The future of chronic disease management with IoMT

Chronic diseases are a growing concern in India, with an estimated 61 per cent of all deaths being attributed to them. The management of chronic diseases can be complex and expensive, which is why healthcare providers in India are constantly exploring new technologies to make the process more efficient and effective. One of the most promising of these technologies is the Internet of Medical Things (IoMT).

Before we go ahead, let’s delve deeper on the topic of chronic diseases. Chronic diseases are long-term conditions that typically progress slowly over time and these conditions can affect various parts of the body and can cause a range of symptoms and complications that can significantly impact a person’s quality of life.

Some common examples of chronic diseases include diabetes, heart disease, arthritis, Chronic Obstructive Pulmonary Disease (COPD) and cancer. These conditions can develop due to a range of factors, including genetics, lifestyle choices, and environmental factors.

Chronic diseases can often be managed with a combination of supplementation, lifestyle changes, and ongoing medical care. Regular medical care is also important for managing chronic diseases, as healthcare providers can monitor symptoms and adjust treatment plans as needed.

Overall, managing chronic diseases requires a holistic approach that addresses the physical, emotional, and social aspects of the condition. With ongoing care and support, many people with chronic diseases are able to lead fulfilling and healthy lives.

What is IoMT?

IoMT refers to the network of medical devices, sensors, and software that can connect to the internet and transmit data in real-time. These devices are designed to collect data on patients’ vital signs, health behaviours, and medication adherence, among other things. IoMT devices can be integrated with electronic health records (EHRs) and other clinical systems to enable providers to access real-time data on patients’ health.

Examples of IoMTdevices

There are several types of IoMT devices that are being used for chronic disease management in India. Some of these include:

◆ Continuous Glucose Monitoring (CGM) systems: CGM systems are IoMT-enabled devices that are used by people with diabetes to continuously monitor their blood glucose levels. These devices provide realtime data on glucose levels, allowing patients to make informed decisions about their diet, exercise, and medication use. Some CGM systems can also transmit data directly to healthcare providers, allowing for more efficient management of the condition.

◆ Remote monitoring systems for cardiac patients: These systems use IoMT devices to re- motely monitor patients with heart disease and other cardiac conditions. Patients can wear devices that monitor their heart rate, rhythm, and other important metrics, and healthcare providers can use this data to identify potential complications and adjust treatment plans as needed.

◆ Smart pill dispensers: These devices can be used to manage medications for people with chronic diseases, such as dementia and Parkinson’s disease. The devices can remind patients to take their medications at the appropriate times and can alert healthcare providers if medications are not taken as prescribed.

◆ Mobile apps for asthma management: There are a variety of IoMT-enabled mobile apps that can be used to manage asthma symptoms. These apps can track medication use, monitor symptoms, and provide personalized feedback and recommendations for patients.

◆ Remote patient monitoring: IoMT devices can be used for remote patient monitoring to keep track of patients with chronic diseases who live in remote areas or who have limited access to healthcare services.

◆ Population health management: IoMT devices can be used for population health management to identify patients with chronic diseases who are at higher risk of complications and intervene with preventative measures. For example, a healthcare provider may use a remote monitoring system to track patients with heart disease and intervene if their blood pressure readings become too high. By using IoMT devices to monitor patients’ health status and provide preventative interventions, healthcare providers can help reduce the overall cost of care and improve patient outcomes.

◆ Clinical trials: IoMT devices can be used in clinical trials for chronic diseases to collect realtime data on patients’ health status and medication adherence. For example, a researcher may use a smart pill dispenser to track patients’ medication adherence in a clinical trial for a new treatment for Parkinson’s disease. By using IoMT devices to collect data in clinical trials, researchers can gain a better understanding of how different interventions affect patients with chronic diseases and identify potential new treatments.

◆ Workplace wellness programs: Employers can use IoMT devices as part of workplace wellness programs to help employees manage chronic diseases and improve their overall health. For example, an employer may offer employees with diabetes a CGM system to help them better manage their condition. By providing IoMT devices as part of a wellness program, employers can help reduce absenteeism and improve productivity in the workplace.

◆ Smart rings: Smart rings are wearable devices that can track a range of health metrics, including heart rate, sleep patterns, and physical activity levels. Some smart rings, such as the Bonatra ring, have been shown to be effective in monitoring symptoms of chronic diseases, such as heart disease and diabetes.

Overall, IoMT devices can be powerful tools for managing chronic diseases in a variety of B2B scenarios. By providing real-time data on health metrics, these devices can help healthcare providers, researchers, and employers make informed decisions about patient care and employee health

Benefits for healthcare providers

IoMT devices have several benefits for healthcare providers in India. Firstly, they provide healthcare providers with real-time data on patients’ health, allowing them to intervene early and prevent complications. Secondly, IoMT devices can reduce the number of hospitalisations and emergency room visits, which can help reduce healthcare costs. Finally, IoMT devices can improve patient outcomes by providing healthcare providers with a more complete picture of the patient’s health.

Conclusion

The use of IoMT devices for chronic disease management is a promising development in healthcare in India. By enabling healthcare providers to monitor patients remotely and intervene, when necessary, IoMT devices have the potential to improve patient outcomes and reduce healthcare costs. However, there are also challenges associated with the adoption of IoMT, such as data security and privacy concerns and the need for healthcare providers to be trained on how to use and interpret the data generated by IoMT. Nevertheless, as the technology continues to evolve, we can expect to see more widespread adoption and integration of IoMT into healthcare delivery systems in India, ultimately transforming the way we manage chronic diseases in the country.

Investment and collaborative efforts from all stakeholders can further strengthen IT enabled radiology sector in India and bring positive change

ByKalyani Sharma

Information Technology (IT) has the potential to revolutionise healthcare delivery in India, especially in the field of radiology. It is a crucial diagnostic tool in modern healthcare, and the use of IT can improve the accuracy and efficiency of radiology procedures.

Overall, the use of IT in radiology can help improve the quality and accessibility of healthcare in India, especially in remote or underserved areas. By adopting these technologies, healthcare providers can improve patient outcomes, reduce costs, and improve overall healthcare delivery in India.

Emphasising on the role IT in radiology, Peeyush Kaushik, VP and Head, Healthcare Innovation Centre, Philips said, “As patients become increasingly interested in actively monitoring and managing their health, and healthcare organisations focus on providing new services to facilitate this process, the role of the radiologist is being revolutionised. Medical imaging is now used not only for diagnosis, but also for treatment and communication, and radiologists must utilise information technology to manage workflow, image collections, processing, treatment, and communication across multiple stakeholders, including patients, surgeons, and hospital staff. With the increasing workload, IT utilisation can help radiologists optimise workflow, simplify procedures, and monitor work processes.”

DrSunitaDube, Founder, MedscapeIndia comments, “IT and radiology go hand-in-hand. Since the emergence of IT within radiology, new imaging techniques are dependent on computers to generate images of one’s internal structures organs for a prompt diagnosis and treatment and it is commonly termed as digital images. Although both IT and radiology tend to appear as one entity at the beginning, they are actually two different within healthcare that have been combined together to meet the increasing demands of the healthcare sector. As such, IT within radiology includes x-rays, Ultrasound,

With the increasing workload,ITutilisation can help radiologists optimise workflow,simplify procedures,and monitor work processes

Peeyush Kaushik VPand Head, Healthcare Innovation Centre, Philips

Teleradiology has grown in demand globally given that it provides a rapid reliable response to medical crisis situations amid pandemic-induced constraints and emergencies

Dr Arjun Kalyanpur Chief Radiologist & Founder CEO, Teleradiology Solutions

Although both ITand radiology tend to appear as one entity at the beginning, they are actually two different within healthcare that have been combined together to meet the increasing demands of the healthcare sector

Dr Sunita Dube Founder, MedscapeIndia

Digital transformation has helped many industries and healthcare is not untouched with this,but there is a lot of opportunity to do more to take benefits of automation,artificial intelligence and improved process and regulatory compliances

Rajaneesh Kini SVP& Chief Technology Officer, Cyient

Computerised Tomography, Magnetic Resonance Imaging, Positron Emission Tomography, SPECT scans, Bone Density, and even Interventional Radiology among others. But we still need advancements in healthcare with the help of technology.”

Market size

According to a report by MarketsandMarkets, the Indian healthcare IT market is expected to grow from USD 1.45 billion in 2018 to USD 2.39 billion by 2023, at a compound annual growth rate (CAGR) of 10.4 per cent. The report further highlights the significant role of IT in radiology, such as Picture Archiving and Communication Systems (PACS) and Radiology Information Systems (RIS), in improving patient care and operational efficiency.

Another report by Research and Markets estimates that the Indian PACS market is expected to reach USD 79.4 million by 2024, growing at a CAGR of 6.4 per cent from 2019 to 2024. The report suggests that the growing adoption of digital imaging systems and the increasing demand for better healthcare infrastructure are driving the growth of the PACS market in India.

Overall, the market for IT in radiology in India is expected to grow at a significant pace in the coming years, driven by factors such as increasing demand for healthcare services, advancements in technology, and government initiatives to improve healthcare infrastructure.

Emphasising on the teleradiology market, Dr Arjun Kalyanpur, Chief Radiologist & Founder CEO, Teleradiology Solutions said, “Teleradiology has grown in demand globally given that it provides a rapid reliable response to medical crisis situations amid pandemic-induced constraints and emergencies. Currently, the global market stands at an estimated US$3.5 billion with the US holding around US$1.2 billion while EU/LATAM & Africa together account for US$1.8 billion, and APAC around US$0.5 billion. In India, the market has rapidly expanded due to joint X-Ray and

PPP projects proposed by NHM-State governments for various high-end modalities. Industry experts predict that pure-play teleradiology services will account for Rs 300-500 crore in the next five years. Several states and regions are acknowledging the need for telereporting capabilities including parts of Northeast, Jharkhand, West Bengal, and Rajasthan for including the underserved segments.”

“These positive market projections are also owing to inherent challenges. India has seen a spurt in multi-speciality medical and diagnostics centres. However, there is a shortage of qualified staff with the right interpretative coverage and speciality expertise. Currently, India with an estimated 1.4 billion people has only 20,000 or so radiologists whereas the US has a much smaller population but has at least 100,000 radiologists. Experts recognise the urgent need to increase training spots to fill this skills gap and meet the spiralling need for timely diagnostic information”, he added.

Current trends

Over the past century, Radiology has evolved from a purely diagnostic tool to an interventional technology that actively participates in patient treatment. The adoption of digital imaging, PACS, cloud-based solutions, AI-enabled diagnosis, and EHRs has improved the quality, speed, and accuracy of medical imaging, making it more accessible to patients across the country.

Radiology is a crucial diagnostic tool in modern healthcare, and the use of IT can improve the accuracy and efficiency of radiology procedures.

Here are some ways in which IT can set the stage for better care in radiology in India:

◆ Electronic Medical Records (EMRs): EMRs can be used to store and access patient data, including radiology reports, images, and other relevant information. This can help healthcare providers make more informed decisions, reduce errors, and improve patient outcomes.

◆ Digital imaging: The shift from analog to digital imaging has greatly improved the quality, speed, and accuracy of medical imaging. Digital imaging allows for easy storage, retrieval, and sharing of images between healthcare providers, reducing the need for physical film and increasing efficiency.

◆ PACS: It is a system used to store, retrieve, distribute, and display medical images. This system can be used to streamline radiology procedures, improve the accuracy of diagnoses, and reduce waiting times for patients.

◆ RIS: RIS is a software system that manages radiology workflow, including patient scheduling, image acquisition, and reporting. RIS enables healthcare providers to manage patient information, track appointments, and generate reports quickly and accurately.

Rajaneesh Kini, SVP & Chief Technology Officer, Cyient expresses that digital transformation has helped many industries and healthcare is not untouched with this, but there is a lot of opportunity to do more to take benefits of automation, Artificial Intelligence (AI) and improved process and regulatory compliances. He added, “As industry 4.0 has helped industries to get benefitted due to connectivity, aggregation of all data on a single platform and then driving business value and bring efficiencies in the system, similarly connected healthcare can bring the data and aggregate on a single platform by integrating various components of Healthcare Information System (HIS) such as patient health recordEHR, RIS, PACS, and Laboratory Information Management System and (LIMS).”

With support coming from different IT tools, modern-day systems allow access to images and reports via email, thirdparty standalone systems, or systems linked to the facility's archive/storage. Most are cloud or web-based and easily accessible from anywhere.

Giving an overview of the PACS, RIS and HIS, Dr Gaurav Malhotra, Sr. Consultant- Radiology, Sri Balaji Action Medical Institute, New Delhi added, “HIS and RIS have revolutionised the field by increasing productivity and efficiency. The HIS and RIS are networked software systems that manage medical imagery and related data, including tracking radiology imaging orders and billing details. PACS is yet another tool from IT which is used widely now. In conjunction with PACS, HIS and RIS manage image archives, record-keeping, and billing. PACS provides electronic storage, retrieval, distribution, and presentation of

PACS has brought a revolutionary transformation in the handling of digital radiology images,allowing clinicians in different locations and settings to easily access and view them,thus improving operational efficiency

Dr Gaurav Malhotra Sr.Consultant- Radiology, Sri Balaji Action Medical Institute

With technological advancements driving its growth in India,radiology is a rapidly evolving field.In recent years,AI and MI have profoundly found their way into many sectors of healthcare including radiology

Dr Aakaar Kapoor Medical Advisor and Chief Radiologist, City Xray & Scan Clinic

AI has begun transforming the way radiology is practiced today.AI algorithms can help radiologists interpret medical images more accurately and efficiently,improving diagnostic accuracy and reducing diagnostic errors as well amplifying the productivity of radiologists and clinicians in turn improving access

Amit Gandhi Chief Business Officer, Deeptek

images. Modern day digital imaging and communications in medicine (DICOM) is a data interchange protocol, digital image format and file structure for biomedical images and images related information. DICOM alongwith PACS increase productivity, save time compared to analog readings, reduce errors, and cut costs.”

“With digitisation in imaging, the flow of data is seamless and wireless. For example, diagnostic imaging can now be reported wirelessly, without the discomfort of cords. With the webbased applications, there is no requirements for any kind setup/exe in any of the end user desktop / laptop which eliminates system configuration dependency. With latest PACS there is zero footprint viewing and easy end user viewer interface. PACS has brought a revolutionary transformation in the handling of digital radiology images, allowing clinicians in different locations and settings to easily access and view them, thus improving operational efficiency. These digital DICOM images offer improved dynamic range and contrast, with exclusive 3D software, enabling accurate diagnosis. The latest PACS systems are stable and provide high degree of security/privacy”, he added.

In terms of economic viability, the PACS is a definite solution for smooth workflow of any medical facility along with DICOM, HIS and RIS.

Dr Dube believes that PACS still needs improvement. She said that while using PACS, it is traditionally an X-ray tech consisting of advanced training in order to handle and maintain the server on a daily basis. But, doing so can invite issues with the IT department. When dealing with the IT department and the radiology department, both departments will consider each other as competition when it comes to who is able to handle the monitoring and tracking of information through the PACS server.

◆ Telemedicine and teleradiology: The use of telemedicine and teleradiology has seen tremendous growth as they have made it easier for radiologists to access medical images and reports remotely. This has been particularly beneficial for rural areas, where access to radiologists is limited. Telemedicine and teleradiology have enabled radiologists to provide expert consultations to patients and healthcare providers in remote locations, facilitating more timely and accurate diagnoses.

Highlighting the benefits of teleradiology, Dr Kalyanpur said, “Teleradiology applications in consultation, monitoring, and diagnostics enable radiologists in their daily tasks through online solutions and real-time analyses accessible via global cloud networks, such as TeleradTech’s Radspa workflow. These services can have a huge impact on India’s population which is largely rural with l imited access to accurate, quality healthcare and diagnostic services.”

“A case in point is the joint efforts for early diagnosis and better healthcare outcomes in rural parts of northeast Indian regions. We partnered with 26 Community Healthcare Centres, District, and Sub-district hospitals in Tripura to facilitate sharing of digital imaging and communications in medicinebased radiographs of patients of all ages/study groups from their sites via a cloud-based Radiology Information System and Picture Archiving and Communication System (RIS-PACS). Expert radiologists at a Teleradiology reporting hub in Bangalore could access these for interpretation at shorter turnaround times. Between 2018-2-12, 78622 studies were interpreted via Teleradiology. As a result, patients could consult their physician with their test reports on the same day and could benefit from optimal care during the same visit. Besides these improvements, Teleradiology leads to numerous other benefits such as reduced cost, and faster diagnosis while reducing the burden of limited staff and addressing the shortage of proficient radiologists. Turnaround times (total time elapsed from ordering imaging exam to) report interpretation) are critical in today’s scenario, and these are efficiently addressed by Teleradiology.”

◆ AI: It can be used to analyse radiology images and assist healthcare providers in making more accurate diagnoses. AI can also be used to identify patterns in patient data and predict outcomes, which can help improve treatment planning and patient care.

Explaining the role of AI in radiology, Dr Aakaar Kapoor, Medical Advisor and Chief Radiologist, City Xray & Scan Clinic said, “With technological advancements driving its growth in India, radiology is a rapidly evolving field. In recent years, AI and MI have profoundly found their way into many sectors of healthcare including radiology. With the exponential increase in data generated by medical imaging, these technologies have been instrumental in facilitating more efficient and accurate analysis of medical images. AI can empower radiology in numerous ways such as image quality improvement and monitoring, scan reading and image interpretation. Additionally, AI and ML algorithms have helped immensely in automating tasks, such as image segmentation, lesion detection, and feature extraction, that were previously performed manually. This has significantly reduced the workload of radiologists and allowed them to focus on more complex cases.”

AmitGandhi, Chief Business Officer, Deeptek also believes, “AI has begun transforming the way radiology is practiced today. AI algorithms can help radiologists interpret medical images more accurately and efficiently, improving diagnostic accuracy and reducing diagnostic errors as well amplifying the productivity of radiologists and clinicians in turn improving access. For instance, AI can be used to identify early-stage cancers that may be missed by human eyes. Additionally, AI can also assist in the triage of patients by prioritising imaging studies based on the severity of their condition. The deployment of AI in radiology has also resulted in significant cost savings and improved patient outcomes.”

Overall, the use of IT in radiology can help improve the quality and accessibility of healthcare in India, especially in remote or underserved areas. By adopting these technologies, healthcare providers can improve patient outcomes, reduce costs, and improve overall healthcare delivery in India.

Kaushik says that while many new technologies have emerged, AI has made significant strides in the past 5-6 years and is essential for addressing the challenges that radiologists face, including overload, fewer resources, and complexity involved in multi-disciplinary treatments. AI will not replace radiologists but will complement them to do their job more effectively and efficiently based on new demands, such as minimal invasive treatments, time optimisation, low radiology dose to patients, and cost reduction.

Areas that still needs to be explored in this segment

Experts believes that automated workflow, connectivity and interoperability supported by cloudbased operations and more focus on enhancing the role of AI will help physicians in delivering better patient care.

Kini suggests that we may look at each segment and suggest how to use latest technologies to improve the efficiency and efficacy of the sub system. This is achieved by improving modules and operation at various stages. Some of the options are as below-

❑ Patient record: Automated patient record from extracting the summary of patient and doctor communication, reading the data from imaging obtained from scanners and pathology slides, and then merging with existing patient records.

❑ Scheduling: Automated patient scheduling, and appointment booking based on the queue of patient at each stage of the workflow, will improve the efficiency and patient’s user experience of the services.

❑ Acquisition: Efficiency and efficacy is improved using automated execution, dose reduction, scan time reduction on the imaging instrument.

❑ Processing: AI based algorithms are helping in improving the post processing, and registration processes, thanks to high performance computing platforms supported by high processing Graphical Processing Units (GPUs). Algorithms improve the efficiencies in segmentation, detection of various conditions and also quantification. This improves overall clinical decision making and reach to more accurate inference.

❑ Reporting and reliable communication: Reporting generation and documentation in custom format and template and Result communication and storage of patient information in secure way is achieved using secure by design, implementing security from end to end, device to storage.

According to Gandhi AI is poised to play a significant role in improving productivity by taking on non-clinical work and reducing the burden of interactions with clinicians. He thinks that this will be particularly important in addressing the shortage of radiologists, a problem that is unlikely to be solved by traditional means. By automating low-end work and enhancing decision-making at the high end, AI will enable physicians to focus on delivering better patient care. However, the widespread use of AI also raises important ethical and responsible practice considerations. AI is a complex technology that can introduce errors, unintended biases, and discrimination in its results. To address these concerns, governments and organisations are developing universal sets of principles to guide the ethical and societal implications of emerging AI technologies.

ITadaption in radiology: Gaps and challenges

While there are many potential benefits to using IT in radiology in India, there are also several challenges that need to be addressed like interoperability which in radiology is important because medical images and data need to be shared between different healthcare providers. However, many IT systems used in radiology are not interoperable, which can lead to delays, errors, and inefficiencies.

Data security is another major challenge. Medical images and patient data are sensitive and need to be secured to protect patient privacy. However, there are concerns about the security of medical images and data stored in the cloud, which can be vulnerable to cyber-attacks and data breaches.

On this, Dr Dube mentions that, “IT and radiology are not always perfect and can fail to give the desired results. Hence, computerisation includes the loss of confidentiality and illicit disclosure of information due to unofficial access by medical personnel. The regulations are formed to protect medical records and other individually identifiable health information even communicated electronically, orally, or on paper. But sometimes it is easy to gather information about any patient violating privacy. IT and Radiology must also implement additional safety mechanisms to protect all information transmitted within the Radiology department.”

Standardisation is also important in radiology because it enables healthcare providers to compare and interpret medical images and data consistently. However, there are still no universal standards for image and data formatting in radiology, which can lead to inconsistencies and errors.

Access to IT infrastructure is still a challenge especially in rural and underserved areas. Healthcare providers in these areas may not have access to the IT infrastructure necessary to support digital imaging, PACS, and other IT systems used in radiology.

It is important for the future radiology workforce to expand and strengthen their skills in line with the need and upgradation of the technology in this sector.

Commenting on this, Dr Kapoor says, “Interventions of IT in radiology have significantly changed the functioning of radiologists, particularly AI has reshaped the way radiologists work. However, lack of adequate training and a systematic flow of information always pose challenges for radiologists while adapting to IT and its advances, reforming the traditional working environment. It is crucial to provide intense training before putting radiologists to use new technologies. There should be a proper demonstration of new technologies being implemented so that radiologists have indepth knowledge about them. Another challenge that radiologists face during the process of adapting to IT is that they find it difficult to entirely rely on technology such as AI for results interpretation. In that matter, such technologies should be introduced first as a pilot to radiologists so that they become familiar with the technologies and are able to identify which part of the technology is producing false outcomes.”

Kaushik stresses that, “IT can help radiologists communicate findings more effectively through integrated imaging and latest software tools to present patient data in a simple, pictorial, structured, multimedia, and personalised report. As the healthcare industry moves towards a patient-centric model of care, real-time data will be critical for both clinical and patient needs, but technical training will play a crucial role in bridging the gap between traditional hospital settings and the adoption of new technologies. Proper training is necessary to equip radiologists with the latest technological tools and their usage."

According to Gandhi, trust and relevance in terms of using AI in radiology are also a challenge. He explains that, one major challenge is trust, which refers to the ability of clinicians, radiologists, and the medical community to hold AI accountable for its outcomes while using it in its complete form. As AI is not easily explainable to the medical community, it can be difficult to trust its accuracy and fairness. AI is often perceived as a ‘black box’ wherein the workings and decision-making processes of a model remain hidden, and, therefore, untrustworthy. However, this does not need to be the case. Transparency in AI allows us to describe, analyse, and communicate the ins and outs of a model in a way that is comprehensible to the public.

In the healthcare sector, the implications of not having responsible AI frameworks are heightened, particularly in terms of user safety and security. AI systems should undergo proper risk assessments at each stage of development to minimise potential negative impacts along the way and ultimately provide reliable results.

Unforeseen conditions and problems should be considered such that a model is able to safely deal with the consequences and adapt to new settings without negatively impacting its users. Furthermore, data and models can behave differently based on ethnicity and can have biases in their training, which can affect their trustworthiness. These issues make it challenging for the medical community to accept AI and its outcomes.

“The other major challenge is relevance. Creating an AI model takes a lot of effort, from regulation processes to building data processes and algorithms. While many AI models are available in the market for different pathologies and modalities, clinicians need multiple AI models in their workflow to make it relevant. One AI model alone cannot change their workflow. Thus, there is a need for a seamless integration of multiple AI models to make them more relevant in decisionmaking processes”, he added.

Wayforward

IT in partnership with radiology is already bringing a positive change in the healthcare sector. As advancements in the field of radiology continue, both IT and radiologists will both find themselves changing roles, tasks, and duties, and they will need to keep up to date with such changes. It is the need of the hour that both IT and radiology come together and function as one entity for outcomes when it comes to the healthcare sector.

Kalyani.sharma@expressindia.com journokalyani@gmail.com