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asia’s first monthly magazine on The Enterprise of Healthcare

eHealth Magazine

volume 8 / issue 11 / november 2013 / ` 75 / US $10 / ISSN 0973-8959

Covering the

Cost of Healthcare Inside Special Focus Hospital Acquired Infections


Leading the Way in Health Insurance

Rajeev Sadanandan, Director General and Joint Secretary for Labour Welfare, Government of India

Health Insurance special

Pankaj Kumar Bansal, Ex-officio Special Secretary, Health and Family Welfare Department, Government of Tamil Nadu

Vini Mahajan, Principal Secretary, Department of Health and Family Welfare, Government of Punjab






ISSN 0973-8959

14 policy


Pankaj Kumar Bansal Ex-officio Special Secretary, Health and Family Welfare Department, Government of Tamil Nadu

cover story Covering the Cost of Healthcare

policy Vini Mahajan,Principal Secretary, Department of Health and Family Welfare, Government of Punjab


Expert speak Dr Vivek Logani,Chief of Joint Replacement Surgery, Paras Hospitals


Pekka Puska, D G, National Institute for Health and Welfare, Finland in conversation


cover story Rajeev Sadanandan, Director General and Joint Secretary, Labour Welfare, Government of India


Gopal Verma,Chairman, E–Meditek Group


S S Gopalarathnam,Managing Director, Chola MS


Ritesh Kumar, MD & CEO, HDFC ERGO


Antony Jacob,CEO, Apollo Munich Health Insurance Company Ltd


Shreeraj Deshpande,Head - Health Insurance, Future Generali India Insurance Company Ltd



november / 2013


Sanjay Datta, Chief – Underwriting and Claims, ICICI Lombard


Suresh Sugathan,Head – Health Insurance, Bajaj Allianz General Insurance


special focus (hospital infections)


Dr B K Rana,Joint Director, NABH


Professor Tom Elliott,Consultant Microbiologist at University Hospitals Birmingham


Dr Victor Rosenthal, Founder and Chairman, International Nosocomial Infection Control Consortium (INICC)


Dr Manju Chhugani, Principal, Rufaida College of Nursing, Jamia Hamdard

tech trend


Dr Sanjeev Sood,Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh


Dr Vidur Mahajan,Associate Director, Mahajan Imaging

zoom in


David McCallen, Director, Marketing Chief, Star Health Network


Dr Anurag Mehta,Director, Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre

Making Hospitalizations Shorter Making Hospitalizations Shorter Improving health and outcome of patients suffering from various types of diseases or illnesses is one of thehealth toughest challenges faced bysuffering the medical community Medical is Improving and of from types of or illnesses Improving health and outcome outcome of patients patients suffering from various various typestoday. of diseases diseases or Nutrition illnesses is is increasingly recognised as a key to effective disease management and improving clinical one of the toughest challenges faced by the medical community today. Medical Nutrition is one of the toughest challenges faced by the medical community today. Medical Nutrition is outcomes. recognised increasingly increasingly recognised as as a a key key to to effective effective disease disease management management and and improving improving clinical clinical outcomes. outcomes. Fondly called a the “Protein People” British Biologicals is a leading global nutraceutical company with over twoa of research Medical Nutrition,is the discovery, development, Fondly called the People” Biologicals a nutraceutical company Fondly called adecades the “Protein “Protein People”inBritish British Biologicals isengaged a leading leadinginglobal global nutraceutical company manufacturing and commercialization of innovative medical nutrition products for disease specific with over two decades of research in Medical Nutrition, engaged in the discovery, development, with over two decades of research in Medical Nutrition, engaged in the discovery, development, conditions. manufacturing and commercialization of innovative medical nutrition products for disease specific manufacturing and commercialization of innovative medical nutrition products for disease specific conditions. conditions. CrtiCare – A division of British biological was started in 2009 with the sole idea of bringing a new dimension medicalof by developing innovative products to support health and CrtiCare Atodivision division ofnutrition British biological biological was started started in 2009 2009 with the the sole idea ideagrowth, of bringing bringing a new new CrtiCare –– A British was in with sole of a wellness of people of all ages through disease prevention and management. Our products are dimension to to medical medical nutrition nutrition by by developing developing innovative innovative products products to to support support growth, growth, health health and and dimension designed to help health care professionals manage the nutritional needs of patients with a variety wellness of of people people of of all all ages ages through through disease disease prevention prevention and and management. management. Our Our products products are are wellness of conditions – health including cancer,manage diabetes, kidney disease, cardiovascular designed to help help health care burns, professionals manage the nutritional nutritional needs of of patients with with a adisease, variety designed to care professionals the needs patients variety refractory epilepsy and others. In doing we play a key role in not cardiovascular only bringing down the of conditions – including including burns, cancer,so,diabetes, diabetes, kidney disease, cardiovascular disease, of conditions – burns, cancer, kidney disease, disease, incidence of chronic diseases but also reducing the cost of treating them, making hospitalizations refractory epilepsy epilepsy and and others. others. In In doing doing so, so, we we play play a a key key role role in in not not only only bringing bringing down down the the refractory shorter and the quality of reducing lives of millions ofof patients. incidence of transforming chronic diseases diseases but also also reducing the cost cost of treating them, them, making making hospitalizations hospitalizations incidence of chronic but the treating shorter and and transforming transforming the the quality quality of of lives lives of of millions millions of of patients. patients. shorter

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asia’s first monthly magazine on The Enterprise of Healthcare volume




november 2013

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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 R P Printers G-68, Sector-6, 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. | | Send us your feedback for any of our Health news, interviews, features and articles. You can either comment on the individual webpage of a story, or drop us a mail:


november / 2013


Health is Wealth In a bid to extend health insurance coverage to the BPL population, Alappuzha district administration in Kerala has started registration of two lakh families under the Rashtriya Swasthya Bima Yojana. RSBY is a smart card based cashless health insurance policy initiated by the Central Government in 2008 and implemented across the country. Comprehensive Health Insurance Agency of Kerala (CHIAK) and Akshaya are the nodal agencies for RSBY in Kerala. Last month also witnessed similar initiatives in other states as well. The National Rural Health Mission in Assam announced to increase the information education communication (IEC) and capacity building activities among the BPL population. This initiative is aimed at attracting more people to the RSBY in the state. Additionally, the Odisha Government announced that it has selected four insurers to roll out its farmers’ health insurance scheme under the Biju Krushak Kalyan Yojana (BKKY). Such initiatives clearly signify the growing importance of health insurance in India. With rising healthcare costs and lifestyle diseases, health insurance has rather become a necessity for all sections of the society. The October issue of eHEALTH brings exclusive coverage of Health Insurance in India. The cover story features in-depth analysis of the growing market and interactions with leading industry stakeholders on the current challenges and opportunities. While the penetration of the market is currently small (10 percent of the total population in India), the World Bank has estimated it shall cover 50 percent of the population by 2015. The new IRDA guidelines and government schemes are catalysing the expansion. The issue also brings a special focus on Hospital Acquired Infections that kill more people than any other form of accidental deaths. Globally, more than 1.4 million patients are affected in a year by HAIs. With a well-documented guide on the Dos and Don’t for medical practitioners to avoid HAIs, the section delves deeper into the issue with interactions with experts. Yet another concern is the pace at which diabetes is spreading in India. With the number of diabetics estimated to go up to 70 million by 2025, India is emerging as the Diabetes Capital of the World, likely to replace China soon. As the World Diabetes Day approaches on November 14th, we find out about the growing popularity of sugar monitoring devices. Technology is increasingly penetrating in the healthcare industry. We bring you emerging trends in healthcare IT and medical technology segments as well.

Dr. Ravi Gupta

november / 2013



Health Care Providers to Spend $ 1 Bn on IT This Year Indian health care providers will be spending $1 billion (Rs 6,117 crore) on information technology (IT) products and services in 2013, an increase of 17 per cent over the last year, according to IT research and advisory company Gartner Inc. This forecast includes spending by healthcare providers such as hospitals and hospital systems, ambulatory service and physicians’ practices on internal IT and personnel, hardware, software, external IT services and telecommunications. Internal services will achieve the highest growth rate among the spending categories, which is forecast at 14.5 per cent in 2013. Internal services refer to salaries and benefits paid to the information services staff of an organisation.

Air Pollution as Bad as Tobacco, Causes Cancer

The International Agency for Research on Cancer (IARC), the specialised agency of the World Health Organisation, announced that it had classified outdoor air pollution as carcinogenic to humans. This is the first time that experts have done so and claimed there is sufficient evidence to prove it. After thoroughly reviewing the scientific literature, the experts convened by the IARC Monographs Programme concluded that there is sufficient evidence that exposure causes lung cancer. They also noted a positive association with an increased risk of bladder cancer. Particulate matter, a major component of outdoor air pollution, was evaluated separately and was also classified as carcinogenic. The predominant sources of the pollution are transportation, stationary power generation, industrial and agricultural emissions, and residential heating and cooking.



Docs need not Split Identities on Social Media Can physicians be among the billion-plus social media users and still maintain their intact personal and professional boundaries? Despite recommendations from professional organizations that say physicians should have separate personal and professional identities in order to respect their doctor-patient relationships, an editorial in the JAMA argues the line between professional and personal profiles can be blurred, as long as content they post is appropriate for public consumption. Rather than being a risk to their professional integrity, combining online presences is what physicians prefer. It is also “inconsistent with the concept of professional identity, and potentially harmful to physicians and patients. In addition, a strict separation of the professional and personal may cause patients to be less trusting and not see their doctors as people.

High-Risk Organs from Deceased Donors are safe Approximately 10 percent of deceased donor kidneys are considered “high-risk” for infection (HIV, HCV, HBV) and disease transmission according to criteria set by the Centers for Disease Control and Prevention. But new research suggests that many of these organs are safe and therefore should not be labeled as high risk. Results of this study will be presented at ASN Kidney Week 2013 Nov 5-10, 2013 at the Georgia World Congress Center in Atlanta. Researchers led by Moya Gallagher, RN, of New York-Presbyterian Hospital/Columbia University Medical Center, found that since 2004, a total of 170 patients received kidneys that met CDC’s high-risk criteria at Columbia University Medical Center.


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Stem Cell Research could Lead to Future Transplant Therapies A new method for creating stem cells for the human liver and pancreases, which could enable both cell types to be grown in sufficient quantities for clinical use, has been developed by scientists. Using the technique, researchers have for the first time been able to grow a pure, self-renewing population of stem cells specific to the human foregut, the upper section of the human digestive system. These so-called “Foregut stem cells” could then be developed further to produce liver or pancreatic cells. The method significantly improves on existing techniques for cultivating this type of stem cell, and raises the possibility that, with further work, they could be grown in large numbers in bioreactors. That would make it possible to use them for regenerative therapies, repairing damaged organs or tissues in the body, and treating conditions such as type I diabetes or liver disease.

Pathway Links Heartburn and Esophageal Cancer More than 60 million adults in the U.S. have acid reflux, or heartburn, and approximately 10 percent are at risk for developing esophageal cancer, due in part to complications from Barrett’s esophagus. But researchers at Rhode Island Hospital discovered a pathway they believe links Barrett’s esophagus to the development of esophageal cancer. Their data suggest that blocking this pathway, such as with a proton pump inhibitor (e.g. omeprazole), may prevent the development of esophageal cancer. The study is published online in advance of print in the journal American Journal of Cell Physiology.

Adding Pharmacist to Web-based Care still Cost-effective A web-based program for managing patients with high blood pressure that included a pharmacist component was cost-effective, according to a study published online Sept. 16 in the American Journal of Managed Care . Researchers from the Group Health Research Institute in Seattle previously reported on the success of the Electronic Communications and Home Blood Pressure Monitoring to Improve Blood Pressure Control trial. They randomized patients in the Group Health Cooperative who were diagnosed with hypertension and were on medications to one of three groups: usual care; usual care plus home blood pressure monitoring (BPM); and usual care, home blood pressure monitoring plus pharmacist care (e-BP). They found that blood pressure control improved in 56 percent of the e-BP group, 36 percent of the BPM group and 31 percent of the usual care group. The e-BP group experienced the greatest reduction in systolic and diastolic blood pressure.



Researchers Close to Unlocking Adenomyosis

For the first time, researchers have created a model that could help unlock what causes adenomyosis, a common gynecological disease that is a major contributor to women having to undergo hysterectomies. In a two-step process, a team led by Michigan State University’s Jae-Wook Jeong first identified a protein known as beta-catenin that may play a key role in the development of the disease. When activated, beta-catenin causes changes in certain cells in a woman’s uterus, leading to adenomyosis.

WHO Informed of New Case of Human Infection with H7N9 Virus The National Health and Family Planning Commission in China has notified the World Health Organization (WHO) of a new laboratory-confirmed case of human infection with avian influenza A(H7N9) virus. The patient is a 67-year-old man from Zhejiang Province. He is a farmer, and has had contact with live poultry. He became ill on Oct 16, 2013, was admitted to a local township hospital on Oct 18, 2013, and was transferred to another hospital on Oct 21, 2013 as his condition deteriorated. He is currently in a critical condition. To date, WHO has been informed of a total of 137 laboratory-confirmed human cases with avian influenza A (H7N9) virus infection including 45 deaths.


Leading the Way in Health Insurance Punjab is among the star performers under the Rashtriya Swasthya Bima Yojana. Vini Mahajan, Principal Secretary, Department of Health and Family Welfare, Government of Punjab, talks to ENN about the initiatives What initiatives have you taken to bring about improvement in healthcare in Punjab?

Vini Mahajan,

Principal Secretary, Department of Health and Family Welfare, Government of Punjab


november / 2013

The Health and Family Welfare Department is committed to provide preventive and curative health services to the people of the State through an efficient network of medical institutions, such as sub-centres, subsidiary health centres, which include dispensaries, clinics, etc; primary health centres; community health centres; sub-divisional and district hospitals, government owned medical and dental colleges. We have initiated large number of schemes covering all aspects of healthcare. This includes schemes for certain specified sections of population like the Mother and Child Tracking System under NRHM. I would also like to tell you about a very special scheme we have launched that is unique in the country. Under this scheme every girl child will get free medical treatment up to the age of five in all government hospitals. The Health Department has announced that it will give an amount of Rs 1,000 to expectant mothers at the time of delivery under Mata Kaushalaya Kalyan Yojana (MKKY). This scheme is meant to promote institutional deliveries in the government hospitals. Our emergency response ambulance service ‘108’ is doing very well. We have implemented essential drugs list through which we provide many kinds of drugs and treatments

totally free of cost to patients who come to government hospitals. We provide generic cancer drugs, which are very expensive, at subsidised rates.

What steps have you taken to make health insurance affordable for the poor? The Ministry of Labour and Employment has launched Rashtriya Swasthya Bima Yojana (RSBY) to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalisation. Beneficiaries under RSBY are entitled to hospitalisation coverage up to `30,000 for most of the diseases that require hospitalisation. The Ministry has noted that Punjab is one of the star performers under RSBY. The state has also launched its own health insurance scheme for other poor families who have not been categoried under BPL. Additionally, the state government, through the Department of Cooperative, is running Bhai Ghanhya Sehat Sewa Scheme. The scheme aims to provide the cashless healthcare facilities and treatment to the members of the Cooperative societies and their family members across the state.

How is the department addressing the challenge of dearth of doctors in rural areas? There were some problems in recruitment process in the past due to which there was lack of good doctors in rural areas. Now we are doing recruitments in a manner that is geared to achieve certain outcomes. We have recruited 300 MBBS medical officers in the recent past. We also conduct regular walk-in interviews for specialists. In addition, we are focusing on maximum optimum utilisation of resources. Punjab already has good infrastructure and ambulance services. We plan to build many more hospitals in all parts of the state. There will be 22 district hospitals, 41 sub divi-

Key Initiatives  Free medical treatment to every girl child up to the age of five years in all government hospitals  Mata Kaushalaya Kalyan Yojana offers grant of Rs 1,000 to mothers at the time of delivery in order to promote institutional deliveries in government hospitals  Successful emergency response ambulance service ‘108’  Essential drugs and treatments provided free of cost to patients in government hospitals

What steps are you taking to provide healthcare services to the urban poor? No paperwork is required in government hospitals for patients to avail medical treatment. The government has launched National Urban Health Mission (NUHM) to bring improvement in the healthcare services in urban cities. This scheme will cover 41 cities across the state of Punjab. The NUHM will meet health needs of the urban poor, particularly the slum dwellers by making available to them essential primary healthcare services. This will be done by invest-

Bhai Ghanhya Sehat Sewa Scheme aims to provide cashless healthcare facilities to the members of Cooperative Societies and their families across the state sion hospitals and 37 block community hospitals. We are also in the process of upgrading infrastructure in our hospitals. In order to encourage doctors to work in rural areas, we are providing certain incentives. And we are getting good response from there.

ing in high-calibre health professionals, appropriate technology through PPP, and health insurance for urban poor. We are identifying urban slums where we will provide preventative and curative healthcare services to the people.

In what ways are you using IT for delivery of healthcare services?

Tell us about the status of medical education in Punjab.

We are also using Direct Benefit Transfer (DBT) for transfer of funds under the Janani Shishu Suraksha Karyakram. In this case we are getting good response. We are using Information Technology in a big way to reach out to the people and acquaint them of various aspects of healthcare. With the help of IT, we monitor work done under NRHM. We are also using IT to track the status of pregnant women. We have installed a very good Hospital Information Management System. We are monitoring the performance of our doctors and institutions online. We are using IT for both data management analysis and disseminating information.

Today, Punjab has two state-run medical colleges, both of which are very well regarded. Many leading doctors in the country have graduated from here. Then we have one medical college at Faridkot that is run by Baba Farid University, which is a state university. We also have a number of good private medical colleges in the state. We also have a good network of nursing training in Punjab. We are now working on skill training and we have set up an expertise committee that has identified certain specified courses that can be introduced in university curriculum for further improving the scope of education being imparted.

november / 2013



Setting a Benchmark

in Public Healthcare Pankaj Kumar Bansal, Ex-officio Special Secretary, Health and Family Welfare Department, Government of Tamil Nadu, talks to Elets News Network (ENN) about why Tamil Nadu has low mortality rates and effective healthcare services for citizens

Please provide an overview of the work that NRHM is doing in Tamil Nadu. The aim of NRHM (National Rural Health Mission) in Tamil Nadu is to provide universal access to equitable, affordable and quality healthcare services. Efforts are being made to add and operationalise new urban and rural PHCs (Primary Healthcare Centres) and provide support for strengthening secondary and tertiary care centres as well. All the PHCs are manned by two Medical Officers so that the quality of care remains universal. New PHCs are established every year and we are also in the process of upgrading one PHC in each block into an Upgraded PHC with 30 beds and better infrastructure. One upgraded PHC in each Health Unit District is being developed into a comprehensive MCH Centre which can handle obstetric emergencies including caesarean section. These centres are adequately provided with manpower and equipments. Tamil Nadu is the only state in the country where almost 70 percent of deliveries take place in government institutions.

Pankaj Kumar Bansal,

Ex-officio Special Secretary, Health and Family Welfare Department, Government of Tamil Nadu


november / 2013

NRHM has strengthened the infrastructure and provided high-end equipments in the Secondary Healthcare Sector, supplementing the inputs by the World Bank funded Tamil Nadu Health System Project. In the Tertiary Healthcare Sector, focus is provided more on very high quality MCH care and every year two medical colleges are strengthened into RCH - Centre of Excellence with additional buildings, equipments and manpower.

Most young MBBS doctors do not prefer to work in rural areas. In what ways are you encouraging them to opt for rural areas? Tamil Nadu is one of the few states in the country with minimum vacancy in healthcare sector, even in rural areas. Credit goes to our recruitment system through which we have successfully encouraged doctors to work in rural places. We have set up Medical Recruitment Board, which is an organisation entitled to recruit doctors by conducting examinations. Recently we have recruited more than 1,500 doctors. We have 19 medical colleges in the state and around 50 percent of

Service to the Public Tamil Nadu Medical Services Corporation Ltd (TNMSC) was set up in 1994 with the primary objective of ensuring easy availability of all essential drugs and medicines in government medical institutions throughout the state. It is engaged in the procurement, storage and distribution of: •

268 drugs and medicines, 84 suture items and 63 surgical items to various Government Hospitals, Primary Health Centres and through them to the health sub-centres across the state.

114 veterinary drugs to various veterinary dispensaries under the control of the Directorate of Animal Husbandry.

The bulk purchase of medicines and other items through TNMSC brings down the prices. Also, suppliers are aware that there should be no compromise in the quality of drugs and other supplies else they would be blacklisted. TNMSC also ensures that there is no shortage of medicine in any government hospital.

Three-staff nurse model in PHCs has increased the number of deliveries in PHCs from few thousands to 3 lakhs post graduate seats are reserved for government doctors. A doctor is entitled for two marks for every year of service in rural areas in his PG entrance exam. Moreover, the facilities and infrastructure available in rural PHCs are at par with medical standards. This gives doctors the satisfaction of putting their medical education to effective use, hence encouraging them further to serve in rural areas.

What has been NRHM’s most significant achievement in Tamil Nadu the past ten years? Tamil Nadu is ranked among the highperforming states in India, in the area of human resource development. The state is noted for its low mortality rates and effective healthcare services for which NRHM has been catalytic in the last decade. The three-staff nurse model in PHCs has enhanced service availabil-

ity and has ensured that there is one skilled birth attendant at any point of time to provide quality service or appropriate referral to higher centres without delay. This along with the improved facilities and infrastructure has increased the number of deliveries in PHCs from few thousands to 3 lakhs at present. This has also enabled us to make all 1,614 PHCs as 24x7 centres for maternity care. This model is being emulated by other states also. NRHM has significantly contributed to the fall in IMR (Infant Mortality Rate) in the state. Under NRHM, 47 NICUs (Neonatal Intensive Care Units) and 42 NBSUs (New Born Stabilisation Units) have been established, while 17 NICUs and 114 NBSUs have been strength-

november / 2013



Maternity Benefits Dr Muthulakshmi Reddy Maternity Benefit Scheme by the Government of Tamil Nadu offers financial assistance of Rs 12,000 to pregnant women from poor families. The grant is given in three instalments: • 1st Rs 4,000 after minimum of three ante-natal check-ups at the end of seven months ened. With support from NRHM, the state has added 211 New PHCs and in the current year 118 New PHCs are in the pipeline. It is noteworthy that 209 PHCs have been upgraded with 30-bedded facilities and we have planned to upgrade 60 more in the current year. 385 Mobile Medical Units are functioning as Hospital on Wheels at one per block. This caters to the people in remote areas by providing healthcare at their doorsteps. Tailor-made healthcare plans are being executed for the tribal population. Birth waiting rooms are provided in tribal areas where the pregnant mother along with one relative can stay well before her expected date. Their food and other expenses during the stay are being met from NRHM allocation. Other than Maternal and Child Healthcare Services, we have created Provision of Emergency Management Services through “108” ambulances with a ‘response time’ of less than 15 minutes in urban areas and 20 min-


november / 2013

• 2nd Rs 4,000 after the baby is delivered in a government institution • 3rd Rs 4,000 when the baby completes immunisation up to the third dose of DPT Criteria for Benefits • The woman should be 19 years and above utes in rural areas; Inter-sectoral Coordination with the Departments of School Education, Sarva Shiksha Abhyan and SCERT; mainstreaming of AYUSH (Ayurvedha, Yoga & Naturopathy, Unani, Siddha and Homeopathy) services; Palliative Care services (next to the state of Kerala); hierarchal steps to reduce the prevalence of preventable blindness from 1.4-0.3 percent through involvement of NGOs; entrusting the public with increased awareness about health related issues both Communicable and Noncommunicable and many others.

What are the challenges in managing a robust healthcare sector in Tamil Nadu? Huge infrastructure is required to provide efficient and effective healthcare to the people. At present, we have the capacity to admit about 70,000 in-patients in all government facilities of the state. Every year we are constructing new buildings and increasing the manpower

• She should belong to the BPL category Under this scheme, Rs 600 crore is currently being transferred to more than three lakh beneficiaries annually. The entire process is online for which it has linked all PHCs in the state with broadband connectivity.

in these facilities to meet the increasing needs. Today the state has 19 Government Medical Colleges and every year we are improving our medical education system by increasing the number of seats and by opening new medical colleges. But our main challenge lies in addressing the gaps in effective coordination among all the health directorates. There are certain areas of Health Provision which need to be strengthened and we also need to involve the private sector for better outcome in those areas. In fact, we are already partnering with many private organisations for implementing the Chief Minister’s Comprehensive Health Insurance Scheme for the people. Also we are involving the Private Sector, wherever necessary, in all high-end requirements. We have made a detailed plan and hope to address the health needs of large number of poor people who live in urban areas and in urban slums through the forthcoming Urban Health Mission.

Cover Story

th ce n al He ura s In

Covering the Cost of Healthcare Rising healthcare expenses, lifestyle diseases and increasing awareness among citizens have together boosted the growth of health insurance in India. The new IRDA guidelines and government schemes are catalysing the expansion. Monalisa, ENN, explores the dynamics of the evolving market


ealth Insurance is among the most rapidly evolving sectors in India, with a compounded annual growth rate of 37 percent. In the Indian non-life insurance industry, health insurance is the second largest segment after motor insurance. While the penetration of the market is currently small (10 percent of the total population in India), the World Bank has estimated it shall cover 50 percent of the population by 2015. This growth can be attributed to the combined efforts of Health Insurance providers, Third Party Administrators (TPAs) and various govern-


november / 2013

ment sponsored schemes such as the Rashtriya Swasthya Bima Yojana.

Market Size “The market size for health insurance for the year 2012-13 was `15,341 crore, which was about 22 percent of the overall non-life premiums. It is likely to be anywhere between 17,500 to 18,000 cores by March 2014,� says Shreeraj Deshpande, Head - Health Insurance, Future Generali India Insurance Company Ltd. According to Insurance Regulatory and Development Authority (IRDA) data, the health insurance industry expanded at a compounded annual

growth rate of 33 percent from 200612. Also, the total number of health insurance policy holders grew from 8.3 million in 2004 to 200 million in 2011. Industry research and consultancy firm, RNCOS, states that health insurance premiums recorded a growth of 14.05 percent from `115 billion underwritten in 2010-11 up to `131 billion underwritten in 2011-12. The premiums are expected to increase at a CAGR of 30 percent during 2012–14, and reach up to `505 billion by 2016.

Growth Triggers Rising incomes and greater awareness have added fillip to the Indian

health insurance market, providing lucrative growth avenues for both the existing players as well as new entrants. “With increasing concern among middle class over lifestyle diseases and increasing government investment in the healthcare industry, the health insurance market sets out vast opportunities for companies planning to penetrate the market,” says Shushmul Maheshwari, Chief Executive, RNCOS. “The market is promising for industries which can devise strategies to overcome challenges of limited product range, price and awareness which restrain the growth,” he adds. High healthcare costs have further accentuated the need for health insurance. Coupled with this is the emergence of multi-speciality hospital chains in metro cities, which have raised the quality and cost of healthcare, hence making health insurance the need of the times. Meanwhile, programmes such as insurance offered by NGOs; community-based health insurance; corporate insurance policies; and government sponsored schemes have enabled low-cost health insurance facilities to the citizens. “The Rashtriya Swasthya Bima Yojana is one such initiative,” points out says Pompy Sridhar, Financial Sector

“The market is promising for industries which can devise strategies to overcome challenges of limited product range, price and awareness” Shushmul Maheshwari, Chief Executive, RNCOS

Development Specialist and Consultant Health Insurance. “Such platforms overcome the handicap of poor rural connectivity and allows for real-time administration of health insurance schemes. They also improve dramatically the viability of the supply side by offering a sustainable business model at lower costs to the intermediary / providers of healthcare through captive volume,” she adds.

Challenges However, despite the best efforts by the regulator, the government and industry stakeholders, the health insurance sector is gripped by a couple of challenges, primary among them being high incidents of fraud claims, lack of standard practices across the industry and long turnaround times for claims settlements, hence keeping the policy holder waiting and dissatisfied. Add to this the low awareness,

Health Insurance Premium (INR Billion) 600 505

500 380

400 294

300 170



131 100 0


2012-13 2013-14*

Source: IRDA, RNCOS; * RNCOS Forecast




lack of understanding of product features and perceived apprehensions in claims procedures and settlement, which further demotivate consumers from buying a health cover. “Quantification of benefits provided under health insurance covers and consistent service standards remain the biggest challenge and are a must to build trust in this sector,” says Sridhar. Also, high claims ratios and inaccurate data regarding consumer profile, disease patterns, etc often act as detrimental factors for insurers in product pricing or development of new products. Another growing concern is the rise in the demand for customised health insurance plans that most enterprises are providing to their employees. This has resulted in huge and multiple formats of data for insurers and TPAs to manage. “There is the cruicial need for data analytics to empower stakeholders through provision of accurate, timely and reliable data. Easy availability, granularity and quality of data can help in more efficient decision making and pricing strategy,” says Suresh Sugathan, Head – Health Insurance, Bajaj Allianz General Insurance. “We have developed an inhouse capability of managing varied requirements of our corporate customers on the bedrock of a robust IT framework. This facilitates a flexible benefit set-up template that allows for various combinations of benefits and Sum insured to be clubbed into a single policy,” says Anuj Gulati, CEO, Religare Health Insurance Company Ltd.

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Policy Change The recent IRDA guidelines are a step to address some of these challenges. With the aim of improving service standards in the health insurance sector, IRDA announced a host of new guidelines this year. First of all, it has standardised 46 most commonly used definitions/terms/conditions in health insurance policies. In order to avoid confusion and reduce turnaround time in claims settlements, the regulator has also standardised pre-authorisation and claims forms to streamline processes at all stages. Most insurers have welcomed these pro-customer initiatives. “There are around 400 health insurance products available in India with various insurance companies. It is

“IRDA’s mandate on tripartite agreement between hospitals TPAs and insurers does away with any variance and ambiguity in the role of each stakeholder” Anuj Gulati, CEO, Religare Health Insurance Company Ltd

Interestingly, the new policies have redefined the role of TPAs as well. IRDA has mentioned that hospitals, insurers and TPAs will now have a tripartite agreement instead of the conventional bilateral agreement between TPAs and hospitals. “This encourages transparency between the stakeholders and also

“Quantification of benefits provided under health insurance covers and consistent service standards remain the biggest challenge and are a must to build trust in this sector” Pompy Sridhar, Financial Sector Development Specialist and Consultant Health Insurance indeed difficult for the customer to choose the best plan for himself when every cover is defined differently,” says S S Gopalarathnam, Managing Director, Cholamandalam MS General Insurance Company Ltd. “The new IRDA health insurance regulations will not only help in bringing a lot of transparency to the customers but also make it easier for customers to compare various benefits/coverage of different health insurance products available across the companies,” he adds. Agrees Sugathan: “Standardisation of medical terms, procedures, claim forms, exclusions and agreements, etc will reduce ambiguity which existed in the market due to variable interpretation of key policy terms.”


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places ownership of the transaction with the Insurance Company, ensuring better servicing and high levels of standardization for the customer,” says Gulati. “The tripartite agreement between the Insurer, TPA and the Hospital makes the Insurer the owner of the Network and ensures standardisation of services levels to the customer,” adds Gulati.

Future Trends With collective efforts by all stakeholders, the future seems bright for the industry. The gap between healthcare expenditure and that covered by health insurance in India is huge, up to USD 57 billion. This is projected to exceed up to USD 200 billion by 2020, which presents a huge opportunity for

health insurance to emerge as a viable financing mechanism for growing healthcare spend. “The health insurance sector in the country will continue to grow between 15-20 percent for the next five years. The focus will have to be on how the retail segment can grow much faster and how group health, which at present is a loss-making business for the insurers, starts turning around,” says Deshpande. Market players foresee the emergence of OPD insurance in a big way, apart from the rise of disease and case management for patients. “Sixty percent of healthcare spend in India is now in OPD and most of it is out-ofthe-pocket. So we are looking at how we can cover that aspect of business and have started offering it as an addon with some of our products,” says Sanjay Datta, Chief – Underwriting and Claims, ICICI Lombard. “Globally the trend is to offer OPD with hospital coverage so we may see similar offerings in India soon,” he adds. Conditions that are rare, cosmetic surgery, congeniality diseases, infertility are not covered in India. Going ahead, these might evolve as separate products going further. Even AIDS has the possibility of coverage in future. “Some of the emerging trends to arise include: programmes to predict, detect and address medical problems; diseasespecific products; employee sponsored wellness activities; empanelment of specialist physicians; HIS and Patient Health Records,” says Sugathan.

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Paying for the Poor’s Treatment Rajeev Sadanandan, Director General and Joint Secretary, Labour Welfare, Government of India, talks to Monalisa, ENN, about the Rashtriya Swasthya Bima Yojana that provides health insurance to low income workers


ith more than 3.6 crore enrolled beneficiaries and 10,887 empanelled private and public hospitals under its ambit, the Rashtriya Swasthya Bima Yojna (RSBY) is set to provide health insurance coverage for Below Poverty Line (BPL) families across the country. Launched in 2008 by the Ministry of Labour and Employment, Government of India, RSBY aims to provide protection to BPL households from medical expenses. “Our first priority is that the programme achieves breadth and depth in coverage.. This means, to cover as many poor as possible and also ensure that in every BPL family, all members are covered,” says Rajeev Sadanandan, Director General and Joint Secretary, Labour Welfare, Government of India, who is currently heading the scheme.

Operating Model This scheme entitles beneficiaries to hospitalisation coverage of up to Rs 30,000 in lieu of a registration fee of `30. Coverage extends to five members of the BPL family who are issued smart cards for the same. The Central and State Governments pay the annual premium to the insurer selected by the State Government on the basis of a competitive bidding. The majority


november / 2013

Rajeev Sadanandan,

Director General and Joint Secretary, Labour Welfare, Government of India

of this premium, about 75 percent, is provided by the Central Government, while the remainder is paid by the respective State Government. After the insurance company is selected, they need to empanel both public and private healthcare providers in the project and nearby districts. “Our next priority is to increase the access of hospitals in remote corners of the country. If people do not have access to hospitals close to their place, the cost of commutation will increase more than the healthcare cost that we pay them,” points out Sadanandan.

cards feed real-time data into the software. “This data is available at our server in a uniquely identifiable fashion. When a person swipes his smart card for claiming health insurance, incidence of that disease is linked to his demographic profile. We get to know the policy details, claims history and other details of the respective policy holder,’ he says. This generates a huge amount of data that is very useful for the health department. This can generate alerts for an epidemic or health hazard for a particular region. “While smart cards have been ac-

Key Features Safety – The use of biometric-enabled smart card containing the beneficiary’s fingerprints and photographs makes this scheme safe and foolproof Portability – An enrolled beneficiary can use his smart card in any RSBY empanelled hospital across India. This is especially beneficial for migrant workers Cashless – An enrolled beneficiary gets cashless benefit in any of the empanelled hospitals by showing his smart card Robust Monitoring – An elaborate back-end data management system is being put in place which can track any transaction across India and provide periodic analytical reports

volvement of the Ministry of Housing and Urban Poverty Alleviation for sanitation workers; Transport department for auto and taxi workers; Ministry of Rural Development for NREGA (National Rural Employment Guarantee Act) beneficiaries and so on. Hence, we are trying to use IT to leverage the presence of other departments in the scheme by creating a win-win situation for all,” says Sadanandan. “The core issue is how to get a unified list of beneficiaries as each department has its own IT division. In fact two different programmes of the same Ministry do not talk to each other,” points out Sadanandan. “We are working with the Ministry of Rural Development to ensure that our databases talk to each other and lead towards unified output. We are also focusing on removing duplication from our respective databases and checking on how our coverage is enabling them to assess their achievement. So this integration could help both departments,” he says.

Challenges When an enrolled beneficiary walks into an empanelled hospital, his identity is verified by his smart card and his fingerprint. After rendering the service to the patient, the hospital sends an electronic report to the insurer/Third Party Administrator (TPA), who after going through the records makes the payment to the hospital. “States which are pro-active in public healthcare have shown the greatest interest in the RSBY programme and have reaped maximum benefits from it. These include states like Chhattisgarh, Himachal Pradesh and Kerala,” says Sadanandan.

Tech-savvy Scheme Talking about the IT architecture in RSBY, Sadanandan says that smart

tive since the beginning of RSBY, we are now moving towards electronic health records. The problem with EHR is to record the data and make it available to clinicians at the time when patients walk into the clinic. Lack of connectivity is a big problem. But if the data is stored in the smart card this can help clinicians even in remote hospitals. Of course safeguards to ensure data security and privacy have to be put in place,” he points out.

Data Integration Sadanandan emphasises the need for data integration, especially because the Ministry of Labour is now working with different departments in order to expand the list of RSBY beneficiaries. “This will bring in-

Sadanandan raises concern over lack of standards, which pose as a major challenge for the healthcare sector. “Standardised clinical pathway is the protocol that is followed when a patient walks into a hospital with a particular symptom. If these pathways are not in place, you cannot have standards and then quality could get compromised. This is a necessary condition for a good insurance programme,” he says. “Second is ensuring quality of hospitals, which is linked to standards used in accreditation. Third is to having an efficient data capture system. Also to ensure that we have efficient data analytics tools. The financial system should be in place for immediate reimbursements,” he adds.

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Offering an End-to-End Link Gopal Verma, Chairman, E–Meditek Group, has spent almost two decades in the insurance industry. He interacts with Monalisa, ENN, about the integral role that Third Party Administrators play in the health insurance supply chain


ith 31 insurance companies and 10,000+ health providers under its network, E-Meditek (TPA) Services Ltd is among the leading Third Party Administrators (TPAs) in the health insurance sector in India. Its TPA services include cashless hospitalisation at network hospitals/ nursing homes; policy holders’ enrollment, online profile management; round-the-clock helpline; claims adjudication, payments and negotiation of tariffs and discounts; Data Analytics and Underwriting Support, etc. Moreover, it offers additional services such as Pre-Policy Health Check-ups, RSBY (Rashtriya Swasthya Bima Yojna) Implementation and Hospital Bill Re-pricing for overseas travel claims, thus offering an end-to-end solution in the health insurance sector.

holders, TPAs play many roles at multiple levels. “Many times policy holders call on our customer care to enquire about policies, claim limits, hospitals networks, etc. So we provide post-sales call centre services too,” he adds. In fact, TPAs have brought in a revolutionary change in the health insurance sector, making it more customerfriendly. “TPAs were introduced in 2001-02, after which cashless facility was introduced to the masses. People started seeing value in health insurance. This marked the beginning of health insurance growth in the country, which is now growing at 25 percent year-on-year,” explains Verma.

Versatile Role “TPAs have become an integral part of the health insurance supply chain,” says Gopal Verma, Chairman, E–Meditek Group. Right after the sale of the policy, the service interface is assigned to the TPA with respect to all claim related services. Right from enrolling customer data to providing all relevant information to the policy


november / 2013

Gopal Verma,

Chairman, E–Meditek Group

Controlling Costs

Technology Adoption

One of the core competencies of TPAs lies in controlling cost of claims. Thanks to them, the average cost of health insurance claims has remained much lesser than the normal inflation rate of the country. “In 2002, average claim size was `14,000 (which in present time would be valued up to `40,000). This has grown up to `30,000 now, which is still less than the rate of inflation. This proves we have been able to control cost of claims, else, insurance companies would have been compelled to increase their premiums,” says Verma. This is primarily because TPAs act as aggregators and deal with large volumes of data. “For instance, in E-Meditek we are aggregating data from all 31 insurers into one entity. This way we also get lots of leverage in negotiating with healthcare providers,” explains Verma. “Secondly, our constant monitoring system during treatments also helps us to overrule unnecessary procedures, exaggeration of bills, hospital overstays, etc, thus keeping costs under control” he adds.

Technology is an essential tool that can help address most challenges of the sector. “E-Meditek is much ahead of its times as far as IT implementation is concerned,” says Verma. “For instance, IRDA guidelines says that hospital tariffs, discounts, package rates, etc should be accessible to the policy holders. We launched our online portal way back in 2007, and currently 4-5 insurance companies are approving claims using our claims management software,” informs Verma. Another achievement has been the TPA’s paperless operations. “The mo-

Challenges Despite being such an important stakeholder in the industry, TPAs face a couple of challenges. “The biggest roadblock is the lack of system integration,” points out Verma. “When a patient reports to a hospital, his policy record for a couple of years should be accessible to the TPA. But because system integration between TPAs and insurance companies is not of that magnitude, the TPA is often unable to access the relevant policy data immediately, and hence cannot deciding whether to admit the liability or not,” adds Verma. This often leads to delays in claims settlements or putting treatments on hold, thus leaving the policy holder dissatisfied.

nology being used in various government initiatives including the RSBY.

Corporate Wellness Integration of wellness services with corporate is another interesting initiative. “We are offering end-to-end wellness services to corporates. This includes creating awareness and education for preventive healthcare and providing basic medical services. We are also operating 180+ medical rooms in various corporate offices across the country,” says Verma. “This is an initiative taken up by corporate with the aim of adopting a proactive approach

TPAs introduced cashless facility to the masses, which marked the beginning of health insurance growth in the country ment any document enters our office, it is scanned and thereafter the entire team works on scanned copy which bears the claim number and policy number. We are not doing it for mere archiving purpose after claim settlement is done. Rather we do it right at the beginning, so that the entire process of verification and claims settlement can be done online,” says Verma. “Last month we started our mobile app for policy holders to access claims information, claims tracker, cashless tracker, hospital search, hospital tariff, etc. on phone. Any information that the customer would need is present in the mobile app. We are soon going to launch it,” says Verma. The Group has recently won an International Award for Best Consumer Prepaid Programmes and has been a finalist in the category of Best Global Prepaid Innovation. It has won another FIPS Award in India for its Bio-Metric Card that has the potential to replace the current tech-

in healthcare, thus reducing cost of claims,” he adds.

Way Forward Verma is optimistic about the growth of health insurance sector and says that by next year it might overtake motor insurance which is currently the leading segment in non-life insurance in India. According to him, outpatient and dental insurance are likely to emerge in a big way. “Outpatient treatment constitutes 67 percent of total healthcare expenditure. This clearly shows that a larger pie has remained untapped by the insurance sector,” says Verma. This has primarily happened due to small tickets size (claim amounts) and high risks of misuse – issues which can be addressed by IT. “eMeditek is designed to meet both the challenges. We have the provision of giving online approvals for treatments and have access to real-time information. This will make the entire process instant and online,” he concludes.

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Automation is the New Buzz S S Gopalarathnam, Managing Director, Cholamandalam MS General Insurance Company Ltd, talks to Monalisa, Elets News Network (ENN), about how automation, right from sales to workflows, enables seamless communication lysed, patterns of frauds do emerge – whether there is a nexus between hospitals, patients and treatments being provided. Data can also throw aberrations where one particular claim is large as compared to same treatment for other patients elsewhere. Medical treatment has evolved in countries like the USA where uniform standards and codes are followed across hospitals, pharmacies, insurance companies, etc, resulting in faster claim settlement, subrogation claims as well as detection of frauds. We will find the same happening in India as well. S S Gopalarathnam,

Managing Director, Chola MS

What are the most pressing challenges for health insurance companies in India? The most pressing challenge for a health insurance company is to avoid any kind of leakages / fraud / over-billing during claims. We believe that up to 30 percent of the total health claims paid in a year are due to these factors. It is important that such frauds are completely controlled, else the profitability of health portfolio of any insurance company will always be under pressure.

How can IT help address other issues such as frauds in claims, data management, etc? When large volumes of data are ana-


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How has technology adoption impacted your operations? Sales automation through ‘Health Proposal on the GO’ enables our agents to distribute and sell policies to the end-customer through mobile devices. Capture of information like personal details, photos and scans and upload of information from anywhere, helps in instant issue of policies by mail. Fax automation through Right Fax server, enables all hospitals to send fax. This is automatically mailed to approving authorities, who are able to validate and verify the data and provide the necessary approvals. The TAT for cashless approvals has been 35 minutes last year, one of the best in the industry. Workflow automation of health proposal has again improved trans-

parency across stakeholders, reduced TAT, etc. Automatic escalation lets in quicker disposal of proposal quotes. Workflow automation of claims is underway for Health LOB. Moreover, a mobile app ‘Wellness’ is being developed. This will have many features for the customers such as his health card on mobile; QR code capturing his policy details; a tracker to follow-up on his medical fitness levels like BMI, blood sugar etc; a pedometer to track his exercise regimen; a GPRS-enabled hospital locator, and so on. This will be supplemented by a hospital app to read the health card and trigger cashless approvals.

In what ways can Information Technology help fill the gap between insurance companies, TPAs and hospitals? Information Technology can help fill the gap on information availability between Insurance Companies, TPAs and Hospitals which will have benefits on many fronts. This will help reduce the turnaround time (TAT) for cashless approvals which also gives the end-user a great mental relief and assurance. This shall also enable streamlined flow of information from hospitals to TPAs, as required for claim settlement by insurance companies, thus avoiding repeat requests for documents and increase FTR percent.

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IT is Cornerstone

for Scalability Ritesh Kumar, MD & CEO, HDFC ERGO speaks to Rachita Jha, ENN, about the role of technology in shaping the insurance industry Your reflections on the low rural penetration of insurance in India. There are two aspects, one is that insurance sector is in some ways a reflection of the overall economy. As an industry we insure the existing asset and incremental asset, and a direct co-relation if the incremental asset is suffering so is our industry. Rural penetration of insurance in India is a concern. More than 70 percent of the population lives in the rural India and 15 percent of this population has a socio-economic profile that is akin to the urban population, so we are talking about 150 million people who have spending powers in rural India and problem really lies in distribution and logistics. Thus there is significant under-penetration, there are fewer schemes that are customized to their needs and reaching out to this dispersed population is a challenge. However, there is an increased focus on addressing this lacunae and schemes such as the RSBY has given the desired push from the government as well.

What were the key success factors of RSBY? Today, the world is trying to learn on success story of RSBY. The scheme has made it possible for health benefits to reach the target audience and right beneficiaries for the first

Ritesh Kumar, MD & CEO, HDFC ERGO

time, and it has been successful only because it is using IT. That was the cornerstone of the scheme, it is an automated process. The government has been very forthcoming in partnerships. Out of the four districts that we have done in Bihar, we have already covered 60,000 claims, that to when we are one of the partners and also a late entrants. The challenges are of fraud prevention and that continues to be in health claims and all other insurance sectors.

Tell us on the IT initiatives at your company, how can mobile technology been used? As a company last year we issued close to 3.4 million policies, 5 million

customer base, we handle 350,000 claims, and if we can service these policies appropriately and each one of policy holders gives back a positive feedback. So we have created a customer experience management set-up and largely cater to post-policy holders and have a cap on grievances and complaints of customers. About 88 percent of the policies we issue are on fully automated model. As an industry, we are hugely paper driven in policy issuance, claims, renewal – all are primarily on paper. We are not yet authorized to give an electronic form of policy. Hence, the insurance industry cannot be paperless. We have Insurance Portfolio Organizer (IPO) which is a mobile app that gives all the details of the policy and can help you connect with nearest cashless hospitals, we also provide our customers to track the status of their claims. Thus today mobile offers us a convenient and easy connect with our customers to offer them our services anytime anywhere. Considering that each year we issue 12 crore policies, have 3 crore claims and 15 crore transactions every year, for the industry as a whole, technology will be an important tool to bring-in efficiencies and cost benefits,. Thus, unless we leverage on technology, the cost of delivery will be too high.

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in Tier-III Cities Antony Jacob, CEO, Apollo Munich Health Insurance Company Ltd highlights the need for taking health insurance to all sections of society What is the current market size of the health insurance sector in India? Health Insurance is an important and a vast subject. The industry is Rs 115,000 crores as of March 2013 and is growing at 20 percent every year. The opportunity for a player like Apollo Munich is quite exciting as it has potential of keep growing by 20-25 percent every year for a long time to come, because even today few people have private Health insurance in comparison to other insurance. Private health insurance is in the range of 75 million people out of 100+ million population. So there is a significant gap to be filled. Healthcare expenditure is close to USD 60 billion and a big chunk of it is financed out of pocket. So we see a significant opportunity to increase the penetration and have a good business model.

Please tell us about your operations. Apollo Munich is little over five years old. We have about five million lives covered already. We are growing better than our plan – we should be a 700 + crore company this year catering to all segments of the population. We cater to people below poverty line, as we participate in the RSBY scheme, designed by the Ministry of Labor. We do above the poverty line with products which are easy to un-


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Antony Jacob,

CEO, Apollo Munich Health Insurance Company Ltd

derstand, small sums insured, relatively cheap from 50,000 to 1 lakh. We also do upper-end, where we have sums insured to up to 30 lakhs. We distribute our products largely through individual agents, close to about 30,000 of them and proud to say that we have customers across India, North, South, East and West, supported by over 55 offices.

What is your strategy to tap in the rural market, the majority share of the Indian economy? The most important thing is to understand what the requirement of the ru-

ral market is and then to build a product which suit their requirements. So if we have the product that works well in Bombay, Bangalore, and New Delhi might not work equally well in Tier-III cities. With the distribution partners, we try and understand what is required in that place and as being told to you we have the capability that we believe is second to none in designing it. We have tremendous amount of learning from markets like Meghalaya, Nagaland, Bihar and Maharashtra where we participated in RSBY schemes, we have actually gone to places where very few people of India have travelled to. So to draw attention of the rural folks we do have experience as to how to broadcast or make them understand what Health insurance, why it is required and how to get it. We also have experience in terms of tying up with hospitals in the rural areas, which we have done.

Is there a need to educate the working class about health insurance? The industry has started an initiative - the General Insurance industry, wherein GI, IRDA and Finance Ministry have started advertising in different media, in terms of the benefits of health insurance. Commercials on radio and TV are educating people and encouraging them to think of Health Insurance and buy it.

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Data Integration

is Crucial

Shreeraj Deshpande, Head - Health Insurance, Future Generali India Insurance Company Ltd, talks to Monalisa, ENN, about the growing role of IT in health insurance sector What are the most pressing challenges for health insurance companies in India? The most pressing challenge is the unregulated healthcare sector in the country. There is no uniformity in the healthcare sector. The insurance industry and the regulator have taken steps towards standardising definitions, formats, etc, among the insurers. Now there is a need to have some sort of regulations in the healthcare sector and also some amount of uniformity among the healthcare providers such as uniform billing patterns, uniform discharge summaries, procedure codings at hospital levels, etc. The other major challenge has been growing the retail health insurance business.

How can Information Technology help address these issues? IT sector has a very major role to play in the health insurance sector. The health insurance business involves a lot of data collection, collation and data transfer between various stakeholders such as insured, corporate, insurance companies, TPAs, hospitals, etc. This data is also a very sensitive and confidential. How smoothly and effectively such large volumes of data can be handled and transferred is the key for successful operations in a health insurance business. There is a need

Shreeraj Deshpande,

Head - Health Insurance, Future Generali India Insurance Company Ltd

for uniform single platform over which data exchange can take place between the various stakeholders. Even claims settlements can become faster with electronic transfer of data from hospitals to insurance companies/TPAs.

How can IT help insurers manage multiple formats of data that result from customised health insurance plans for enterprises? Insurers need very flexible IT software to take care of such variations in customised healthcare plans. To-

day this is a very big challenge where the available softwares are more rigid in their approach and find it very difficult to cater to such tailor-made requirements. The idea is to have software which help in customisation, but also have validations built into the same and come out with excellent MIS reports which would help the insurers in pricing, detecting frauds, controlling claims, as well as operations. Data Analytics and IT tools should either be in-built or be plug-ins into the base softwares.

What technologies have you adopted recently and in what ways have they impacted operations? Our health insurance vertical includes all processes such as underwriting, enrolments, claims as well as customer service. We have an exclusive e-health module where corporate employees can log in and enroll, add dependents, print cards, download forms, see the status of their claims, cashless, find hospitals, etc. We have all proper documented processes and the KPIs are measured and tracked on regular basis. We make neft payments to our hospitals as well as clients for their claims. We scan all our claim documents and archive the same which helps in proper storage and recovery at any time.

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PPP in Healthcare

Need of the Hour With years of experience in general insurance, Sanjay Datta, Chief – Underwriting and Claims was part of the start-up team at ICICI Lombard in 2001. Since then he has grown the business into a market leader. Rachita Jha, ENN, reports Tell us about most exciting phase to be in the insurance sector now. It is exciting to see the level of awareness and acknowledgement of need for insurance among citizens to plan for the future. They are now aspirational and responsible now – with safeguards for the future. If we want to improve healthcare dramatically year-on-year, we need to begin on PPP models of collaborations. This will result in big gains.

What are the ways on fraud management? Fraud has many manifestations – one is that the treatment has not taken place at all and a claim has been filed; second is about wastage and abuse which includes over-medication, overdiagnosis, etc. The first step is to set standards across the country wherein we can verify claims. So we as an industry have started to collaborate and share data and learning on frauds. There is also a need to work together with hospitals to benchmark treatment processes, as it is the patients’ right to get optimal and quality healthcare at any hospital. We should start to measure health outcomes and adopt accreditations to have checks on quality, so that there is peer review of doctors as well as facilities. The healthcare ecosystem will need


November / 2013

Sanjay Datta Chief – Underwriting and Claims, ICICI Lombard

to work together instead of competing with each other.

In what ways are you working with hospitals? The relationship is strengthening as we move ahead; we have begun with working together as partners. Initially we began with simplifying of processes of working together with authorisation mechanism and understanding of each other, claim application and approval processes. The first challenge in the last few years has been addressed with regulations coming in and acceptance of insurance as a benefit of the patient.

Secondly, we need to understand what is good of the patient that needs alignment of the patient treatment modality and insurers to work together. The regulators have reduced the friction between the insurers and healthcare providers and have thus standardised the processes of giving finance such as cashless authorisation, agreements have been standardised and considerable work is on by regulators to form a health insurance forum where hospitals and insurers are represented. And soon we will be working on treatment guidelines.

Your views on the RSBY scheme and some take-away for the insurance industry From a design perspective it is one of the most well-designed schemes in the world, which caters to scale. The entire paperwork is eliminated at it uses the simple technology of a smart card. It has revolutionised the health insurance for Indian citizens the way ATMs have changed the ease of banking for citizens. From a transaction architecture perspective, it is one of the easiest solutions created for the patient. The only drawback is that it now in the government space and is based on the mission to deliver insurance to the poorest of poor in the country where there is empowerment of access of healthcare with a smart card.

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Offering Real-time

Access to Data Suresh Sugathan, Head – Health Insurance, Bajaj Allianz General Insurance interacts with Monalisa, ENN, on how digitising of processes has eliminated the need of physically the updating documents, hence saving both cost and time What operating model have you adopted to cater to the Indian healthcare sector?

facilities by policyholders and under use of preventive care are another concern areas. Concealment of material information at the proposal stage leading to customer grievances at the time of claims and increasing health insurance frauds add to the challenges faced by the health insurance companies.

At Bajaj Allianz we are currently driving health insurance business through our bancassurance and agency channels. Bajaj Allianz has also strengthened its web-based platforms for selling health insurance products. For the ease and the convenience of our customers we have adopted the tele-underwriting process for faster decision making and acceptance of the proposals where the underwriting decisions are referred to head office.

In what ways can IT help fill the gap between insurers, TPAs and hospitals? Automation and IT initiatives can help bridge the gap between various stakeholders. A single database storing diverse data on demography, gender and past medical records etc will bring in operational efficiency. Another initiative which is setting up hospital information exchange and linking it with Electronic Health Records with real-time access to patient health records will enable quick and effective decisions. It also help in mitigating frauds across the industry by sharing information with all stakeholders on a single platform. Traditionally insurers had to deal with huge volumes of physical documents. Digitising of processes eliminated the need for physically

How can IT help address other issues such as frauds in claims, data management, faster claims settlement, etc?

Suresh Sugathan

Head – Health Insurance, Bajaj Allianz General Insurance

updating and share documents which will save both cost and time. Use of IT will prove to be effective in disaster recovery management, i.e, all records can be easily accessed even in the event of a calamity.

What are the most pressing challenges for health insurance companies in India? Though health insurance is a necessity with the growing health inflation, lack of awareness among the masses about its benefits and insufficient distribution are major pressing challenges for the industry. Apart from these, lack of regulation and control of healthcare providers, over utilisation of healthcare

By leveraging on technology we have created a fraud indication meter called – Fraud-o-meter that can give automatic triggers if a fraud is detected and has proved to be very effective in preventive fraud management. We have created a unique identification number for easy verification of customer history / credentials through biometric. In terms of claim settlement real time access to Hospital Information System (HIS) can help bring down turnaround time.

How do you foresee the sector’s growth in the coming years? Healthcare expenditure will touch USD 220 billion by 2020. This presents a huge opportunity for health insurance to emerge as a viable financing mechanism. Some of the trends that shall emerge include: disease and case management for patients; disease-specific plans; employee sponsored wellness activities; empanelment of specialist physicians; and HIS and Patient Health Records.

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Health HealthWatch Watch

The Bitter Reality

of Sweetness One of the most common noncommunicable diseases and a major cause of morbidity and mortality affecting nearly all age groups, diabetes has reached an alarming stage in India. Ekta Srivastava, ENN, delves upon the issue as the World Diabetes Day approaches on November 14th 32

November / 2013


he International Diabetes Federation (IDF) reports that there were approximately 40 million diabetics in India in 2007, and their number is estimated to go up to 70 million by 2025. It’s no surprise why experts have written off India as the emerging Diabetes Capital of the World that is likely to replace China soon. Diabetes has shaken medical practitioners across the country as it’s fast becoming a major health concern in urban and rural India. According to the World Health Organization (WHO), diabetes will be the seventh leading cause of death worldwide by 2030, including China and USA bringing down every fifth person suffer-

ing from the disease. These figures are not just increasing the economic burden, but also associated complications which lead to increased mortality and morbidity rate in the country. As per WHO study, mortality from diabetes, heart disease and stroke cost about USD 210 billion in India in 2005. Interestingly, much of these heart disease and strokes were linked to diabetes. WHO estimates that diabetes, heart disease and stroke together will cost about USD 333.6 billion over the next ten years in India alone.

Blame Lifestyle “Obesity is an important modifiable etiology for diseases like diabetes, heart problems and hypertension. By reduc-

“Proper diet and exercise is more expressed and most physiological treatment modality without any side effects for obesity control. Definitely, exercise and strict diet can help in ideal body weight management” Dr Ajay Agarwal, Senior Consultant & HOD, Endocrinology department, Fortis Hospital

ing weight, the risk for above diseases can be reduced significantly. Low calorie diet and exercise help in reducing weight, which also help control blood pressure. Modest weight reduction of five to seven percent leads to better diabetes control,” says Dr Ajay Agarwal, Senior Consultant & HOD, Endocrinology department, Fortis Hospital, Shalimar Bagh. “However, if blood sugar levels still remain high, anti-diabetes medication can be used to control blood sugar. Stress and illnesses are important reasons for high blood sugar, which result from the release of certain counters regulator hormones to cope up with strums and illness,’’ he adds. With them rapid urbanisation and industrialisation have produced advancements on the social and economic front in developing countries such as India which have resulted in dramatic lifestyle changes leading to lifestyle related diseases. The transition from a traditional to modern lifestyle, consumption of diets rich in fat and calories combined with a high level of mental stress have compounded the problem further. There are several studies from various parts of India which reveal a rising trend in the prevalence of Type II diabetes in urban areas. A National Urban Survey in 2000 observed that the prevalence of diabetes in urban India in adults was 12.1 percent. Recent data has illustrated the impact of socio-economic transition occurring in rural India. The transition has occurred in the last 15 years and the prevalence has risen from 2.4 percent to 6.4 percent.

What’s Missing? In India, lack of proper healthcare infrastructure, rampant ignorance and absence of clear-cut guidelines mean that approach to the management of diabetes is done on ad hoc basis. Lack of awareness among patients and General Practitioners (GPs) is a key factor for poor care. There are practically

“We expect a great spike in sales during this season - Diabetic sweets are a popular category for gifts around Diwali and thereafter as the awareness campaigns pick up for the World Diabetes Day, we expect the Testing Meters and Strips to really pick up’’ Prashant Tandon, MD & Co-Founder, HealthKart no nurse educators or diabetic counselors, no podiatrists and very few dieticians who mean that the treating doctor has no support and has to take the entire burden of caring for these patients. The patients’ inability/unwillingness to pay for this additional support also hinders the treatment.

Even after the diagnosis, monitoring of diabetes is very poor. Most of the patients initially visit a doctor and then discontinue their treatment once their symptoms and controlled. A majority of the patients abandon modern allopathic treatment in favour of indigenous treatments. Further, more patients with poor control avoid insulin for fear of injection and belief of addiction of insulin. Hence, they keep changing doctors and hop from one system of treatment to another leading to further complications and early death. Lack of resources, medical reimbursement and poor state funding for diabetes is a barrier to quality care often because the patient is unable to afford the high cost of treatment.

Monitoring Devices While the disease has marked its strong foothold on the country, the new monitoring devices to get the exact calculation and safety measures have in-

creased rampantly. “Popular monitoring devices among customers include J&J OneTouch, AccuChek by Roche, FreeStyle from Abbott, and Contour from Bayer. For diabetes nutrition/ food, Splenda, Extend and Glucerna are doing very well,” says As Prashant Tandon, Managing Director and CoFounder of – an online shopping portal for medical devices. Apart from insulin injections, insulin pump therapy is the new technological advancement that the medical fraternity has achieved for effective treatment of diabetes among children. Being flexible and eliminating the daily pain of insulin shots, it is becoming the foremost advantage of insulin pump therapy. The latest technology in insulin pump therapy is the CGM-ready insulin pump with an automatic insulin shutoff mechanism. This is taking diabetes management to a new level. One risk associated with Type I diabetes is the risk of death through low blood sugar. There is ample evidence to suggest that preventive measures to reduce the burden of diabetes are needed. Studies have conclusively proved that lifestyle modification including weight loss, increased physical activity and dietary changes can prevent or delay the onset of diabetes. The need of the hour is direct public education and mass media campaigns, awareness about diabetes and its complications. There is a need to spread the message that diabetes is preventable and we need to have a behavioral change to adopt a healthy lifestyle.

November / 2013


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Expert Speak

Redesigning Joint Replacement Surgeries With special interests in knee and hip replacements and computer navigation for joint replacements, Dr Vivek Logani, Chief of Joint Replacement Surgery, Paras Hospitals, Gurgaon, shares his views on the technology-driven medical facilities with Ekta Srivastava, ENN Tell us about your journey so far in joint replacement specialty.

Dr Vivek Logani,

Chief of Joint Replacement Surgery, Paras Hospitals


november / 2013

I started my career in joint replacements at the prestigious All India Institute of Medical Sciences. Before Paras Hospitals, I was engaged with two high volume centres. I am one of the regular faculties for various arthroplasty courses and forums across India and abroad. At the same time, I am also involved in implant design in collaboration with a multinational organisation. I am also carrying on a CT-based pilot study to generate a sound database for knee anatomy of various sub-groups of Asian patients which will be used to guide the implant design specifically suited for Asian patients. My team has established a Centre of Excellence for joint replacements at Paras Hospitals with special focus on computer navigation, revision arthroplasty and bone bank. I am working in arthroplasty for the last 12 years, which includes more than 2,800 primary joint replacements and about 300 revision joint replacements.

Although joint replacement surgeries alleviate pain and restore functions, they are known for associated risks. What is your take on it? Well, it’s true that any surgical procedure, and not just joint replacements, is associated with its inherent risks. As an exclusive joint replacement surgeon, it is my endeavour to keep uplifting my own benchmarks everyday. These benchmarks include delivering better outcomes and minimising risks and complications. We at Paras Hospitals are able to do this since we have a very stringent process of patient selection, patient preparation for surgery, meticulous and unambiguous surgical and post-operative protocols. Every week, I refuse three to four patients who have bad knees, but are not good candidates for surgery owing to certain other issues like severe nerve compression coming from spine, severe Parkinsonism, gait and coordination disorders, etc. If the patient’s choice or lifestyle itself is wrong, any surgery is doomed for failure. Moreover, good pre-operative screening and medical work up, meticulous surgical techniques and rehabilitation protocols help us to minimise the risks associated with the surgery.

What are your main focus areas? One of my major focus areas is Computer Navigation for knee replacement with the help of which, we are able to avoid all human errors during the procedure which were hitherto unavoidable in up to five to seven percent of cases. It is an infrared-based active system in which we generate a real-time model of the patient’s knee during the surgery and are able to accurately align hipknee-ankle mechanical axis within zero degrees of error. This ensures accurate placement of the implant, thereby providing maximum longevity to it. In fact, ours is one of the very few centres in India and the world that are using this technology for knee replacement.

Apart from these, we get numerous cases of revision hip and knee replacements, where the first surgery was done a couple of years ago and the have worn out. In such cases we need to take the previous implants out, reconstruct the existing bone defects or complete bone loss with allograft bone from our bone bank and put new implants. Such revision joint replacement surgeries are of high magnitude and usually involve meticulous planning and a geared-up operation theatre staff.

What new technologies are being introduced in the field of joint replacement? Apart from computer navigation for primary knee replacements, other develop-

compartments of the knee. The life of partial knee replacements, provided they are done by a trained surgeon, is the same as that of total knee replacements. For revision joint replacements, Trabecular Metal and Modular Implants enable us to perform surgeries with more predictable and good longterm outcomes.

Tell us about your team here, and what are you able to achieve that wasn’t possible elsewhere? At our centre, we have developed a streamlined protocol for pre-operative assessment, intra-operative work and post-operative care. This requires collective effort of the surgeon, assistant surgeons, anesthetists, nursing staff,

One of our major focus areas is Computer Navigation for knee replacement, with the help of which, we are able to avoid all human errors during the procedure ments have happened in terms of newer and better implants for knee and hip replacement. To enumerate a few, we have better quality of Cobalt Chromium and Oxinium Implants which have a much lower wear rate; better quality of Ultra-High Molecular Weight Polyethylene Spacers which last much longer; better implant designs which have better fit for Asian bone anatomy; implants suited for severe osteoporosis and bone defects; newer bearings like Oxinium and Ceramics for hip replacement in younger patients; hip resurfacing for select group of young patients who want to return to sports activities after surgery for hip arthritis, and so on. Apart from these, certain concepts have become successfully executable like Unicondylar Knee Replacements, Patellofemoral Joint Replacements in which only one compartment of the knee which is most damaged is resurfaced, thereby giving long-term pain relief and preventing damage to other

rehabilitation staff, housekeeping staff, counselors, physicians and many more, so that the patient has a flawless, wholesome experience not just from entry to exit, but even at home. We have a specialised and customised home-based rehabilitation programme for needy patients with a continuous follow-up and feedback system in place so that we are able to monitor closely the recovery of patients who have been operated up on by us and modify the protocols, if needed. Infrastructure wise, we have the world’s most advanced NAV3 computer navigation system for performing knee replacements, a dedicated allograft bone bank (in which we preserve human bone after meticulous screening) being run on the guidelines of American Association of Bone and Soft Tissue Banking. This bone bank is absolutely essential to be able to do justice to complex revision joint replacement surgeries which usually have bone defects.

november / 2013


Zoom in

Improving Lab Processes through

Inter-laboratory Comparison Inter-laboratory data management and peer group reporting allows laboratories to effectively manage, interpret and compare Quality Controls data to other laboratories using the same QC


nyone working in a clinical laboratory will understand the importance of performing External Quality Assessments (EQA) to retrospectively assess analytical performance. EQA is vital in the detection, reduction and correction of deficiencies in a laboratory’s internal analytical process, which is critical in ensuring accurate patient diagnosis. Run in conjunction with Internal Quality Controls (IQC), which assesses day-to-day performance, it’s not unreasonable to believe you are carrying out a robust assessment of performance. However, acceptable EQA performance on the day of analysis will not guarantee the accuracy and reliability of future laboratory test results, particularly as EQA is often performed infrequently or at irregular intervals. Running controls on the same machines only gives a limited picture of the performance of that instrument and won’t account for gradual changes in test systems caused by reagent/calibrator reformulations, standardisation changes or instrument software changes.

Assessing Performance Inter-laboratory data management and peer group reporting allows laboratories to effectively manage, interpret and compare Quality Controls data to other laboratories using the same QC. When conducted via webbased software, such as Randox’s Acusera 24.7 Live Online, you have an easy-to-use yet comprehensive plat-


november / 2013

form on which laboratories can monitor and analyse daily control data and compare peer group statistics. It can: • Identify any trends, system errors or reagent issues as soon as they arise • Improve EQA performance eliminating any undetected bias • Help your laboratory gain accreditation and meet regulatory requirements • Minimise false rejections whilst maintaining high error detection through the use of multi-rule QC procedures • Ensure confidence in assigned target values Through access to peer group data generated from over 20,000 laboratory participants worldwide, labs can quickly and easily identify trends, system errors and reagent issues, minimising expensive repeat tests and the need for unnecessary troubleshooting.

Acusera 24.7 Live Online is designed to complement the Acusera range of third-party Quality Controls and will automatically analyse all Quality Control data, applying user defined QC multi-rules. In summary: Online access 24 hours a day, 7 days a week - Whether in the lab, office, at home or even on vacation, with 24.7 Live Online QC data can be accessed at a time and place that is convenient for you. No need for local installation – The web-based nature of Acusera 24.7 Live Online makes it the perfect solution for affiliated laboratory groups and laboratory chains. Effectively monitory laboratory performance – A comprehensive range of detailed reports available including interactive Levey-Jennings and Histograms which help to identify trends or bias. For more information visit:

special focus Hospital Acquired Infections

The Unwanted Fury of Infections International Infection Prevention Week (IIPW) is celebrated between October 20-26. It is a timely reminder of the deadly and dangerous bacteria and viruses lurking in our hospitals. In India, hospital infection rate is almost 25 percent. Here hospital acquired infections kill more people than any other form of accidental death. Stay informed with ShahidAkhter, ENN


november / 2013

Quick Facts •

80 percent of infectious diseases are transferred by touch

Globally, hospital acquired infections affect more than 1.4 million patients in a year

Bloodstream infections related to Central Venous catheterisation are the most common device-associated infections

45-50 percent of stopcocks are contaminated and could allow potential entry of micro-organisms

• One out of every four catheter may be occluded


ospital acquired infections, until recently, were considered as side effects or inevitable risks of healthcare and hospitals were woefully underprepared to tackle them. Today there is no second thought about the possibility of prevention for nearly all types of hospital infections. We all are aware of the science behind infections and prevention. Despite this, hospitals have failed to comply with norms and this allows the infection rates to percolate alarmingly to over 60 percent. On the other end of the spectrum lie countries like Finland and Denmark, that have been successful in keeping HAI rates below one percent. No scientific breakthrough knowledge is required to achieve this target. The marvel behind the miracle lies in rigorous hand hygiene, cleaning of equipments and other preventive measures.

Poor Hygiene Patients’ room are often contaminated with MRSA (methicillin-resistant S aureus) and VRE (vancomycin-resistant enterococci). These bacteria are known to linger on environmental surfaces of the bed rails, bedside tables or any similar surface. One touch by the patient or the doctor or any other health provider makes them prone to victims and vectors for disease. The solution lies in hygiene. Besides the unsuspecting surfaces, the other sources of bacteria are the patients entering the hospital. Do we test the incoming patients? Absolutely not. Do the doctors bother to clean their stethoscopes, pulse oximeters, blood pressure cuffs and similar array of gadgets? Possibly not. Routine interaction with the infected patients may result in picking up the bacteria through the white coats and uniforms and these may be passed on to other patients or may harm the

caregivers themselves. Do we take steps to prevent this spread of bacteria through clothing? Certainly not. How frequently and properly do the healthcare givers wash their hands and ensure cleanliness? This little issue has garnered the most attention today. Hospitals have installed secret observers to monitor their doctors; wrist bands have been developed to warn healthcare works if they have washed their hands properly. Have you? The simple solution lies in good housekeeping and the will to take little, life-saving precautions.

Transmission Routes The chief transmission avenues of hospital-acquired infections are through contact, droplet, airborne and common-vehicle. The most common is the contact transmission which is most preventable. Direct contact involves body to body surface contact that facilitates the transfer of microorganisms. Indirect contact involves body surface contact with contaminated objects. This usually happens when person gives the patient a bath or other patient care activities that involves direct personal contact. These transmissions can be substantially reduced by hand hygiene, ie washing. Droplet transmission takes affect when droplets containing infected microorganisms travel through the air and reach the mouth, eyes or nose of another person. This usually happens during coughing, sneezing or talking. When these droplets evaporate and remain in the air for long it leads to airborne transmission which occurs with dust particles containing infectious agents. Covering the face or at least the nose, mouth and eyes is the only solution. Besides these, some common vehicles of transmission include food, water, medications and devices that have been contaminated.

Hospital Acquired Infections Fact Sheet •

Healthcare-associated infections, or infections acquired in healthcare settings are the most frequent adverse event in healthcare delivery worldwide.

• Hundreds of millions of patients are affected by health care-associated infections worldwide each year, leading to significant mortality and financial losses for health systems. • Of every 100 hospitalised patients at any given time, 7 in developed and 10 in developing countries will acquire at least one healthcare-associated infection. • The endemic burden of healthcareassociated infection is also significantly higher in low- and middleincome than in high-income countries, in particular in patients admitted to intensive care units and in neonates. • While urinary tract infection is the most frequent healthcare-associated infection in high-income countries, surgical site infection is the leading infection in settings with limited resources, affecting up to one-third of operated patients; this is up to nine times higher than in developed countries. • In high-income countries, approximately 30 pecent of patients in intensive care units (ICU) are affected by at least one healthcare-associated infection. • In low- and middle-income countries the frequency of ICU-acquired infection is at least 2/3 fold higher than in high-income countries; device –associated infection densities are up to 13 times higher than in the USA. • Newborns are at higher risk of acquiring healthcare-associated infection in developing countries, with infection rates three to 20 times higher than in high-income countries.

november / 2013


special focus Hospital Acquired Infections

NABH Accreditation Standards hold true for an Infection Control Program. This program aims for patients, visitors and healthcare workers, and includes surveillance activities to capture and monitor data related to infection prevention and control.

HIC 7 – There are documented policies and procedures for sterilisation activities in the organisation. HIC 8 – Bio-medical waste (BMW) is handled in an appropriate and safe manner. HIC 9 – The infection control programme is supported by the management and includes training of staff and employee health.

Summary of Standards

Should hospitals be asked to furnish or display their infection record?

HIC 1 – The organisation has a well-designed, comprehensive and coordinated Hospital Infection Prevention and Control (HIC) programme aimed at reducing/ eliminating Dr B K Rana, risks to patients, visiJoint Director, NABH tors and providers of care. HIC 2 – The organisation impleWhat are the accreditation ments the policies and procedures laid standards in India for infection down in the Infection Control Manual. control in hospitals? HIC 3 – The organisation perFor accreditation in India, hospitals forms surveillance activities to capare required to follow certain standture and monitor infection prevention ards for infection control and prevenand control data. tion. NABH accreditation Standards HIC 4 – The organisation takes for Hospitals has an entire Chapactions to prevent and control Healthter- Hospital Infection Control (HIC) care Associated Infections (HAI) in enumerating requirements for infecpatients. tion control and prevention. The first HIC 5 – The organisation prothing hospitals must have is a docuvides adequate and appropriate remented Infection Control Program sources for prevention and control which requires hospitals to measure of Healthcare Associated Infections and act appropriately to prevent/ re(HAI). duce Healthcare Associated Infection HIC 6 – The organisation identi(HAI). No program can be made effies and takes appropriate actions to fective unless supported by adequate control outbreaks of infections. facilities and resources and the same


november / 2013

A far as NABH accreditation is concerned, hospitals are required to furnish records of infection rates and associated activities during on-site assessment. Further, NABH has defined eleven mandatory indicators including surgical site infection rate, intra-vascular device infection rate, respiratory infection rate, urinary tract infection rate for which data must be submitted to NABH every quarter. As a best practice, hospitals should display their infection rates, however there is a risk to the reputation of hospitals. Moreover, in India we do not have any such policy on that and hospitals displaying their rates might be frowned upon. Further, there is lack of awareness and the patient/public is not educated for that matter in order to comprehend infection rates, worse still compare them. In current circumstances, hospitals should be encouraged to follow best practices to prevent/ control infections to not only provide ‘Safe Care’ but also make the hospital a ‘Safe Place’.

Can the Use of Copper Help Prevent Infection?

Prof Tom Elliott,

Consultant Microbiologist at University Hospitals Birmingham

Addressing the question: ‘Can the use of copper help prevent infection?’ Professor Tom Elliott, Consultant Microbiologist at University Hospitals Birmingham, said in a presentation at the Infection Prevention 2013 conference that copper and copper alloy touch surfaces (collectively termed ‘antimicrobial copper’) may indeed have a role in providing patients with a safer, more hygienic environment. In the first clinical trial – carried out at Selly Oak Hospital in Birmingham in 2007–2008 – it was shown that microbial load on frequently-touched surfaces such as taps, light switches, grab rails, bedside tables and toilet seats could be reduced by greater than 90 percent by replacing these items with antimicrobial copper equivalents. These observations have subsequently been supported by similar studies in healthcare facilities across the world. Clinical trial shows copper continu-

ously reduces bacterial burden by 83 percent and reduces the risk of infection by 58 percent. Most recently, a preliminary report on the effect of antimicrobial copper touch surfaces on the incidence of healthcare-associated infections (HCAIs) in an ICU environment showed a patient’s risk of acquiring an HCAI is reduced when just six key touch surfaces in their vicinity are made from antimicrobial copper. This supports the use of antimicrobial copper touch surfaces as an adjunct to existing infection control procedures, in conjunction with continued regular surface cleaning and disinfection. ‘These trial results raise a simple question,’ explains Professor Elliott, ‘why select a material other than antimicrobial copper when specifying surfaces that may be vehicles for the spread of infection? With the advent of multiple antibiotic-resistant bacteria causing HCAIs, some of which are very difficult to treat, such an approach – with the continuous antimicrobial activity of copper – is potentially even more relevant and important in today’s healthcare setting than ever before.’

World’s First Antimicrobial Copper Train Antimicrobial Copper touch surfaces are becoming increasingly common in hospitals, but a train on the Valparaiso Metro in Chile is the first of its kind to be equipped with Antimicrobial Copper hand rails and poles. The move is intended to help reduce the risk of infections spreading between the Metro’s 18 million annual users and improve the public transport experience.

Patients’ Watch Out •

Make sure that the hospital staff clean their hands before and after patient care. Hand washing alone accounts for prevention of 70 percent infections

• If you have an intravenous catheter, keep the skin around the dressing clean and dry. One out of every four catheter may become occluded •

Ensure that the diaphragm of the stethoscope is wiped with alcohol. It could be contaminated with Staphylococcus aureus and other dangerous bacteria

Make use of Personal Protective Equipments (PPEs) and ensure that gloves are used correctly

Get your shots, and ensure those close to you also get vaccinated

Think and look in terms of environmental cleanliness and hygiene and follow the rules of isolation

Ensure safe injection practices

Don’t overlook or ignore disposal of sharps and bio medical waste

Be particular about processing, disinfection and sterilization and storage of equipments

Think twice about antibiotics usage and be aware when it is inappropriate

Ensure that your clothing does not become a source of infection

Keep handy the contact details of infection preventionists in your hospital

Advise patients to take shower with chlorhexidine soap before a surgery

november / 2013


special focus Hospital Acquired Infections

Mission HAI Elimination Dr Victor Rosenthal, Founder and Chairman, International Nosocomial Infection Control Consortium (INICC) interacts with Shahid Akhter, ENN, on the measures that can help combat HAIs

Infectious diseases in India account for the maximum number of deaths. Could you outline primary reasons for them? Mortality rate of hospital acquired infections (HAI) is between 30-60 percent. The number of patients acquiring HAIs is more than those with cardiac problems, cancer and AIDS. India is one of the countries with the lowest HAI rates in the South Asian Region. The known HAI rate of India is from the private sector. For instance, Central Line Associated Bloodstream (CLAB) Infections from


November / 2013

the private sector is around 5 CLAB per 1000 CL days; meanwhile in USA the CLAB rate is 1 CLAB per 1000 CL days. The HAI rate from public sector is unknown and probably is 3-4 times higher than the private sector. In India such infections are on the rise because of various reasons, such as – lack of microbiology departments, limited awareness among health workers and unavailability of specialised courses in infectious diseases. Overworked staff and overcrowded wards also have contributed to the problem. For patients, it will

mean getting readmitted to hospitals and enduring medical costs.

Which HAIs are the most common? The most prevalent HAIs, which are also known as nosocomial infections, worldwide in limited resources countries are CLABs, Ventilator Associated Pneumonia (VAP), Urinary Catheter Associated Urinary Tract Infections (CAUTI), and Surgical Site Infections (SSI). There are no significant differences when comparing HAIs in different regions. UTIs and SSIs are the

most prevalent among these. The infections are mostly bacterial or fungal. They can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body.

Which part of the hospital is most prone to infections and the most common transmission route? The Intensive Care Unit and the operating theatre are the two biggest sources of HAIs in any hospital. This is because these include settings where patients are exposed to invasive devices. Infection rates are higher among patients with increased susceptibility because of old age, underlying or chronic disease or those undergoing chemotherapy.

How does India compare with the rest of the world in combating HAIs? India is one of the countries with the lowest HAIs rate among all limited resources countries. HAI rate of India is higher than USA and Germany, but is one of the lowest in the rest of the world.

In India we have a dearth of qualified infectious disease physicians or specialists? How would you address this problem, given the spate of deaths related to the disease? India has a small group of great experts in infection control. The International Nosocomial Infection Control Consortium (INICC) has been collaborating with them for more than ten years, providing tools and methods to measure HAI rates, consequences, compliance with guidelines to prevent HAIs. The reduction of HAIs in India was very significant during the last decade.

How much of HAIs can be attributed to antibiotic resistance? HAI rates are not related to antibiotic resistance. Rather they are related with lack of compliance with infection control guidelines, such as low

compliance with hand hygiene, lack of antisepsis with chlorhexidine, use of femoral vascular central line, high use of three-ways stop cock, etc. A point to note is that antibiotics are not responsible for higher HAI rates, but for higher bacterial resistance. HAI rates and bacterial resistance are independent and almost unrelated. By changing policies for antibiotics, we would reduce only bacterial resistance, but this will never reduce CLAB rates, PNEU rates or UTI rates. Better antibiotics use could help only when used correctly for surgical prophylaxis.

What are the challenges that you find in combating HAIs in India? As in the rest of the limited resources countries, major cities and private hospitals have great results. But, smaller cities and public sector need more training and support. In general the “outdated technology� is a very significant risk factor for HAIs, such as three-ways stop cocks, IV admixture at the pharmacy, semi rigid IV containers among many others; instead of split septum, single use prefilled flushing device, and collapsible IV containers.

Tell us about the surveillance tool that you are developing. How could it change the way HAIs are treated? The New INICC Online System was designed to keep the effective methodology. INICC has been applying successfully from 1998 to 2013 in 50 countries of Latin America, Middle East, Asia, Africa, and Europe, and through which INICC has published more than 300 scientific papers, book chapters, and collaborated with edition and review of bundles to prevent healthcare-associated infections (HAIs) of WHO, JCI, Argentina, Brazil, Peru, Colombia, Mexico, China, Taiwan, Hong Kong and many other countries and international organizations.

INICC methods are responsible for the fast, effective and significant reduction of HAI and mortality rates worldwide, as documented, published, and expressed in papers published by different authors and organisations including WHO. INICC methods and definitions are those of CDC-NHSN (USA), plus some extra advantages, such as validation, accuracy, identification of risk factors, measurement of extra mortality, extra length of stay and extra cost, measurement of compliance of bundles to prevent HAIs, and much more.

The Intensive Care Unit and the operating theatre are the two biggest sources of HAIs in any hospital Can you suggest remedial measures to ward off the nosocomial infections in India? In the absence of any health policy or mandatory rules, how do you collect the data on hospital infections when the authorities may not be willing to share or provide inputs? Spreading awareness or education; outcome surveillance of HAI rates and consequences with accurate definitions and methodology; process surveillance of compliance with bundles to prevent CLAB, VAP, CAUTI and SSI; feedback of HAI rates and consequences; performance feedback of compliance are some ways that can be implemented. The passion of doctors and nurses is what stimulate them to measure and reduce HAIs.

November / 2013


special focus Hospital Acquired Infections

Silent Sentinels in Infection

Prevention and Control

A nurse plays a critical role in preventing and controlling infectious disease. Dr Manju Chhugani, Principal, Rufaida College of Nursing, Jamia Hamdard, New Delhi, shares her thoughts with Shahid Akhter, ENN, on infection control from a nursing perspective Where do we stand today in Healthcare Associated Infections (HAI)? In spite of the exhaustive amount of literature and research evidences available on various aspects of infection – its causes, factors, preventive strategies, control and much more – infection prevention and control continues to an area of great concern in healthcare. Even after decades of various programmes, guidelines, etc having been invented and adopted for combating infection, both developed and resource-poor countries are still faced with the burden of healthcare associated infections. “Infection prevention saves lives”. In developing countries, the WHO reports hospital wide infection rates are usually higher than 15 percent. Maintaining a sterile, well-organised health facility can help protect both the health worker and a patient from risk infection.

How do you define HAI? Dr Manju Chhugani Principal, Rufaida College of Nursing, Jamia Hamdard


November / 2013

As a better reflection to the diverse healthcare settings and health related aspects, the terms nosocomial, hospital-acquired or hospital-onset infections have been replaced by healthcare associated infections. HAIs are defined as infections not present and without evidence of incubation at the time of admission to a healthcare setting. HAI may be caused by viral. Bacterial, fungal pathogens, the most common types being Blood Stream

Infections (BSI), Ventilator Acquired Pneumonias (VAP), Urinary Tract Infections (UTIs), Surgical Site Infections (SSI). All such infections result in longer hospital stay, increased mortality and morbidity while also enhancing healthcare costs. On the other hand a decrease in the HAIs will lead to better utilisation of resources and improving upon the quality and satisfaction of client care.

What role does the nurse play in preventing HAI? Because of the proximity to the patients and the pivotal role in healthcare delivery, nurses are in a unique position to make efforts in breaking the chain of infection. Being frontline workers, it is essential to educate and train them in various methods, norms, strategies, etc for prevention and control of HAIs.

How do nurses or other healthcare workers protect themselves? We need to understand the importance of protecting ourselves and thus helping in the control of infections. Immunisation also has a role to play in this. For example Hepatitis B vaccine can prevent blood-born infection Hepatitis. In hospitals there should be clear display and availability of Post Exposure Prophylaxis in case of needle stick injury to protect the staff from blood-born infection (such as HIV). There should be refresher training programme for all levels of workers in healthcare setting to update them with best practices. Infection prevention and control is a team work and every one and every action counts and thus in training and monitoring even sweepers and ward boys need to be taught and monitored adequately to break the cycle of infection.

An important aspect in preparing for clinical nursing practice

is an understanding of the infection process and prevention techniques? How far do you think this objective is fulfilled? The Nursing curriculum, infection control has always been a subject of utmost importance. Right from the first year of the entry of students in the Nursing profession, they are taught and trained about various spheres of infection and its prevention like study of microbes, procedure for hand washing, gowning, gloving, etc, methods of disinfection, sterilization, so on in subjects like microbiology, fundamentals of Nursing, etc. If you ask students or fresh recruited staff theoretical questions related to infection prevention they usually answer but if you ask them to really do it they partially do it. When I was interacting with one of

taught and practiced. In developed countries, the protocols are so strictly followed and remain same in teaching as well as in practice.

Who is more responsible for infection prevention? Doctors or nurses? Infection prevention and control cannot be successfully achieved only by nurses. Microbes cannot identify Doctor, nurse, patient and sweeper thus to achieve infection prevention every personnel working in the hospital has to know the sources of infection and basic guidelines to prevent it, because its team work. It has been evident from the research that Nurses wash hands more and doctors neglect this aspect. In 250 bedded hospital in a infection

“Researchers found that nurses had highest compliance rates, 71 percent across all pilot sites and doctors compliance rate was 60 percent” my hospital nurse about this, she said, “madam they need to do it during their training with close supervision and monitoring by clinical instructors so that they really do drill.”

Do you find anything amiss in the curriculum? There are loopholes in the implementation aspect. Hence it is recommended to have more of practice in clinical area, synchronization of practices taught and implemented in health care setting and then plan repeated trainings and more focus on this area. The major problem in relation to nursing is that they are taught as per syllabus, but when they are exposed to clinical setting they do not find in India the protocols being followed as per their teaching so they land up into confusion between what is being

prevention team, a nurse in an important member and is actually a functionally active member around whom most of the activities revolve. She takes round, takes culture and strictly stops people entering Critical areas without following protocols for example in my own hospital at HAHC, Jamia Hmadard my nurse will not let even VC to enter ICU without wearing shoe cover and using hands rub. Thus nurses are gatekeeper of checking others also so that they do not break the protocols. In short, clinical care nurses directly prevent infections by performing, monitoring, and assuring compliance with aseptic work practices; providing knowledgeable collaborative oversight on environmental decontamination to prevent transmission of microorganisms from patient to patient.

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Interoperability Matters Haji Mazhar Pasha, President and Managing Director, Netripples Software Group feels a lax approach to EHR interoperability has hindered efficiency in healthcare model. In Conversation with Elets News Network (ENN) rapid growth in infrastructure. Healthcare providers planto spend an estimated ` 5,700 crore (USD 986.16 million) on IT products and services in 2013, a 7 percent rise over 2012 revenues of ` 5,300 crore (USD 916.96 million), as per a report by Gartner.

What are the components (like EHR/EMR/HIS etc) of Health IT in India? Which one is the strongest?

Haji Mazhar Pasha President and Managing Director, Netripples Software Group

How the Indian Health IT market is growing and in what percentage? What is the current market size? Healthcare industry in India includes hospitals, medical infrastructure, medical devices and equipment other than clinical trials, outsourcing, telemedicine and health insurance is valued at USD 79 billion in 2012, and is expected to reach USD 160 billion by 2017. This sector is expected to grow at about 15 percent on account of factors such as


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The last decade, EHRs /HIS/EMR aren’t exactly saving money and improving efficiency. Thanks to a lax approach to EHR interoperability. Thus a meaningful use of EHR will be the trend of 2013. The healthcare industry is three years into meaningful use, an ambitious incentive program to convince hospitals and private practices to use HER software. NABH is bringing standards and strengthening them with amendments. The rule of protecting patient data, into the 21st century becomes essential. The same goes for telemedicine. On top of that, healthcare finally seems ready to benefit from big data, cloud services and other disruptive technologies that have dramatically changed other vertical industries.

What are the new trends of Health IT in India? What new developments have taken place in this field? Healthcare is getting ready to benefit from big data, cloud services and mobile technologies similar to vertical industries. But these advances won’t come without a fight.

What kind of solutions you provide to hospitals or to Indian healthcare? Netripples has been in Healthcare IT solutions since last 20 years. We have now over 75 Healthcare IT Products ready to use. These include Clinic and Medical practitioner software to minor, major and large hospitals. We have setup a Web Store. Today we cater to over 3000 clients worldwide and our reach has been phenomenal in short time since the launch of our web store. We are now upgrading the same to meet the demands.

In providing solutions to hospitals and to others, what kind of challenges you face? What are your suggestions to improve it? Key issues while providing solutions has been to keep the client aspirations down to the reality. Still many new entrants in healthcare provider business like just setup hospitals expect IT or software to do magic and weed out all their problems for now or future and demands keep increasing. Sometimes, enhancing their requirements more than the specification agreed. The stake holders’ expectations become high as they indicate the selection of vendor has been done over competition and demand more. User acceptance levels across the organiswation from a head of the organisation to the department head or functional head and to a simple and direct user in front office. Each user has certain acceptances which a solution has to be met. This needs to be tackled carefully to avoid flash points between implementers and users.


a conference on

Strategic Management & Enhancement of Clinics & Clinical Practice Hotel Bangalore International Sunday, 01st Dec 2013 ; 9:00 am to 6:00 pm Topics and Discussion Registration of Clinics & the Medical Establishment Act. Legal issues related to Documentation, Waste Management and other issues related to enhanced Clinical Practise Marketing, Branding and Advertising Strategies for Clinics. Surviving Market Competition and Big Brands in the neighborhood Role of IT in improving Clinical practice and Healthcare delivery Virtual Medical Practice, Tomorrow's care Today. An Excellent Disease Management Tool. Virtual Practice : Benefits, Patient acceptance & Future in Chronic Care - A Case Study Social Media Marketing : Marketing your services on Facebook, Twitter and LinkedIN. Learn to Create your Clinic's Facebook Page Communcation skills for Doctors @ Clinics. Innovative Strategies for Patient Retention.. and Ensuring Customer Delight Scaling Up from a Stand alone Clinic to a chain of Clinics - Issues, Strategies and Challenges

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Tech Trends



Trends In Healthcare IT Information Technology is an enabler and differentiator of quality services provided to the end users across all sectors. It is an effective tool that makes the systems more efficient, accessible, innovative and productive and at the same time improves quality and safety. Healthcare sector is no exception and it needs IT diffusion at all levels. However; it is yet to fully exploit the various benefits of fast-changing trends in IT. Some of these trends have already found wide acceptance and some are yet to be adopted. Here is a lowdown on Top Ten emerging trends in healthcare IT that are here to stay and can transform healthcare:


Cloud Computing: This is a model for enabling ubiquitous, convenient, on-demand network access to a shared pool of configurable computing resources (eg, networks, servers, storage, applications and services) that can be rapidly provisioned and released with minimal management effort or service provider interaction. It comprises five essential characteristics: ondemand self-service, broad network access, resource pooling, rapid elasticity and measured service. More and more Healthcare Organisations (HCOs) are migrating their data to cloud using SaaS (Software as a Service model), sharing IT infrastructures and reducing their costs.


Virtualization: This allows running of multiple virtual machines, ie different applications and Operating Systems on a single physical machine, with each virtual machine sharing the resources of that one physical computer across multiple environments. Virtualization offers two major advantages for healthcaresecurity of sensitive patient information and cost reduction of IT infrastructure. It delivers software that’s more flexible, scalable and accessible, with lower upfront costs.

Dr Sanjeev Sood, Hospital and Health Systems Administrator, Air Force Hospital, Chandigarh


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Health 3.0: is a health-related extension of the concept of Web 3.0 whereby the users’ interface with the data and information available on the web is personalised to optimise their experience. Improved access to health related information on the web via semantic and networked resources facilitates an improved understanding of health issues with the goal of

multiple devices on the move at PoC. To achieve mobility, IT administrators need to move away from the current device-centric approach and towards a more user-centric approach. Today, the healthcare providers have access to smartphones, tablets, ultrabooks, COWs (computers on wheels) and PDAs; and they may alternate between devices, depending on their location and task requirements. While these devices are serving clinical care providers well, IT is challenged with ensuring that the right content is available across each device, with the correct levels of security and regulatory compliance. IT departments need to adapt how they deploy and manage mobility and device sharing in the HCO.

increasing patient self-management, customised treatment solutions, preventative care and enhancing health professional expertise.


Interconnectivity and Interoperability: Caregivers should be linked to one another for every patient. Patients should have consistent access to both caregivers and medical information. Full and secure access to data will give physicians visibility into patient status and health history, improving diagnosis and delivery of care. Interoperability refers to electronic communication among organisations so that the data in one IT system can be incorporated into another. These technology solutions should aim to connect medical devices with HIS, one hospital department with another, one HCO with another and eventually all stakeholders together.


Mobility: With the use of different device types and multiple devices per users becoming common, hospital staff members have become increasingly mobile. They need to access their data and applications from


Convergence: Convergence enables the seamless integration of data, audio and video, for a consumer-driven healthcare. Convergence enables lower storage cost of digital data and optimises the flow of information between the facility’s equipment and systems. Also, it offers enhanced quality of digital content and an assurance of quality improvements in future along with high bandwidth transmission of digital content between any two places. To ensure the continued and reliable use of multiple patient care applications and medical systems, it is essential to converge the infrastructures upon which these systems operate.


Data Analytics: They can be defined as the science of extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions. The data has been increasingly used by HCOs as a part of Business Intelligence, to make strategic decisions and choices, and to gain competitive advantage in market. Data analytics in healthcare facilitates practice of evidence based medi-

cine, effective inventory management and prevention of fraudulent health insurance claims. Today, analytic strategy is viewed as a key engine of a dynamic capability of an HCO.


Medical Applications: These are programmes designed to help HCPs perform an activity in a user friendly manner and specific for a particular OS such as Android, Blackberry or iOS. They could be paid or free and can be downloaded by HCPs and patients alike on their smartphones or desktops from the app store. These serve as useful tools in referring to and accessing medical or patient information at the PoC (such as accurate doses, Lab values or Continuing Medical Education); or for patients to monitor their health parameters (such as body weight or blood sugar levels), or better drug compliance or simply about disease education and management or EMRs and much more.


Unified Communication: It can be defined as converged communications that integrate real-time services such as IM, presence, IP telephony, video conferencing with non real-time communication services such as unified messaging, integrated voice mail, email, SMS and fax to enhance productivity and business continuity. It helps in easier communication amongst care providers, between management and employees, R&D labs, doctors and patients. It enables hospitals to transform information sharing by automating and streamlining the way HCPs, their devices, and systems interact. The goal is to optimise workflows in new ways that improve staff efficiency as well as patient care and safety.


BYOD: Bring Your Own Device phenomenon has become a fact of the modern business world. Already several companies support a policy allowing.

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8 Tech Trends

Emerging Trends in Medical Technology

Dr Vidur Mahajan,

Associate Director, Mahajan Imaging


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Broadly segmented into medical equipments, implants, and medical disposables & furniture, the medical technology market offers a wide range of products – from insulin pens to pacemakers, MRI scanners, life-support machines and so on. Given the global interest and concurrent research and development in healthcare, following are some of the most important and broadbased technological advances today


Management Information Systems: Whether a simple physician’s clinic, or a large nation-wide chain of hospitals, an information system of some form has become almost mandatory in any healthcare setting. Such systems are generally marketed as clinic management systems, lab management systems, radiology information systems or hospital information systems. Today, when analysis of “big-data” is fast catching on, such information systems are most often the origin of most healthcare related data. With NABH and NABL accreditation also fast becoming a norm, such systems are essential to deliver the extensive quality reporting required to maintain these accreditations.


Electronic Medical Records: Every epidemiologist’s dream is to have a database of the medical history of every person alive. It would, in theory, help predict disease outbreaks and epidemics, determine causative and risk factors and in turn, help reduce general mortality and morbidity due to preventable and curable illnesses. Unfortunately, it is not possible to have a database of everyone as yet, but with Government initiatives such as the Aadhaar-UID project, and widespread computerisation of medical records via information systems, all that is required is for someone to assume the role of a “connector”an organisation whose sole responsibility would be to integrate all the various software systems implemented across the country with the Aadhaar card.


Telemedicine: Telemedicine initiatives have been around in India for quite a while, especially teleradiology, for which India has become a hub. Many radiologists today work either from their homes or from corporate offices, where they report MRI, CT and X-Ray cases from around the world. Recently,

the concept of Intensive Care Units which are linked to control rooms in large cities has picked up. This will not only exponentially increase the quality of care provided in non-metro cities, but will also provide a unique training opportunity to intensive care physicians in such cities. USB enabled ECGs, thermometers, pulse-oxymeters and even ultrasounds are bound to increase penetration of healthcare services in rural India, by simply using existing 2G and 3G networks.


Computer Aided Diagnosis: Computer Aided Diagnosis/ Detection (CAD) systems are software solutions that assist radiologists in seeing images and diagnosing diseases in cases where either the lesions may be too small or the data-set too big. I include such a specific technology in this list because it is testament of the incursion of artificial intelligence and related algorithms into commercially available medical technology. Recently, CAD systems were introduced for the first time in India with mammography system to assist in breast cancer screening. Globally, CAD systems are being used, but sparingly so, in colon cancer and lung cancer screening.


Robotics: Robots are everywhere today. They are helping give arms to amputees and mobility to the paralysed. They help surgeons do complicated surgeries (halfway across the world!) and pathologists perform guided biopsies. Robotics is one field in medicine today that is limited only by one’s imagination. There are even extremely small robots that are swallowed as pills and go inside the intestines all the while clicking photographs and sending them to a computer outside via Bluetooth! In fact, micro-robots are currently under development which may go and directly target harmful bacteria.


Simulation Learning: From emergency care to advanced laparoscopic procedures, today’s technology makes it possible for budding healthcare providers to acquire their skills without the possibility of making mistakes on live human patients. High-resolution CT scanning, combined with the ability to “print” 3D models internal organs of specific patients, even makes it possible for surgeons to “practice” complicated cases without actually touching the patient at all. Simulation learning is an evolving field with huge potential and scope to change medical practice.


Non-invasive Treatments: Non-invasive treatment methodologies are a step beyond minimally invasive surgeries, where there are absolutely no incisions that are made on the patient’s body. CyberKnife and GammaKnife radiotherapy treatments are very popular for targeting cancers. Newer non-invasive treatments include High-Intensive Focused Ultrasound (HIFU) which uses ultrasound rays to “heat” the tumour and in turn triggers the tumour to die. It has been successfully used in fibroids, bone cancer and prostate cancer. Proton Beam therapy, although prohibitively expensive, is touted to be the next big thing in radiation therapy with near 100 percent accuracy.


Health Information Portals: In today’s cyber-age, information is but a mouse-click away. Patients are becoming more knowledgeable than doctors and hence, the onus of directing patients in the right direction, to reliable sources of medical information has become part of a doctor’s job. The need of the hour is to have dedicated sources of such information with an Indian perspective. Such websites, combined with information portals, would give quality advise to patients and hence facilitate the treatment process improving clinical outcomes.

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zoon in

Pathways to Excellence in

Cancer Genetic Profiling David McCallen, Director & Chief of Marketing and Strategy, Star Health Network shares his vision of high quality precision medicine that is personalised through DNA Sequencing and delivered across the globe. He shares the revolutionary module with Shahid Akhter, ENN Star Health Network (SHN) seems to be a unique health company. Can you please outline the basic features, services and the modus operandi? Star is a unique global health network that connects the centres of excellence in the United States to centres of need around the world. Star’s integrated healthcare network, wherein more than 50 American, European and Indian Hospitals work together in science, technology and patient treatment methodologies, is revolutionizing the delivery of healthcare globally. Star’s Connected Health Programs promote advanced care around the world. Connected Health Program Services include: World-Renowned Experts Come Together: Star’s network enables physicians and their patients to participate in “two-way” second opinion consultations with specialists at network hospitals, facilitating a global collaboration in patient care. Personalized Medicine For Every Patient: From genetics to stem cells, from cancer to neuroscience, Star network partner doctors are in the vanguard of their fields. These doctors work as a team to provide personalized treatment for every patient. Discoveries Move Quickly To The Bedside: Generations of researchers at U.S. University hospitals have worked tirelessly to unravel the mysteries of disease, push the boundaries of medicine and develop break-


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through treatments that change lives. Today, Star’s network hospitals are actively working to bring advanced care and technologies to their patients. Global Collaboration In Treatments Of The Future: Star’s interinstitutional clinical and basic science research programs foster collaborations in new treatments and new drug development. Creating A True Global Medical Fraternity: Physicians, nurses, and medical technologists are benefiting

by visiting Star’s US partner hospitals to gain advanced training and nurture exchange of ideas, knowledge and expertise. Clinical Program Development: Star’s U.S. partner hospitals, with their large reservoir of medical intelligence, assist in upgrading or establishing advanced care capabilities at partner hospitals outside the United States.

Is it akin to consultancy via telemedicine? Star has put together all the pieces – medical expertise, technology and patients - so that our US institutional partners and their top-notch physicians are capable, for example, of providing a

Sick patients don’t have the stress of having to travel, while saving time and money, and there is a much larger pool of expertise that can be accessed on a virtual basis

David McCallen,

Director, Marketing Chief, Star Health Network

second opinion to a cancer patient in India with a particularly difficult case. So it is a telemedicine consult, a way that the patient and their physician can get another opinion about their case from an expert, remotely. This is a normal, typical process for any primary care doctor, to refer his patient to an expert; we are providing that expert remotely, through technology, so that the patient doesn’t have to go to the expert, which is significant. We are getting the primary physician, who has the relationship and trust of the patient, to tap into Star’s global medical intelligence pool. This is quite the opposite of most telemedicine projects that we look at, which are attempting to provide a patient with access to basic medical services, information, and a remote doctor, as the case may be. All are needed, but it is a different segment of the telemedicine market.

What is your bandwidth? The spread of doctors and hospitals associated with you? Before we can talk about the bandwidth of the system, let’s take a step back and figure out what a system that works may look like. This is the process we went through. First, we needed to determine the specific areas in healthcare where the disparity in expertise created an opportunity. Then we had to identify the right partners in those areas and establish those relationships, and figure out how to provide their expertise in services that would meet the needs we saw in the marketplace. Next was creating the structure, financial model and process to create the agreements with all the participants, so that this made sense to them. Once that was done, we figured out the tools required to provide the service so that the business will scale. None of these are trivial matters, so it has taken some time. Today, our US hospital partners include and Thomas Jefferson University-Kimmel Cancer Center, Yale University Genomics and Pathology through Precipio Diagnostics, Fox Chase Cancer Center at Temple University, DuPont Children’s Hospital, Willis Eye Centre, and Magee Rehabilitation Hospital; our most notable Indian hospital partner is Rajiv Gandhi Cancer Institute and Research Centre - one of the top cancer treatment and research centres in India; we also have established relationships with Healthcare Global group, a commercial cancer treatment group with 28 hospitals, and RG Stone, a Nephrology/Urology institution with 16 hospitals; we are beginning to integrate them into the global community.

How do you decide upon a particular doctor or a hospital from a massive pool of 4000 doctors? There are areas of specialization that exists within each of these institutions; depending on the patient, their condition is matched to the appropriate specialist

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zoon in

by a coordinator; we are now developing tools to electronically match the expertise to the patient’s condition, which will become part of the system and allow us to scale up as volume grows.

Is Star confined to oncology and tumor profiling (Cancer DNA sequencing) or does it incorporate other faculties as well? All our Institutional partners in the United States are centres of excellence in all areas of medicine. We are not confined to any area; our original concept was to bridge the gaps in expertise, and provide access to the super-specialty areas of medicine. Cancer happened to be the best example of a huge disparity, so we chose to deploy our business model in oncology first, which is where we are today. While we have other opportunities today to expand into other areas, we remain focused on building out our oncology footprint while exploring the next best super-specialty area to branch out into, which we will do in time.

To participate in a Star consult, is it important to have a standby, local, treating physician? Having a local, treating physician is a requirement. We see this relationship between the physician and the patient to be a fundamental part of how medical care is dispensed; we are looking for participation from the physician, as opposed to trying to replace him.

Can any physician function as an intermediary support or has it to be in alignment with a hospital? Yes, it is no different than how any physician operates now, which is vital; they can seek a referral through the network. Today, we are doing these consults between the US and India; soon, the consults will be done within India, between any physician and an expert, for example, at RGCI&RC; if their expert can’t handle the case, it will be referred to an expert in the


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US. As the consults occur, each physician benefits – they learn from the interaction, and collaboratively make decisions about the nature of the care that needs to be provided; most importantly, patient care is improved.

Is Rajiv Gandhi Cancer Centre the first hospital to avail your services? Yes, RGCI&RC is the first hospital to offer these services. RGCI&RC is a cancer-specific hospital with high volumes of patients and many difficult cases. RGCI&RC understood both the practical nature of our services for their patients, as well as the value of a relationship with leading academic institutions that Star has in the US. So RGCI&RC understood the importance in providing their patients access to genetic testing

their expertise. Star’s goal is to advance the delivery of healthcare and improve the lives of as many patients as possible; to do so, we created an economic business model where everyone wins.

Your future plans and potentials that you envision for your global network? The last 50 years have witnessed tremendous growth in medical infrastructure and the incorporation of new technologies to detect and monitor disease; however, the medical expertise to serve humanity has lagged behind. Medical intelligence, as we all know, has taken centuries to develop; now we have the tools to deploy this knowledge and expertise. The disparity in the availability and access to medical intelligence can,

The world of genomics and personalized medicine has evolved and advanced to the point that cancer experts understand it is the future of oncology today, making them among the first to do so and a true leader in the field, and they also understood that to eventually provide such a service in India, it made sense to learn about it, to become familiar with genomics and understand it more deeply so that they would be able to establish their own genomics capabilities along with partners with the expertise to do so.

Please give some idea about the fee that you charge for connecting patients to worldclass experts who are leaders in their area of medicine? There is no charge to the institutions joining the network; each service has a fee, which is shared among all participants. This is an important element of our model; it ensures that each participant has the appropriate economic, as well as medical, incentives to provide

however, be overcome by employing information technology that fosters a global collaboration between hospitals and physicians. This in my mind is the way to leapfrog the current situation to one where advanced medical expertise is made available to anyone with an Internet connection; an inflection point that changes medicine fundamentally and is a tremendous win for all participants, including the patient. The potential of Star’s model is enormous - it’s a game changer: medical expertise will be shared anywhere, anytime. It is now possible for physicians and hospitals within Star’s network to tap into a collective medical intelligence pool which facilitates collaboration in science, technology and patient care. There are approximately 5000 hospitals in India; Star intends to invite them all to join the global community of hospitals.

Zoom In

Molecular Profiling Wheels the Onco Revolution Dr Anurag Mehta, Director, Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre, recently visited the US to get a glimpse of the oncology revolution. He shares his account with Shahid Akhter, ENN You have visited the Star Health partner institutions in the US, including Yale and Thomas Jefferson? What’s your impression about their foray into medical research and technology? Star Health has built a Medical Gateway that provides medical expertise and best practices in healthcare delivery from various hospitals in the United States to patients and hospitals internationally. Both Yale and Thomas Jefferson are top notch hospitals. US News & World Report this year named Jefferson University Hospital as among the best in the nation in several specialties. Smilow Cancer Centre, a Yale University affiliate, is reckoned as a national leader in cancer research and treatment. Here, the best minds in medicine develop new therapies and detection strategies. These institutions are recognised for excellence in both, research and clinical care. In the US, the diagnostic approach is laudable. There is concretisation of the process of molecular diagnostics through extensive validation and quality assurance programmes. In addition, what I found throughout was multi-gene tumour profiling being used more and more often. This is being used for prognosis, predicting response to therapy and most importantly for identifying the targets for precision medicine.


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Dr Anurag Mehta,

Director, Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre

What exactly is molecular tumour profiling (TP) technology and how does it impact cancer diagnosis and treatment? Cancer is a characterised by cells that have genes gone awry. These cancer cells, originating within tissues are immortalised and proliferate uncontrollably. They simply refuse to respond to signals that command normal cell growth and death. Over time they acquire attributes which allow them to breach anatomical barriers and spread (metastasize) to other sites of the body. The current strategy to treat cancer is to morphologically type it using features elucidated under the microscope assisted by some auxiliary testing. This organ and morphological based tumour typing, lumps together a wide variety of genetically heterogeneous tumours. This is the reason why different people respond differ-

Given the cancer burden of India and our existing healthcare resource and response, how fruitful do you think our partnership with Star Health will be? Cancer burden is on the increase and so is cancer research and treatment. In days to come cancer treatment may become easier and doctors will have greater confidence in dealing with the deadly cells. In India, besides traditional testing, we do carry out single gene analysis, ie sequential testing for possible mutated genes starting from the one most likely to alter to the lesser ones. This method though contemporary is time consuming, sample inefficient and in many cases costly when a rare genetic alteration happens. Comparatively, multiple gene analysis is a high-end profiling platform where all relevant genes are explored in one

Cancer burden is on the increase and so is cancer research and treatment entially to chemotherapy. The best way of course will be to type tumours based upon their genetic alteration(s). This is where the tumour gene profiling steps in. It is a test that checks all possible genes that can go amiss in a particular cancer type and prepares a profile of genetic signatures and hence the name “Tumour Gene Profiling.� These molecular differences within one cancer type allows better determination of prognosis, predicting response to treatment and for therapy specific to the identified genetic lesion, the form of treatment we now call personalized / precision medicine and is the newest strategy to treat cancers. This test has been available in the US for past three years but, has been introduced in India just five months back.

go (single analysis). It saves time, is tissue efficient and tissue does not become a limiting factor to successful diagnosis and hence to the most appropriate treatment. Soon it will be the elemental strategy to diagnose and treat cancer using best evidence based practices. Partnership with Star Health paves the way to get the state of art available today. In India, we are good at managing cancer but when it comes to advanced diagnostics, we need to catch up especially in field of next generation sequencing and bioinformatics. Even if we import the technology overnight, we need to train the manpower in these aspects of molecular diagnostics. Additionally, a string of issues like validations, quality assurances, accuracy of results, etc are also concerns at

present. Most importantly, if you have a result that is falsely negative, then the patient is deprived of potential benefits of a very useful targeted therapy. On the other hand, if the outcome is falsely positive then the patient pays unnecessarily for drugs that may harm him.

Once these mutations are precisely exposed, do we have the relevant drugs to target them? Can we call this precise and personal medicine? Yes; this is the concept of targeted or personalised medicine. The concept invokes identifying the prime genetic change and using drugs to nullify its harmful effects. Today there exists more than a dozen of drugs to take care of possible genetic targets like erlotinib, gefitinib for EGFR mutations; herceptin and lapatinib foe Her2 amplification and , crizotinib for alk rearrangement. There are more and they are changing the landscape of treatment in these situations. Nearly 200 or more molecules are in various stages of development. Some are in clinical trials.

Are there any successful case study that has been initiated at RGCC via Star Health collaboration and how about the expense factor? So far we have taken up seven cases in collaboration with Star Heath and they are all doing well. More cases are lined up. As of today it may be a bit worrisome to pay 3750 USD but again you are getting the state of art without travelling to the US. Even if you go to US, you will end up paying more for the same tests. Molecular profiling is not just a sure and better way of diagnostics but there are so many other benefits too. It leads to improved quality of life, less cost on supportive treatment, hospitalisation is reduced or not required at all.

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cover story expert speak

Finland firm on stubbing out cigarettes Some of the world’s toughest measures to curb smoking emanate from Finland. Pekka Puska, D G, National Institute for Health and Welfare, Finland in conversation with Shahid Akhter, ENN discusses the endgame of tobacco in Suomiland

In 2010, Finland became the first country in the world to completely ban smoking. Is it an outright ban ? Can you please tell us more about this new tobacco act ? In 2010, the Parliament outlined that the law subjects to a “smokefree Finland”. Passing of this Act was challenged by the tobacco industry as unconstitutional, since tobacco business is still recognized as a legal industry – although domestic tobacco factories were shut long ago because of shrinking markets.


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The intention of legislation is to create conditions in which smoking and tobacco use would gradually became very rare This Act prescribes measures to prevent people from taking up the tobacco products, it promotes quitting their use and to protect the population against exposure to tobacco smoke. The Act tends to stop the use of tobacco products containing compounds that are toxic to humans and create addiction. The intention of legislation is to create conditions in which smoking and tobacco use would gradually became very rare.

When was ‘Smoke Free Finland’ initiated and how did it evolve ? Its backed by a long process of tobacco control in Finland since 1970’s. The first tobacco act in 1976 was already very comprehensive with total ban of advertising and smokefree public places. Since then the law has repeatedly been amended and strengthened, together with many other tobacco control activities – and great reduction in smoking rates, leading to environmental smoking control. Major amendments in the tobacco law were in 1995, when worksites were made practically smokefree and the age limit for sale ban to minors was increased to 18 years, and in 2006 when restaurants and bars were made smokefree. Already in the original tobacco law in 1976, all advertising and sales promotion were prohibited also the Health related warnings were made. In the latest amendment, among other things; display of tobacco products in shops was also prohibited – i.e.

they must be under the counter. For instance even at Helsinki airport tax free area, no tobacco products are seen. Finnish government has proposed to EU to move towards plain cigarette packaging. Sale of smokeless tobacco (snus) was prohibited in Finland since 1995, while now its across EU, except in Sweden. Tobacco taxation is regarded as an effective measure towards tobacco control. Taxes add up to an enormous figure of 81 per cent of cigarette prices in Finland, also recently the government again increased the tax effective from the beginning of next year.

The Government of Finland is undertaking policies to make Finland tobacco-free ( Savuton Suomi) by 2040 ? What have you achieved so far and the road ahead ? The endgame target “smokefree Finland” seems possible only because the tobacco use has reduced considerably. Currently the prevalence of daily smoking has reduced to 16% of adult population. Attitudes among people have greatly changed towards smokefree direction, smoking is no more regarded as a “normal behavior”, places such as restaurants, worksites etc have become smokefree. The road ahead is to continue with the process and also to outline final endgame measures. Intially, the experts thought that the smokefree target can only be achieved by 2040, while with the current developments it seems a reality by 2030. The road to smokefree Finland is continuously assessed by a core group of Finnish experts, representing research, NGOs and government officials. Monitoring and evaluation data by the National Institute for Health and Welfare (THL) is a major tool in this. The aim is to strengthen existing tobacco control measures, as well as to look for new endgame instruments.

Legislation and laws apart, how good is public awareness and participation ? As indicated above, the prevalence of smoking among adults is 16% of the adult population. This rate is declining considerably among all age groups. Remaining smokers are worried about their smoking habit and would likely to stop smoking. While among the youth, smoking is no more “cool”. National surveys show that out of the remaining daily smokers, 80% are worried about the impact of their smoking on their health, 60% say that they would like to stop smoking, and as many as 40% say that during the last year they have made at least one serious effort to stop smoking. Thus the issue for the national tobacco control is not to motivate or persuade smokers to quit but to help them in their smoking cessation efforts. That means both individual supports to smoking cessation and policies that make smoking cessation easier.

Please tell us about anti smoking laws in your neighbouring Nordic countries Like in most “Western countries”, the legislation in the Nordic countries has now pretty advanced. All the Nordic countries have ratified the FCTC. As per EUs directive, Finland and Denmark have banned sale of smokeless tobacco. Sweden is an exception in EU – there sale of smokeless tobacco is still allowed. To sum up, EU tobacco policy has developed quite favourably. The EU tobacco directive gives reasonably good basis, upon which many countries like Finland have built even more strict policies. Strengthening of EU tobacco policy is being planned and will take place, in spite of the lobbying against the tobacco industry.

november / 2013


launch pad

Digital Radiography Detector Carestream Health’s wireless CARESTREAM DRX 2530C smallformat digital radiography detector is now available to healthcare providers across the globe. The detector, which received FDA clearance several months ago, offers high quality, low dose X-ray exams for pediatric, orthopaedic and general radiology applications. The new cesium iodide detector’s smaller size (25 cm x 30 cm) and high DQE (Detective Quantum Efficiency) can enhance care for premature babies and infants in the pediatric ICU. It can also offer lower dose than computed radiography cassettes or gadolinium scintillator detectors. The new DRX 2530C detector fits into a tray located underneath an incubator, so it allows technologists to obtain X-ray images to monitor the condition of ill or premature babies without moving them. It is also ideal for tabletop exams such as knee, elbow, skull and other exams that may require a patient to hold the detector or require a smaller field of view.

World’s First Leadless Silent Scanners GE Healthcare introduced Silent Scan, a revolutionary technolPacemaker ogy designed to address one of the most significant impedi-

St Jude Medical introduces the world’s first leadless pacemaker. Unlike conventional pacemakers that require a more invasive surgery, the Nanostim leadless pacemaker is designed to be implanted directly into the heart via a minimallyinvasive procedure. The device is delivered using a steerable catheter through the femoral vein, eliminating the need to surgically create a pocket for the pacemaker and insulated wires (called leads) that have historically been recognised as the most vulnerable component of pacing systems. It is less than 10 percent the size of a conventional pacemaker. The small size of the device and lack of a surgical pocket, coupled with the exclusion of a lead, improves patient comfort and can reduce complications, including device pocket-related infection and lead failure. recently received CE Mark approval and will be available soon in select European markets.


November / 2013

ments to patient comfort – excessive acoustic noise generated during an MR scan. Conventional MR scanners can generate noise in excess of 110 dBA (decibels), roughly equivalent to rock concerts. GE’s Silent Scan technology is designed to reduce MR scanner noise to near ambient (background) sound levels and thus can improve a patient’s MR exam experience. This is an outcome of two years ago of research by GE engineers. They developed software – a radically new type of 3D MR acquisition, in combination with proprietary high-fidelity gradient and RF system electronics, and the noise is not merely dampened, it is virtually eliminated at the source. Silent Scan is available on new as well as existing Discovery MR750w with GEM and Optima MR450w with GEM systems.

eHealth november 2013  

Covering the Cost of Healthcare

eHealth november 2013  

Covering the Cost of Healthcare