’s archive/ storage system. Most are cloud- or
“Exciting new technology we are awaiting to arrive in India are wireless transducer, 640 slice CT scanner, noiseless MRI, peri-operative MRI, OLED displays and cloud based imaging.” Dr Abhay Shah, Department of Radiology, Hinduja Healthcare Surgical, Khar
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Web-based systems so they can easily be accessed outside of a hospital’s computer system. All offer data encryption and password protection.3Dand 4D ultrasound hasrevolutionized the field of obstetric ultrasound, which has now become a more patient friendly and interactive experience.The use of CT scans in diagnostic radiology has skyrocketed in the past decade, which warrants the need for creating awareness about the importance and methodology of dose reduction among physicians and radiologists.Adds Dr Patel, “Our CT scanner has an inbuilt real time dose modulation software which lowers the radiation exposure to the patient (CARE Dose 4D and Adaptive dose shield). Quick scanning with the newer
multislice CT in difficult patients like trauma, geriatric and children reduces / negates the need for repeat studies and indirectly decreases radiation dose to the patient.”
“We have 2 Siemens PACS workstations with 2DPlaza and 3D – Syngovia software which allow efficient reading and decrease post processing workload.
State of the art PACS
Dr Anupam Dudani, Department of Radiology, Hinduja Healthcare Surgical, Khar
PACS (Picture Archiving and Communication System) is now becoming anecessity for the radiologist’s workflow. The continuous increase in diagnostic imaging like CT, MRI and related newer advances drives the increasing need for efficient image review and management solutions that PACS has to offer. In consequence the speed and capabilities of image storage and visualization is also increasing. PACS has become an invaluable tool for communicating diagnostic results across healthcare systems, and is being integrated with other healthcare enterprise systems, such as HIS. “We have 2 Siemens PACS workstations with 2D- Plaza and 3D – Syngovia software which allow efficient reading and decrease post processing workload. In addition speech recognition software has been configured on PACS, which enables direct dictation of reports on PACS. Intra and cross modality comparison of scans is possible with entire radiology investigative data of each patient available on one click,” says Dr Anupam Dudani, Department of Radiology, Hinduja Healthcare Surgical. There is permanent archiving of images and a report that helps in reporting follow up patients. PACS viewing is available in all wards, ICU and OPD room computers where the clinicians can view the scans and reports of their patients. Home viewing is available for the consultants, which
helps in problem solving during emergencies. Interesting case libraries can be made which can be used as an academic tool and in presentations. Use of the speech software negated the need for a medical transcriptionist.
IT in Radiology Department Emerging innovations in ultrasound, such as development of wireless transducers are set to keep the market going throughout 2014.Technology has now become a backbone of radiology both in terms of hardware and software. Superior configurations of different hardware components enables better scanning and reporting. Advanced software available in the scanners and 2D and 3D PACS render the raw data in visuals for diagnosis and analysis purpose. Hospital Management Information System(HMIS) provides an easy to use and user-friendly interface towards multi-dimensional and intricate healthcare operations.
Cross Functional Role The role is multi-functional for the radiology section. Breast elastography is a new sonographic technique that provides additional characterization information on breast lesions over conventional sonography and mammography.Freehand ultrasound, or compression elastography is based on the application of a compressive force to
“We have speech recognition software configured on PACS, which enables direct dictation of reports on PACS.” Dr Zena Patel, Department of Radiology, Hinduja Healthcare Surgical, Khar
the breast and on the measurement of the shape-deforming effect, thus providing a value of lesion stiffness compared with that of surrounding tissues. Breast elastography can substantially improve ultrasound capability in differentiating benign from malignant breast lesions – thus reducing the number of biopsies. Earlier cardiac catheterization was the only way to look at the coronary arteries. With the 128 slice CT scanner, Coronary CT Angiography can be performed in just 5 seconds and it gives spectacular images of the heart. Advanced post processing software helps in creating wonderful 3D images of the heart. CT Coronary angiography has revolutionized the screening of patients for coronary artery disease. “USG and CT guided biopsies of tumors is routinely performed in our department. Histology and grade of tumor diagnosed from the biopsy specimen is crucial for the oncologist in deciding further management. Palliative treatment in the form of tapping of large amounts of fluid in the chest and abdomen is also done in our department,” says Dr Abhay Shah, Department of Radiology, HindujaHealthcare Surgical. With the combination of thin data (0.6 mm) and advanced viewing and post processing workstations, detection, localization and evaluation of morphology of tumors can be done with precision in oncology patients that helps in preoperative assessment and staging. With the 3D software, images can be viewed in different planes and early cancer can be picked up. Follow up studies can be directly compared on the PACS workstations as images and the reports are all archived. This is timesaving in oncology reporting.
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launch pad
Non-invasive cardiovascular screening monitor OMRON Healthcare India – a key player in the health care segment providing innovative devices for monitoring vitals – has introduced OMRON VP1000 Plus - an avant-garde, non-invasive vascular screening monitor for the prevention of cardiovascular diseases. The product was launched at Chennai today in the presence of Mr. Shinya Tomoda - MD, OMRON Healthcare India and Mr. Elango Devy - Director, Diabetic Foot Care India Pvt. Ltd. Based on advanced ‘bio information sensing’ technology, OMRON VP-1000 has numerous features including the TBI package which makes it unique in the market. It brings together the techniques of blood pressure monitoring and pulse wave measurements to act as a communication platform between human body and medical professionals so that they are able to monitor and treat cardiovascular patients in a reliable, accurate, effective and a well-timed manner.
Affordable Listening Device Conversor Pro is an affordable assistive listening device that offers users the versatility to enjoy the most out of everyday life. Conversor Pro is the perfect hearing companion for anyone with a hearing difficulty. It is designed for easy use with Telecoil-equipped hearing aids and cochlear implants or with binaural headphones or earphones.Hearing aids compensate for the lowering of sound level by amplifying sound. However, most hearing aids are unable to replicate aural focus due to the way they pick up and amplify all of the sounds surrounding the wearer.Conversor Pro helps you to focus on desired sounds, near or far away, filtering out unwanted background noise up to 30 dB, and greatly enhancing sound level and clarity. By removing background noise, the desired sound is much clearer and more intelligible, even in noisy environments. By increasing the available sound level, less strain is placed on hearing aid amplifiers, eliminating distortion and feedback.
uDivine App Massage Chair Massage combined with best-in-class mobile app technology OSIM India introduces uDivine App Massage Chair, the most advanced massage chair ever.Now more than just ‘Massage fit for a king’, the OSIM uDivine App Massage Chair innovates and pushes its supremacy further - leveraging the power of smart phones and mobile technology.The patented OSIM uDivine App Massage Chair has the most innovative massage technology that provides an intelligent and precise massage based on the human body contours. The uDivine App Massage chair is made up of finest materials for comfort. The uDivine App Massage chair now comes equipped with an uDivine Application supporting all your Apple gadgets. The uDivine App works with Apple iPod touch, iPhone; and iPad, the OSIM uDivine App massage chair re-est ablishes the benchmark for massage chair innovation, transforming it to an intelligent, multi-sensory enjoyment for the body, mind and soul.
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belief
Veritable : Unique diagnostics with second opinion on every test
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Core Diagnostics Private Limited 406, Udyog Vihar, Phase III, Gurgaon 122016
Core Diagnostics, Inc 2458 Embarcadero Way, Palo Alto, CA
Phone: +91 124 4615 615
Phone: 650-532-9500
info@corediagnostics.in
www.corediagnostics.in