Express Healthcare September, 2013 Part 1

VOL.7 NO.9 PAGES 118

Market Ontario: A medtech Mecca Knowledge Protecting the heart of future Radiology Myriad advantages of MRI-compatible pacemakers

www.expresshealthcare.in SEPTEMBER 2013, `50

GE Healthcare

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INSIGHT INTO THE BUSINESS OF HEALTHCARE

VOL 7. NO 9, SEPTEMBER 2013

Chairman of the Board Viveck Goenka Editor Viveka Roychowdhury* Assistant Editor Neelam M Kachhap (Bangalore) Mumbai Sachin Jagdale, Usha Sharma, Raelene Kambli, Lakshmipriya Nair, Sanjiv Das Delhi Shalini Gupta

CONTENTS STRATEGY RGJAY: Jay or parajay? PAGE 29 Hospital good governance (Sustainable practices) PAGE 34

KNOWLEDGE Recording it right PAGE 39 ‘Keeping up with new tech, whilst improving surgical skills is topmost challenge facing orthopaedic surgeons' PAGE 41 Atrial fibrillation increases the risk of stroke four fold PAGE 42

MARKETING Deputy General Manager Harit Mohanty Assistant Manager Kunal Gaurav PRODUCTION General Manager B R Tipnis Manager Bhadresh Valia Senior Executive Scheduling & Coordination Rohan Thakkar Photo Editor Sandeep Patil

HOSPITAL INFRA A measure of health: Sustainability in the healthcare industry PAGE 43 Achieving excellence in procurement & inventory management PAGE 53 Strategising for success PAGE 55

RADIOLOGY

DESIGN Deputy Art Director Surajit Patro Chief Designer Pravin Temble Senior Graphic Designer Rushikesh Konka Layout Vivek Chitrakar

‘Canada gets many newer technologies sooner than India’ PAGE 58

IT@HEALTHCARE

CIRCULATION Circulation Team Mohan Varadkar Express Healthcare Reg. No. MH/MR/SOUTH-252/2013-15 RNI Regn. No.MAHENG/2007/22045 Printed for the proprietors, The Indian Express Limited by Ms.Vaidehi Thakar at The Indian Express Press, Plot No. EL-208, TTC Industrial Area, Mahape, Navi Mumbai - 400710 and Published from Express Towers, 2nd Floor, Nariman Point, Mumbai - 400021. (Editorial & Administrative Offices: Express Towers, 1st Floor, Nariman Point, Mumbai - 400021) *Responsible for selection of news under the PRB Act. Copyright @ 2011 The Indian Express Ltd. All rights reserved throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is prohibited.

SEPTEMBER 2013

PAGE 11

MARKET New Zealand firm Pictor’s innovative test to bring down infant mortality PAGE 16 College of American Pathologists along with BD announce strategic alliance PAGE 18 Narayana Nethralaya and MedGenome in JV PAGE 21 CDC and The Abraaj Group to invest in Rainbow Hospitals PAGE 22

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Risk management in hospitals with CoBIT 5 PAGE 62 ‘SHL adopts the strictest rules and standards regarding patient confidentiality’ PAGE 65 ‘Increasing automation in the healthcare environment and broader access to patient information are expanding the risk of data breaches’ PAGE 66 ‘A very efficient and simple EMR is an extremely integral part of the hospital infrastructure’ PAGE 67

NORTH INDIA SPECIAL 68-87

LIFE Memoirs of the golden days PAGE 88 Book Review PAGE 90

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EDITOR’S NOTE ADR Reporting: A doctor’s duty?

IT IS VERY CLEAR THAT WITHOUT AN ATTITUDINAL AND CULTURAL CHANGE AMONG PRACTISING CLINICIANS, NURSES AND ALL HEALTHCARE PROFESSIONALS INVOLVED IN PATIENT CARE, THERE IS NO WAY PVPI CAN ACHIEVE ANY DEGREE OF SUCCESS

After quite a few false starts (See article Pharmacovigilance: The way forward for India; Express Pharma, September 1-15, 2013; http://bit.ly/15UnKEM) the Pharmacovigilance Programme of India (PvPI) seems to be finally picking up some momentum. A recent workshop saw some interesting interactions between various stakeholders - policy makers, doctors, pharmacologists, pharmaceutical companies, anticounterfeiting device manufacturers, and patients (currently represented by consumer/patient activist groups). India has a long way to go but these are important steps towards getting all stakeholders on the same page.

The workshop was the second national training workshop on “Secured Medicines & Robust Pharmacovigilance hosted by the Partnership for Safe Medicines (PSM) India Initiative and followed a similar session in Bengaluru.

An interesting query posed was whether doctors should be paid to report if their patients suffer from adverse reactions to the drugs they prescribe. The question was raised by Dr VG Somani, Joint Drugs Controller India, in response to a slide in Dr Urmila Thatte's presentation, where she mentioned that a research study done among resident doctors in KEM Hospital revealed that 16 per cent of them expected payment for reporting adverse drug reactions (ADRs).

As professor and head of the department of clinical pharmacology of KEM Hospital, she was quite adamant that ADR reporting was part of a doctor's duty and no extra payment was required.

Others in the audience, some of them heads of ADR monitoring centres (AMCs), seconded her stance saying that studies conducted at their hospitals threw up similar percentages of RMOs expecting payment.

So, clearly it’s not an isolated phenomenon.

Dr Thatte brushed away the finding saying that it was still a minor percentage compared to other challenges to spontaneous reporting of ADRs across countries: 95 per cent of healthcare professionals claimed ignorance, while lethargy (77 per cent), diffidence (72 per cent), indifference and insecurity (67 per cent) and complacency (47 per cent) were the other challenges listed. Her point was that an alert healthcare professional is really the key to spontaneous reporting of ADR and we therefore needed to educate doctors/prescribers, which she believes will be dependent on pressure from patients.

It is very clear that without an attitudinal and cultural change among practising clinicians, nurses and all healthcare professionals involved in patient care, there is no way PvPI can achieve any degree of success.

Therefore such workshops serve as an opportunity to brainstorm for ways to strengthen PvPI. For instance, rather than remuneration, it was very clear that recognition of their efforts will convince doctors to report ADRs. Today, most of them shy away from playing their part in PvPI. For instance, Dr Ketan Parikh, a paediatric surgery consultant who also runs his own nursing home in Mumbai, related how his one attempt at reporting an ADR got no result, and he felt that it was an exercise in futility. His recommendation therefore was doctors must be convinced that reporting ADRs had a purpose.

If naming the top ADR reporters- and shaming the laggards – would do the trick then we need look no further than the monthly 'report card' of AMCs posted on the website of the Indian Pharmacopoeia Commission. IPGIMER, Chandigarh tops the July report, with the highest number of ADR reports in VigiFlow (301) followed by 203 reports from JSS, Mysore; 169 reports from MMC Chennai; 129 reports from TNMC, Mumbai (Dr Thatte's hospital); and at fifth place, 125 reports from JIPMER, Puducherry.

Rather than the prosaic line: 'We appreciate the progress of all the AMCs', the National Coordination Centre should play up the efforts of these centres, especially when you consider that 33 out of 90 AMCs did not provide any ADR’s reports via VigiFlow in June.

It is interesting to note that the top performers in June were more or less the same institutions, with some change in rankings. This makes at least three things very clear. Firstly, once ADR reporting starts, it becomes easier to build and sustain the ADR reporting culture and this is a sign of hope for those AMCs still struggling to get started.

Two, the 'toppers' need to 'mentor' the laggards and three, the naming and shaming has to be louder and more stringent. Maybe organisations like PSM India and the like can start building awareness among patients about the need to report ADRs and more importantly, reporting on their doctors who try to brush their complaints under the carpet. For once, doctors and hospital managements will be forced to listen to their patients. This is one prescription they cannot afford to ignore.

Viveka Roychowdhury viveka.r@expressindia.com

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EXPRESS HEALTHCARE

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SEPTEMBER 2013

Letters QUOTE UNQUOTE

Well written article

An informative article

I have read the article titled ‘Conquering the summit,’ and would like to comment on how comprehensive, well-written and accurate it is. When I start reading the article, I literally travelled with Dr Murad Lala and experienced the same cold that he would have felt at the Everest peak. I started the journey with Dr Lala and finished it with him through the article.

The article, 'Internal audit and healthcare: A strategic partnership' is extremely insightful for those developing guidelines, regulations and legal provisions. The article is a useful source of data for futuristic directions.

“We need to ensure that Indians not only get prompt and easy physical access to healthcare facilities but also that they can also afford the treatment. This can only be done by reducing the out-of-pocket healthcare expenditure in India, which is currently as high as 75 per cent.”

Dr IS Gandhi redinra@gmail.com

Hirenbhai Vasania Marketing Manager- Healthcare Inox Air Products, Mumbai

Tapan Ray (Director General, OPPI)

INSIGHT INTO THE BUSINESS OF HEALTHCARE

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SEPTEMBER 2013

MARKET UPFRONT MOHFW releases National Occupational Standards for Allied Health & Paramedics hulam Nabi Azad, Minister for Health and Family Welfare released the National Occupational Standards for Allied Health & Paramedics at the Healthcare Skill Summit, organised by CII, NSDC and Healthcare Sector Skill Council (HSSC). He said that this was a very important initiative from the point of view of both public health as well as employment generation.The Government of India attaches highest priority to skill development, aimed at creating productive employment, he added. He was particularly happy that as many as fifteen allied health areas requiring diverse skill sets had been covered in the occupational standards by the HSSC in the first instance itself.These job roles were critical supportroles in the healthcare delivery system and having a uniform standard would definitely help in better provision of patient care services in different categories of health institutions located across the country.

Azad also highlighted various initiatives undertaken by the Ministry of Health and Family Welfare which had transformed the health sector in the country.

Some of these were screening for diabetes and hypertension, free entitlements for mothers and children, mobile medical units and ambulances and Rashtriya Bal Swasthya Karyakram. He emphasised that successful and effective implementation of all these initiatives and national programmes required greater availability of trained and skilled human resources and therefore he drew a lot of satisfaction at the constitution of the Healthcare Sector Skill Council

by National Skill Development Corporation and CII. The Minister hailed HSSC for responding to community’s needs by choosing community related job roles such as Diabetes Educator and Frontline Health Workers on priority basis.

EH News Bureau

SEPTEMBER 2013

INSIDE

G

UK university develops new treatment for brittle bone disease Demonstrates that use of risedronate can reduce the risk of fracture in children with brittle bones

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Pg 16

College of American Pathologists along with BD announce strategic alliance To support laboratory quality and performance in India

Pg 18

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B Besides being known for attractions like the CN Tower and Niagara Waterfalls, Canada also boasts of a flourishing healthcare industry, especially in medical technology (medtech). According to MEDEC, the national association created by and for the Canadian medtech industry; over the years, this sector in Canada has established itself as a formidable pillar of the country's $200 billion healthcare sector with sales of over $7 billion per annum.

Ontario: Land of opportunities For business leaders with big dreams, bright ideas and innovative concepts, Ontario should be the next big destination. Ontario is home to people from across the world with varied backgrounds. “In

Ontario we speak over 150 languages,� informs Reza Moridi, Ontario Ministry of Research and Innovation. He further points out that Ontario has always welcomed collaborations. MaRS Investment Accelerator Fund, Health Technology Exchange Funding, Ontario Networks of Entrepreneurs (ONE) and Scientific Research and Experimental Development (SR & EDs) are some of the places in Ontario where the worlds of science, business and government come together to drive the innovation process.

The Ontario government has taken a very pro-active approach and created an environment conducive to growth and progress. They are working with companies and organisations across all sectors of its economy and the research communities to support their innovation activities. Today, Ontario drives about half of all Canada's life sciences economic activity. Ontario ranks second only to California in the number of medtech firms in North America. Forbes named Ontario as the top destination for foreign direct investment (FDI), job creation, tax reform and healthcare in North America.

Foreign Direct Investment Projects 116

California

40

Ontario New York

37

Texas

16

British Columbia Qubec

13 9

Benefits galore Overall business costs in Ontario are lower than in the US, France, Italy, Germany, Australia or Japan (Source: KPMG, Competitive Alternative, 2012 Edition).

Lower taxes is yet another

as well as the average federal-state CIT rate in the US. Canada ranks third in KPMG Economic Competitiveness, behind US and Germany.

(Average rates are legislated corporate tax rates in 2012 based on information available as of March 1, 2012.

Sources:OECD and Ontario Ministry of Finance)

Ontario G20 Average G8 Average US Average 15

20

25

30 35 Per Cent

benefit that it offers. The state's combined general federal-provincial corporate income tax rate of 26.5 per cent is lower than the average of G8 and G20 countries

40

45

Timely access to the market largely decides the success of any business. Total international trade by Ontario companies tops $1 billion per day. Its products have

Advanced medtech industry support Industry support Centre for Imaging Technology Commercialisation

Health Technology Exchange

Techna

Ontario Network of Entrepreneurs Excellence in Clinical Innovation and Technology Evaluation

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Role Accelerates commercialisation of imaging innovations by: 1.Supporting researchers and companies with expertise, technical capabilities and infrastructure to grow 2.Partnerships: Promote new strategic partnerships 3.Training: Create knowledge and skill advancement opportunities with experts Supports and accelerates growth of the medical technology sector Techna aims to go beyond research by engineering technology to address unmet clinical needs, engaging academics, clinicians, industry and government as a network of partners in the development and deployment of health technologies. This will result in improved health outcomes and a growing industry sector.

Connects industry to academia, capital and advisory support from product development to market EXCITE helps companies accelerate the adoption and reimbursement of innovative, disruptive health technologies through a single, harmonised, pre-market, evidence based process.

Industry Association

MEDEC is Canada's National Medical Device Association

Clinical Trials Ontario

Clinical Trials Ontario provides a streamlined approach to multi-centre clinical trials, ensuring ethical standards for patient safety.

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SEPTEMBER 2013

M|A|R|K|E|T Reza Moridi,Ontario Ministry of Research and Innovation, briefs media over the strengths of Ontario in the medtech sector duty free access to the $17 trillion+ NAFTA marketplace if 62.5 per cent of the content is manufactured in Canada.

Ontario's R&D incentives are among the most generous in the world. A $100 R&D expenditure can be reduced to an after-tax cost of about $56 or $38 for small businesses. A broader range of R&D costs qualify for tax deductions here than in many jurisdictions and tax credits can be carried back three years forward for 20 years. Ontario provides a broad and stable economic base. The World Economic Forum ranks Canadian banks as the soundest in the world.

Ontario, Toronto in particular, is one of North America's top centres for sophisticated financial services.

Global connectivity is also a factor that drives many business houses towards Canada. There are five international airports: Toronto, Hamilton, London, Ottawa and Thunder Bay. Toronto's Pearson International Airport offers same plane service via 75 carriers to 29 Canadian, 50 US and 105 other international destinations.

Canada is the global hub of medical devices manufacturers. As far as Ontario is concerned, it is home to renowned names like GE Healthcare, Baxter, Agfa Healthcare, Nordion and Trudell Medical International. More than 17000 employees work for approximately 900 medical technology firms in this state. 60 per cent of Canadian medical devices R&D spending occurs in Ontario. $1.4 billion exports which is equal to 63 per cent of Canadian medical devices exports. Toronto is also a home to GE's first Global Pathology Centre of Excellence.

It seems innovation is the norm for the medtech industry in Canada. This sector has come up with different kinds of products for the diagnosis of varied disease types. For example, the greatest challenge in radiation therapy is to accomplish the tumour control and spare healthy tissue. 4D dosimetry system, RADPOSE, handles this challenge quite successfully.

OtoSim has developed a simulation and training platform which has been applied to otoscopy (ear examination) and ophthalmoscopy (eye examination). Abbott SEPTEMBER 2013

Diagnostics develops and markets critical handheld medical diagnostic and data management products for rapid blood analysis. Its i-STAT is a market leading hand-held blood analyser. eSight eye wear has given a hope to low vision patients across the globe. Overall, Canada has established itself synonymous with medical devices industry.

MaRS EXCITE It enables better health technologies to get to market faster for improved health outcomes. Excellence in Clinical Innovation and Technology Evaluation (EXCITE) moves Ontario's traditional post market health technology assessment (HTA) and comparative effectiveness review (CER), into the pre-market and harmonise it with Health

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Fig.1 Canada regulations. EXCITE transforms HTA/CER from a punitive gate of reimbursement to a product optimisation tool, in collaboration with a world class customer, the Ontario Health System.

(See Fig.1)

Lion’s share for life sciences About 58 per cent of Canadian life sciences R&D spending occurs in Ontario.

There are about 1000 life sciences firms in Ontario. Thus, it is no wonder that the life sciences sector here alone employs about 38,000 people.

Ontario also has the distinction of being second in North America in terms of the number of life sciences establishments.

Ontario has a very strong research base with 44 universities and colleges producing approximately 30000 skilled graduates in science, engineering and mathematics each year.

Four of the top ten Canadian research universities are located in Ontario. 46 per cent of Canada's bibliometric output is being produced by Ontario and it accounts for 45 per cent of Canada's gross domestic expenditure on research and development (GERD).

Many giants from the life sciences sector have established themselves in Ontario.

GE Healthcare's global pathology imaging centre of excellence at the MaRS Centre in downtown Toronto.

The $10 million centre focuses on developing innovations in digital imaging, work flow and computer aided diagnostics to improve patient care and reduce healthcare costs. There is GlaxoSmithKline, which has undertaken a $33.6 million expansion of its state-of-the-

R&D OPPORTUNITY

MEDICAL NEED

Ottawa’s lure INNOVATION

DEVELOPMENT

EXCITE PREMARKET EVALUATION

MARKET INTRODUCTION

HTA / CER DIFFUSION INTO ULTIMATE USE Source: William W.Lorance, New Medical Devices (Washington, DC: National Academy Press,1988).

art manufacturing facility in Mississauga and launched the $50 million GSK Canada Life Sciences Innovation Fund to invest in early stage Canadian research. Novartis Pharmaceuticals has partnered with the Population Health Research Institute, Hamilton, for a $100 million global clinical study of a new high blood pressure drug that will involve more than 11000 seniors in 20 countries.

Novocol Pharmaceuticals has invested $54 million to expand production and R&D capacity at its Cambridge facility. Roche Canada has invested $190 million to establish a new global pharma development site in Mississauga to manage all stages of global clinical trial research.

Teva Canada launched a $56 million expansion of its High Potency Manufacturing Centre of Excellence in Stouffville.

Media briefing at one of the radiology equipment manufacturing units

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benefit.

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Ontario ranks third in North America as far as the number of pharma and medical manufacturing establishments are concerned.

The MaRS Centre works with partners to catalyse, accelerate and amplify innovation, its phase 2, a 20 storey state-of-the-art facility is nearing completion in downtown Toronto. It will be more than double the current size of MaRS, upto 1.5 million sq ft, making it one of the largest urban innovation hubs in the world.

Ontario also has significant presence of contract services that include leading contract research and manufacturing organisations such as Kendle, Patheon and Canadian-based Therapure Biopharma, Nucro-Technics and Gamma-Dynacare.

Contract services in Ontario offer lowers clinical trial management costs, an added

Ottawa, a G8 capital, is a progressive centre of innovation. With almost 2000 knowledge-based businesses, 44 federal laboratories and research organisations and four post secondary academic institutions, Ottawa ranks as one of the top three research communities in Canada. It is one of North America's fastest growing economies and one of the world's most progressive centres of innovation. For that reason Ottawa offers great opportunity for international expansion in knowledge-based business.

Part of Ottawa’s economy's strength is the diversity of its knowledge-based industries. With over 2000 companies and nearly 80000 people, this sector is one of the largest employers in Ottawa. Ottawa has one of the highest levels of R&D spending per capita in North America and, not surprisingly given the number of federal and private sector research labs housed in Ottawa, one of the highest concentrations of PhDs per capita in North America.

Ottawa's diverse economy navigates global fluctuations with stability and purpose. Unemployment rate continues to be one of the lowest in Canada, while its rate of business growth eclipses many NorthAmerican cities. Ottawa is the home to almost 2000 knowledge-based companies representing diverse sectors.

Ottawa is widely known for its proactive approach to development and business support. Several incubators and accelerators operate throughout the city, including Invest Ottawa, designed to fortify the wealth, connectivity and entrepreneurial momentum of Ottawa's business community. Canada's largest research facility, the National Research Council, is based in Ottawa, pioneering more than 50 years of support for startup and spin-off companies across the city.

Ottawa has more than 130 embassies and consulates, giving local companies front line access to worldwide trade and investment opportunities. Ottawa's international airport, voted the best in the world for its size, connects Canada's most luxurious and affordable workplaces to flourishing global markets. Local busiSEPTEMBER 2013

M|A|R|K|E|T Advanced medtech instruments are being used at the hospitals in Ontario

MaRS Innovation

ness leaders prosper from this geographical advantage, making Ottawa one of the most competitive cities in North America for global trade and connectivity.

Its strong pool of researchers, coupled with advanced research facilities and incentives offered to propel the growth of the medical devices industry, make Canada a key destination for the Indian companies to collaborate, invest and grow. For a country like India, where a large chunk of medical

Can you please give me the anaesthesia notes of Prashant Kumar’s previous admission?

Sure Sir, in a minute!

devices are being imported, such collaborations matter even more. With international experience in hand, such associations may even pave the way for Indian companies to become indigenously capable of manufacturing such products in their own country. Fortunately, India also

has a large resource of skilled researchers, which can be utilised to achieve this aim.

Becoming indigenous also means creating job opportunities in the country.

However, easier said than done. Currently, Canada rules the market of medical technology. As quoted by JF

Ware, 'The future is an opportunity' and Canada is the land of opportunities. It's high time that Indian players cashed these opportunities and reaped the benefits in the form of technology and experience that can be put to good use in their homeland. sachin.jagdale@expressindia.com

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DCDC ties up with Delhi government via PPP Aims to bring down cost of dialysis per session by 35 per cent

D

CDC Kidney Care has acquired three dialysis centres during a recent PPP bid held

by Delhi government. The combined capacity of centres is 60 machines. The centres will be located at LNJP Hospital, Rajiv Gandhi Super Specialty Hospital, Tahirpur and Dr Hedgewar Arogya Sansthan.

Aseem Garg, Founder and MD, DCDC Kidney Care said, “We are humbled and honoured to be given this opportunity to serve the end-stage renal disease (ESRD) patients of Delhi. The government’s role has become very important in addressing the crisis at hand and we are very glad to be a part of this initiative in Delhi and would be very keen to replicate the same model in other states too.”

DCDC Kidney Care is reportedly going to provide quality dialysis at less than $20 which is a fraction of the cost of dialysis in the US where average treatment is at $300. DCDC Kidney Care aims to bring down the cost of dialysis by at least 35 per cent through its innovative service offerings.

Garg added, “This is a step in the right direction and is clearly the future for ESRD patients.

Hopefully this is just the beginning and with time we will see more opportunities like this arising in other states. The Delhi government has recognised our abilities which is itself a motivation to reach our goal of 100 centres by 2015.”

The PPP in dialysis is expected to work in favour of citizens with below poverty line (BPL) cards and can avail the facility at Rs 1073 after the referral from government hospitals.

EH News Bureau

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New Zealand firm Pictor’s innovative test to bring down infant mortality Known as TorCH test, it offers simple, low cost testing platform for toxoplasma, rubella, cytomegalovirus and herpes simplex virus 1 and 2

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n innovative new low cost ToRCH testing kit designed in New Zealand aims to help doctors prevent thousands of these deaths and assist in reducing India’s infant mortality rate.

The brain child of Indian born scientists, Dr Sarita and Dr Anand Kumble of a New Zealand-based company, Pictor, the testing kit provides a simple low cost testing platform for five of the major killers of infants - toxoplasma, rubella, cytomegalovirus and herpes simplex virus 1 and 2.

Known as the ToRCH test, the name is an acronym for the five infectious diseases.

“The ToRCH infections are responsible for causing over 20 per cent of deaths in new born infants in India

and across South East Asia.

These diseases also cause hearing impairment, eye problems, mental retardation, and autism. Traditional tests examining these pathogens have often been too expensive for many poorer families, leaving doctors to make their diagnosis based on symptoms alone,” commented Dr Kumble of Pictor.

Used on expectant mothers, Pictor’s test reportedly utilises immunodiagnostic technology which allows up to eight tests to be accurately performed together on a specially designed microscope slide, using only a single drop of blood. Results are read on the company’s low cost portable reader powered through a computer

USB port, and analysed using Pictor’s exclusive data analysis software which provides results within two minutes of test completion.

A company release claims that the tests can be easily integrated into laboratories of all sizes, including the small manual operations still dominant in India and South East Asia, in addition to its low entry cost, fast results and minimum technical training requirements, make the technology ideal for developing countries.

Pictor developed the technology in Auckland, New Zealand, with the aim of offering the low cost diagnostic solutions to developing parts of the world, and has already launched the kits in Thailand and Malaysia

with much success.

New Zealand Consul General and Trade Commissioner in Mumbai, Gavin Young said, “Pictor’s ToRCH test is an exciting development offering real benefits for Indian families, where these diseases have caused loss and distress through long-term health damage. The technology is yet another example of the innovative developments in the health sector coming from New Zealand, more of which will be seen in India.”

Pictor launched the ToRCH test in the Indian market this month with distribution partner, Lilac Medicare a leading Indian in-vitro diagnostics company.

EH News Bureau

KIMS performs its first liver transplant The transplant was successfully accomplished in 12 hours

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IMS hospital successfully completed its first liver transplant surgery, thus reportedly becoming the first hospital in South Kerala to perform this type of intensive procedure. The 43year-old patient, Meenakshi Sundarmurthi from Tirupur, who was suffering from chronic liver disease, underwent the 12-hour surgery on the July 20, and was reported to be recovering well.

The liver was harvested from a 30-year-old patient who was admitted with severe injuries to a private hospital in the city after an accident in Tamil Nadu and

was later declared brain dead. The deceased’s relatives shared their willingness for organ donation and this set the wheels rolling for performing the first liver transplant in KIMS. The information regarding the availability of the healthy liver was shared with the Kerala Network of Organ Sharing who identified Sundarmurthi as undergoing treatment at KIMS and seeking a B+ve liver.

The legal formalities for approving the transplant were carried out by the nodal officer Dr Noble Grace and officials at KIMS Hospital.

The patient was admitted at KIMS early on the day of the operation and KIMS’ team of experts under the leadership of Dr Venugopal, liver transplant surgeon, travelled to the hospital where the donor had been prepared for organ harvesting. The liver was successfully harvested and the team returned immediately to KIMS where in the meantime Sundarmurthi had been fully prepped for the surgery. The transplant was successfully accomplished in 12 hours. Sundarmurthi was discharged on the tenth day following the operation.

KIMS liver transplanta-

tion unit boasts of a complete multidisciplinary set up confirming to international standards. The unit is led by experts trained in some of the best liver transplant centres in India and abroad.

There is an excellent blood bank with 24-hour apheresis facility, advanced laboratory and microbiology (infection control) support, advanced cardiology, DSA and interventional radiology, ultrasonology, 64 slice CT scanner, MRI, and nephrology (including 24-hour dialysis and CVVHD) facilities.

EH News Bureau

UK university develops new treatment for brittle bone disease A study by the University of Sheffield demonstrate that use of risedronate can reduce the risk of fracture in children with brittle bones and have rapid action

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new treatment for children with brittle bone disease has been developed by the University of Sheffield and Sheffield Children’s Hospital.

The study of the new treatment for children with the fragile bone disease, Osteogenesis Imperfecta, was published this week in the world's leading

general medical journal, The Lancet.

This is reportedly the first study to clearly demonstrate that the use of the medicine risedronate can not only reduce the risk of fracture in children with brittle bones but also have rapid action - the curves for fracture risk begin to diverge after only six weeks of treatment. www.expresshealthcare.in

Nick Bishop, Professor of Paediatric Bone Disease at the University of Sheffield said, “We wanted to show that the use of risedronate could significantly impact on children's lives by reducing fracture rates - and it did.

The fact that this medicine can be given by mouth at home (other similar medicines are given by a drip in hospital) makes it family-

friendly.”

The study, funded by the Alliance for Better Bone Health, trialled children with Osteogenesis Imperfecta aged 4-15 years and showed that oral risedronate reduced the risk of first and recurrent clinical fractures and that the drug was generally well tolerated.

EH News Bureau SEPTEMBER 2013

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United Way of Mumbai and AmeriCares India organise street plays for Hepatitis awareness With Bristol Myers Squibb Foundation’s support many more awareness activities have been planned

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nited Way of Mumbai and AmeriCares India Foundation came forward to educate and spread awareness about hepatitis among the citizens of Mumbai. Street plays were organised by these NGOs on August 1, 2013 at Worli and Wadala. On August 2, they were organised at Malad, Jogeshwari, Andheri, Churchgate and CST. This community-based awareness programme is a part of project PAHAL being implemented by United Way of Mumbai, AmeriCares India Foundation and National Liver Foundation with support from the Bristol Myers Squibb Foundation.

It has been carried out with the Green Ribbon Brigadiers, a group of student volunteers from well known city colleges Sydenham College and Jai Hind College.

The street plays were about the need to address the lack of awareness among the people despite more than 100,000 people dying in India due to the disease. They also aimed to educate about the ‘silent’ nature of the disease and how important it is for people to address the disease facts in the right manner.

Hepatitis B and C together affect 500 million and approximately kill one million people every year. These are indicative of insufficient awareness among people about the disease.Through such initiatives these NGOs are trying to spread awareness among the people with a goal to help them make better decisions regarding their health.

EH News Bureau

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College of American Pathologists along with BD announce strategic alliance To support laboratory quality and performance in India

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ith the aim to provide quality diagnosis and better treatment outcomes for patients, the College of American Pathologists (CAP) and BD Diagnostics have launched a new strategic alliance that would help more pathology labs in the country to offer high quality services at par with the rest of the world.

Laboratories play a critical role in the diagnosis and treatment of disease for more than a billion people who live in India. The BD/CAP strategic alliance will improve access to external quality assurance/proficiency testing (PT) that can have a direct and positive impact on laboratory quality, and therefore, patient outcomes. Together BD and CAP will provide education to improve awareness of global practice standards and training that will help laboratories achieve their quality improvement goals.

“As countries around the world heighten their focus on healthcare, patients and healthcare professionals wish to achieve higher quality across the entire spectrum of care. The clinical laboratory and pathology contribute more than 70 per cent of the information used to determine diagnoses and drive treatment decisions. CAP has all the necessary tools to help laboratories improve and monitor efforts that drive quality performance. This strategic alliance with BD will increase access to these essential resources, helping

laboratories accelerate their quality improvement journey so that they can contribute to better quality care, differentiate themselves and their institutions, and be recognised globally among the best providers of laboratory and pathology services,” said Stanley J Robboy, President, CAP. At present CAP’s Laboratory Accreditation, Surveys, PT programmes, and other quality management resources combined with BD’s in-depth clinical knowledge of preanalytical systems provide a comprehensive, expert-based toolkit to help laboratories in India continuously improve the quality of the testing services they provide to patients.

Through participation in CAP accreditation, laboratories in India can demonstrate their compliance to the most robust and comprehensive

clinical laboratory testing standards in the world.

“This historic initiative brings together two of the leading global organisations that are ideally positioned to support laboratory improvement efforts around the world, particularly in India,” said John Ledek, President, BD Diagnostics – Preanalytical Systems. “BD offers extensive reach across the continuum of healthcare and laboratory testing operations, with a deep understanding of quality processes from both a technical and clinical perspective. CAP is the recognised leader in establishing pathology and laboratory standards and practices and developing tools to guide and monitor lab progress on improving quality. From preanalytical specimen collection through post-analytical result reporting and interpretation,

together, CAP and BD can provide more integrated laboratory quality improvement solutions that begin and end with the patient.”

Having operated in India since 1996 supporting public and private sector partners in enhancing laboratory standards, BD has extensive experience in deploying clinical expertise and educational resources, as well as a deep understanding of the unique needs of laboratories in the country. In India, of the 71 laboratories participating in CAP PT, 42 have achieved CAP-accreditation.

BD’s access and logistics experience will support CAP PT importation and ensure more timely delivery and quality, reduce participants’ administrative work, and allow billing in local currency.

EH News Bureau

Wockhardt Hospital, Goa gets NABH accreditation Becomes the first NABH accredited hospital in the state

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ockhardt Hospital, Goa has received accreditation from National Accreditation Board for Hospitals and Healthcare Providers (NABH), the highest national recognition and a mark of quality patient care and safety. This makes Wockhardt Hospitals, Goa the first to be accredited in the state. With this recognition, Wockhardt Hospitals has received their fifth NABH accreditation, reportedly making them the only hospital group with the high-

est accreditations in the West zone. Wockhardt Hospitals, Goa, offers comprehensive, end-to-end care in cardiology, cardiac surgery, neurology, neurosurgery, orthopaedics and joint replacement surgery.

Speaking on the occasion, Zahabiya Khorakiwala, MD, Wockhardt Hospitals said, “We at Wockhardt Hospitals are proud that our Goa hospital has been accredited by NABH. We are constantly working towards providing the best of services www.expresshealthcare.in

to our patients, enabling the benefits of the latest technological developments in the field of medicine. Patients are the highest beneficiaries of the accreditation as it assures high quality of patient care and safety. This achievement strengthens our commitment to fulfill the needs of the community and provide patients care essential for their well being.”

Dr KK Kalra, CEO, NABH spoke on the benefits of accreditation to the patients, society as well as medical

community. He mentioned, “It was a moment of pride for NABH also to be awarding the first accreditation to Goa, which is the 15th state in the country to have an accredited hospital. It is the continuous efforts of the Quality Council of India and NABH to ensure quality of care the patients receive at a hospital. The objectives of accreditation are patient safety and promotion of evidence-based medicine.”

EH News Bureau SEPTEMBER 2013

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UKTI seminar outlines funding initiatives for life science sector Attended by around 50 delegates from the healthcare industry and allied services

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ith the rising cost, risk and complexity of R&D, it has become increasingly difficult for life science companies to commercialise medical innovations, informed Dr Adam Hill, UK Government Sector Specialist for Medical Technology and healthcare.

Speaking at the Going Global Through the UK Seminar in Bangalore, Dr Hill said that the UK government has introduced a suit of fiscal and funding measures to stimulate innovation and growth for business of all sizes.

The seminar was jointly organised by the UK Trade & Investment (UKTI) in association with BioSpectrum, CEO Council and The Indus Entrepreneur (TiE) Bangalore Attended by around 50 delegates from healthcare industry and allied services the seminar was first in a series of events to facilitate Indian companies to invest in UK life science arena.

The seminar addressed the Indian life sciences companies who are interested in expanding their business base in the UK and wanted to know more about the business opportunities in the UK. Speaking about the event Dr Prasad Rao, CEO, Lablinks said, “Such events are interesting and provide information and guidance to companies who wish to expand business beyond Indian markets.”

Prashant Sabeshan, Partner, Majumdar & Partners, corporate lawyers said, “The talk mostly revolved around outbound business. The inbound aspect was missing.”

Dr Hill discussed UK Government’s Life Science Policy, the opportunity and marketplace, access to the UK at every stage of the medical

technology development |pathway, and the new NHS structure.

UK Trade & Investment is the national government

agency that offers free support and independent advice to foreign companies looking to invest or locate in the UK. Gita Krishnankutty, Senior

Trade & Investment Adviser, UK Trade & Investment was also present at the event.

EH News Bureau

THE SEMINAR WAS FIRST IN A SERIES OF EVENTS TO FACILITATE INDIAN COMPANIES TO INVEST IN UK LIFE SCIENCE ARENA SEPTEMBER 2013

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SERB & NIBIB in research collaboration To develop durable, low-cost blood pressure measurement technologies for either passive or active monitoring of hypertension

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he Science and Engineering Research Board (SERB), Department of Science and Technology, Government of India and the National Institute of Biomedical Imaging and Bioengineering (NIBIB, NIH) have joined hands to encourage research collaborations within and between India and the US for the development of durable, low-cost blood pressure measurement technologies for either passive or active monitoring of hypertension. The priority areas for these research initiatives are: High-throughput blood pressure systems that can measure the blood pressure of a large number of individuals. The measurement should ideally integrate with a routine daily activity in such a way that there is minimal added effort required by the individual; minimal interaction, low-cost blood pressure measurement systems capable of making measurements in a home environment in a manner that adds little or no burden to the individual. These devices should be suitable for use at home and small health-care centres; measurement technologies should be simple, low-cost, reliable and should not need clinical expertise for operation.

Applicants for this endeavour can include entities from academia, national laboratories, nongovernmental R&D institutions, industry and start-up companies. The proposal should be science-driven aiming towards prototype development/demonstration with a definite commercial potential and intent/plan to commercialise the technology.

Prospective applicants are required to submit an Expression of Intent (EOI).

EH News Bureau

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Access to medicines’ policies failing vulnerable Indian citizens claims report Recommends better mutual understanding and constructive international dialogue needed

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new UCL School of Pharmacy report entitled ‘Health and Health Care in India: national opportunities, global impacts’, claims that India, world’s largest generic medicines exporter, still lacks assured free access to good quality generic medicines and the support needed to use them to best effect for large section of its population. This unmet need is particularly high in the context of preventing and treating the growing burden of heart problems, strokes and other non-communicable diseases (NCDs) like diabetes, as per the report.

‘Health and Health Care in India’ estimates that NCDs already cost India the equivalent of 12.5 per cent of the nation’s GDP in lost welfare terms. A similar (though falling) burden is still imposed by infections and events such as traffic accidents and violent deaths in groups such as relatively young women.

Co-author of the report Professor David Taylor observed, “India currently spends only a little over one per cent of its GDP on publicly funded healthcare, and only about 0.1 per cent of GDP on publicly funded medicines for the Indian

people. These are very low figures, even by the standards of the world’s least developed countries. It would be tragic if plans for extending universal health coverage and increasing the supply of free generic medicines for those who lack the resources to purchase even minimal cost modern treatments for common conditions such as high blood pressure and type 2 diabetes are not taken forward as an urgent priority.”

The new UCL School of Pharmacy analysis in addition argues that well-off individuals and groups living in every part of the world should contribute to the global costs of high risk bio-medical research as failures to respect appropriately intellectual property rights needed to protect research investment risk will undermine the future development of new and more effective medicines for conditions such as cancers and dementias. They could also endanger other forms of bioscience-based progress.

Adding further, Professor Taylor said, “Some people wrongly believe that steps like cutting the prices of products like new anticancer drugs that can only

be used effectively in high technology settings will significantly improve public health in India. But this is not the case. Measures like imposing compulsory licences on such medicines are in fact only likely to benefit well-off individuals. The mass of the population will gain from better day-to-day access to low cost but highly effective treatments that are already freely available.”

The UCL School of Pharmacy report concludes that, without enhanced universal access to essential medicines and other forms of cost effective care, health improvement and social tran-

‘HEALTH AND HEALTH CARE IN INDIA’ ESTIMATES THAT NCDS ALREADY COST INDIA THE EQUIVALENT OF 12.5 PER CENT OF THE NATION’S GDP IN LOST WELFARE TERMS

sition in poorer parts of India may stall. Given the size and importance of the Indian population this could in future have harmful global impacts.

Report co-author Dr Jennifer Gill said, “There are no easy answers as to how the world community can ensure that poor people everywhere get good access to essential medicines without over-supplying products like antibiotics or undermining provisions like patents that are needed to promote ongoing investment in medical and pharmaceutical innovation.

We need strengthened mutual understanding to achieve better care in poorer areas and to sustain investment in innovative research, without which global progress cannot continue” ‘Health and Health Care in India’ highlights the potential value of solutions such as internationally agreed tiered or differential pricing arrangements. These should allow public healthcare providers in low income countries to obtain essential patented medicines at affordable costs from the producers responsible for their development.

EH News Bureau

Manipal Health Enterprises forays into Malaysia Acquires two hospitals in and around Klang, Selangor District anipal Health Enterprises, the healthcare arm of the Manipal Education and Medical Group, announced the acquisition of a 70-bed hospital in Klang, Selangor District of Malaysia. This acquisition by Manipal Hospitals also includes a new 200-bed tertiary care hospital which is presently under construction in a nearby location, which will be commissioned by last quarter of the financial year 2014-15. The facility is being implemented in accordance with the Malaysian healthcare guidelines, MSQHA and also JCI. The hospital will focus on a healthy combination of wellness, prevention and curative

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care (secondary and tertiary) levels — for both the domestic and an emerging overseas patient traffic into Malaysia from neighbouring countries.

According to Swaminathan Dandapani, Executive Chairman, Manipal Health Enterprises, “This acquisition is a part of the company’s evolving strategy to expand its footprint in India and in identified countries of the Middle East, Africa and Asia Pacific. In the near term,

significant capacities will be created to add on to the present group capacity of 15 hospitals, 5,000 beds and a patient traffic of about two million annually.”

According to Rajen Padukone, CEO and MD, Manipal Health Enterprises, “Manipal is a well-established name in Malaysia, with over 25 per cent of the doctors in the country being alumini of the Manipal University. The access to this pool of talent, trained in

THE HOSPITAL WILL FOCUS ON A HEALTHY COMBINATION OF WELLNESS, PREVENTION AND CURATIVE CARE www.expresshealthcare.in

India at Manipal University and at Melaka, has been a key driver for Manipal to venture into setting up hospitals in Malaysia. The existing employees and doctors would continue to be engaged with the hospital in Malaysia. Dr Poravi will continue to provide help and guidance as required to the new dispensation.

Ramkumar Akeila will be leading the operations as CEO and MD.” The Manipal group already has two campuses in Malaysia, a medical school at Melaka since 2001 and a newly formed (in 2012) Malaysia International University at Nilai, Kuala Lumpur.

EH News Bureau SEPTEMBER 2013

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Narayana Nethralaya and MedGenome in JV Sets up a genetic testing lab called 'Multi-omics Diagnostics Lab'

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angalore-based eye hospital Narayana Nethralaya formed a joint venture called ‘Multiomics Diagnostics Lab’ for genomic testing with MedGenome, a part of Chennai-based SciGenom for a combined investment of $5 million (Rs 30 crores).

The new genetic testing lab will cover genetics, gene testing, whole genome sequencing, gene expression microarrays, proteomics and immunochemistry. Apart from this, there is an operational flow cytometry facility for research as well as diagnostic evaluation of blood markers.

The announcement was made by Sam Santhosh, Chairman, MedGenome, Dr K Bhujang Shetty, Chairman & MD, Narayana Nathralaya, Dr Rohit Shetty, Vice-Chairman, Narayana Nethralaya, Dr V Ramprasad, COO, MedGenome and Dr Arka Ghosh, molecular biologist.

Speaking at the event Santosh said, “MedGenome will have a panel to test cancers, cardiovascular diseases, eye diseases, neonatal disorders etc.” Commenting on the partnership, Dr Shetty, remarked, “This is a landmark achievement for us as well as the medical fraternity, as we are taking a big leap in addressing the health issues at the fundamental level through advanced tests.”

“This will add a muchneeded edge over any other hospital system in the coun-

THE NEW GENETIC TESTING LAB WILL COVER GENETICS, GENE TESTING, WHOLE GENOME SEQUENCING, GENE EXPRESSION MICROARRAYS, PROTEOMICS AND IMMUNOCHEMISTRY SEPTEMBER 2013

try in terms of translatingbenchtop research to the patient’s bedside in the hands of the physician and surgeons. Alongside these diagnostic testing modalities, this initiative also aims to develop in-house tests/kits for genes ordis-

eases specific to the Indian population with the help of the research groups/ clinicians on campus and around the country,” said Dr Ramprasad.

Narayana Nethralaya and MedGenome are also reportedly collaborating to

establish a proteomic facility that will have capability to analyse small molecules/ metabolites/amino acids/ proteins for diagnostics of metabolic syndromes/IEMs as well as perform whole proteome analysis from any source. “Once functional,

this will be the first set-up to provide genomic testing and personalised medicine, gene therapy for eye disorders in India,” said Dr Rohit Shetty, Vice-Chairman, Narayana Nethralaya.

EH News Bureau

TATA INSTITUTE OF SOCIAL SCIENCES Deonar, Mumbai-400088

School of Health Systems Studies Admission Open to Executive Post Graduate Diploma in Hospital Administration (EPGDHA) The School of Health Systems Studies (SHSS) of Tata Institute of Social Sciences in Mumbai, pioneers of Hospital Admnistration education in the country, invites application for their prestigious EPGDHA programme. It is a 12-month (two semesters), dual mode programme consisting of online learning and two weeks of contact programme in each semester.

The programme is intended to enhance the knowlege and skills of working personnel in the hospital.

Eligibility: Graduates in any discipline with a minimum of 2 years of experience and currently working in hospital. Candidates sponsored by hospitals will be given due preference.

Total Seats: 50 only.

Application form and admission: Application forms can be downloaded from the Institute website: www.tiss.edu. Filled-in application form and necessary documents should be submitted, along with the registration fee of Rs. 1,000 to be paid through DD in favour of Tata Institute of Social Sciences at Mumbai, to The Secretariat, School of Health Systems Studies, Tata Institute of Social Sciences, V.N. Purav Marg, Deonar, Mumbai 400088. The last date of receiving application is 30th September 2013. Admission will be based on the interview at TISS, Mumbai.

Programme Fees: The total fees for the programme is Rs. 1,00,000/- (One Lakh Only), payable in two installments. The fees include tuition fee, learning resources, library and computer services and other programme related expenses.

CONTACT: Telephone: 022-2552 5510/ 5000 /5523 or E-mail: epgdha@tiss.edu www.expresshealthcare.in

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HealthsStylus: a mobile app for medical records An easy-to-use app to carry and access medical records anywhere anytime

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ealthStylus, a mobile app, enables users to record and maintain their health record electronically. It empowers an individual to be self-sufficient in storing their medical records digitally and be able to carry and access medical records 24x7.

The app has been developed mainly for Indian users and hence works in both online and offline mode. It has an emergency feature that enables a user to send GPS coordinates and initial automated calling and SMS to friends and family.

The app reportedly offers the following features: ● Taking pictures of prescriptions and medical reports using mobile phone’s camera. ● Reminder functionality to remind of an upcoming appointment(s), taking medication, etc. ● Easily record health statistics like blood pressure, sugar, child growth numbers, asthma, etc. ● Graphical representation of health statistics captured ● Add item related to spending. Track all healthcare related expenditures medications, doctor visits, lab tests, etc. ● Allows the user to enter and access data without internet connectivity. ● Initiate doctor calling instantly through this application. ● The data on our secured server can be synched on your new device anytime by verifying certain parameters. ● Every input transaction takes less than 60 seconds to perform. ● Secure access to application. ● Doctors, pathologists, radiologists can manage patients information, appointments and reports. ● Doctors can share data amongst them with patient permission.

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CDC and The Abraaj Group to invest in Rainbow Hospitals Capital to support expansion of business and creation of new hospitals

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DC, the UK’s development finance institution and The Abraaj Group (Abraaj), a leading investor operating in growth markets, announced their investment in Rainbow Hospitals, a 450-bed paediatric and maternity healthcare business based in Andhra Pradesh. This is CDC’s first direct equity investment in India since the launch of its new strategy in late 2012.

The investment represents its sixth healthcare investment in the region.

Rainbow Hospitals is a large and specialised paediatric and maternity care company with four maternity, paediatric and neonatal intensive care units and one outpatient clinic in Hyderabad. The business has expanded with four centres added in the last six years.

Dr Ramesh Kancharla, Chairman and MD, Rainbow Hospitals said, “This invest-

ment lets us expand and develop our high-quality medical facilities, allowing us to replicate the successful pioneering model across the country, including in cities such as Bangalore, Chennai and Pune. In parallel, we would also like to develop tertiary paediatric care in Tier-II cities like Visakhapatnam and Kurnool.

The current investment would give us the capacity to expand the number of beds available to patients from the current level of 450+ to close to a 1000 by 2017.

Dr Kancharla added, “The patient investment approach taken by CDC and Abraaj gives us the space to focus on the longer-term business quality and performance essential in multispeciality paediatric care.”

Srini Nagarajan, Regional Director - South Asia, CDC said, “This is an exciting first direct equity investment in

India for CDC. Rainbow is a company with great financial and development potential.

We will work closely with the company to give them the long-term capital and support they need to build the business. With employment in the group currently at around 1,000 people, we expect this to grow as much as four times over the course of our investment, led by the rapid growth in the Indian healthcare market. With demand expected to grow at around 15 per cent per annum over the next decade it’s clear that the gap in provision of healthcare in India will need to be plugged by the private sector. We’ll help the business develop its plan to become a national centre of excellence for the teaching of paediatric medicine and for helping other institutions to deliver quality care – with a focus on lower income groups.

Balaji Srinivas, MD, The Abraaj Griup added, “The Abraaj Group have been early and committed investors in the healthcare space and this transaction represents our 28th investment globally. We are confident that our investment and support, alongside CDC, will facilitate Rainbow’s ongoing growth to help it reach its goal of becoming the leader in women’s and paediatric care.

Under its new strategy, announced in September 2012, CDC now provides direct debt and equity investment to businesses in South Asia and Africa as well as continuing to act as a fund-of-funds investor. From 2004 – 2010 CDC operated primarily as a fund-of-funds investor, investing in companies through intermediary fund managers.

EH News Bureau

OPPI holds seminar on healthcare access in India Top policy makers and healthcare stakeholders offer rich insights for achieving efficient and affordable healthcare access for all

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he Organisation of Pharmaceutical Producers of India (OPPI) held a seminar in the Mumbai, titled ‘Access to Healthcare – Challenges and the Way Forward.’

The event reportedly brought together distinguished professionals, acclaimed experts, policy makers and other stakeholders from the Indian healthcare industry and allied sectors to share their vision and key insights about how the overall status of healthcare access can be improved in the country.

In his welcome address, Tapan Ray, Director General, OPPI, deliberated upon the healthcare consumption trends in India. Setting the agenda for the day, he stated: “Access to healthcare is a subject of immense significance for India particularly with the increasing incidences of new diseases in the country, from cancer and diabetes to chronic kidney disease and cardiovascular

diseases. We need to ensure that Indians not only get prompt and easy physical access to healthcare facilities but also that they can also afford the treatment. This can only be done by reducing the out-of-pocket healthcare expenditure in India, which is currently as high as 75 per cent. The government needs to move quickly on plans for universal healthcare access and renew its focus on public health infrastructure and the healthcare delivery system.”

A recent study ‘Understanding Healthcare Access in India – What is the Current State?’ by the IMS Institute for Healthcare Informatics has revealed that the out-of-pocket expenditure for both outpatient and inpatient treatments in the country can be reduced by as much as 45 per cent by addressing four critical dimensions of healthcare access: ● Physical accessibility and location of healthcare www.expresshealthcare.in

facilities Availability and capacity of needed resources ● Quality and functionality of service required for patient treatment ● Affordability of treatment relative to a patient’s income The IMS Study, reportedly based on a survey of nearly 15,000 households across 12 states along with 1,000 doctors and experts, has revealed that while progress has been made in India over the past decade by both public and private sector initiatives, significant challenges persist in providing quality healthcare on an equitable, accessible and affordable basis across all regions and communities.

Providing insights into the Indian healthcare market to improve access, Amit Backliwal, MD, IMS Health Information & Consulting Services said, “Inadequate resourcing and financing of the public sector health infrastructure negatively ●

impacts the availability of healthcare workers and creates a poor perception of public health facilities.

This forces the rural poor to seek costlier treatment options, which in turn adversely impacts overall healthcare access. This study is an important step in advancing the cause of healthcare access in India.

It helps develop a road map to improve availability, affordability and performance levels.”

Delivering the inaugural address, Ranjit Shahani, President, OPPI, and Vice Chairman & MD, Novartis, said, “While the IMS Study provides a valuable information tool for policy makers and the healthcare and pharmaceutical industry as a whole, the presence of so many stakeholders for the seminar signals an acceptance of the need to align efforts to advance healthcare access for all Indians.”

EH News Bureau SEPTEMBER 2013

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ASK Pravi invests in OMNI Hospitals Investment to help OMNI Hospitals to expand in South and East India

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SK Pravi, a JV between ASK Group and Pravi Capital, has announced its investment in OMNI Hospitals, Hyderabad. The investment of Rs 60 crores will give ASK Pravi a substantial minority stake. The infusion of funds will enable OMNI Hospitals expand its network of hospitals across south and east India.

Anand Vyas, Managing Partner, ASK Pravi Capital Advisors, is also joining the board of directors.

OMNI Hospitals is a tertiary care hospital chain promoted by INCOR Group founded by Anand Reddy Gummadi and Surya Reddy Pulagam. It already operates two hospitals in Hyderabad and Visakhapatnam.

Speaking about the investment, Pulagam, Managing Director, OMNI Hospitals, said, “OMNI plans to expand into a network of tertiary care hospitals across South and East of India in the coming three to five years. The investment from ASK Pravi also helps bring on board experienced private equity professionals who can work closely with us as we scale up our operations.”

Vyas said, “OMNI Hospitals has successfully demonstrated the ability to execute and manage a scalable asset-light hospital model. They have made a mark in providing affordable high quality healthcare services in a short span of time. Their philosophy of involving key doctors and creating value through a shared ownership will help the company as it scales up its operations across different towns.”

Jayanta Banerjee, Managing Partner, ASK Pravi Capital Advisors, said, “This investment fits in perfectly with our strategy of partnering with entrepreneurs seeking to expand businesses that serve the domestic market. In keeping with our philosophy of ‘Active Investing’, we are excited to partner with OMNI as it builds its network of hospitals.”

Spark Capital acted as the sole financial advisor to OMNI Hospitals for this transaction. Tatva Legal

SEPTEMBER 2013

THE INVESTMENT OF RS 60 CRORES WILL GIVE ASK PRAVI A SUBSTANTIAL MINORITY STAKE. OMNI HOSPITALS IS A TERTIARY CARE HOSPITAL CHAIN PROMOTED BY INCOR GROUP

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acted as the legal advisors to ASK Pravi and Grant Thornton conducted the financial and accounting due diligence for the transaction.

EH News Bureau

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POST EVENT Healthcare Marketing MasterClass The participants got an opportunity to understand various aspects of marketing and how to use it effectively in healthcare

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atan Jalan, Founder and Prinicipal Consultant, Medium Healthcare conducted a one-day marketing masterclass in Bengaluru recently with the stated objective that ‘marketing is all about topline and bottomline’.

On whether we should market healthcare, most of the participants agreed on the same.

The session began with an understanding of the 4Ps of marketing- Product, Price Promotion and Place. To help the participants relate to this concept and bring in fresh perspective, a case study on Nano formed a part of the first opening session on marketing, essentially talking about the reasons for the not so successful Nano case study.

Product branding and pricing A session focussed on how critical it is to understand product attributes and positioning. Positioning is all about some of the fundamental attributes of the business model, which would differentiate it from others and which have an inherent service delivery model built into it. Indigo for instance, is positioned as an on time carrier. This attribute is the key differentiator of the model, a promise that is delivered across the organisation. In healthcare, most of the providers talk about care and compassion which is hardly reflected in the overall service delivery and which is quite subjective. Some of the newer hospitals project themselves as a ‘new dimension in healthcare’ or ‘redefining healthcare’ which to a consumer practically means nothing. As per Jim Collins, ‘Positioning is all about what you decide not to do’. It starts with identifying an opportunity area and creating a precise solution for it.

The opportunity area could be anything – right from a specialisation to a softer aspect such as patient centricity.

Brand is not a logo or a colour, but a promise the firm makes to the customers. It is formed by what the firm does rather than what it says.

Finally, the session talked about pricing and creating value to the patients in a healthcare facility. It is about managing costs, managing

perceptions and value surplus.

creating

Public relations Another session focussed on Narayana Hrudyalaya as a case study and the way it has built credibility over time apart from establishing its reputation. This session discussed at length on the seven tenets of the PR strategy, starting all the way from determining a theme, deciding the face, staying consistent, building credibility, choosing the right media and the right language and creating a story.

Managing and handling crisis at healthcare facilities was discussed with the participants taking the fire incident at AMRI hospital, Kolkata into account. Finally it is about leveraging opportunities in the right sense. Case in point could be the Uttarakhand example. None of the organised healthcare providers came forward to help people in the state during need. Had someone looked at this as an opportunity to help people, build relations and establish credibility in the market, it would have meant a lot for everyone

Advertising The session on advertised gave insights on how any advertising essentially starts with the communication objective of the provider and the target segment for the intended communication.

The communication message

should be specific, credible, engaging and more importantly, simple to understand.

In today’s context, a lot of people talk about revolutionary technologies, for instance ‘CyberKnife’ or ‘The world’s first non invasive whole body robotic radiosurgery system’ which the patient does not even understand. It should be kept in mind that a good ad and a bad ad cost the same. It is for the hospital to think of an ad, which people could relate to. Setting communication budgets and evaluating media options is critical to the success of any marketing campaign, depending on the nature of the hospital. A television commercial for instance may work better in a high-involved category, which has a severe compromise on life for instance an obesity facility rather than an outdoor.

A careful evaluation of shelf life of the ad is also critical.

For instance a print ad in a leading newspaper could be expensive with a shelf life of a single day.

Sales force effectiveness This session was on how pertinent it is to understand the question: ‘whom to sell’.

Selling to everyone never yields expected results. A hospital targetted towards relatively underprivileged segment of the population would need to target patients covered under government health insurance schemes whereas a hospital for relatively affluent

QUOTE UNQUOTE “Healthcare industry suffers from an institutionalised myth that long gestation period for a hospital is inevitable. Mr Jalan firmly believes that this is largely a consequence of lack of strategic focus while deciding what the product should be and also inadequate and delayed marketing.”

– Ratan Jalan, Founder, Medium Healthcare "People often get misled by their over-simplified notions about synergy and, in the process, lose the focus.

Companies, which ignore 'the factor, which got them the success in the first place' usually suffer and then, a long time to recover the lost ground."

– Prof Mithileshwar Jha, Professor of Marketing, IIM, Bangalore

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The hospital needs to proactively engage media during the good times in creative goodwill for the institution. Credit points earned during the good period' can really help, when you get into a crisis situation.

McDonald's, as an example, handles the PR being in a sensitive business like food & beverages and a somewhat hostile environment faced

by MNCs. – Dilip Yadav, Deputy Managing Director, Weber Shandwick “The sessions made me realize that marketing healthcare and hospitals is much more than sales and referral network. We identified with a lot of case studies presented during the session and realise that we need to

think beyond the obvious” – Tarun K, promoter of a leading multispecialty hospital in Andhra Pradesh “The contents of the MasterClass were very well structured and relevant to the current marketing challenges. The session on Digital and Social media, in particular, I am sure will help me immensely in marketing my facility” – Dr Lalita Delima, Head - Medical Services, Fortis Hospital

"The simple and effective two way communication" - Raghvendra Bagla. MediCounsel

www.expresshealthcare.in

"The way the things were explained was excellent" - Divya Jain, MediCounsel "Excellent use of examples to explain concepts" - Praveen Venkatagiri ,NCRI "I liked the fact that it was interactive and the points were communicated quite clearly."

- Nikhil Poddar, Iris Hospital "Very Contextual and Relevant.

Marketeers always talk about target group focus, I think this masterclass achieved just that!"

- Zeeshan Basu, Columbia Asia Hospitals

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people need not necessarily worry about insurance patients. Another area which more often than not has always been compromised is the quality of sales team.

Unfortunately the only topic, which is invariably discussed, is the contacts with physicians and the compensation. Issues such as domain/product knowledge, or even questions like ‘how to sell’ are never discussed.

Further, the performancebased incentives are far too less than the actual contribution by value by the sales team. Last but not the least, monitoring productivity is invariably linked to the conversion of cases by number.

Contrary to this, productivity is measured on different parameters such as Productivity cannot be just measured on the increase in footfalls, it is measured on different parameters, for instance, Increase in number of cases from the target group, Leakage of cases, Increase in the number of high margin cases and new relationships developed and market potential of these relationships

Social media Healthcare as a sector is largely driven by ‘word of mouth’ which is nothing but conversations. Taking the logic further, Social media is all about conversations. In fact a closer look at Facebook would show communities such as pregnancy, infertility, obesity, osteoarthritis, asthma among others where patients continuously engage with each other. However just creating a Facebook profile does not serve any purpose. Hospitals could target patients based on the user info. It could be age, gender, geography, work, education, common interests or some support groups. For instance, a birthing facility could customise the Facebook search to married women who attend prenatal yoga or who stay in a specific locality.

Unlike other marketing activities, social media activities and platforms such as Facebook do not involve exorbitant spending and can be monitored precisely.

However, it has to be highly involved relationship with the hospital. Finally contrary to the common perception, negative comments are a blessing in disguise. They help the hospital understand their problems and to help patients who have complaints about any service.

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MEDICALL 2013 Chennai – A roaring success Held recently at Chennai, MEDICALL 2013 attracted professional visitors and manufacturers under one roof in large numbers

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EDICALL 2013, Chennai lived up to the successes achieved by its predecessors and has also managed to set up a precedent for future MEDICALL expos, thereby giving credence to its reputation as India’s premier medical equipment expo and the first real 'supermarket' for hospital equipment and supplies Held at Chennai Trade Centre from August 2-4, 2013; MEDICALL in its 11th edition attracted visitors from the entire spectrum of the healthcare industry. Doctors, equipment manufacturers, service providers, hospital owners, healthcare administrators, marketing professionals, healthcare consultants all were a part of this four-day event.

Healthcare professionals benefitted from the show as they could find the entire range of medical equipment and technology under one roof. Reportedly, some hospitals even placed firm orders at MEDICALL 2013 with Indian medical manufacturers.

Organised by Medexpert, this year too MEDICALL had its share of interesting segments and sessions which captured the interest and elicited admiration of the delegates and participants. Some that definitely need a word of mention are as follows:

Interesting seminars The seminars that were organised at MEDICALL 2013 covered an eclectic range of topics pertinent to the healthcare industry. Experts spoke on topics like branding of hospitals, managing familyowned hospitals, innovations in healthcare, hospital project – build it faster cheaper and better, essential it skills for hospital owners and doctors, robust medical records for hospitals, setting standards in sterilisation department and answered any queries that the audience put to them. Many from the audience were seen sharing their own experiences as well and seeking the experts' advice for the same.

Excellent exhibition The exhibitions at MEDICALL have always been noteworthy. This year was no exception. MEDICALL 2013 Chennai had hosted a huge exhibition where both national and international healthcare players had put up their stalls to showcase their latest and best offerings. Hospital

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flooring, avant-garde equipment used in hospitals, modular OTs, telemedicine technologies, diagnostic tools, surgical instruments et al were part of the exhibition.

Renowned companies like RD Plast, Schiller India, EGO Flooring Systems, Philips, Skanray, Force Motors, Godrej Interio, Allengers, Premier, Shuter, Fuji Film, Konica Minolta, AGFA, SNG, Machin Fabrik, etc were some of the www.expresshealthcare.in

exhibitors.

A networking platform With the representatives of the entire healthcare spectrum present at MEDICALL 2013, Chennai; the event also served as a very good networking platform.

Hospital owners, doctors, medical directors and purchase heads, in addition to producers, dealers and suppliers were all present at the

event. It gave the visitors an opportunity to interact with people pertinent to their business.

Medexpert, the organisers of MEDICALL, are a reputed name in events and trade shows for the healthcare industry. Now they are organising a show in Srilanka during March 2014. For more information contact panchal@medicall.in or visit www.medicall.in SEPTEMBER 2013

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EVENTS UPDATE Spectrum 360o Date: September 21, 2013 Venue: MGM Institute of Health Sciences Auditorium, Kamothe, Navi Mumbai Organisers: MGM School of Health Management Studies, Navi Mumbai Summary: MGM School of Health Management Studies (constituent college of MGM Institute of Health Sciences) will organise the second chapter of Spectrum 360o under the theme Supply Chain in Healthcare – 'Delivering Care in Real Time'.

Contact Tel: 9892194282/9833774269/9987539191 Email: spectrum360@outlook.com Website: www.spectrum360.webs.com

India/Sri Lanka, Executive Vice PresidentMedical and Clincial Research, GSK Pharmaceuticals; Dr Rajendra H Jani, Senior Vice President -Clinical R&D, Cadila Healthcare; Dr Rajesh Avinash Chavan, Consultant ENT & Principal Investigator, Jehangir Clinical Development Centre; Kapil Maithal, Director, International AIDS Vaccine Initiative; Dr RS Paranjape, Director, National AIDS Research Institute [NARI]; Dr Siddarth S Chachad, Head Global Clinical Development, Cipla; Dr Prasad Kulkarni, Medical Director, Serum Institute of India; Dr Khalid Saifuddin, Group Head-Central Continuous Remote Monitoring (CCReM), GCOOBD, Novartis Healthcare; Dr Deepa Arora, Global Head, Drug Safety & Risk Management, Lupin; Dr Himanshu Gadgil, Vice President, Intas Biopharmaceuticals; Dr Ranjeet S Ajmani, Chief Executive Officer, PlasmaGen BioScience; Dr Shravanti Bhowmik, General ManagerClinical Research, Sun Pharma Advanced Research Company.

Clinical Trials Asia Summit Date: September 26-27, 2013 Venue: Hyderabad Summary: Clinical Trials Asia Summit will have a total of six sessions. They are Clinical trials: Current scenario and complexities; The pain points: regulation, ethics and bottom-lines; Quality Control; Emerging trends: vaccines and BA-BE; Quality by design (QbD); The combined learnings. Speakers who will take part in the summit are Dr TS Rao, Adviser, Department of Biotechnology, Ministry of Science & Technology, Govt of India; Dr Shreemanta Parida, CEO, Vaccine Grand Challenges Program, Dept of Biotechnology, Govt of India; Dr Sadhna Joglekar, Area Medical Director-

Contact details: Tikenderjit Singh Tel: +91 20 6727 6403/+91 20 6727 6412 Tel: +971 4 609 1570 Email: tikenderjit.singh@fleminggulf.com th

11 National Conference of IART Date: November 22-24, 2013 Venue: Jawahar Lal Nehru Auditorium, AIIMS, New Delhi Organiser: Department AIIMS, New Delhi

of

Radio-diagnosis,

Summary: The 11th National Conference of IART will bring together experts from the field of radiology to deliberate on topics such as radiography, radiological imaging, radiology equipment, professional issues related to the subject, radiation protection, patient care and many more Contact Organising Secretary Department of Radio-diagnosis, Ansari Nagar, New Delhi-110029 Tel: 09868398808, 01126546230 Email: ramesh_sh@hotmail.com

AIIMS,

66th Annual conference of Tamil Nadu and Pondicherry Chapter of IRIA Date: December 13-14, 2013 Venue: Scudder Auditorium, CMC Campus, Bagayam, Vellore Organiser: Department of Radiology, Christian Medical College, Vellore and the Vellore subchapter of the TN & PY chapter of IRIA Summary: The 66th Annual conference of Tamil Nadu and Pondicherry Chapter of IRIA will lay emphasis on the ongoing and upcoming trends in the field of radiology and diagnostic imaging.

Contact Department of Radiology, Christian Medical College, Vellore Tel: 0416 228027 Email: registration@iria2013vellore.in; radio@cmcvellore.ac.in

To tie up with

for Media Partnerships Contact kunal.gaurav@expressindia.com

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www.expresshealthcare.in

SEPTEMBER 2013

W H AT ’ S INSIDE

STRATEGY

Hospital Good Governance (Sustainable practices) PG 34

MARKET 11 KNOWLEDGE 36 HOSPI INFRA 43 NORTH INDIA SPECIAL 68 LIFE 88

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Maharashtra Government's commitment towards making healthcare affordable and accessible to the people has been quite visible in the past one year. The government has been coming up with various initiatives to enhance healthcare delivery within the state. For instance, the wide spread campaign by the government, with the help of OPPI and Rotary club, to reduce maternal mortality rate (MMR) and infant mortality rate (IMR); the public private partnership (PPP) that the Maharashtra Government got into with GE technology and Ensocare to provide diagnostic services to poor patients in 22 districts; or the most talked about healthcare insurance scheme —the Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY). All of these initiatives demonstrate that the state has trained its focus on uplifting its healthcare system; especially in the case of RGJAY. The scheme, ever since its launch, has caught the public eye. In fact, it is one of the healthcare initiatives that has kept the Maharashtra Government in the good books of the people.

How did the idea germinate?

Provisions of the scheme RGJAY is a unique PPP model health insurance scheme tailor-made to meet the out-of-pocket health expenditure requirements of below poverty line (BPL) yellow card holders and above poverty line (APL) orange card holders families as well as Antyodaya cardholders (families who have income of less than Rs 250/per capita per month) and Annapurna cardholders (issued to shelterless people) for identified speciality services requiring hospitalisation for surgeries and therapies or consultations through an identified network of healthcare providers. The state government has partnered with private hospitals and National Insurance Company to effictively execute this yojana. It is being implemented throughout

Source: www.jeevandayee.gov.in

Celebrating RGJAY's 1st anniversary

In the 90s, many poor patients approached the then Chief Minister of Maharashtra, Manohar Joshi to seek financial assistance for treating catastrophic illnesses such cancer, kidney

and heart diseases. In order to address this, the Government of Maharashtra launched the 'Jeevandayee Yojana' in 1997 for covering few catastrophic illnesses among the poor families.

However, the scheme had many shortcomings related to the coverage of illnesses, access of medical services and out-of-pocket spending by beneficiaries. Therefore, last year the state embarked on a new scheme, the RGJAY, to improve healthcare access to the people of Maharashtra.

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CHINMAYA PADHI.

SURESH SHETTY

Head – Payer, IMS Health

Minister for Public Health and Family Welfare, State of Maharashtra

Since the scheme covers invasive procedures, we may see issues related to converting a potential treatment from non-invasive basis to invasive basis

It is our attempt to alleviate the healthcare maladies that this country faces and the RGJAY is a step in the right direction

the state of Maharashtra in a phased manner for a period of three years. The yojana was introduced with the guiding principle that insurance schemes should be targetted at catastrophic illnesses and the benefits in primary care would be through free screening programmes and outpatient consultations.

RGJAY's implementation is being assisted through effective use of IT-based solutions which help in reaching out to the beneficiaries as well as keep track of its implementations.

The scheme provides coverage up to Rs 1,50,000/per family per year to meet all expenses related to hospitalisation in any of the empanelled hospital subject to package rates on cashless basis. The benefits are available to each and every member of the family on floater basis i.e. the total annual reimbursement of Rs 1.5 lakhs can be availed by one individual or collectively by all members of the family. Immunosuppressive therapy is required for a period of one year in case of renal transplant surgery. So, the upper ceiling for renal transplant is Rs 2,50,000 per operation as an exceptional package exclusively for this procedure. The premium of Rs 333 per family per year is borne by the state government.

Under this yojana, the beneficiaries would be provided with health cards for identification purpose.

Family health cards have been prepared using data from valid yellow or orange ration cards. As an interim

measure, till the issuance of health cards, the valid orange/yellow ration card with Aadhaar number or in case of Aadhaar number not being available, any photo ID card of the beneficiary, issued by government agencies (driving license, election ID), to correlate the patient name and photograph is also accepted in lieu of the health card.

How does it work?

According to Dr RM Jotkar, Assistant DirectorHealth Services, RGJAY Society, Government of Maharashtra, there are multiple stakeholders involved in this yojana, namely: the state, network hospitals, the insurance company, the TPA involved and the beneficiaries. He informed, “In order to streamline the entire procedure and to safeguard the rights and responsibilities of all stakeholders we have established a society called the RGJAY Society. This Society has prepared certain guidelines and protocols that needs to be followed by all stakeholders involved. It also acts as the watchdog to ensure that every stakeholder is observing the rules of the yojana so that none of them can exploit the scenario to their advantage.”

Explaining the procedures involved in detail, Ajay Gulhane, Additional Collector & Deputy CEO, RGJAY Society elaborates, “Firstly, the government provides health cards to the beneficiaries and also conducts health camp with the help of the network hospitals.

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the benefits under this yojana, they have to first register themselves at the Arogyamitra kiosk which is stationed at every network hospital. The beneficiaries will have to provide the appropriate referral card and health card as well as documents to prove their proper identity.

The Arogyamitra at the network hospital will then examine the documents, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The information like admission notes, test/s done are then captured in the dedicated database by the medical coordinator of the network hospital as per the requirement of the Society.

Afterwards the network hospital, based on the diagnosis, admits the patient and sends e-preauthorisation request to the insurer, same can be reviewed by the Society. So, we had two levels of vigilance done in the pilot stage. If the document

and report are clear the insurer and the society send their approval within 12 working hours and immediately in case of emergency wherein e-preauthorisation is marked as EM, we have a system called the Emergency Telephonic Intimation in which an approval can be given within an hour for emergency reasons. After performing the procedure, the network hospital forwards the original bills, diagnostics reports, case sheet, satisfaction letter from patient, discharge summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to insurer for settlement of the claim.�

Well, the protocols involved in this yojana may seem very convoluted; nevertheless this makes the system more organised and can be easily audited feels Dr Jotkar. As a matter of fact, this has also been one reason for the successful completion of the first phase

of the yojana.

As mentioned above, the RGJAY has been designed to function in phases.

Launched on July 2, 2012, the first phase of the RGJAY was introduced in eight districts of Maharashtra: Gadchiroli, Amravati, Nanded, Sholapur, Dhule, Raigad, Mumbai and its suburbs on a pilot basis. The government tied-up with 147 private and government hospitals to provide these services. The insurance coverage in this phase was offered to approximately 49.03 lakh eligible beneficiary families. The yojana provided medical aid for 972 surgeries/therapies/procedures along with 121 follow up packages in 30 identified specialised categories in this phase.

PRAMOD LELE Chief Executive Officer, PD Hinduja Hospital, Mumbai

Rates provided for various procedures’ reimbursement are about 40 to 60 per cent below the tariffs of most of the tertiary care hospitals. That is why most of the big hospitals did not opt for the scheme

First phase of the journey The response received in this phase is quite commendable. According to the updates given by the RGJAY society, there are 83,268 surgeries/therapies

performed till the afternoon of August 21, 2013 out of which the private hospitals contributed to 56293 surgeries/therapies and the government hospitals 26975

APPOINTMENT

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respectively. As on August 21, around Rs 229.29 crores have been infused in this yojana, out of which the private hospitals' share stands at Rs 149.63 crores and Rs 79.66 crores being the government hospitals' share.

These enticing figures only prove that the people of Maharashtra are certainly making good use of the available benefits. Also, the government and the network hospitals through their health camps have left no stone unturned to spread the word.

Expressing his joy on the success of this yojana, Suresh Shetty, Minister for Public Health and Family Welfare, State of Maharashtra, in a public meeting said, “It is our attempt to alleviate the healthcare maladies that this country faces and the RGJAY is a step in the right direction.” Adding to this, Dr K Venkatesh, CEO, RGJAY, during the anniversary celebration, mentioned that the people of Maharashtra started owning the scheme right from the beginning which is one of the biggest advantage he sees. “We have received a very good response from the

people. We have also kept a track on the feedbacks by patients and they are happy with our services. We have a call centre that daily receives calls from satisfied patients”, adds Gulhane.

Dattatray More, a patient from Mumbai who underwent a bypass surgery under the RGJAY, testifies his experience and says that he feels very gratified on receiving this aid from the government. He goes on say that with his financial condition he would never have been able to bear the cost of his surgery. Now that he has received medical aid free of cost he can lead a normal life. Shahida Khan, a young girl residing in Mumbai was house bound for 12 years due to an orthopaedic problem which was resolved with the help of this yojana.

Her mother vouches for the yojana and calls it a saviour scheme. She says that her daughter can now walk and has taken up a small job to support her family.

Apart from the government officials and beneficiaries of the scheme, the yojana is much appreciated by network hospitals from Maharashtra's impoverished districts where the yojana

Parameters

At a glance (Since July 2nd 2012)

Families

118676

Benificiaries

225256

Enrollment Health Camps

1349 Screened

176804

Registered

190299

Government

13007

Private

30952

Total

43959

Government

31617

Private

61662

Total

93279

Government

28441

Private

58584

Total

87025

Government

27478

Private

57323

Total

84801

Government

Rs.81.06 Cr

Private

Rs.152.73 Cr

Total

Rs.233.79 Cr

Patients

Out Patients

In Patients

Preauthorisations

Surgeries/Therapies

Amount Preauthorised

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was introduced. Dr Vipul Bafna, Dhule, feels that the RGJAY is a revolutionary scheme. He explains why, “In a place like Dhule where the human index is very low and there is not much economic development as well as healthcare facilities are bare minimum, this scheme is a boon. Up till now we have performed more than 600 angioplasties and around 200 dialysis under the yojana. Apart from this, during our health camps we conducted more then 1500 angiographies free of cost.”

When asked about how has his hospital benefited from the scheme, Dr Bafna replied that the government has not designed any attractive package for private players in this scheme; however, they have this advantage of earning in volumes.

Dr SM Deshpande from National Insurance Company, is of the opinion that the yojana has taught the insurance company to see healthcare in a different light. He discloses that working on a large social initiative like RGJAY has taught them lot of lessons on the roles and responsibilities of an insurance company.

While stakeholders involved appreciate the yojana and its functions, other industry experts also feel that the scheme is a good initiative. Chinmaya Padhi, Head – Payer, IMS Health find the amount of the coverage more impressive as this element of the scheme acts as a great support to the needy who otherwise may not have access to such expensive treatment”.

However, Pramod Lele, CEO, PD Hinduja Hospital, Mumbai, states, “I feel that it’s a good scheme but requires some changes to make it more viable for the participating hospitals.

Entire thought process is good viz. to make available healthcare available to poor and needy people below Rs one lakh pa family income.

They have covered 900+ categories of illnesses, mostly surgical. It’s a decent coverage, though may not be all encompassing.”

So far, everything seems to be hunky-dory with the scheme. But does it mean there aren't any loopholes or scope for improvement?

All that glitters may not be gold!

It is a known fact that any government venture in India has to overcome a lot of bottlenecks. RGJAY is no

different. The scheme has been criticised by health activists for being procedure or operation driven.

Padhi warns, “Since the scheme covers invasive procedures, we may see issues related to converting a potential treatment from non-invasive basis to invasive basis. Though invasive basis treatment is covered, follow-up visits which are most common post many surgeries are not covered.

Hence, hospitals may not focus on the overall health of the patient, which is the most critical underlying intent of such schemes.

Regular audits should be undertaken by using services of firms with expertise in this area. This will ensure usage of quality materials in implant-based surgeries and will help bring down percentage of surgery failures and incidences of repetitive surgeries.”

Apart from the threat of malpractice, another area that the government battles with is roping in private hospitals to partner the scheme.

The Health Minister of Maharashtra observes that the leading private hospitals had shied away from coming on board, citing the reason that the rates fixed for treatments would compromise their profitability. “We fixed the rates of the procedures after a thorough discussion, but now it is a question of profitability for private hospitals,” the Minister reveals.

Lele presents his counterviews on the same.

“Rates provided for various procedures’ reimbursement are about 40 to 60 per cent below the tariffs of most of the tertiary care hospitals.

That is why most of the big hospitals did not opt for the scheme.”

Apart from roping in private hospitals, the government has had a tough time negotiating with charitable hospitals as well. The Health Minister also claims that since Mumbai is the prime healthcare hub for Maharashtra they had approached all charitable hospitals to start this scheme within their hospital premises. However, they declined this offer.

Justifying their side, Lele replies, “Charitable hospitals carry out lot of free/concessional treatment to patients under order of the High Court. In the process, many of our beds are occupied by these concessional patients. It is not SEPTEMBER 2013

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Source: www.jeevandayee.gov.in

RGJAY Phase II MoU was signed between Maharashtra government and NIC on 8th August 2013

possible to provide the expected additional beds under the RGJAY scheme (25 per cent). It would render the whole hospital unviable. Charity hospitals would be able to implement only one scheme – either the existing High court charity scheme or RGJAY (with some modifications).

One more aspect that needs to be looked into is the timely payment promised under the RGJAY scheme, it generally never comes on time, putting more strain on the finances of the hospitals.”

In juxtaposition with other schemes Well, with all its boons and banes, the RGJAY has still earned enough goodwill to its credit. But, how is it faring in comparison to other states' healthcare schemes like Arogyashree and Yashaswini?

“Most of the features in these schemes, which are totally funded by respective state governments, are similar – for example the base cover under RGJAY and Rajiv Aarogyasri Health Insurance Scheme (RAHIS) is Rs.1.5 lakh per family per year. However, while RAHIS has additional cover of Rs 50000 beyond base cover as buffer, RGJAY has Rs 2.5 lakh extra cover for renal transplantation, while Yashaswini scheme covers only surgical expenses of all rural co-operative society SEPTEMBER 2013

members, members of self help group/Sthree Shakti Group having financial transaction with the cooperative society/banks, members of weavers, beedi workers and fisherman cooperative societies. RAHIS and Yashaswini schemes cover treatment as inpatient, but RGJAY has extension of cover to outpatients also,” analyses Padhi.

Analysts compare the RGJAY with renowned government initiatives present in the country, but does the government do so?

“The RGJAY is a replica of the (RAHIS) of Andhra Pradesh”, admits Dr Jotkar.

He informs that the Maharashtra Government haves picked up the same the idea from the from RAHIS but made few changes to suit the people of this state. However, the RAHIS underwent through a very rough patch due to the involvement of a TPA. Additionally, the scheme that was kicked off with a noble idea turned out to be a money-spinner for the corporate hospitals, so why did Maharashtra decide to replicate the same model?

Dr Jotkar expounds, “This is because initially we were not confident of managing it alone but eventually we do have plans to eliminate the TPA just like RAHIS did in order to make the scheme viable. Also, where the question of misconduct by private players are conwww.expresshealthcare.in

cerned we have tried are best to keep stringent protocols and RGJAY is yet in its infancy, we will surely make this scheme more efficient in the time to come.”

Agreed that the scheme in its nascent stage and the RGJAY Society will leave no stone unturned to make it more viable in the long, but what are the immediate alterations done from the lessons learnt so far?

Tightening loose ends The first phase is complete and the yojana has entered in its second phase which is supposed to be done on a much larger scale.

But, before implementing the second phase, the Society is trying to filter the blunders of the first phase, discloses Dr Jotkar.

“In the first phase we received a very good response; however, we have had certain learning lessons.

Based on these lessons we have done some modifications for the second phase in order to improve the scheme.” Explaining the challenges and alterations done so far, he goes on, “We had to work on the vigilance part. Initially, we had two levels of scrutiny of the beneficiary's documents now we have kept only one level where the TPA would validate the documents and reports and the RGJAY Society will only check the rejected cases. This is to reduce the time taken to

give approvals for procedures.

Another change which will be implemented in the second phase is that we have kept 132 procedures that covers surgeries such as hysterectomy to be performed at government hospitals only. This is done to avoid malpractices. Also, we have reduced the number of procedures from 972 to 971. We have taken out conservative acute myocardial infarction (AMI ) from the list,” he adds. When asked the reason for deleting this procedure from the list, he replied that this was one of the abused areas.

Looking forward By and large, the RGJAY Society has a clear vision for the future. That the government has taken efforts to learn from their mistakes and even rectifying the errors is certainly commendable. With the same ardour, the Maharashtra Government signed the MOU with the National Insurance Company, on August 8, 2013, to initiate the second phase. In this phase, the state government plans to step into 27 districts, reaching out to more people of Maharashtra. In future, to make it a more viable model, the government will need to work on efficiently administering claims as well as managing expenses and fraud in the right manner. raelene.kambli@expressindia.com

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INSIGHT Hospital good governance (Sustainable practices) Meeta Ruparel, Director, AUM MEDITEC expounds on the importance and benefits of good governance practices in hospitals

Meeta Ruparel Director, AUM Meditec

G

rowing consumer awareness and patient demands for easy and prompt access, higher quality services and opportunities of second opinions and selection, regulatory, statutory and political influences; all demand for a continuous mode of strategic innovations that meet these demands, trends and assure quality of care delivery as well as sustain businesses along with a closely followed path to stakeholder satisfaction. Hospitals can achieve these goals by implementation of good governance practices.

The meaning of the term 'governance' as reported has a broad range; centres of the World Bank defines governance as: 'exercise of political power to manage a national affairs. 'The management faculty also places considerable emphasis on governance. Management gurus like Jeffrey P and Henry Mintzberg said, organisations are more than just systems for coordinating and supervising work: they are also systems for determining goals, coping with

Consensus oriented

Accountable

Participatory

Transparent

Good governance Follows the law

Responsive

Effective and efficient

conflict and allocating costs as well as benefits.

So also, Sir Adrian Cadbury said, good corporate governance is concerned with holding the balance between individual and communal goals and economic

Equitable and inclusive

and social goals; to create and sustain businesses legally and ethically. And at the same time ensure a high level of satisfaction to all its stakeholders.”

In one of the WHO research study publications

on public hospitals; it is stated that the term 'hospital governance' emphasises on a set of discrete processes and tools and its effective utilisation. It highlights that the act of governance reflects a variety of organisational

FAQS AND MORE What is the approach to Hospital Good Governance?

One needs to accept that all businesses in India have a good mix of traditional ties as well as the technically advance conduct, therefore often the International standards though very technically sound sometimes become difficult to understand and implement for the executors at the hospital level. The approach has to be simple; it has to be applicable and has to be uniform yet unique for each organisation as per the policy of the said organisation.Therefore identifying this need a Code Of Conduct (COCHO) is developed to cater to the needs of Hospital Good Governance best suited to Indian set up.

What is code of conduct?

A code of conduct is a voluntary framework of guidelines outlining the responsibilities of or proper practices for an individual, party or organisation. (Including ethical codes, industry compliance and best trade practices) What is COCHO?

COCHO is a derived set of ‘code of conduct for hospital organisations’, specially evolved from research data based on best practices in Hospital Governance and the industry set up.

COCHO framework is based on four sustainability pillars in terms of four Ps: Principles, People,

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Planet and Profit.

Why COCHO?

We may have 'good' hospital systems in private and corporate institutes and many of our government hospitals also follow quality and patient safety protocols, but there are discrepancies observed; Let us talk of some examples here… ● Kolkata hospital fire; resulted in a casualty of approximately 80 patients. ● Air ambulance crash in northern India resulted in casualty of the ailing passenger ● Recently one of the newspapers stated that approximately 11 hospitals in Delhi itself did not have fire clearance. ● We still don't seem to awaken; after Kolkata hospital fire there were more hospital fire incidents; two hospitals in Delhi and one hospital in Pune. ● Just a few months ago a television channel covered that due to lack of availability of skilled staff there was an autorickshaw driver who gave an injection to a patient seeking medical care!

The coverage further objected that practice insisting on some introspection and regulatory control. ● Recently I read an article which stated that officials in the Indian health ministry have accepted that about 26 new drugs were permitted for sale

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in the country without holding any clinical trials on Indian patients to test safety and efficacy. ● Allow me to mention here staff harassment (case of a nurse going in coma due to harassment) ● Above all this and most important let us not forget here; medical errors and act of negligence that are raised by aware consumers today. ● In spite of regulations, statutory norms many hospitals are not compliant to important social responsibility/sustainability criteria; as simple as proper hospital waste disposal. (case of hospital used and contaminated disposals found in Delhi streets garbage collection area) One is forced to question that are these hospitals in questioned not certified for different standards under ISO/accreditation for quality, health and safety, environment etc. If the answer is yes then these protocols needs to be revisited and reviewed.

On further introspection one realises that the standards compliance help to meet the wall requirements of numerous certifications for the business model and maybe it is not sufficient. So understanding the root cause of the problem, it evolved that the issue is to develop a spirit of compliance rather than a certificate.

After informal discussions with industry takers it was felt that there needs to be voluntary involvement and passion to improve the industry at all segments and all level. Hence the COCHO framework

SEPTEMBER 2013

S|T|R|A|T|E|G|Y

MORE ABOUT ISDC Integrated Social Development Consultancy (ISDC) is a not-for-profit firm, which works extensively in the field of developmental issues, social compliance/audit, code of conduct assessments and audits, CSR audits, business and human rights agenda and Sustainability. ISDC has beset as a pioneer in India for the concept of Hospital Good Governance and the COCHO framework.

ISDC in consultation with eminent panelists from fair trade practitioners, CSR experts and healthcare management professionals have evolved with the COCHO framework and compliance criteria for assessments. ISDC has skilled professionals, CSR and Code Of Conduct assessors who religiously work towards the betterment and development of good governance, CSR and sustainability practices.

elements and/or stakeholders, at national (macro), organisation wide (meso) and operational management system (micro) levels. Each of these three levels interacts with each other forming complex patterns and thereby defining unique/individual 'Hospital governance structure' specific to that organisation. Each level has its own distinct characteristics and its respective team of decision makers.”

●

●

●

Current issues and challenges ●

●

Some of the commonly cited system failures are communication, monitoring of policy implementation, record keeping, training, leadership, etc.

Some recent representative examples are listed below.

UK’s The Sunday Times (1999) said: “blunders by doctors kill 40,000 a year”.... “Medical error is the third most frequent cause of death in Britain after cancer and heart disease. This may be a study outcome only for the UK, but the status quo isn’t so good/acceptable worldwide either. In India, this kind of study outcome is not an updated declaration as yet.

was developed to enhance the industry to have the flexibility of customised approach and to be able to accept that there are certain areas of improvement on a voluntary, responsible and accountable participation to make it more sustainable.

● ●

●

Responsibility for the effectiveness of systems rests unambiguously at the board room agendas.

Compliance failures and statutory regulations and initiatives have placed good governance systems and cannot be surpassed anymore.

Globalisation leads to increasing cross-border investment opportunities but it can result in a lopsided development if there is a lack of knowledge about the regulatory framework of international standards and expectation of foreign investors.

Loss of trust of investors.

Good governance is at the heart of investment decisions; a research survey analysed that 75 per cent of stakeholders are ready to pay a premium for higher good governance standards Investors are not willing to invest in countries/companies/organisations that are not build on inclusive growth models, are corrupt, prone to fraud, poorly managed and lacking sufficient protection for relevant stakeholders and lack of compliance on business and human rights agenda.

Understanding of the term ‘hospital governance’ is somewhat complicated and equally critical. Hospital decision makers and policy makers traditionally tend to view key elements of hospital performance through the related but narrower perception of ‘hospital management’ and ‘patient volumes’.

In true sense the term governance in general is related to directing policy (e.g. accountability, stewardship, etc.) and so it tends to be difficult to be able to transit in form of operational actions for better performance.

The aim is to align as nearly as possible the interests of all stakeholders, individuals, corporations and society at large.

The scope of hospital good governance is to promote: ● The efficient use of resources ● Establishing the trust of investors ● Economic development ● Good governance performance ● Socially responsible citizenship ● Business excellence ● Regulatory Compliance ● Stakeholder satisfaction ● Risk management and sustainability ● Safety

healthcare rules of prevention is better than cure.

Hence, the healthcare service providers now need to evaluate their professional functioning to contribute to social responsibility and sustainability agenda in terms of four Ps: principles, people, planet and profit.

How is it different from business ethics?

Business ethics aims at imbibing a culture of responsible business conduct within an organisation; Hospital Good Governance supplements the legal and ethics framework with a holistic approach (inclusive of organisational leadership, social accountability, sustainability, professional ethics and business conduct for good management practices).

How is this different from national accreditation standards?

The COCHO guidelines are not standards these are frameworks customised to suit the uniqueness of each organisation policy and functioning.

Often it is argued that healthcare is a charitable cause and hospital is an organisation registered as trust, society or 25 C company and are already having the philanthropic agenda. And they extend their work with community outreach programme.

Which is true to a good extend but is it all that one should aim at? Therefore one needs to evaluate who is the beneficiary? How do you define the community for healthcare service provider and who are my internal and external stakeholders?

And last but not least what is the impact made?

The spirit should be adopted from the basic

SEPTEMBER 2013

The five key elements of hospital good governance are: ● Accountability ● Fairness and ethics ● Safety ● Transparency ● Independence

Benefits of hospital good governance practices ●

● ●

Facilitates the successful implementation of important strategies Leads to better accountability and transparency Prevents managers from making wrong strategic decisions.

care organisation/healthcare providers to serve patients and the society in a more efficient, ethical and effective manner. Hospital Good Governance also plays an important role in maintaining industry integrity and managing the risk of resources, fraud combating against management misconduct and corruption. I foresee that soon there will be enforcements on hospitals from international clientele to comply with fair practices and good governance code of conduct, which will possibly be a supply chain check for medical tourism to ensure stakeholder satisfaction on a global sustainable platform.

What are the benefits of implementing COCHO? ●

A hospital generally conducts health awareness programmes and free medical camps; is this CSR?

Hospital good governance practice is: ● Operates in line with fundamental principles of transparency, integrity and accountability ● Provide high quality healthcare ● How the organisation is led and structured ● Organisation’s objectives are delivered economically, efficiently and effectively ● Protecting interests of both the individual and the organisation. ● Protecting staff against any possible accusation that they acted insufficiently. ● Promote stakeholder satisfaction organisation wide.

● ● ● ● ● ●

Ensures adherence to statutory and other regulatory compliance Inculcates safety systems and practices.

Inculcates a 'responsible' organisational behaviour.

Establishes fair and sustainable practices recognition and thereby build enhanced brand value.

Gains trusts amongst stakeholders, funders and investors Evolves to a sustainable programme, organisation wide on a continual improvement basis.

Encourages inclusive growth models.

Building a case to implement COCHO.

The purpose of COCHO is to enhance the health-

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Is COCHO framework available for all and how can a hospital initiate the COCHO process?

Yes, COCHO framework is available for all Indian organisations interested to participate and implement within their organisation. The first step to initiate COCHO process is to send an expression of interest. On receipt of the expression of interest, an appropriate road map is rolled out with an orientation of COCHO with the applying organisations management, followed with the assessment programme. AUM MEDITEC in association with ISDC provide consultancy and services to help deploy hospital good governance best practices and COCHO compliance. For more details contact: meeta@meditecindia.com

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W H AT ’ S INSIDE

KNOWLEDGE

Recording it right PG 39 ‘Keeping up with new tech, whilst improving surgical skills is topmost challenge facing orthopaedic surgeons' PG 41 Atrial fibrillation increases the risk of stroke four fold PG 42

PROTECTING THE HEART OF FUTURE MARKET 11 STRATEGY 29 KNOWLEDGE 36 IHOSPITAL INFRA 43 IT@HEALTHCARE 62 LIFE 88

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Heart disease can be prevented and childhood is the best time to inculcate healthy heart habits and reduce the risks. M Neelam Kachhap finds out more about CVD risk among children in India

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SEPTEMBER 2013

K|N|O|W|L|E|D|G|E DR PRABHAT KUMAR

KRISHNA KUMAR

Columbia Asia HospitalPune

Professor and Head, Paediatric Cardiology, AIMS, Kochi

Medical nutrition therapy, physical activity, and smoking cessation (if applicable) form the cornerstone of paediatric dyslipidaemia management

I have come across children with hypertension, only four to five required drug treatment but in all them it was morbid obesity which was the cause

There are no standard guidelines for primary prevention of CVD beginning in childhood as developed in the UK or US for implementation on a national scale

Malnutrition is the missing link

form of malnutrition, is undoubtedly related to CVD in later life.

DR ASHUTOSH MARWAH Senior Consultant, Paediatric Cardiologist, FEHI, New Delhi

R

Risk of heart disease appears early in childhood.

Though it is not a major cause of death among children and teenagers, heart disease is one of the largest causes of death among adults. However, most risk factors that affect children can be controlled early in life, lowering the risk of heart disease in adults.

This year, on the occasion of World Heart Day, the World Heart Federation, along with its members, is calling on individuals and parents to reduce their own and their family’s risk because healthy children lead to healthy adults, who in turn lead to healthy families and communities.

Incidence in Indian children Heart disease in children are mostly birth defects or genetic or rheumatic. “In children, cardiovascular diseases (CVDs) include congenital heart disease and rheumatic heart disease,” states Dr Sunita Maheshwari, Senior Consultant, Paediatric Cardiologist, Narayana Hrudayalaya, Bangalore.

Dr Krishna Kumar, Professor and Head, Paediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre (AIMS), Kochi elaborates, “Congenital heart disease (CHD) prevalence at birth is 6-8/1000 as determined through large studies specifically undertaken by Indian Council of

SEPTEMBER 2013

Medical Research (ICMR) for this purpose. The prevalence of critical CHD at birth is approximately 2-3/1000.”

No incidence of coronary artery disease in Indian children is known since this is not specifically looked for.

“Although coronary artery disease rarely manifests in childhood, atherosclerosis, the major precursor of cardiovascular disease begins in childhood,” informs Dr Maheshwari.

Adding to this, Dr Prabhat Kumar, Paediatric Cardiology, Columbia Asia Hospital, Pune says, “When we talk about CVD which is related to counterpart of adult CVD we talk about CVD on a structurally normal heart. This CVD is due to extrinsic factors having influence on a child’s heart which is mainly due to dietary factors and obesity. Hypertension in young age is the usual outcome of this. Rarely, few diseases due to faulty cholesterol metabolism coronary artery disease may occur at an early age.”

The prevalence of rheumatic heart disease (RHD) is quite variable in India.

The disease is clearly on the decline in selected parts of India. “Many large institutions in South India report a decline in proportion of hospitalisations from RHD as well as a progressive reduction in the number of balloon mitral valvotomy procedures and heart valve surgeries for RHD,” informs Dr Manu Raj, Assistant Professor, Paediatric Cardiology and Public health, AIMS, Kochi.

“Anecdotal reports suggest that the disease continues unabated in parts of India that have low human developmental indices,” he further adds.

It is known that obese children are at higher risk for CVD in adulthood. But researchers have found that undernourished children are also at risk of heart disease.

“Malnutrition means an improper diet and technically includes under nutrition i.e. where the child does not get enough nutrition as well as over nutrition, typically called obesity,” explains Dr Maheshwari. “Under nutrition causes deficiency of various vitamins and essential factors required for maintenance of cardiovascular health, whereas over nutrition predisposes to various risk factors such as hyperlipidaemia, hypertension and diabetes mellitus,” says Dr Ashutosh Marwah Senior Consultant, Paediatric Cardiologist, Fortis Escorts Heart Institute, New Delhi.

It was hypothesised that undernourished foetuses during pregnancy may have higher incidence of diabetes and CVD in adult life. This is debatable.

However, over nutrition i.e. obesity, which is also a

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Ground realities Poor cardio respiratory conditioning is also increasing among children.

“Apart from a rising number of obese and inactive children in clinic, I have seen children with unusually high cholesterols. This is related to diet and in all cases, I managed them with dietary intervention,” reveals Dr Maheshwari. “I have also started seeing children with chest pain on walking up a few steps, and after investigation find it is due to poor cardio respiratory conditioning. With the increasing concrete jungles that our cities are becoming, and the increasing emphasis on ‘marks’ and tuitions, today's children are not playing sports or exercising every day, leading to poor lung and heart conditioning. This, along with reduced hours of sleep in the Facebook generation, is leading to obesity,” she explains.

Recounting his experience, Dr P Kumar says, “I have come across children

with hypertension, only four to five required drug treatment but in all them it was morbid obesity which was the cause. In other children usually dietary modification and counselling with life style modification helped.”

Screening programmes There are no large scale screening programmes developed and implemented by the government to check risks of CVD in Indian children. “CVD in children is not a well recognised problem and is not a priority for our country. There is no large scale screening programme for this kind of CVD,” complains Dr P Kumar. “I wish!” says Dr Maheshwari.

Time to act “There are no standard guidelines for primary prevention of CVD beginning in childhood as developed in the UK or US for implementation on a national scale,” informs Dr K Kumar. “There are attempts to improve health of school children (by Central Health Ministry & NRHM) but

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these are not in the form of any formal guidelines,” he specifies. India is yet to formulate systematic evidence based guideline for CVD prevention starting from childhood. “Additionally, it must be recognised that creation of guidelines is unlikely to help unless there is a carefully thought out plan for its implementation. Large-scale national implementation is a far bigger challenge than developing a guideline,” he laments.

Risk assessment Body mass index (BMI) is commonly used to assess obesity in children. But recent studies suggest waist circumference (WC) and weight to height ratio (WHtR) as better ways of predicting obesity. “BMI is widely used to assess the impact of obesity on cardiometabolic risk in children but it does not always relate to central obesity and varies with growth and maturation. WHtR is a relatively constant anthropometric index of abdominal obesity across different age, sex or racial groups and serves as a useful tool,” explains Dr Marwah.

“WC and WHtR have been used by many authors and have been found to be a better age independent criteria for predicting obesity in children and adolescents.

A weight: height ratio of > 0.445 is considered as overweight for both the genders, whereas a WHtR of > 0.485 in boys and WHtR of > 0.475 in girls is used to define central obesity.

In Bogalusa Heart Study (BMC Pediatrics 2010, 10:73) it was clearly shown that children without central obesity were likely to

have higher levels of highdensity lipoprotein (HDL) cholesterol and lower levels of low-density lipoprotein (LDL), triglycerides and insulin as compared to children with central obesity,” says Dr Marwah.

“Compared to just measuring WC, WHtR is fair to both tall and short people and is a better method to use to assess abdominal obesity. There are studies in adults showing that WHtR is as good a predictor as BMI since abdominal fat is worse than other body part fat.

However, there are no major studies in kids showing this benefit. So BMI is still commonly used,” opines Dr Maheshwari.

Expressing a different view Dr Raj says, “WC, BMI and WHtR are all equally good in predicting cardiovascular risk among children. It’s hard to say which of the three is better than the other two as the evidence is not clear, and studies support one or the other.”

“From a public health point of view, there is no need to debate which of the three is the best as the difference would be minimal and all three are easy to measure on a population setting. The measurement error possible in waist circumference may make WC and WHtR inferior in large screenings. (weight and height don’t have that big a measurement error in comparison to WC),” he further adds.

New advancements It is said that a simple way to assess a child’s arterial health is by a calculation based on triglycerides.

Researchers believe that the triglyceride to HDL ratio corresponds closely with arterial stiffness. “Yes,

high triglyceride to HDL ratios have been associated with a higher incidence of heart attacks but studies in children are relatively new,” says Dr Maheshwari.

Agreeing Dr K Kumar says, “Triglyceride to HDL ratio is an emerging concept – seems good as per some studies. More evidence is needed to say that this is superior to conventional markers like BMI or WC.”

Medicine free heart management Generally, doctors are reluctant to give medications to children who may have a risk of CVD, as they don’t have any visible diseases. “I would agree that it is not appropriate to give medications to children with risk factors for adult CVD except for some very rare exceptions,” says Dr Raj. Agreeing Dr P Kumar says, “I personally try to counsel for lifestyle modifications, and if not successful, give drugs for cholesterol lowering.”

Offering her view, Dr Maheshwari says, “In children, doctors tend to want to manage via non medical means such as diet, exercise etc., with medications being a last resort. To some extent, this makes sense as once medications are started the question is how long to continue, any side effect of long term use etc.”

Explaining the merits of lifestyle modification, Dr Marwah says, “For children and adolescents with elevated lipid levels, intensive lifestyle modification, with an emphasis on normalisation of body weight and improved dietary intake, is recommended as a first-line approach because lifestyle intervention is considered to be most effective early in

Downstream interventions

Strategy

Practicalities

Recommendation

Nationwide newborn screening with Pulse Oxymeter

Impractical as a screening method; limited sensitivity and specificity

Very expensive, substantial resource limitations

Not recommended

Screening infants for CHD during immunisation visits

Potentially useful; has not been systematically tested

Expensive, important resource limitations

Consider systematically testing the recommended strategy

Annual clinical examination of school children (weight, height, waist circumference, BP, cardiac auscultation) followed by echocardiography for positive cases

Simple, potentially easy to implement, helps identify RHD, CHD and those at risk for adult cardiovascular disease

RHD: Penicillin prophylaxis CHD: Surgery or catheter interventions (Expensive)Lifestyle changes (inexpensive but often unsuccessful)

Consider a practical plan for phased implementation after careful consideration and deliberation

Source: Dr K Kumar and Dr Raj, Amrita Institute of Medical Sciences and Research Centre (AIMS), Kochi

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life, while behavioural habits are being established. Medical nutrition therapy, physical activity, and smoking cessation (if applicable) form the cornerstone of paediatric dyslipidaemia management and are recommended for all patients with LDL-C levels greater than 110 mg/dL.” “Only a few clinical trials have investigated the use of drug therapy for the management of paediatric dyslipidaemia, and the potential long-term effects of lipid-lowering medications on growth, development, and biochemical variables are unclear. As such, evidence-based recommendations are limited, and pharmacotherapy must be prescribed based on empiric and indirect evidence,” he further adds.

It is recommended that such lifestyle changes in children be implemented for at least six to 12 months before considering drug therapy. “In a six-year study, adolescents who maintained a high level of physical activity during the transition into adulthood exhibited higher HDL-C to total cholesterol ratios, lower serum triglyceride and insulin concentrations, and lower body fat percentages than those who were physically inactive,” informs Dr Marwah.

“When evaluating the need for lipid-lowering drug therapy in paediatric patients, both the nature of the paediatric dyslipidaemia and the potential impact of delaying treatment until adulthood must be considered,” he says.

“There is general consensus that lipid-lowering medications should be used to achieve LDL-C levels less than 130 mg/dL in children and adolescents with certain types of genetic dyslipidaemia, particularly when there is an associated coronary artery disease (CAD) risk,” he explains.

As such, American Association of Clinical Endocrinologists (AACE) recommends considering drug therapy in children and adolescents older than eight years who satisfy the following criteria: LDL-C =190 mg/dL, or LDL-C =160 mg/dL and the presence of two or more cardiovascular risk factors, even after vigorous intervention like being overweight, being obese, havSEPTEMBER 2013

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● ●

Current projections suggest that India will have the largest cardiovascular disease burden in the world.

One fifth of the deaths in India are from coronary heart disease. By the year 2020, it will account for one third of all deaths. Sadly, many of these Indians will be dying young. ● Heart disease in India occurs 10 to 15 years earlier than in the West. ● There are an estimated 45 million patients of coronary artery disease in India. An increasing number of young Indians are falling prey to coronary artery disease. With millions hooked to a roller-coaster lifestyle, the future looks even grimmer. ● There are at least 50.8 million diabetics in India, which is the highest ever reported number from anywhere in the world, according to International Diabetes Federation. The prevalence of diabetes varies between 6-8 per cent in urban and 2-3 per cent in rural adults. ● Indians tend to be diabetic at a relatively young age of 45 years which is about 10 years earlier than in West. ● The prevalence of diabetes varies between 6-8 per cent in urban and 2-3 per cent in rural adults. ● There appears to be a steady increase in hypertension prevalence over the last 50 years, more in urban than in rural areas.

Hypertension is 25-30 per cent in urban and 10-15 per cent in rural subjects.

Source: Dr Marwah, Fortis Escorts Heart Institute, New Delhi

ing other elements of the insulin resistance syndrome, or a family history of premature CAD (before age 55 years).

Additionally, the American Academy of Pediatrics (AAP) recommends that paediatric patients with diabetes be considered for pharmacologic intervention if they have an LDL-C concentration of 130 mg/dL or greater.

Road ahead Screening children for risks and popularising healthy lifestyle by awareness programmes are simple

and easy methods of avoiding a cardiovascular epidemic. Elaborating on its advantages, Dr K Kumar says, “Screening is very simple and requires measurement of simple anthropometric indices. This can be easily arranged in most schools.

Since a substantial proportion of children with obesity are also hypertensive, it is important to obtain a blood pressure record annually for all school going children, particularly as they approach adolescence.” “Screening helps identify a population at risk for adult cardiovascular disease. However, down-

stream interventions that include counselling for lifestyle changes often have relatively limited effectiveness because of poor adherence,” he adds.

The government needs to recognise the benefits of these interventions and screening methods.

“The government could ensure that open play spaces are not encroached upon, giving children the space to exercise; help reduce pollution levels since it has been shown to increase atherosclerosis; ban smoking effectively and do public interest campaigns on diabetes

and CVD prevention,” lists Dr Maheshwari.

Childhood and adolescence is the time when unhealthy lifestyle habits get inculcated so it is imperative that prevention of heart disease must begin there.

Today, we have an opportunity to impact the future, to prevent heart disease. More needs to be done in screening and awareness programmes by the government.

Our leaders should also wake-up to the need for essential guidelines to take the road to a healthy heart.

were maintained for nearly 25 years.

But now, the Health and Family Welfare Department of certain states have given specific time duration for maintenance and preservation of medical records. They are: ● Non medico legal IP . . . . . . . . . . . . .3 years ● Medico legal IP and death cases . . . . . .6 years ● Master case sheet in speciality hospital 20 years ● Scientific and research oriented IP . . . . . . .12 years ● Paediatric medico legal IP records, death case . . . . .12 years

care settings, by being embedded in networkconnected enterprise-wide information system.'

After the enactment of the Information Technology Act, 2000 and subsequent amendment in the Information Technology (Amendment) Act, 2008, any records in electronic form can be produced before any authority as a valid proof.

Appropriate amendments were also carried out in Sec. 3 of the Indian Evidence Act, 1872. The electronic records are acceptable evidence in the Court of Law.

Electronic medical records and its validity

Protection of medical records

Electronic medical records are an evolving concept defined as 'a systematic collection of health information about individual patients in electronic form. It is a record in digital format that is capable of being shared across different health

Medical records are the life blood of healthcare delivery system and a complete medical record should describe all aspects of patient care. There are greater possibilities of misuse of medical records. So, there is a need to restrict access at the same

mneelam.kachhap@expressindia.com

INSIGHT

Recording it right Samuel Abraham & Kamalini, Legal Officers, CMC Vellore, give an overview on the importance of maintaining medical records to enhance healthcare delivery, and the ways and means to do it right

M

odern communication systems and advanced technology have become a part and parcel of all the healthcare sectors and medical records are not an exception to this.

Medical records are the who, what, where, when and how of the patient/s. Medical records act as a means of communication and it is an easy reference for continuity of care.

Document >Record A document becomes a record when that particular document is archived. A document can be archived at any time but once a document is archived then no further changes can be made to it.

Ownership D Samuel Abraham Sr Law Officer, Directorate, CMC Vellore SEPTEMBER 2013

Medical records are considered to be the physical property of the facility.

Regulations regarding access to medical records vary

depending on state law. The fact that the facility owns the paper upon which the particulars/information are written does not prevent others from submitting legitimate claims to see and copy the information therein.

Preservation of records Neither uniform policy nor definite guidelines has been evolved as to the time limit for the preservation of records.

Under the Limitation Act, maximum of three years is allowed for filing a case. In the earlier days, charts of the patients

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Functional comparison – paper record vs electronic record Function

Paper based record Electronic record

Availability

One location

Multiple

Cost

High

Low

Data

Difficult to extract

Easy to extract

Durability

Low

High

Duplication of records Possible

Not-possible

Security

Low

High

Audit Trial

No

Yes

Practitioner

Freedom

Restricted

time it should serve legitimate purpose only. The place of access and the time of access play a vital role in use of electronic records.

●

●

Other role of medical records In addition to helping the medical professionals in assessing the health condition of the patient, medical records provide a major role in defending the institution against possible litigation.

The “FORM System” may be used in the arrangement of medical records.

F- Forming data’s in O- Order or proper arrangements of R- Required way of M- Management The medical records also provide a helping hand to do research:

●

To evaluate the performance of health professionals.

To evaluate the use of the institution’s resources such as special diagnostic equipment and services offered by the facility.

To evaluate the care which the institution provides for certifying and accrediting purposes.

RTI and medical records With the advent of Right To Information (RTI) Act, the role of medical records has gained paramount importance. The demands for information in medical records are increasing rapidly. The personnel who are in-charge of the medical records should be well versed with the provisions of RTI Act so that he/she will be able to

know whether the request for information should be provided or not.

The request for information from the third-party about a patient does not come under the definition of 'information' provided under Sec. 2 (f) of the RTI Act. This is because there is a contractual relationship between the Hospital and the patient and the concept of privity of contract comes to play. All the information requested through RTI need not be disclosed. Sec. 8 of the RTI Act, 2005 provides certain exemptions from disclosure of information: “The information available to a person in his fiduciary relationship need not be disclosed unless, the competent authority is satisfied that the larger public interest warrants the disclosure of such information.” (Sec. 8 (e) - RTI Act, 2005) “The information which relates to personal information the disclosure of which has no relationship to any public activity or interest, or which would cause unwarranted invasion of the privacy of the individual need not be disclosed unless the Central Public Information Officer or the State Public Information Officer or the appellate authority, as the case may be, is satisfied that the larger pub-

lic interest justifies the disclosure of such information.”

(Sec. 8 (j) – RTI Act, 2005)

Digital signature Digital signature enables the subscriber to authenticate his electronic record. It cryptographically binds an electronic identity to an electronic document and the digital signature cannot be copied to another document. Digital signature can be a good replacement for traditional system of ink signature and can be used widely.

Conclusion Hospitals all over the globe are swiftly moving from paper to paperless. The transformation to electronic health record is an advocated and accepted philosophy which can provide swift, safe, high qualitative care with reasonable cost to the patient care. By gone would be the days when voluminous papers charts are carried in hand-driven trolleys from Medical Records Department to various clinical areas and back to congested corridors of hospital! The voluminous medical records are at a distance of a click in his personal computer of a medical professional and next second he can visualise the minute details of a particular patient.

‘Keeping up with new tech, whilst improving surgical skills is topmost challenge facing orthopaedic surgeons’ The University of Dundee's Master of Orthopaedic Surgery (MCh Orth) recently celebrated its 20th anniversary with the award of official accreditation from the Royal College of Surgeons of England. A pioneer when it was started, the course has over 370 graduates spread around the globe, mainly in India. Its Director, Professor Rami Abboud, Head of Department, Orthopaedic & Trauma Surgery /Director, Institute of Motion Analysis & Research (IMAR) , University of Dundee and Editor-in-Chief of The Foot medical journal was recently in India to catch up with some past students. He highlights the challenges INTERVIEW facing orthopaedic surgeons today, recent treatment trends, the courses offered by his department as well as its impact on the careers of past students to Viveka Roychowdhury What were the main objectives of the Institute of Motion Analysis and Research (IMAR) when it was set up in 2003?

IMAR main objectives are to promote excellence in teaching, research and the provision of clinical service in the field of musculoskeletal, biomechanics and motion analysis.

What are the challenges and trends facing orthopaedic surgeons in the practice of orthopaedic and trauma surgery?

I would believe that keeping up to

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date with new and evolving knowledge and technology whilst improving their surgical skills is the top most challenge facing orthopaedic surgeons today.

Keeping abreast of implant developments and monitoring the long-term outcomes of these to identify any issues with new designs etc. is another challenge. For example, recent problems with the metal on metal hip prosthesis highlighted problems with this specific design, which have resulted in annual, life-long follow-up all of these patients as UK government policy.

Challenges therefore are present in www.expresshealthcare.in

many aspects of practice, from choosing the best design, to being innovative but managing the ability to evaluate individual practice. Orthopaedic surgeons should be involved in research projects to evaluate specific practices, such as investigating the alignment of forces across the knee joint and the impact of orthoses use which may prevent or delay surgery.

Demographic studies show ageing populations are going to be the norm in most countries and with this reality, come related bone SEPTEMBER 2013

K|N|O|W|L|E|D|G|E health risks. How is IMAR preparing orthopaedic surgeons to meet these treatment challenges?

IMAR is in collaboration with the Ageing and Health department, looking at balance and how this may be managed with medical intervention. Other IMAR research projects have studied the long-term biomechanical changes in different types of joint prostheses and the impact this has on functional ability. Long-term monitoring and feedback of outcomes of arthroplasty surgery informs surgeons of how well clinically all age groups of patients do postoperatively. Research and audit projects performed at IMAR provide reflections that allow surgeons to use evidence-based practice within their own practices.

What are the recent treatment trends in trauma surgery?

One of the recent trends is the use of technology in assessment to choose the most appropriate treatment modality. For example, motion analysis in cerebral palsy patients; computer aided navigation in total hip and knee replacements; surgical oncology; minimal invasive surgery; laparoscopic investigation and surgery, etc.

Is the role of biomechanics and motion analysis in meeting these treatment challenges part of the formal medical education system?

In order to effectively treat any part of the human musculoskeletal system, it is important to fully understand its biomechanics and yet biomechanics is still not part of any undergraduate medical or vocational curriculum worldwide other than on our courses at IMAR at the University of Dundee.

What are the different courses in orthopaedic and trauma surgery offered at the University of Dundee?

How are these courses different from those offered by other institutes? ✦ Master of Orthopaedic Surgery (MCh Orth) Course accredited by the Royal College of Surgeons of England: this degree aims to provide a Masters degree consisting of taught, clinical attachment and research components delivered through a balanced and synergistic syllabus of clinical orthopaedic theory and practise with closely related basic sciences and biomechanics. It also provides a high level of experience in the design and execution of a substantive research project in the field of orthopaedic, biomechanics, motion analysis and/or rehabilitation technology and its underlying science. This degree is unique in its structure, content and high level of relevant clinical research in association with IMAR. It is a full time face-to-face course.

There are six main reasons why we think this course is better than any other course offered by other institutions: (1) Best lecturing faculty drawn from specialists across the entire UK, (2) Best research experience in clinical

and biomechanics in association with IMAR, one of the leading facilities in biomechanics and motion analysis worldwide, (3) Associated clinical attachment with a consultant orthopaedic surgeon for the duration of the course with no need for GMC registration, (4) Our MCH Orth philosophy is to recruit ambitious orthopaedic surgeons with career aspirations that encompass leadership, academic excellence, and the highest level of skills and expertise, (5) Our successful graduates value education and recognise the need for professional reflection lifelong learning to deepen their understanding , and to enhance their ability and develop a sound professional judgement, and (6) The Dundee MCh Orth Course is accredited by the Royal College of Surgeons of England. ✦ Master/Diploma in Orthopaedic Science accredited by the Royal College of Surgeons of England: this MSc will provide a robust and wide-reaching education in the fundamental physical sciences relating to orthopaedic surgery. It is the only programme amongst the few comparable MSc programmes in the UK with a specific focus on the theoretical and practical application of technology within orthopaedics. Additionally, it equips trainees with the knowledge of fundamental science required for the FRCS exit exam. Only orthopaedic trainees or consultants can apply to undertake this course, face-to-face or by distance learning. ✦ Master/Diploma in Orthopaedic & Rehabilitation Technology (ORT): this MSc is intended to provide students with an understanding and knowledge of the technological aspects of orthopaedics and rehabilitation. University graduates with a relevant discipline (e.g. doctors, engineers, physiotherapists, nurses, podiatrists, etc…) could apply to this course and it can be undertaken face-to-face or by distance learning. This course has been on offer since 1994 and it is unique in its structure, content and the in-depth information and advanced technology that covers. ✦ Master/Diploma in Motion Analysis: this is the only master degree worldwide in clinical gait analysis and motion analysis.

Anyone with a good university degree (as with ORT) could apply to this course and it can be undertaken face-to-face or by distance learning. ✦ MSc in Sports and Biomechanical Medicine: this MSc is designed to follow on from the undergraduate programmes in medicine, engineering, science, podiatry, sports science, biology, clinical health professions and as such uses these subjects as a reference point. Graduates from the programme will be able to use their skills and knowledge to successfully increase their level of integration of sport and exercise medicine within their respective professions and disciplines at an advanced

BIOMECHANICS IS STILL NOT PART OF ANY UNDERGRADUATE MEDICAL OR VOCATIONAL CURRICULUM WORLDWIDE OTHER THAN ON OUR COURSES AT IMAR AT THE UNIVERSITY OF DUNDEE SEPTEMBER 2013

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practitioner level. This degree is unique in its structure and content and its association with IMAR. ✦ Bachelor of Medical Science with Honours in Applied Orthopaedic Technology: this undergraduate degree is aimed for medical students who have completed three years of their medical curriculum and wish to take a year out to further expand their knowledge in Orthopaedic and related technology that is not covered in their medical MBChB or MBBS degree.

This programme aims to provide the students with an early understanding of the principles involved in the development and application of orthopaedic technology and orthopaedic biomechanics. It is the only one in UK. ✦ MSc, MD and PhD by research in any area of orthopaedics, biomechanics and/or motion analysis.

What is the yearly intake in these course and from which countries?

Does the institute offer funding options, scholarships for these programmes?

The yearly intake is between 50 and 75 students on all courses – worldwide. There are no scholarships; all students are selffunded irrespective if they are UK/EU or overseas.

In terms of accreditation, are any of these courses accredited and by whom?

All courses are accredited by the Scottish Credit and Qualification Framework and monitored by the University of Dundee Senate. In addition, the Master of Orthopaedic Surgery (MCh Orth) Course and the Master/Diploma in Orthopaedic Science are further accredited by the Royal College of Surgeons of England.

What is the value addition of these courses to the attendees in terms of future career prospects, setting up or expanding their own practice?

The feedback that we receive from many graduates highlight the importance of our degrees and the knowledge gained in shaping their careers and expanding their own practice in UK and in their own home countries.

One of the best examples is to look at Dr Parag Sancheti of Sancheti Orthopaedic Institute in India and his career progress since he completed his MCh Orth degree with us in 2003. In his testimonial on our website, he recommends this course for “enhancing all-round development in orthopaedics and also for sharpening research and academic communication skills with special emphasis on producing a well written and structured dissertation for peer review publication.”

Another graduate, Dr Rajesh Garg who completed his MCh Orth in 2007 and is a Consultant Orthopaedic Joint Replacement Surgeon, at the Centre for Joint Replacement Surgeries in India indicated that though it took him two years to gain admission onto the MCh (Orth) course due to the huge volume of applicants, “it was worth the wait as the course offered continuous academic lectures (something lacking during his postgraduate training) by an incredible faculty.” viveka.r@expressindia.com EXPRESS HEALTHCARE

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‘Atrial fibrillation increases the risk of stroke four fold’ Coronary heart diseases are on the rise in India, however, heart rhythm disorders might lie at the heart of many of these.

Dr Paul Dorian, Department Director, Division of Cardiology, University of Toronto and Staff Cardiac Electro-physiologist at St. Michael's Hospital sheds light on arrhythmia in an interview with Shalini Gupta What percentage of those with a heart ailment go on to develop arrhythmias? What triggers such a condition? Is this genetic?

There are hundreds of different types of heart diseases and dozens of different types of arrhythmia.To put it roughly, heart diseases contribute one third of all the possible diseases in the world and a quarter of these heart diseases are due to heart rhythm disorders.The likelihood of developing a heart rhythm disorder also depends on the type of atrial fibrillation and the severity of atrial fibrillation. In a condition called, 'primary arrhythmia syndrome' the heart is structurally normal but electrically abnormal. Atrial fibrillation is the most common type of heart rhythm disorder and can occur in presence or even in absence of a structural heart disease. In India, one of the common causes of developing atrial fibrillation is a rheumatic valvular heart disease that occurs in patients who suffer a condition called 'rheumatic fever' due to bacterial infection. Many a times high or uncontrolled blood pressure can lead to thickening of the heart muscle or hypertrophy of heart, thereby later developing atrial fibrillation in many cases.There are cases where atrial fibrillation can occur in absence of any abnormality of heart.

This condition is called as ‘idiopathic atrial fibrillation’ which could be inherited and genetic but such cases are not very common. Heart rhythm disorders are most commonly linked to an underlying heart disease. Increased income levels lead to better nutrition status, obesity, high blood pressure and diabetes which are risk factors for developing a coronary artery disease, that in turn leads to arrhythmia.

What are the symptoms of atrial fibrillation? Is it age specific, are obese and hypertensive people more susceptible to it? What complications could arise if left untreated?

Atrial fibrillation in many but not all patients causes the heart to beat rapidly and irregularly, that is felt by the patient as 'palpitations', an unpleasant sensation of rapid and irregular heart beat in the chest leading to dizziness, light headedness, shortness of breath and effort intolerance (difficulty in carrying out routine activities like

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carrying a load or climbing stairs) However, diagnosis is difficult since other diseases can also cause similar symptoms.The only certain way to diagnose atrial fibrillation is by recording electrical signals of the heart with the help of electrocardiogram. It is a very commonly used test which is relatively simple, quick and non invasive and provides 100 per cent accuracy in diagnosis of atrial fibrillation if it exists at the time of the test. Sometimes, atrial fibrillation is intermittent. It means, patients may have it few hours every day, few hours every week or even few hours every month, where most of the times patients are perfectly fine but from time to time they would suddenly develop a rapid and irregular heart rhythm and to diagnose this, we need to capture this abnormality the moment it occurs because once the episode is over patients once again start feeling fine and start feeling completely normal.

We take this condition seriously because: Patients with atrial fibrillation frequently feel unwell, tired and are unable to function properly. It also increases the risk of stroke. In such a person,the collecting chambers of heart called , ‘atria’ are not beating properly.

This may lead to formation of blood clots in the heart chamber that can get dislodged, traverse through circulation and get impacted in the blood vessels supplying the brain, blocking the blood flow to that part of the brain causing an irreversible damage to brain, leading to stroke. Very importantly, this complication can be prevented by giving blood thinners or ‘anti-coagulants’, that prevent the formation of blood clots, in turn preventing stroke.

What are some of the drugs to prevent arrhythmias? How do they act? Is the mechanism different?

How expensive are these drugs? Are they accessible to heart patients in countries such as India?

Two types of drugs are used to treat atrial fibrillation. First type is ‘antiarrhythmic’ drugs.This is a category of drugs with a chemical effect on the electrical function of heart. And their purpose is to prevent atrial fibrillation or to restore the heart rhythm and revert it to normalcy.There are approximately seven or eight different types of such drugs available worldwide.

None of them are particularly new.They

INTERVIEW

are modestly effective in restoring the heart beat.They don’t work perfectly in at least half of the patients.They can have serious side effects and they are not so easy for patients to take due to their side effects.They are not very expensive. Most commonly used drug worldwide is Amiodarone (also most commonly used in India), but it needs monitoring due to potential side effects.

The second type is even less expensive and probably simpler but doesn’t completely fix the underlying problem, they are called ‘rate control drugs’, which are a relatively simpler option.

They don’t restore the heart rhythm to normalcy but can control excessively fast heart rate. Patients usually feel better and don’t suffer from excessive symptoms of atrial fibrillation.The third category of drugs doesn’t treat the underlying heart rhythm problem but are designed to prevent the complication of atrial fibrillation, which is clot formation, leading to stroke.These drugs are called anti-coagulants.The cost of drugs in this class varies.The more traditional drug in this category is Warfarin which has been in the market for the last 50 years and its cost is not high. But patients on Warfarin therapy need to be monitored very frequently and carefully to check whether the blood thinner is not over-acting or under acting.The monitoring is relatively complicated and it can be costly. Some of the novel oral anti-coagulants that are present in the market since last few years are expensive but easier to regulate as they don’t require frequent monitoring due to their predictable effect.

What is the incidence of atrial fibrillation (Asian vs Western) ?

Have there been any studies to establish this correlation?

Atrial fibrillation increases the risk of stroke approximately four-fold. For

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instance, if a patient is around 65 years of age and does not have atrial fibrillation, the risk of developing stroke is about 0.5 to 1 per cent per year. In persons with atrial fibrillation, the risk increases to around three to four per cent per year and is as high as 10 per cent per year in a patient above 75 or 80 years of age. As far as the risk of stroke related to atrial fibrillation is concerned, there is not much difference between India and the Western world.

Strokes are relatively common in India or Asia compared to North America or Western Europe, and that is possibly because there are more patients with valvular heart disease in Asia due to higher incidence of rheumatic valvular heart diseases and also because of the rising incidence of uncontrolled blood pressure.

You recently visited India. What is the awareness level of antiarrhythmia amongst patients, doctors etc?

I did not get an opportunity to meet patients in India but I did interact extensively with cardiologists and physicians in India.The awareness levels in doctors about arrhythmias is extremely high.They are extremely well informed are using the latest treatment options to treat patients.The only limitations that I see from the treatment perspective are essentially related to the availability of medical care in smaller communities of the country side and some of the complexities involving very large population with standard of living not as high as the Western world.

You have been a pioneer in revolutionising standard practices in resuscitative medicine. Tell us something about your findings and how they could be applied in clinical settings.

This is my life story in a way and something close to my heart. Currently much of my research rests on the belief that when you have a complicated condition like atrial fibrillation to manage with relatively complicated treatments, the best way to manage the problem is to simplify the management as much as possible. We are working on a system of care around this belief by involving patients as partners in their own healthcare. Our programme involves: 1. Identifying or increasing the diagnosis of the heart rhythm disorder by routine ECG screening.

2. Providing an educational material to patient for their easy understanding of the disease and to understand their treatment better.

3. Keeping a checklist of items for doctors ensuring a standardised approach in treatment for all patients with atrial fibrillation. shalini.g@expressindia.com SEPTEMBER 2013

W H AT ’ S INSIDE

HOSPITAL INFRA

Achieving excellence in procurement and inventory management PG53 Strategising for success PG 55

A MEASURE OF HEALTH:

MARKET 11 STRATEGY 29 KNOWLEDGE 36 IT@HEALTHCARE 62 LIFE 88

SEPTEMBER 2013

Sustainability in the healthcare industry Kshama V Kaushik, Director and Rosanna M Vetticad, Principal Consultant,Thought Arbitrage Research Institute give a detailed analysis on the Indian healthcare industry and stress on the need for sustainability to plug the loopholes in vital areas including infrastructure, medical insurance and human resources

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he Indian healthcare sector is the second largest and fastest growing services sector in the country with estimated revenues of around $30 billion constituting five per cent of GDP and employing around four million people. By 2025, the Indian population is estimated to reach 1.4 billion with about 45 per cent urban adults (15 years+). To cater to this demographic change, the healthcare sector will have to be about $100 billion in size contributing nearly 8 to 10 per cent of the then GDP (according to CII).

PwC estimates that the industry is growing at a CAGR of 15 per cent and is expected to touch $250 billion by 2020.

The key drivers of this growth are increasing population, increasing disposable income, increasing lifestyle health disorders, cheaper treatments, thrust on medical tourism, improving health insurance penetration, government initiatives and focus on public private partnerships, advances in science, using the knowledge of biosciences and genomics to deliver safer, more personalised, preventive and cost-effective healthcare.

T

Kshama V Kaushik

Rosanna M Vetticad

Background In spite of the growth in the healthcare industry indicated above the country faces a number of challenges, including significant shortage of beds, doctors and nurses, as depicted in the table below.

It is relevant to note here that actual doctor and nurse density falls to 1.9 per 1,000 due to the high proportion of inactive nurses and registered practitioners, and AYUSH doctors and rural practitioners not actively involved in the formal sector.

While public spending on healthcare has increased (although not at the same pace as the GDP) out-of-pocket expenditure continues to be high. Healthcare infrastructure has also not kept pace with the growing population.

Healthcare reforms prompted by continuing rapid economic growth has resulted in increased investments in emerging markets like diagnostic chains and medical device manufacturing units.

The 12th Five Year Plan

seeks to strengthen initiatives taken in the 11th plan to expand the reach of healthcare and work towards the long-term objective of establishing a system of Universal Health Coverage (UHC) in the country. The plan intends to work towards national health outcome goals which target health indicators, some of which are common to UN’s Millennium Development Goals (MDG) [viz. reduction of infant mortality rate (IMR), reduction of maternal mortality ratio (MMR)] and others such as: reduction of poor households’ out-of-pocket expenditure, reduction of total fertility rate (TFR), prevention, and reduction of undernutrition in children below three years, raising the child sex ratio from 914 to 950, etc.

The Indian healthcare industry is under the charge of the Ministry of Health and Family Welfare (MoHFW). It functions with four departments, the Department of Health and Family Welfare, the Department of Ayush (deals with Ayurveda, yoga and naturopathy, unani, siddha, homoeopathy and other alternative systems of medicine), the Department of Health Research and the Department of Aids Control.

Challenges in the hospital industry With the rapidly growing population and economic development, the Indian hospital industry faces many challenges primarily with regard to making healthcare affordable and accessible to all citizens. To ensure sustainable growth and development of this industry, these challenges need to be met head on. They primarily include: Infrastructure gaps: As mentioned earlier, the hospital bed density (per 1000) in India stands at 1.3 in 2010. There are 11,993 hospitals with 784,940 beds in the country; out of these 7,347 hospitals are in rural areas with 160,862 beds and 4,146 hospitals are in urban areas with 618,664 beds (National Health Profile 2011). This excludes the 148,124 sub-centers, 23,887 primary health centres and 4,809 community health centres in India as on March 2011.

Table 1: Shortage of beds/doctors Particulars*

2010

WHO Std

Hospital Bed Density (per 1,000)

1.3

3.5

Doctor & Nurse Density (per 1,000)

2.2

2.5

*”India Healthcare: Inspiring possibilities, challenging journey” a McKinsey & CII report of Dec 2012

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In order to meet the global average of around three beds per 1000 population, India needs approximately three million more beds. To achieve quality standards set forth in the 12th Five Year Plan a minimum norm of 500 beds per 10 lakh population in an average district would be required.

Human resources in health sector: The country faces an acute shortage of medical and paramedical professionals. According to the National Health Profile 2011 there are 97,648 government allopathic doctors and 3,875 dental surgeons serving an average population of 12,005 and 302,530 respectively. The number of doctors possessing recognised medical qualifications (under I.M.C Act) registered with state medical councils/ Medical Council of India up to 31 December 2011 was 922,177 and the number of dental surgeons was 117,825.

The number of registered nurses (ANMs) and pharmacists in India were 603,131 (as on 31 December 2010) and 657,230 (as on 31 December 2011) respectively. To reach the ratio of one doctor per 1,000 individuals by 2025, the country needs approximately 700,000 more additional doctors. According to the 12th Five Year Plan at the start of the 11th Plan, the number of doctors per lakh of population was only 45, whereas, the desirable number is 85 per lakh population. Similarly, the number of nurses and auxiliary nurse and midwifes (ANMs) available was only 75 per lakh population whereas the desirable number is 255.

Rural areas are especially

poorly served.

Expenditure: In India, about 70 per cent of the healthcare delivery system is dominated by the private sector. While government expenditure and plan outlays have been increasing in absolute numbers over successive five year plans, the proportion of government expenditure to private expenditure is rather wide.

According to the National Health Accounts (NHA-2009) the total expenditure on healthcare, taking public, private and household out-ofpocket (OOP) expenditure was about 4.1 per cent of the GDP in 2008–09, which is broadly comparable to other developing countries, at similar levels of per capita income. Public expenditure on health however was at dismal low of about 27 per cent of the total in 2008–09 (NHA, 2009).

The budgetary support for the 12th Five Year Plan (2012-17) for the various departments of the MoHFW has increased by 335 per cent from Rs 89,756 crores in the 11th Five Year Plan to Rs 300,018. Total public funding on core health therefore is being increased from 1.04 per cent of the GDP in 2011-12 to 1.87 per cent of the GDP by the end of the 12th Plan.

Education faculty and underutilisation: There is an acute shortage of faculty in medical colleges in India.

In order to sustain the projected growth of the industry, availability of a welltrained work force is of paramount importance. This includes not just doctors and nurses, but also paramedic SEPTEMBER 2013

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staff, lab technicians, OT attendants, radiologists and pharmacists. Capacity building on this front may be enhanced through public private partnerships.

Increasing costs: The increasing cost of healthcare especially tertiary care is a major problem for a majority of the population. Public healthcare services are limited and inadequately funded pushing large numbers of people to incur heavy OOP on services purchased from the private sector. OOP expenditure arises even in public sector hospitals, since lack of medicines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness.

Technology & retention of work force: Technological up gradation is one of the big challenges of the sector. At a conference in Washington in 2012 (organised jointly by CII and the Center for Strategic and International Studies (CSIS)), Dr. Prathap Reddy, Chairman of the Apollo Group of Hospitals emphasised the need for new tools to transform healthcare delivery, such as through information technology (IT) and lauded the ongoing efforts in the US to digitise healthcare data through Electronic Medical Records. As part of the 12th Five Year Plan, computer with internet connectivity would be ensured in every PHC and all higher level health facilities. Connectivity can be extended to sub-centres either through computers or through

cell phones, depending on state of readiness and the skill-set of functionaries. All district hospitals would be linked by tele-medicine channels to leading tertiary care centres, and all intra-district hospitals would be linked to the district hospital and optionally to higher centres.

The role of the MoHFW would be to lay IT system standards. States will be funded for their initiatives in this field at primary or secondary levels through the National Health Mission.

Retaining the medical/ healthcare work-force has been a problem in India for long. The big challenge is to develop an environment conducive to attracting talent back to India. Incentivising those who chose to remain in India and study further or practice is also extremely important – for this, the government needs to improve infrastructure and increase emoluments. Medical professionals find rural postings unattractive as these areas lack facilities in terms of poor living conditions, low pay scales and professional satisfaction.

Poor bio-medical waste (BMW) disposal practices According to the World Health Organisation (WHO) waste generated by healthcare activities includes a broad range of materials, from used needles and syringes to soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices and radioactive

materials. Poor management of healthcare waste potentially exposes healthcare workers, waste handlers, patients and the community at large to infection, toxic effects and injuries, and risks polluting the environment. For this purpose it is essential that all medical waste materials are segregated at the point of generation, appropriately treated and disposed off safely. In some circumstances they are incinerated and dioxins and furans and other toxic air pollutants may be produced as emissions. Exposure to dioxins and furans may lead to the impairment of the immune system, the impairment of the development of the nervous system, the endocrine system and the reproductive functions. WHO has established a Provisional Tolerable Monthly Intake for dioxins, furans, and polychlorinated biphenyls. The unsafe disposal of health-care waste (for example, contaminated syringes and needles) poses public health risks. WHO estimated that, in the year 2000, injections with contaminated syringes caused 21 million hepatitis B virus infections (32 per cent of all new infections), two million hepatitis C virus infections (40 per cent of all new infections) and at least 260,000 HIV infections (five per cent of all new infections).

Failure to safely dispose of syringes may lead to dangerous recycling and repackaging which leads to unsafe reuse. A 2002 assessment done by WHO in 22 developing nations found that 18 to 64

per cent of healthcare facilities do not use proper waste disposal methods.

Disposal of medical waste therefore requires close attention to avoid diseases associated with poor management of such waste, these include use of incinerators (mostly used in the developing world) and more advanced systems like autoclave, shredder or microwave. Irrespective of the method/technology used, best practices should be followed starting from effective reduction of waste and proper segregation.

In India the following rules and guidelines exist: Bio-medical Waste (Management & Handling) Rules 1998 notified by Ministry of Environment and Forests, Government. of India to provide a regulatory framework for segregation, transportation, storage, treatment and disposal of bio-medical waste generated from the healthcare facilities (HCFs) in the country so as to avoid adverse impact on human health and environment.

The National Guidelines on Hospital Waste Management based on these rules released by MoHFW and distributed to all States/Union Territories in 2002 for implementation.

National Policy document and Operational Guidelines for Community Health Centres, Primary Health Centres and Sub-centres developed by Ministry of Health and Family

BIOMEDICAL WASTE DISPOSAL - CASES REPORTED IN THE RECENT PAST ❖

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The status of disposal of bio-medical waste of over two dozen hospitals and nursing homes in Bhopal is not known as these nursing homes remain uncovered.

Even the Madhya Pradesh Pollution Control Board (MPPCB) doesn't have any clue about it. For around 30 nursing homes, there are no records available about their location and, most importantly, how they go about disposing of medical waste. (Feb 2013) Two Jalandhar hospitals get Punjab Pollution Control Board notice over faulty waste management.

(Jan 2013) The health department of Surat Municipal Corporation (SMC) slaps notices on four private hospitals, includ-

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❖

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ing a well-known IVF centre, for flouting norms on disposal of bio-medical waste. (May 2013) A used syringe thrown unmindfully into a domestic bin pierces the wrist of a daily wage worker sorting garbage for the Corporation of the City of Panaji (CCP) at their centre at St Inez. 29 other workers at the same centre are exposed to serious health risks at work everyday as unaware residents dispose their daily waste carelessly. (Jan 2013) ❖ The Nagpur Municipal Corporation (NMC) slaps a penalty of Rs 30,000 on a hospital for dumping biomedical waste in the garbage.

(Jan 2013) Two people arrested in Nagpur for illegal sale of biomedical waste to a scrap deal-

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er instead of disposing it of hygienically at Bhandewadi dumping yard. (Nov 2012) Karnataka-the highest producer of bio-medical waste.

Over 62,241 kg of medical waste and 43,971 kg of disposable medical waste are produced daily in the state, according to a survey.

A 2012 BBMP survey of 1,844 private health units revealed that only 30 per cent have obtained no objection certificate (NOC) from the Karnataka State Pollution Control Board (KSPCB). KSPCB officials say it's the big hospitals in the city that follow the rules while the smaller nursing homes and health centres often flout guidelines to dispose of their medical waste.

(Oct 2012).

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The civic body in Margao Goa which is clueless over how to go about putting in place a system to ensure scientific disposal of bio-medical waste in the city. Though a few hospitals in the city claim to have bio-medical waste treatment facilities, several nursing homes, clinics, laboratories, etc. do not have any such system as a result of which the bio-medical waste invariably finds its way to the Sonsoddo waste dump, mixed with the municipal solid waste.

(July 2012) Lack of knowledge of requirements: No civic hospital in Pune has ever obtained the permission to BMW because the PMC authorities never knew they needed it.

(Sept 2012)

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Welfare has been released for proper bio-medical waste management under implementation of Infection Management and Environment Plan (IMEP) The Central Pollution Control Board (CPCB) has prescribed guidelines for Common Bio-Medical Waste Treatment Facilities as well as for design and construction of Incinerators.

However, health being a state subject, it is the responsibility of the concerned State Government to take necessary steps to monitor the disposal of biomedical wastes through the State Pollution Control Boards (SPCBs)/ Pollution Control Committees (PCCs) in the Union Territories, as per the provisions made under Bio-medical Waste (Management & Handling) Rules, 1998, as amended in the years 2000 and 2003. The State Pollution Control Boards (SPCBs)/ Pollution Control Committees (PCCs) are the prescribed authorities to grant authorisation for the BMW Management.

They are empowered to ensure the compliance of provisions of these rules.

Despite the existence of strict guidelines for the disposal of BMW, numerous instances of improper management, illegal dumping of medical waste and even sale of waste (rather than appropriate disposal) continue to be reported.

Box 1 shows that improper disposal of medical waste is still quite rampant, in spite of strict laws in place for the past 15 years. The main challenge lies in segregating waste.

Segregation should start at the source of waste generation and end at its disposal.

According to WHO, management and operational problems with incinerators, including inadequate training of operators, waste segregation problems, and poor maintenance, are the critical issues that should be addressed in assessment and waste management plans. The state pollution control boards need to follow a no-tolerance policy and appropriately reprimand generators of medical waste for flouting norms and not obtaining licenses. Best practices should also be adopted/adapted to develop a sound system of disposal.

Recently King George’s Medical University (KGMU) received a Special Recognition Award from the United Nations Development Programme (UNDP) and the WHO in Lucknow recognising the outstanding work of

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Table 2: Selected Companies - Hospitals & Medical Services Company Name

Location

Net Sales (Rs Crores)

Apollo Hospital s Enterprise Limited

Chennai

2800.07

Opto Circuits (India) Limited

Bengaluru

669.74

Indraprastha Medical Corporation Limited

New Delhi

502.97

Fortis Health care Limited

New Delhi

281.09

Kovai Medical Center and Hospital Limited

Coimbatore

222.37

Poly Medicure Limited

New Delhi

208.84

Dr. Agarwal’s Eye Hospital Limited

Chennai

103.5

Fortis Malar Hospitals Limited

Chennai

94.8

Span Diagnostic s Limited

Surat

58.54

Noida Medicare

Noida

58.49

KGMU medical staff in transforming the hospital over two and a half years from an institution without any effective waste management programme into a regional model institution for sound bio-medical waste management practices.

Sustainability reporting practices in the hospital industry Indian companies: For the purpose of this report we selected the top ten companies in the hospitals and medical services sector, in terms of net sales based on their latest available financial statements Based on our review, we found that none of these companies prepares a separate sustainability report. We therefore reviewed the Annual Reports or websites of these companies. The annual report of Noida Medicare was not available.

The purpose of reviewing the Annual Reports/websites was to ascertain the nature (if any) of disclosures with relation to sustainability or corporate social responsibility (CSR).

CSR disclosures: Four of the companies in our sample had detailed disclosures on their CSR activities. CSR activities were mainly of the nature of various health related programmes conducted by these companies targeting specific diseases or sections of the population. Two companies only had a brief note stating essentially that they conduct business in a sustainable and socially responsible manner focusing on health and safety of employees, environment protection and quality of life. Three companies had no disclosures on CSR activities (if any) at all in their www.expresshealthcare.in

annual reports.

The nature of some the detailed disclosures are: mother and child health programmes for pregnant women and new born especially in rural areas; organising free surgeries and health check-up camps, imparting education, awareness building activities on health and environmental concerns; health insurance for the differently abled and lifesaving surgeries; lectures, educational programmes and training sessions on occupational health hazards; training people in basic life support an cardiac pulmonary resuscitation; HIV/AIDS awareness programmes; congenital heart issues in children; free subsidised cancer treatment to

patients and cancer awareness programmes; Blood donation camps and awareness campaigns on organ donation; Mobile healthcare schemes and monthly clinics.

The only specific disclosures related to the environment were those related to energy conservation, that are made to comply with the requirements of the Companies Act, 1956 – all nine companies (whose annual reports were available) made these disclosures.

One company touched upon improving the supply chain management; another discussed developing cost effective and environment friendly processes for manufacturing quality medical devices; while two referred to SEPTEMBER 2013

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Table 3: List of Global Healthcare Services Companies Rank

Company

Country

Sales

Nature of Busines

170

Express Scripts

United States

$93.9 B

Healthcare management & administration services

352

HCA Holdings

United States

$33 B

Operates hospitals and related health care entities

810

DaVita

United States

$8.2 B

Provider of dialysis services in the United States for patients suffering from chronic kidney failure

1090

Quest Diagnostics

United States

$7.4 B

A provider of diagnostic testing, information and services

1282

LabCorp

United States

$5.7 B

A clinical laboratory company

1299

Community Health Systems

United States

$14.5 B

Operates hospitals in the United States.

1365

Universal Health Services Inc.

United States

$13.9 B

Operating acute care hospitals, behavioral health centers, surgical hospitals, ambulatory surgery centers and radiation oncology centers

1397

Catamaran

United States

$9.9 B

Provider of pharmacy benefit management (PBM) services and healthcare information technology (HCIT) solutions to the healthcare benefit management industry

1423

Cerner Corporation

United States

$2.7 B

Supplier of healthcare information technology solutions, services, devices and hardware

1441

Celesio

Germany

$28.6 B

Pharmaceutical distribution holding company

infection control.

Apollo Hospitals had a rather detailed discussion on what they call ‘clinical governance’ aimed at continuously improving the safety and quality of clinical care rendered to patients. It is noteworthy here that while management and disposal of biomedical waste is a huge issue for the hospital industry as discussed earlier, none of the companies in the sample has deliberated on this subject at all.

Risks identified: The following chart shows the nature of the risks identified in the annual reports by companies in our sample. As mentioned earlier, the annual report of one company was not publicly available, hence the graph below represents reporting by nine companies.

The most common risk identified by all but three companies was the acute shortage of trained and qualified medical professionals, from doctors and nurses to paramedics. 56 per cent (five companies) considered inflationary pressures, rising input costs and the competitive environment as risks. While three companies considered the highly capital intensive nature of the industry and obsolescence of medical equipment as a risk only two identified inadequate quality education for paramedics as a risk.

Global companies To understand the extent of reporting vis-à-vis companies in the same industry across the globe, we selected the top ten companies in the ‘Healthcare services’ sector from the latest Forbes 2000 list published in April 2013.

Sustainability disclosures: A majority of the SEPTEMBER 2013

companies did not have any report or information available on sustainability. Four companies either had separate sustainability or corporate responsibility reports or a page on their websites dedicated to the subject. They did not report using any recognised reporting framework.

Two of the four operate hospital/similar services, one company provides diagnostic services and the remaining company is engaged in pharma distribution. Discussions in these reports/pages range from transparency, product life management and diversity, to commitment to the society (including patient and employee safety and satisfaction), environment (including waste disposal, energy and water conservation) and the economy. Community health systems has a rather detailed discussion on waste and management of hazardous and non-hazardous waste, including medical waste, laboratory solvents, asbestos, ethylene oxide (used for a variety of sterilisation purposes) and pharma waste.

Risk factors: Risks are not discussed in the sustainability/corporate responsibility reports or web pages dedicated to the matter, therefore we scrutinised the annual reports of these companies to ascertain the nature of the risks they have identified. The risk factors identified by global companies are quite different from those identified by Indian companies. The common risk factors are the risk of recruiting and retaining qualified staff and the competitive market that nine out of the 10 companies in our sample have identified. Apart from this all companies have identified risk related to compliance www.expresshealthcare.in

with the regulatory environment, mergers and acquisitions and pending/future litigations. Security of technology infrastructure and system failures and uncertain economic conditions have been identified as risk factors by nine companies.

Health insurance industry Only about 25 per cent of the Indian population has some sort of insurance coverage. The potential in the health insurance market is therefore huge. A CIIMcKinsey report estimates the number of insurable lives at 315 million with a potential of $ 7,700 million in health insurance premium by 2015.

None of the major insurance companies in India is a listed company which would require them to follow certain minimum standards of reporting and demonstrate responsible behaviour. Interestingly, most large insurance companies currently operating in India (other than LIC of India) are joint ventures between an Indian partner and a large foreign insurance company who would be subject to stricter rules of reporting in their own countries.

Lack of penetration of insurance

The 12th Five Year Plan

strategy is to move towards universal health care. Until the 11th Five Year Plan, health insurance was available only to government employees and workers in the organised sector and although private health insurance has been in operation for several years, its coverage has been limited and the poor did not have access to any insurance in in-patient care. The percentage of the total population estimated to be covered under these schemes was only 16 per cent.

In 2007 however (11th Five Year Plan) the ‘Rashtriya Swasthya Bima Yojana’ (RSBY), was introduced, designed to meet the health insurance needs of the poor.

As of now, there are three central government health insurance schemes run by two ministries (CGHS by the Ministry of Health and Family Welfare) and (ESIS and RSBY administered by the Ministry of Employment and Labour) that independently facilitate healthcare treatment for different sets of population whereas levels of care differ. A research study prepared by Public Health Foundation of India (PHFI) in January 2011 sponsored by the Planning Commission recommends organising all three schemes under one umbrella and integrating them to achieve value EXPRESS HEALTHCARE

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for money thus ensuring efficient allocation and utilisation of funds. The large network of underutilised hospitals and dispensaries under the ESIS scheme can be thrown open to CGHS and RSBY beneficiaries. State sponsored schemes have also increased the span of coverage. The figure adjacent shows a better representation of the extent of penetration. As indicated above, only 25 per cent of the total population has any sort of health insurance coverage, with the state schemes in Andhra Pradesh, Tamil Nadu and Goa appearing to be the most successful.

Nexus between healthcare stakeholders The chances of fraud in the health insurance industry are likely to be higher, primarily due to lack of strong vigilance. Most cases of fraud relate to collusion between providers and patients.

Currently the significant thrust of health insurance cover is on in-patient care. The research study referred to above prepared by Public Health Foundation of India (A Critical Assessment of the Existing Health Insurance Models in India) states that one of the prime reasons for excluding drugs and out-patient coverage under insurance schemes is the influence of all stakeholders (i.e. patients, pharmacists, physicians etc.) on the outcome. While physicians have the incentive to increase the number of visits of patients, prescribers and pharmacists would be encouraged to prescribe unnecessary and expensive medicines. Insurers on their part could influence outpatient visits by levying a high deductible on the patients. In addition, the administrative cost of managing drug reimbursement could be a nightmare for insurers, as it involves low-value, high-frequency transactions. Thus, though desirable in principal, practical implementation and the associated problems of

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enforcing medicine reimbursement to patients would be a stupendous task and could fiscally strain the coffers of the government.

Identifying frauds is the first step towards eliminating or reducing fraudulent activity. One of the ways to detect it is to analyse deviations in behaviour through the use of statistical tools and information technology. insurers and third party administrators (TPA) should also not shy away from questioning medical practitioners about the best course of medical treatment. For this, the insurers and TPAs would also need medical teams that are well versed with best practices and treatment protocols. Once it has been detected, the course of action needs to be determined, which in most cases would be rejection of a claim and/or removing a provider from the insurers network.

Fraud detection is always difficult in spite of the most fool proof safeguards, because those committing fraud tend to rationalise it. The PHFI study shows that 20-30 per cent customers overstate figures of incurred expenditure, as they believe that insurance companies will always pay lesser than what has been claimed even if claims are

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accurate. There is also a general belief among a section of policy holders that there is nothing wrong in making a claim after the premiums have been paid for a few years. In case of health insurance it is particularly challenging to detect or manage the fraud as the sheer cost of monitoring individual claims and hospitals on a regular basis is so high that it would increase the overall cost of insurance. A fraud detection system should therefore be devised involving all stakeholders viz. insurance and medical regulators and a strong vigilance mechanism will go a long way in identifying and preventing fraud.

Towards this end, in December 2012 the Insurance Regulatory and Development Authority (IRDA) invited requests for proposals from organisations for finding a solution to fraud in the health insurance segment. The IRDA said in its notice that to reduce the cost of insurance inflicted by fraud, it is proposed to build advanced detection and prevention systems at industry level to identify fraudulent claims before payment occurs and to improve the accuracy of fraud detection

Conclusion Availability, affordability and quality are the cornerstones of inclusive healthcare.

A dichotomy exists in India while we face a shortage of finances, beds and healthcare professionals (providers and academia), we are also home to world class facilities, due to which India ranks amongst the top 5 medical tourism destinations in the world. Thus in order to achieve the long term objective of universal healthcare for all set out in the 12th Plan, the government will have to engage with all stakeholders to ensure sustainable development, as the

public sector alone will not be able to cater to the healthcare requirements of the entire population. While providing affordable healthcare is a formidable challenge it is also a huge opportunity available for the industry to tap.

Opportunities present itself to the hospital industry, pharma industry, health insurance, research companies, medical devices and equipment as well as education and information technology sectors.

Sustained efforts should also be made to reduce the environmental impact of the industry by repeated emphasis and enforcement of biomedical waste management systems.

References 1.http://www.cii.in/Sectors.as px?enc=prvePUj2bdMtgTmvP wvisYH+5EnGjyGXO9hLECvT uNu2yMtqEr4D408mSsgiIyM/ 2. http://www.pwc.in/industries/healthcare.jhtml 3 Central Bureau of Health Intelligence 4. Global Infrastructure: Trend Monitor Indian Healthcare Edition: Outlook 2009–2013 (A KPMG Report) 5. Health Financial IndicatorsNational Health Profile (NHP) of India – 2011 6. http://www.who.int/topics/medical_waste/en/ 7. http://tinyurl.com/cc9xgj3 8.www.moneycontrol.com/stoc ks/top-companies-inindia/net-sales-bse/hospitalsmedical-services.html 9.http://www.forbes.com/global2000/#page:1_sort:0_direction:asc_search:_filter:Healthc are%20Services_filter:All%20c ountries_filter:All%20states 10 Twelfth Five Year Plan (2012–2017) Social Sectors 11 A Critical Assessment of the Existing Health Insurance Models in India, Public Health Foundation of India 12 Donald R. Cressey’s Fraud triangle hypothesis SEPTEMBER 2013

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CASE STUDY Achieving excellence in procurement and inventory management A 120-bed, multi-speciality hospital in Mumbai was facing significant challenges with its procurement and supply chain management process. Without a proper and efficient system in place, medical stock levels were not aligned with demand, leading to frequent complaints of stock-outs and increased manual intervention that was consuming valuable clinician time. A case study detailing how IMS Health India was able to uncover critical insights into spending, inventory levels and end-user behaviour, and ultimately deliver recommendations that would drive significant bottom-line savings without impacting service delivery by delving deep into the hospital's supply chain system

Client’s issue and request The procurement and supply chain management (PSCM) processes at a multispecialty hospital in Mumbai were tardy and the total medical stock was around $327000. The hospital was also experiencing frequent complaints of materials stock-out, pilferage, lack of trust in inventory parameters set in the hospital information system (HIS) and increased dependency on manual work. Hospital management was quick to realise that clinicians needed to focus more on what they do best (taking care of patients) while administration invested in operational transformation.

IMS Health India was asked by the hospital management to rationalise and re-design the supply chain processes and to realign inventory levels in order to lower the spend base and achieve bottom-line savings.

Key objectives and scope of the study were: ●

●

Map and determine the total improvement potential in the core PSCM practices and identify the key initiatives required to achieve these results Establish a robust implementation plan for how

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●

to achieve quantifiable results within agreed timelines Support exceution of the plan and put in place the control mechanisms required to sustain performance over time

IMS India’s approach The IMS team initiated the project with an in-depth, two-week diagnostic phase, mapping the entire supply chain system and conducting a detailed gap analysis.

After detailed conversations with various stakeholders and a comprehensive analysis of the processes, spend base, stock levels and consumption patterns, the key root causes were identified and presented to management for implementation.

IMS uncovered eight leading causes of the high spend base and inventory levels: ● Lack of clearly defined sub-categories leading to inaccurate estimation of the spend base and sub-optimal negotiating position ● Lack of stock keeping unit (SKU) rationalisation across major categories of items leading to increase in the number of SKUs being purchased ● Excess of suppliers across

Challenge/Bottlenecks

Recommendation

Impact

Inability to accurately forecast and plan

Make HIS changes that would accurately classify the items under various cost heads

Exact estimation of the spend base leading to accurate forecasting and budgeting for next year and more negotiating power

Difficulty managing increasing inventory levels

Rationalise the number of SKU’s being currently used in the hospital with the help of clinicians

Less confusion, reduction in excess inventory as well as fewer stock-outs and a reduction in pilferage

Unable to procure material at best rates from vendors

Rationalise the number of vendors supplying materials to the hospital

Increase bargaining power at time of rate negotiations with limited set of suppliers to lower purchasing costs

Inability to manage procurement processes and increased inventory levels of multiple brands

Finalise the drug formulary with the help of consultants especially for oral drugs and surgical materials

A more strategic, and more informed process for purchasing, lowering inventory levels and ensuring everyone uses the same set of brands

Increasing concerns over excess working capital being locked in inventory

Create one- week stocking norms at end user level fed by main pharmacy store amounting to total of 30 days of stock

Freeing of storage space at the stores and release of working capital ($96-115 K reduction in stock)

Duplicity of storage areas

Streamline the supply of materials to Cath lab, CTVSOT and ICCU from the common cardiac pharmacy in the cardiac block

Streamlining of processes, freeing up of space and reduction in inventory by $27-29 K

Increasing dependence on a subjective approach to defining order level

Use of scientifically-determined ROLs at all levels of storage areas

Real-time tracking of stocks with regular SKU level alerts on critical items based on revised inventory policy and ability to maintain service levels of 99.9 per cent

Tendency to stock on higher side at the level of end users

Implement a twice-a-week delivery system from main pharmacy to end users

Lower stocking pattern in the supply chain downstream, leading to a reduction in pilferage and a more efficient utilisation of space

Figure 1

●

●

all categories of items being procured leading to a lack of bargaining power at the time of rate negotiations Lack of collaboration between clinicians and planning teams leading to procurement of multiple brands across oral drugs and surgical consumables Stocking pattern not in sync with vendor delivery times, leading to excess www.expresshealthcare.in

●

●

working capital locked in inventory Duplicity of storage areas, such as the separation of stocks for cath lab and cardio thoracic vasuclar surgery operation theater (CTVSOT) inside the cardiac block Lack of ownership on re-aligning inventory parameter settings in HIS, resulting in judgmental approach to defining

●

order levels Misalignment in demand and planning cycles, leading to higher stocking patterns at the level of end users (15 days)

IMS recommendations For each of the issues identified, IMS laid out specific recommendations that would alleviate the bottleneck and positively impact the inventory and supply EXPRESS HEALTHCARE

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POTENTIAL BOTTOM-LINE SAVINGS ACROSS PSCM PRACTICES Savings resulting from streamlining procurement practices

Savings resulting from streamlining inventory practices

Unit

Current Inventory (Value)

Current Inventory (No. of days of storage)

Best practice (No. of days)

Potential savings

Main OT store

$ 85 k

110 days

7 days

$ 33-36 k

Pharmacy store

$ 71 k

17 days

15 days

$ 25-27 k

Cardiac block

$ 75 k

69 days

7 days

$ 25-27 k

Pathology store

$ 27 k

45 days

7 days

$ 13-15 k

General store

$ 23 k

88 days

15 days

$ 7-9 k

Total hospi$ 310-318 k tal inventory

45-50 days

15-20 days $ 90-110 k

Category

Current spend base

Improvement potential

Potential savings

Surgicals

$745 k

8-10%

$60-75 k

Cardiac

$782 k

15-20%

$117-156 k

Pharma

$727 k

10-15%

$73-109k

Others

$218 k

8-10%

$17-22 k

Total spend base

$2470 k

10-15%

$247-371 k

Figure 2 chain system (See Figure 1) The IMS team then also suggested a step-by-step implementation plan that would ensure not only the success, but also the sustainability of this new system and substantial cost savings (see Figure 2).

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This implementation plan included: ● Creation of a project management office to drive the PSCM recommendations ● Handing over HIS upgrades/customisations to an IT vendor ● Performing a detailed analysis of the spend base

●

●

at sub-category and supplier level Aggressively labelling excess stock as ‘stocked up’ and shortages as ‘stock deficient’ and performing a physical stock check of all stores, along with pharmacy personnel, across the hospital Streamlining processes to

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●

●

ensure all patient billings are done on a real time basis Rationalise the number of SKU’s within each sub-category in collaboration with central committee, clinicians and planning team Consolidation of volume annual demand estima-

tions including quantities after bundling process and projections for the financial year ● Facilitating vendor workshops with rounds of negotiation to close and sign-off on rate contracts ● Revising inventory parameter settings for all major stores across the hospital to be in sync with twice-a-week indent system and partnering with IT dept to upgrade HIS With this project, IMS India was able to achieve 25 per cent improvement in working capital and 8-10 per cent in bottom-line savings. Additionally, overall satisfaction and trust across stakeholders within the organisation was significantly improved, implying that initial investments in setting up robust supply chain processes can be a boon for the entire hospital ecosystem. Moving forward, the outcomes of this study is expected to set the stage for continuous, sustainable improvements as the system matures into a best-in-class model of operational efficiency.

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INSIGHT

Strategising for success Sudarshan S Ananth, VP & Business Head,Trane and Thermo King India elucidates on the best way to optimise your high performance hospital maintenance strategy

Sudarshan S Ananth VP & Business Head, Trane and Thermo King India

D

eveloping and implementing an effective high performance building maintenance strategy can help hospitals reduce their energy and operating costs, improve reliability and avoid unplanned system failures that could threaten the quality of care they provide.

Most healthcare organisations recognise that a wellmaintained, well-operated facility makes a huge difference when it comes to creating a positive physical environment of care. At the same time, they face a wide range of challenges to implementing a maintenance strategy that aligns with the organisation’s mission and critical operating requirements.

Following are four things that hospitals need to consider while developing an effective maintenance strategy: ❖ Operating environment – Energy costs are rising, the healthcare regulatory environment is in flux, budgets are tight and the pressure is on to make every investment pay for itself. Facilities teams need to develop a keen understanding of their hospital’s mission and goals and how high performance building technologies and operating practices can contribute to the organisation’s success.

SEPTEMBER 2013

It is also important to understand the building and how it is currently operating.

Facilities professionals need to ask themselves a series of questions. “What are the most critical building systems and components?” “How are they working today?” “What happens if they fail or under perform?” Candid answers to these and similar questions set the stage for developing a mission-centric maintenance strategy.

Most hospitals benefit from conducting a critical systems audit (CSA) to assess how well heating, ventilating and air conditioning (HVAC) and other building systems are operating and identify potential problems before they can cause a costly system failure.

An audit also provides insights into how and where the hospital is using and perhaps wasting—energy, which can help the staff identify, select and prioritise energy conservation measures. As a result, CSAs usually pay for themselves in energy savings. ❖ Operating risk – Information gathered during a CSA helps hospital facilities professionals identify and address potential building system issues. The remedy may vary depending on the problem that was identified.

For example, the hospital may choose to overhaul or replace a mission-critical HVAC system component before it has a chance to break down and cause a serious problem but it may choose not to repair a lesscritical piece of equipment until it shows signs of imminent failure.

The high performance building approach to maintenance helps organisations recognise the “real” costs of a building system failure, balanced against the cost of a preventive, predictive or results-centred maintenance plan. In a hospital setting, the real impact goes beyond the substantial expense of replacing or repairing equipment in a reactive mode to include the costs of the disruption caused by an unplanned system failure.

Such costs could include lost revenue, unproductive staff

that can provide a level of service tailored to the organisation’s specific needs, whether that means alerting the in-house facilities staff when problems occur, continuously monitoring building systems and responding to trouble calls, or taking full responsibility for delivering a specified level of building performance.

time or even compromised standards of care and potential lawsuits; avoiding these costs more than justifies the expense of adopting an effective maintenance strategy.

In evaluating risk, facilities professionals also need to examine equipment warranties and existing service agreements to understand exactly what they cover and, just as importantly, what they do not cover. Actions may be required to fill in the gaps and provide extra levels of protection for missionessential systems.

Finally, hospitals need to have effective contingency plans to ensure that they can respond immediately and recover quickly from an unforeseen system failure without impacting the quality of patient care. ❖ Traditional maintenance options – Most hospitals today use a preventive maintenance strategy in which facilities staff members or their service partners perform prescribed maintenance tasks at scheduled intervals recommended by original equipment manufacturers.

Meanwhile, technology advancements have enabled predictive capabilities that technicians can use to gather and analyse performance information so they can perform maintenance tasks when they are needed, rather than on a predetermined www.expresshealthcare.in

schedule.

For example, instead of changing HVAC system air filters on a set schedule, it is now possible to monitor air quality and replace filters when they are no longer doing their job.

Fault detection and diagnostics (FDD), predictive modelling and other analytical tools let technicians address system performance issues before they can cause serious problems. For example, advanced diagnostic tools can continuously monitor motor performance and vibration levels, compare findings to aggregate data on the same motor type and alert service personnel if performance varies from the expected range.

Through their existing building automation systems, most hospitals already have the technology backbone in place to implement a predictive maintenance model.

Today’s advanced building automation systems provide facilities teams and their service partners with a wealth of actionable information that can be accessed from any computer with Internet access.

Building commissioning, re-commissioning and continuous commissioning are effective ways to restore building systems to their original design specifications.

Many hospitals find that it makes sense to work with a building service company

❖ Building performance – Technology advances and the availability of real-time building system data are reshaping the way that healthcare organisations think about maintaining their high performance hospital buildings.

For decades, the focus has been on restoring or maintaining original design performance levels. With a building performance model, the structure is managed to deliver specific outcomes that are tied to the organisation mission, rigorously defined, supported by predetermined performance standards and continuously measured and evaluated.

Using an intelligent services approach, a building is managed to perform within acceptable tolerances of an established set of performance standards. In a healthcare environment, these standards might include unit-specific air quality, temperature and humidity levels; HVAC reliability and uptime performance; or agreed-upon levels of energy and water consumption or environmental compliance.

Among other advantages, the building performance approach to maintenance enables hospitals to make better-informed decisions, collect data over long periods of time to inform the decision-making process, track variables to enable better performance and document progress toward high performance building status.

These are challenging times for healthcare administrators and facilities teams as they strive to do more with less while creating the best possible physical environment of care. Critical to achieving that mission is developing a maintenance strategy that makes sense for the organisation and all of its stakeholders.

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W H AT ’ S INSIDE

‘Canada gets many newer technologies sooner than India’ PG 58

RADIOLOGY Myriad advantages of MRI-compatible pacemakers Dr Ketan Mehta, Consulting physician & Cardiopulmonologist, Health Harmony & Asian Heart Institute, gives an insight about pacemakers that are MRI-compatible and the manifold benefits they offer over regular pacemakers

Pacemaker implant surgery

MARKET 11 STRATEGY 29 KNOWLEDGE 36 HOSPI INFRA 43 IT@HEALTHCARE 62 NORTH INDIA SPECIAL 68 LIFE 88 56

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S

Some hearts beat regularly while some don’t. The normal, healthy heart has its own pacemaker called the sinus node that regulates

the rate at which the heart beats. It produces impulses that travel through electrical pathways in the heart and cause the heart muscle to contract and pump blood as it’s needed by the body.

Sometimes, this natural mechanism becomes diseased so that impulses are irregular - too slow, too weak – or its impulses may be blocked by other disorders.

Bradycardia is the name for a group of diseases in which the heart beats too slowly to support the circulatory www.expresshealthcare.in

needs of the body.

If this happens, the person may feel dizzy, weak, or just very tired. An artificial pacemaker may then be used to restore a consistent flow of proper electrical impulses, thus improving blood circulation and restoring a general feeling of well being to the patient. When people refer to a pacemaker, they are actually discussing a pacing system, which includes the pacemaker and leads. A pacemaker is a small device that is implant-

ed under the skin, typically just below the collarbone.

The device delivers therapies to treat irregular, interrupted, or slow heartbeats. Leads are thin, soft, insulated wires about the size of a spaghetti noodle. The leads carry the electrical impulse from the pacemaker to the heart and relay information about the heart’s natural activity back to your pacemaker. It is prescribed for people whose hearts are beating too slowly or irregularly. A pacemaker may also SEPTEMBER 2013

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be used to treat fainting spells (syncope), congestive heart failure, and hypertrophic cardiomyopathy.

So, how does a pacemaker work?

Dr Ketan Mehta Consulting physician & Cardiopulmonologist, Health Harmony & Asian Heart Institute

A pacemaker is designed to mimic the heart’s natural pacemaker, the sinus node.

The pacemaker has two main purposes – pacing and sensing. ● Pacing: A pacemaker will send an electrical impulse to the heart through a pacing lead when the heart’s own rhythm is too slow or interrupted. This electrical impulse starts a heartbeat. ● Sensing: A pacemaker will also “sense” (monitor) the heart’s natural electrical activity. When the pacemaker senses a natural heartbeat, it will not deliver a pacing pulse.

General steps for implanting a pacemaker include: ●

●

●

●

A small incision, approximately two to four inches long, will be made in the upper chest area, just below the collarbone One or two leads will be guided through a vein into the heart, and the leads will be connected to the pacemaker Pacemaker settings will be programmed, and the device will be tested to ensure that it is working properly to meet the patient’s medical needs The pacemaker will be inserted beneath the skin, and the incision in the chest will be closed.

Living with a heart device Living with device usually

a heart requires

Interesting facts ◗ Over 20 million Indians suffer from cardiac arrhythmias and sudden cardiac deaths account for more than 40-45 per cent of cardiova scular deaths in India ◗ Cardiac arrhythmias are under diagnosed (more than 50 per cent) due to the lack of awareness or quality of diagnostic tools ◗ In India, 25,000-30,000 people resort to pacemakers and devices annually

SEPTEMBER 2013

some adjustments, such as restricting your arm movements for the first few weeks and visiting your doctor for regular check-ups. But, pacemakers help millions of people live more full and active lives.

A patient’s medical condition determines the type of pacemaker one may receive.

Pacing therapy is diverse because the underlying heart conduction disorders that result in rhythm disturbances are different. If your medical condition or pacing requirements change, your doctor may prescribe adjustments in certain functions of your pacemaker.

Pacemakers have improved in size, better life and functionality since the early days. This, in turn, has led to better patient outcomes, lesser side effects and hospitalisations and improved longevity including quality of life. The technology has also helped in lowering cost of managing the disease.

MRI compatible pacemaker – the ‘smart’ choice For millions of patients with cardiac devices, MRI scans are unsafe and contraindicated. While a traditional pacemaker helps to treat a form of cardiac arrhythmias known as bradycardia (slow heart beats) and normalise the heart rhythm, it may pose challenges for cardiac patients with other health complications who need to be exposed to an MRI scan.

These include high-risk elderly patients, with diseases of the brain, spinal cord, or joints.

Furthermore, it may also include individuals over the age of 65 who are twice as likely to undergo a scan for the liver, gall bladder, pancreas and kidney.

This turned out to be true in the case of a 76-year old woman from Mumbai. She had been suffering from diabetes from the past 20 years, hypertension for 15 years and Ischemic Heart Disease (IHD) for 12 years.

She was implanted with a dual chamber pacemaker due to complete heart block (CHB). A dual-chamber pacemaker typically www.expresshealthcare.in

use two pacing leads, one placed in the right atrium and the second placed in the right ventricle; the electrical pulses delivered to the heart are timed so that the atria and ventricles are beating “in sync” with each other, however such a pacemaker is not MRI compatible.

Over two years back, she went through a contrast CT scan of the abdomen which was performed for suspected acute pancreatitis. However she got an anaphylactic reaction which is very dangerous for the patient. She has been getting repeated episodes of transient giddiness and ataxia requiring frequent hospitalisation since the last six months on which she was advised to go for MRI or CT scan by the neurologist.

Unfortunately, she could not be subjected to a CT scan due to allergic reaction and could neither go for MRI due to non-MRI compatible pacemaker. Due to these complications the patient was unable to go for the right investigation tests, and hence she has been treated symptomatically. If this patient were with an MRI compatible pacemaker the right diagnosis could have been made and subsequently her trauma and suffering could have been reduced to a great extent.

Currently, most pacemakers are not considered safe in an MRI environment because the MRI could change the settings, temporarily affect the normal operation of, or potentially damage the pacemaker. As an MRI machine uses a strong magnetic field, it exposes the patient to the risk due to heating up at tip of the metal wires of these pacemakers that is in contact with the heart and thus damaging cardiac tissues resulting in loss of stimulation of the heart to beat. Also the strong magnetic field could reset the device or affect its pacing function giving rise to abnormal heart beats.

Research has shown that even if the device is turned off or set at a constant rhythm during the scan there are slight changes in electrical parameters required for stimulating the heart to beat after the MRI scan compared

to pre-scan. This also raises several concerns for the practitioners who are carrying out the scan. The magnetic field will not only reset the pacemaker but may permanently damage it.

Switching off the device is not possible in many patients as it could prove fatal even if it is for a few minutes.

Medical and surgical specialists rely on MRI for diagnosis. In fact, MRI is the gold standard diagnostic tool for soft tissue imaging for neurologists, oncologists, and orthopaedic surgeons. MRI is extremely necessary for diagnosis of internal soft tissue injury and diseases. This stresses on the need for pacemakers suitable for allowing MRI scan.

Generally, bradycardia (slow heart beats) can be diagnosed with symptoms like dizziness, fatigue, fainting and other non-invasive tests.

The only reliable treatment is pacemaker implantation.

Medtronic has a pacemaker system which is FDA approved for use in the MRI environment. This pacemaker system has a unique design, developed so that under specific conditions, patients may safely undergo MRI scans. With regular pacemakers, patients would be barred from undergoing any MRI scanning as exposure to magnetic radiation could lead to several complications. But MRI conditional pacemaker has no such adverse effects and has truly emerged as a technological boon for patients who suffer from bradycardia (slow heart beats) who may require an MRI scan in future. However, patients implanted with an MRI conditional pacemaker should consult their cardiologist before undergoing the scan.

Conclusion MRI compatible pacemakers have maintained a positive track record and gained acceptance from cardiologists both in the national and international heart centres. It is important that we are aware of these technological advancements and utilise them to counter unforeseen health issues if it ever strikes someone around us.

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R|A|D|I|O|L|O|G|Y

‘Canada gets many newer technologies sooner than India’ Canada is a large exporter for medical devices and many entrepreneurs of different nationalities have set up medical devices firms in the country.

Krishnan Suthanthiran, President, Best Medical International, Canada reveals key aspects of his radiology business, growth prospects in the Canadian market, and compares it with opportunities in the Indian market, in discussion with Sachin Jagdale

INTERVIEW

You have spent more than four decades in Canada. As an immigrant from India what challenges did you face while setting up your business in Canada?

I arrived in Canada in 1969 with very little urban cultural and social habits. So, it was a huge transition.

Being an immigrant from India I had to face many challenges. I wasn't fluent in English so communication was a major problem. I didn't have money, at least initially, until I got research assistance. Issues like different food habits and varying climatic conditions also bothered me during my initial days in Canada.

How is the Canadian radiology market different from its Indian counterpart?

India has many private centres with new technologies, however Canada is a lot like US, they get many newer technologies sooner than India.

However, there is a long waiting time for everyone if they want to get them

does GBT overcome this shortcoming?

under government-run programmes.

Like everywhere, if you are willing to spend money of your own, you have many options. The radiology procedures are cheaper in India to some extent than Canada. In Canada, radiology procedures are similar to that in US.

Radiation therapy today can be very specific, e.g. multi leaf collimators. Our company, Nomos, invented intensity modulated radiation therapy (IMRT), and image guided radiation therapy (IGRT).

Brachytherapy is highly localised treatment. We are also developing particle therapy (proton to carbon), heavy ions that are very precise. Thus, with many new and innovative technologies, radiation therapy is the most target specific.

Best Theratronics specialises in gamma beam teletherapy (GBT).

Tell us about it. What kind of response have you received from radiologists in India?

GBT can be used for non malignant disease treatment as well as malignant. There were as many as 300 GBT units in India earlier, I do not know the current number. There are others products in the market, copies of our units, but these GBT units are not as reliable and they do not last as long as our units. Some of our products in use have been reliably functioning for 40 years or more.

Will you be launching manufacturing operations in India?

As far as manufacturing is concerned, it is always an option.

However, I find it difficult and moreover financing is very expensive in India. It is tough to run manufacturing facilities in many unionised parts of the world.

No radiation therapy is completely target specific. To which extent

sachin.jagdale@expressindia.com

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SEPTEMBER 2013