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November 2012 ` 50



November 2012 ` 50

Coming Soon Hospital Infra Special & In Imaging Special December issue


Hospital Infra Flooring facts Page 33

Knowledge Diabetes management – future trends Page 37



VOL 6. NO 11, NOVEMBER, 2012

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 MARKETING Deputy General Manager Harit Mohanty Senior Manager Tushar Kanchan

The Great Indian Healthcare Factories-I: Narayana Hrudayalaya ..........................30

Assistant Manager Kunal Gaurav PRODUCTION


General Manager B R Tipnis Production Manager Bhadresh Valia Asst. Manager - Scheduling & Coordination Arvind Mane Photo Editor Sandeep Patil DESIGN Asst Art Director Surajit Patro Chief Designer Pravin Temble

Page 9

Senior Graphic Designer Rushikesh Konka Layout Rajesh Jadhav

ESA calls for new research to improve surgical outcomes of patients ..........................................................16 India moves to end discrimination against leprosy

CIRCULATION Circulation Team Mohan Varadkar

Express Healthcare Reg. No. MH/MR/SOUTH-252/2010-12 RNI Regn. No.MAHENG/2007/2045 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)

affected people ....................................................................16

‘IDF predicts that the number of people with diabetes will rise to 552 million by 2030’ ..............41


BD to form Association of Diabetes Educators in India ..........18 Menopause doesn't cause weight gain: IMS Study ................18 Kartavya Healtheon launches its disease management services for HIV patients ....................................................20 Max Super Speciality Hospital, Patparganj launches speciality institutes ..............................................................20 Fortis Memorial, a quaternary care hospital, to be launched in Gurgaon ..................................................22 Extend Nutrition enters the Indian market

*Responsible for selection of news under the PRB Act.

with Indraprastha Apollo hospital launches,

Copyright @ 2011 The Indian Express Ltd. All rights reserved

USG in breast cancer: the old and the new ..............43

'Go Pink, Get Screened' campaign ........................................24

throughout the world. Reproduction in any manner, electronic or otherwise, in whole or in part, without prior written permission is prohibited.


Regulars Letters ...........................................................................................................................................................8




Keeping doctors engaged to the noble profession Many medical colleges 'borrow' the names of doctors as full time faculty members for a nominal annual fee, usually paid in cash, to meet the norms of MCI

eachers and doctors were considered some of the noblest people and as children we were taught to respect representatives of both professions. So logically, a doctor who teaches would be doubly noble. But, both professions seem to have fallen off the pedestal. And the recent news that the Medical Council of India (MCI) has asked state councils to de-register the names of 32 doctors who posed as full time faculty at a medical college, bears out the fact that being in a noble profession does not stop you from being human and trying to squeeze out an extra buck. But the MCI seems to have decided to make an example of this case, after a CBI investigation found that these 32 doctors fraudulently claimed they were full time faculty at Tamil Nadu’s Melmaruvathur Adiparasakthi Institute of Medical Sciences (MAIMS), when in fact, they were on campus for just a couple of days a month. Though some of the doctors have chosen to take legal recourse, the case serves to once again highlight the fact that medical education in India is probably nearing its nadir, barring a few centres of excellence. Like MAIMS, many medical colleges 'borrow' the names of doctors as full time faculty members for a nominal annual fee, usually paid in cash, to meet the norms of MCI inspection. India has both a rich-poor as well as rural-urban divide when it comes to healthcare, with the people-doctor ratio six times lower in rural India in comparison to cities. We are unable to churn out enough doctors as we do not have enough medical colleges, and while Dr Devi Shetty's suggestion that the government should open 100 medical colleges with upgraded district hospitals every year for the next five years is aimed at addressing this issue, we still do not seem to have enough doctors willing to teach. The poor doctor-patient ratio also stems from the fact that there is a severe doctor drain. The Health Ministry is trying to stem this drain to countries like the US, UK, etc by insisting that doctors westward bound for further higher medical studies need to sign a bond. How effective this will be remains to be seen. But there are signs that this brain drain of young medics may be balanced by a reverse flow of senior doctors to India, who find that corporate hospital chains in India today have the capital to invest in the latest medical technologies to offer them an opportunity to showcase their skills and expertise. A more insidious doctor drain is the loss to other non-clinical professions like the insurance sector. Doctor-MBAs are becoming more common, partly due to the fact that a business degree guarantees better remuneration without the stress and strain of being on call 24x7x365. This trend is more commonly observed with medics from the so-called alternative schools of medicines. Referred to as AYUSH doctors, they do prescribe allopathic medicines, and though the debate on this continues to be a hot button issue, maybe it's time to integrate these practitioners into the mainstream, after supplementary training, etc. Will the increased allocation to healthcare in the 12th Five year plan finally do the trick? A FICCI and Ernst & Young report release earlier this year projects that the planned implementation of Universal Healthcare Coverage (UHC) is likely to increase the consumption of healthcare services. But of course, the report also highlights that one of the key levers for achieving UHC is filling the human infrastructure gap. Arresting this downward spiral will be crucial for our country.


Viveka Roychowdhury





Humanising organ transplantation our editorial on humanising and evolving the organ transplantation act is timely and excellent. The benefits of having a cadaver transplant programmed are beyond words. Young patients with end stage organ diseases can get their organs transplanted. The cardiac valves can be used to replace the diseased valves and the vessels can be used as conduits. Further, it will eliminate organ trade. One brain dead person




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can give new lease of life to at least 10 persons. It is important to have stringent rules and regulations. However, any number of laws and regulations will not improve the organ donation. There is a lack of awareness among the public and even among the doctors. Continuous education and creation of awareness among the students about brain death and organ donation is vital. During the last three decades, significant progress has been made in establishing the concept of brain death. Traditionally, five reasons given for non referral of a potential donor are: 1. Lack of information about whom to contact 2. Worry about the legal aspects 3. Not willing to discuss with relative s to discuss about donation at the time of grief 4. Lack of time 5. Lack of knowledge about the benefits of donation These issues can be overcome effectively by continuous education of the public and the media plays a major role. One of the significant step will be to include the willingness to donate organs in driving Licenses. It does not automatically give consent for organ donation. Still the consent from relatives is essential and it only gives an indication and helps to initiate the request for donation.

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UPFRONT Delhi to become the heart attack capital of India: ASSOCHAM study


survey by ASSOCHAM revealed that Delhi tops the list of 'heart disease amongst corporate employees'. The survey covered 10 cities, where Delhi led the tally with maximum number of heart ailments. Not only are men at risk, but also women have come across as a vulnerable community for cardiovascular diseases. It was observed that 72 per cent of the corporate employees in Delhi suffer from CVDs, especially those working night shifts due to unhealthy behaviours such as eating junk food, sleeping badly and not exercising. As a result, Cardiological Society of India (CSI), the apex body in India for cardiology, kick-started its campaign with the aim to reverse trend of heart disease in the capital and also in the other key cities. CSI President Dr Ashok Seth, discussed a larger agenda for change with Delhi Chief Minister Sheila Dikshit to bring down incidence of heart attacks in the city. The manifesto reiterated the role of health access, right nutrition and stress free lifestyles and included institution of certain policies to create a heart healthy population in the state which comprised: 1. Healthy food and curriculum should be mandatory in corporates/schools 2. Reforms in primary healthcare system of the country to include basic cardiac diagnostic and treatment facilities available at district level 3. Regulation of transfats in packed food as well as restaurants 4. Regulating corporate world to create stress free and heart healthy environment for employees including exercise equipment 5. Strict policies on encouraging green spaces and walking grounds in all areas 6. State driven micro-insurance to cover the whole population for accessing the treatments In its response to the startling survey results, the corporate sector also came out strongly against the diseases and supported the campaign. EH News Bureau OCTOBER 2012

Market ‘Accreditation and standardisation are the key to succeed in medical tourism’ Varsha Lafargue, Founder and Chairperson, IMTCA and i-Transition Worldwide

Insuring progress in healthcare Shobha Mishra Ghosh, Senior Director and Sidharth Sonawat, Sr Assistant Director, FICCI on promoting quality in healthcare through health insurance

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M|A|R|K|E|T umbai! The city that never sleeps has many interesting stories to tell, of poverty and riches, successes and failure, courage and conformity, all of which makes it a fascinating city in its own right. Born out of seven pieces of marshy islands, reclaimed from the choppy waters of the Arabian Sea, the city was groomed by a progressing India. In the course of time, the city evolved radically in all spheres of life, with business in the spotlight. Slowly, all the major industries established their foothold here. With rapid industrial development taking place in the other parts of the country, many of these industries moved their bases out of Mumbai, leaving behind the film industry, real estate and the healthcare sector to thrive here.


The evolution... Speaking of the healthcare sector, it is important to note that this sector shares a strong bond with the history of this enchanting city. Mumbai's healthcare sector characterises the evolution of modern medicine in India. Its journey began way back, during the British era, when Sir Robert Grant became the Governor of Bombay. During those days there were no proper medical aid available in this part of the country. Sir Grant was deeply touched by the vast number of people who died for want of proper medical care. Thus in 1845, Mumbai's first hospital and research institute- Grant Medical College (GMC) and Sir J.J. Hospital was established. The establishment of this hospital brought great respite to the inhabitants. Later, the Bai Motlibai Wadia Hospital, Cama Hospital and Albless Hospital were established to provide sufficient medical aid. As the city developed further the needs for hospitals increased. In 1926, one of India’s most premium medical instituteKing Edward Memorial (KEM) Hospital was set up to cater to the immigrants who came to Mumbai in large numbers from other parts of the country. At this juncture, healthcare delivery was the sole responsibility of the government. The state government delivered healthcare mainly through three major multi-speciality hospitals: J J Hospital, KEM Hospital, Parel and Lokmanya Tilak Municipal General Hospital, Sion. The rest was managed by primary healthcare centres and family physicians.



And the revolution began.... The 1960s saw a new wave. The healthcare sector in Mumbai moved from individual doctor-driven practices to institutionalised care delivery. Several charitable trusts came forward to establish hospitals and medical educational institutes. This change also marked the entry of the private sector in the field of healthcare. Mumbai became a leading city in terms of healthcare facilities and medical education. During this era, the city recorded the maximum number of hospitals. The time between 19702000, Mumbai's healthcare sector reached at the peak of success. One can call this era as the period of healthcare revolution within the city. Mumbai, became a preferred healthcare destination. The city attracted patients from Rajasthan, Gujarat, and other northern states of India. The sector was dominated by private trust hospitals, leaving behind the government-run hospitals which by this time had reached stagnation. Some of the leading trust hospitals who continue to be the vanguards of healthcare transformation in Mumbai are, Bombay Hospital. Jaslok Hospital, Tata Memorial and Research Institute, PD Hinduja Hospital, Breach Candy Hospital, Holy Family Hospital so on and so forth.

Winds of change The new millennium ushered the winds of change for Mumbai's healthcare sector with the emergence of stand-alone medical centres and corporate hospitals. During this phase, the sector witnessed a rush of healthcare providers who flocked to Mumbai in order to set up super-speciality hospitals. Major corporate players who entered the market at this time were, Lilavati Hosptial, LH Hiranandani hospital, Asian Heart Institute, Wockhardt Hospital, Apollo Hospitals, Fortis Group of Hospitals, Saifee Hosptial, RG Stone, Kokilaben Dhirubhai Ambani Hospital and Medical Research, Nova Medical Centre, Cumballa Hill Hospital, etc. These players brought in the corporate revolution within the sector which made Mumbai stand out in the crowd. The city was positioned to be much ahead of other cities in the country in terms of pioneering clinical practices, incorporating technological advancements, and very importantly, considering healthcare delivery as a

ness proposition. The increasing corporatisation of hospital groups, promotion of medical tourism and increasing consumerism within the industry became the key drivers for growth. This in turn, propelled hospitals to resort to marketing and branding themselves as models of excellence that provide high standard of care to their patients. Five-star, uber-luxe hospitals were constantly in the news. From politicians to film stars and the nouveau riche, everyone checked in at these highly recommended hospitals for their worldclass, state-of-the-art healthcare facilities.

In the last 10 years So far so good! However, after experiencing a northward incline for almost three decades, the healthcare sector in Mumbai reached a plateau. Currently, the sector seems to be gripped by many challenges that could be nocent for its future augmentation. Expressing his views on the present scenario, Dr Rana Mehta, Executive Director, Healthcare, PWC says,“In the last 10 years the hospital sector in Mumbai has seen little activity. There are few entrants in the business. This is mainly due to exorbitant real estates prices in Mumbai which make it extremely difficult for private sector players to do viable business. Moreover, finding an appropriate piece of land in Mumbai to construct a hospital is another issue." “Entrepreneurs find it extremely difficult to make a project viable or sustainable due to the high real estate cost,” reiterates Joy Chakraborty, Director – Administration, PD Hinduja Hospital. Likewise, Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital and Medical Research, feels that the mounting land prices in Mumbai will act as a barrier in attracting new players in the market. What’s more, high land cost is one of the key factors for rising healthcare costs in Mumbai. The debt that hospitals bear for acquiring land makes it extremely difficult for them to provide medical services at a lower cost. The other major road block is disproportionate distribution of healthcare services within the city. Throwing some light on the issue related to distribution of healthcare, Dr Narain, discloses,“Hospitals and medical centres in Mumbai

are clustered in the southern parts of the city making it very difficult for Mumbaikars living in the suburbs to seek these services.” Dr Mehta informs that studies conducted by the PWC indicate that the bed-to-patient ratio in the south is seven per 1000 beds, but in the north it is two per 1000 beds. This creates a divide of healthcare facilities within the city. Moreover, the cost of creating a bed is high in Mumbai when compared to the other parts of the country. Chakraborty also agrees that distribution of healthcare facilities is not very homogeneous across the geographical territory of the city. He also highlights the other challenges in Mumbai’s healthcare sector and says, “Availability of trained human resource is another area to be looked into carefully. Even though corporatisation of healthcare is happening, many facilities are not able to come up further due to shortage of this resource. Probably the other issue that needs to be attended through regulatory mechanism is standardisation of infrastructure support and care delivery process.” Furthermore, the quest to be the best model of healthcare delivery in the city has coaxed hospitals to adopt high-end technology that at times may not be necessary. High-end technology involves a lot of investments and if the returns on investment is not achieved at the right time, the hospital could run into a loss. Dr Narain urges hospitals in Mumbai to be very careful while selecting their medical equipment and technology. He goes on to say, “It’s time to think what kind of technology is actually needed for a particular hospital setting. Before making your choice, evaluate the technology and its usage in your hospital setting. It is important to position yourself in the right direction in order to run a viable business model.” In addition to all the market impediments, the healthcare sector within the city also confronts the challenge of dealing with increasing disease burden of non-communicable diseases such as diabetes, CVDs, breast cancer as well as other ailments like malaria, dengue, tuberculosis and asthma. With too many obstacles in its path, some experts feel that this could lead to the descent of Mumbai's healthcare sector. “Mumbai was NOVEMBER 2012

M|A|R|K|E|T probably the best centre for healthcare in India but others are now catching up, especially Delhi, Bengaluru and Chennai,” opines Shantanu Deb Mookerjea, Executive Director – Equity, LSI Financial Services. Dr Narain also believes that metropolitan cities like Delhi, Chennai, Hyderabad and Bangalore have stolen the medical tourism market from Mumbai. Besides these metro cities, tier II cities of Maharashtra like Kolhapur, Solapur, Ahmednagar, Nagpur, Jalgaon etc are also catching up with Mumbai.

area,” he states. “This can be done through a collaboration between real estate developers and hospital owners where the hospital will be developed by the real estate entity and the same will be run by the hospital as they have the proper domain knowledge. This model is working well in Delhi and Bengaluru,” chips in Mookerjea. To tackle the manpower problem, Dr Chatterjee sug-

gests that the nursing staff must get a unique identity, as in the West. He further says, “It's not only money that causes them to go elsewhere but the recognition that they are an integral part of the whole team. While the doctor is the captain of the team as a whole, the nurse should be the in-charge of the ward, the one who follows the ward processes and the one who has the authority and the responsibility to correct any-

one who does not toe the ward rules. The nurse will then develop the leadership that is required of her and a number of tasks that a doctor does today will be done by the nurse. This will give doctors more time with patients.” Dr Sunita Dube, President, Medscape India urges the industry to focus on single speciality set ups and to come up with new healthcare delivery models that can meet the demands of

the citizens. Citing the examples of Dr Batra’s Clinics, Kaya Skin Clinics, Talwalkars Wellness Centres, Nova Medical Centres etc., she speaks of creating brands that can provide focussed care that is packaged well to suit the needs of its customers. Dr Narain also vouches for new business models like Healthspring Community Healthcare Centres, hub and spoke models and other

In pursuit of prosperity The road ahead seems to have many stumbling blocks, but the city's healthcare players look at this situation in a different light. The healthcare providers are certain that if there is a challenge at hand then they will certainly find its solution as well. Dr Narain feels that the industry needs to find a mechanism which can bring down the cost of land. He prescribes, “In Mumbai, Brihanmumbai Municipal Corporation (BMC) offers long term leasing facilities to hospitals on certain conditions such as offering some percentage of benefits to poor patients. I think the private sector players can opt for land on lease adhering to the terms and conditions set by the Corporation. It has to be a win-win situation for both parties”. In order to deal with the high cost of land, Dr Sujit Chatterjee, CEO, Dr LH Hiranandani Hospital recommends that cost containment has to be done through new business models such as collaborative healthcare. Dr Narain also agrees that the industry should try and explore the public private partnership (PPP) model in Mumbai. Dr Sanjay Arora, MD, Suburban Diagnostics sees consolidation between healthcare providers as a good option, “There is large amount of consolidation happening in India. Maximum consolidation is taking place in diagnostics and pharma sector. It offers huge opportunity to players on both sides to be part of a large organised structure. Healthcare players in Mumbai can explore this NOVEMBER 2012



M|A|R|K|E|T disease management models which are quite capable of creating a niche segment within the industry. He also points out that major tertiary care providers need to focus on complex medical cases, shifting the burden of primary and secondary care delivery to stand-alone healthcare set ups in order to synchronise care delivery among all healthcare providers within the city. All these recommendations will help clear the clouds that have shadowed the industry; but a little backing from the government will fasten the progress. “The government of Maharashtra needs to enforce a time frame for infrastructure projects in Mumbai. A well-known housing complex

in Kandivali, a very huge infrastructure project, has a binding as per government rule to establish a hospital within the residential complex. The residential complex has been up and running since a very long time but there is no sign of a hospital within the complex. There are many such infrastructure projects that fail to deliver their responsibilities on time. The state needs to look into such matter,” informs an industry source who does not wish to be named.

New entrants Although the current healthcare scenario within the city appears to be sluggish there are some new players who will soon enter the market. Global Hospital,

Lower Parel is slated for a full launch in mid-November and Parkway Khubchandani Hospital, Juhu will be commencing their operations in few months time. Sahyadri Hospitals and Raptakos Brett, a leading nutraceuticals company also plan to set up their healthcare facilities in Mumbai. On the government front, there are plans to set up a tertiary care hospitals in the western suburbs of the city.

In hope of a new dawn Moving forward, the healthcare players in Mumbai will have to break all jinxes that surrounds the sector. It is time for the city to rise up and take steps to herald the transformation which would again put Mumbai’s health-

care sector on the forefront. Market players will have to shift their focus from South Mumbai towards the northern and eastern suburbs. Experts feels that places like Andheri, Mira-Bhayander, Vasai, Malad, Borivali, Navi Mumbai and Vashi can become the next healthcare hot spots in Mumbai. In these areas, the lands prices are better priced as compared to South Mumbai and have much scope for growth. But after all that is said and done, it is Mumbai Meri Jaan. Let's hope that the famous 'never say die' spirit of Mumbai prevails and helps its torch bearers to bring in the much needed renaissance in healthcare.


‘Accreditation and standardisation are the key to succeed in medical tourism’ Varsha Lafargue FOUNDER AND CHAIRPERSON, IMTCA AND I-TRANSITION WORLDWIDE


ith healthcare costs in the developed countries reaching the skies, India is now emerging as one of the world’s most cost-efficient medical tourism destinations and thus, attained a position among the global leaders. According to a report published by RNCOS, India’s share in the global medical tourism industry will reach around three per cent by the end of 2013. Varsha

Lafargue, Founder and Chairperson, IMTCA and iTransition Worldwide speaks about the booming medical tourism industry on the global front and in India, in conversation with

Raelene Kambli What are the major reasons for the increase in medical tourism in recent years? While medical tourism is a newly coined industry; it has been prevalent since ancient times. In 4000 B.C., the Sumerians constructed the earliest known health complexes alongside mineral water springs that included elevated temples and flowing pools. There are several factors



that drive individuals to seek medical tourism or healthcare travel. Some travel because there are little or no healthcare facilities in their own countries; some travel because the costs of healthcare is very high in their own countries and others travel because they have long waiting periods to get medical specialists. While the most common factor is cost of

countries. While countries like Israel, Jordan, etc. have limited natural resources, the revenue contribution through medical tourism towards their GDP’s is substantial and growing. Jordan enjoys five per cent of their GDP from medical tourism and Israel’s is in growing double digit figures. Moreover, medical tourism has really become a major industry in the past few

The growth potential projected for the medical tourism industry in India for the next year is approximately 30 per cent

healthcare; the majority is to avail higher quality healthcare that is not available to them within their own geographical boundaries.

What is the medical tourism scenario on the global front? Medical tourism has become a major source of national income in many

years. More steps are taken to document the needs and requirements of the World Patient TM. Countries like Turkey, Germany, South Korea, Singapore, Malaysia, Costa Rica, etc., have certainly gained a headway in establishing a structured growth for this industry to prosper in their respective domains.

Where does India stand on the global medical tourism map? Which are the factors that attract medical tourists to India? India plays a very important place in the medical tourism industry. Currently, the volume in terms of patients and the turnover from medical tourism in the country is $35 billion approximately The growth potential projected for the medical tourism industry in India for the next year is approximately 30 per cent cumulative . A few reasons for its importance are: India is the largest democracy in this world India is an English speaking country India offers both traditional and alternative healthcare practices Indian doctors have proven their skills globally and are well known for their excellent credentials and hard working nature India also offers lower costs for healthcare treatment and hence is more competitive

What according to you is the USP of medical tourism industry in India?


M|A|R|K|E|T There are several driving forces which make individuals to avail healthcare overseas; a predominant reason for them to consider India would be the affordability factor and the alternative medicines practices. The Ayurveda and Yoga have been other attractions for centuries.

Which country do you think is India's biggest competitor in medical tourism?

The countries enjoying the major share of medical tourist population have been adopting evaluation, accreditation and compliance practice

There are several reasons why healthcare tourists seek a particular destination for a procedure. The less ‘intense’ or ‘cosmetic’ procedures are subject to higher cost savings, both through procedural and travel costs. The more ‘serious’ procedures require the availability of technology, skill, access and affordability. Countries such as Thailand, South Korea, Malaysia, China, etc. and others are European destinations which offer similar attractive cost packages coupled with tourism attractions, and are stepping forward in an organised way.

accreditation and compliance practice that are necessary to sustain a structured growth, lack of which can be detrimental to any nation.

What are the key regulations and policies concerning medical tourism in India? A medical visa has been introduced which can be given for a specific purpose to foreign tourist coming to

India for medical treatment. This visa is issued to a patient with a companion for a period of one year. It can be extended up to three years subject to terms, conditions and recommendations from the accredited medical authorities. The ban of commercial organ transplantation in medical tourism to protect the locals is commendable.



As per the current market scenario, which hospitals and states in India are leading the growth of medical tourism? What are the key trends in the sector? There are many corporate and noncorporate hospitals across India that cater to medical tourism. While a handful of them are practicing International standards, others simply stumble upon them due to their creative marketing. Moroever, accreditation and standardisation are the key to succeed in medical tourism. Apart from this, engaging in best practices and transparency in healthcare are also crucial.

What would be the major deterrents for the growth of medical tourism in India? How can we overcome them? The major source of success for countries enjoying the major share of medical tourist population (in terms of revenue) have been adopting evaluation, NOVEMBER 2012




Insuring progress in healthcare Shobha Mishra Ghosh, Senior Director and Sidharth Sonawat, Sr Assistant Director at Federation of Indian Chambers of Commerce & Industry (FICCI) give an insight on promoting quality in healthcare through health insurance and elaborate on FICCI's role in doing so ndian healthcare is characterised by a huge demand-supply gap. The demand is increasing due to higher disposable incomes in the hands of ever expanding middle-class and growing penetration of governmentsponsored health insurance schemes (GSHIS). Overall health insurance penetration has risen to ~24 per cent of the population and growing at a fast rate fuelled by rapid enrolment under GSHIS. On the supply side, the government infrastructure growth has not kept pace with the demand, both quantitatively and qualitatively. Currently, healthcare needs in rural India are met either by government primary or community healthcare centre and small private healthcare facilities. For secondary or tertiary care, rural India has to travel to nearby towns and cities and spend out of pocket for the treatment. The private sector that provides 80 per cent of the healthcare in the country is concentrated in the urban centres. As the disposal incomes in the hand of people have increased and quality of public healthcare facilities is not upto mark, even the poor prefer to go to private healthcare facilities, which are a huge financial burden. This has presented an opportunity to private entrepreneurs to cater to this demand and a number of stand-alone hospitals and chains are coming up in smaller cities and towns. However, the aspect of quality still remains nebulous in government and private facilities alike. The current perception is that promoting quality escalates the cost of care which is already unaffordable. However, anecdotal and select analytical evidence suggests that implementing quality practices reduces the cost of care delivery in the long run. Accreditation is a quality tool which ensures minimum quality standards of care delivery and is voluntary in nature worldwide. In India, National Accreditation Board for Hospitals and Healthcare Providers (NABH) is the Accreditation Body under Quality Council of India which has been set up in 2005 and has accredited so far only around 140 hospi-




tals. The challenge is to create an awareness amongst the providers about the benefits of accreditation accruing to the health facilities, amongst insurers about the impact of accreditation on reduction of claim ratios and amongst consumers about the quality of care delivered owing to the accreditation.

practice would require, collection and analysis of quality data, establishing minimum threshold, incentives for continuous improvement to achieve accreditation and to keep upgrading beyond accreditation. This cycle has to reinforce itself through a continuous monitoring and evaluation exercise.

Anecdotal and select analytical evidence suggests that implementing quality practices reduces the cost of care delivery in the long run Promoting continuous quality upgradation to achieve accreditation and beyond is a complex exercise which has to address multiple levels involving a number of stakeholders. International experience shows that payers can incentivise healthcare facilities to improve quality of care and data reporting on patient satisfaction through performancebased purchasing. Payers can encourage providers to measure and report quality-related data and improve quality processes through strategic purchasing and rewarding for excellence in quality. However, introducing such a

International experience of “Pay for Quality” ensures adoption of quality framework by providers which acts as the qualifying criterion for negotiation of rates from insurers. However, this would also require that the insurers have sufficient data to suggest that adoption of quality framework results in lowering the cost of claims. This mechanism can run parallel with the accreditation process where the hospitals can move through various levels- ’preassessment”, ‘pre-accreditation’, and ‘accreditation’ stages. A similar example is prevalent in Brazil. UNIMED,

a private insurer in Belo Horizonte, Brazil, has linked reimbursement rates of networked hospitals to their achievement of accreditation levels of the National Accreditation Organization. The insurer increases the reimbursement by defined percentages according to the accreditation levels attained e.g. level 1 receives an additional seven per cent, level 2 gets nine per cent, and level 3 is paid an extra 15 per cent. (Source GovernmentSponsored Health Insurance in India: Are You Covered? Gerard La Forgia and Somil Nagpal, World Bank). In India, insurers find it challenging to use this principle due to lack of a critical mass of accredited hospitals. To get the payers adopt pay for quality framework would mean having a pool of about 7500 to 10,000 accredited healthcare facilities out of a universe of more than 20,000 hospitals and nursing homes in the country. Most public and private healthcare facilities do not have the capabilities or capacity to complete the accreditation process within the stipulated timeframe of nine months. Further NABH also has about 200-250 active assessors who have their hands full. To initiate the “Pay for quality” in the country we NOVEMBER 2012


need to expedite the process of accreditation of hospitals. Hence, FICCI’s multi stakeholder health insurance Advisory Board comprising insurers, providers GSHIS, NABH and World Bank have suggested the staging strategy for accreditation. Further, FICCI is also working towards suggesting a strategy to leverage the empanelment of providers by the payers for enrolment of small healthcare facilities up to 50 beds for accreditation by NABH to "jump-start" the initial evaluation and screening process. Keeping in mind the diverse nature of healthcare facilities in the country, FICCI has been working on the premise that there should one comprehensive and uniform national quality framework which should be easy to adopt by all levels of healthcare facilities including those that are empanelled for the GSHIS. It was under this background that the minimum quality indicators and empanelment criteria for hospitals were developed. Further, to implement “Pay for quality” in the country a draft incentive disincentive mechanism was suggested. FICCI recommended that one of the first steps to trigger adoption of quality by providers would be for the social insurance schemes to mandate reporting on quality to their provider base. A survey of ~100 hospitals carried out during 2011 by FICCI suggests that most of the providers are in a position to provide data on basic quality indicators. The second step in this regard would be to create a fund that would provide a small cash incentive for providers who are part of the hospital network for social insurance and government insurance to preregister for quality. Another very significant initiative undertaken by the FICCI Health Insurance Group has been initiating development of 20 evidence-based minimum standard treatment guidelines (STGs) that would ensure the quality of treatment in all types of healthcare facilities. On behest of IRDA, the Ministry of Health and Family Welfare, GoI, initiated development of STGs NOVEMBER 2012

across 20 specialities and appointed FICCI to facilitate the process. About ~250 STGs have been developed by a mix of clinical experts from all types of healthcare facilities pan India and peer reviewed by specific clinical associations and submitted to the Ministry. Adherence to treatment guidelines will shift the focus from experiential based treatment to an

evidence based treatment. This is significant when quality clinical practitioners are in short supply especially in the rural areas. FICCI’s role as a thought leader and change agent in enabling quality healthcare in the country has now been endorsed by the IRDA when the latter decided to include the following (with some modifications) developed by

FICCI in the proposed health insurance regulations: ● Standard definitions of critical illnesses ● Standard list of expenses generally excluded ("nonmedical expenses") in hospitalisation indemnity policies ● Suggested quality indicators ● Hospital empanelment criteria

● ●

Standard billing format Standard discharge summary format FICCI’s continuous endeavour is to facilitate the standardisation process to develop a self sustaining pay for quality framework through consultation and consensus and ensure affordable quality healthcare provision is a reality in the country.





First IARC Regional Hub for cancer registration launched


ata Memorial Centre (TMC) and the International Agency for Research on Cancer recently inaugurated the first IARC Regional Hub for Cancer Registration at the new facilities in the Homi Bhabha block of the Tata Memorial Hospital in Mumbai. The plaque was unveiled by Dr CP Wild, Director of IARC, together with Dr RA Badwe, Director of TMC. Dr A Garg, Joint Secretary, Ministry of Health & Family Welfare in India, Dr PK Singh, Deputy Regional Director of the South East Asia Regional Office, and Dr P Rajaraman, Director of South Asia Programs, Center for Global Health, US NCI, based in Delhi were some of the people who attended the ceremony.The Mumbai hub will offer the needed support, training, advocacy and research opportunities to cancer registries across 30 countries in South Central, South Eastern and South Asia. The hub operations will be expanding programme of direct assistance to registries in the region via collaborative agreements with IARC. Initially, three registries in Indonesia, Mongolia and Sri Lanka are being targetted for improved training and support in order to raise the profile of their registration activities in the context of national cancer control planning. The Mumbai hub at TMC will serve as a local resource centre to offer developmental support towards, and for, population-based cancer registration in defined world regions, as part of the ‘Global Initiative for Cancer Registry Development in Low- and Middle-Income Countries’. A second hub located in Izmir, Turkey will be established in December 2012, to assist cancer registries in 27 countries of Northern Africa and Western Asia. EH News Bureau




ESA calls for new research to improve surgical outcomes of patients The call came after the European Surgical Outcomes Study (EuSOS) revealed that non-cardiac surgical mortality was higher than previous estimates, in some European countries uropean Surgical Outcomes Study (EuSOS), published in The Lancet on September 21, 2012; revealed that noncardiac surgical mortality was higher than previous estimates, in some European countries. For example, surgical mortality is 3.6 per cent in the UK as against the earlier national estimates of one to two per cent. What is more alarming is the fact that 73 per cent of those who lost their lives had not been admitted to critical care wards post-surgery. 43 per cent of those who were admitted to critical care after surgery, died after being transferred to a regular ward. Moreover, the overall European surgical


mortality figure of four per cent contrasts sharply with the two per cent mortality following emergency cardiac surgery, in which admission to critical care is generally standard. The European Society of Anaesthesiology (ESA) stated that these revelations raises doubts over the allocation of vital facilities in hospitals across Europe and has called for new research into how to improve the surgical outcomes of patients, including better ways of monitoring and preventing complications in those at highest risk of death. “Of particular concern to ESA is that the study reveals that critical care resources do not appear to be allocat-

ed to the patients at highest risk of death,” said Professor Andreas Hoeft, Chairman of ESA’s Research Committee and co-author on The Lancet paper. “Simply calling for more intensive care unit (ICU) beds will not solve the problem. No health system in Europe can afford to transfer all surgical patients routinely to an ICU or intermediate care, as it is current practice in cardiac surgery and most neurosurgery,” stated Hoeft and added, “New, costeffective ways of identifying and monitoring patients at risk must be developed. These findings provide further evidence that current clinical practice fails to identify patients at risk at an

early stage and to detect and treat complications early enough. We might need such cost-effective monitoring and alarm systems on regular wards in the future.” Hoeft is based at the Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany. Data from EuSOS was first presented in June at Euroanaethesia 2012, the annual congress of ESA. The study was funded through a joint research grant from ESA and the European Society of Intensive Care Medicine (ESICM). Source: The Lancet EH News Bureau


India moves to end discrimination against leprosy affected people Announced a special Forum of Members of Parliament, who will ensure implementation of UN’s P&G and to address the issue of stigma t the recently held ‘Second International symposium on Leprosy and Human Rights’, a special announcement was made to form a forum of Members of Parliament in India to ensure the implementation of ‘Principles and Guidelines (P&G) for the Elimination of Discrimination against Persons Affected by Leprosy and Their Family Members’ adopted by the UN Human Rights Council. The purpose of the announcement was to address the issue of stigma against leprosy. The two-day symposium, was organised by SasakawaIndia Leprosy Foundation and The Nippon Foundation. It was attended by Mukul Wasnik, the former Minister for Social Justice and Empowerment, as the Chief Guest. Some of the key dignitaries present were Yohei Sasakawa – WHO’s Goodwill Ambassador for Leprosy Elimination and Chairman, Nippon Foundation;

Dr Samlee Plianbangchang, Regional Director of WHO South-East Asia Region; Stuti Narayan Kakkar, Secretary, Department of Disability Affairs; Dinesh Trivedi, Member of Parliament; D Purandeswari, Union Minister of State for HRD; V Narsappa –Chairman, National Forum India; and Prof Yozo Yokota, Director, Center for Human Rights Education and Training, Japan. The highlights of the discussions held during the two-day symposium are: ● Role of NGOs/persons affected by leprosy/government/in implementing P&G: good practices and future plan of actions ● Social aspects – living conditions of leprosyaffected people in Asia ● How to follow-up on the implementation of P&G by International Working Group ● Leprosy situation – WHO facts, figures and numbers


The key dignitories who attended the symposium

EH News Bureau


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Industry update

President stresses on the need for high quality national health system

BD to form Association of Diabetes Educators in India


It is a venture in collaboration with Diabetes Endocrinology Nutrition Management and Research Centre (DENMARC)

ddressing the 40th Annual Convocation of All India Institute of Medical Sciences on October 16, 2012 in New Delhi, the President of India, Pranab Mukherjee stressed on the need a high quality national health system that is used by the poor and rich alike. He also expressed concern about the the impact of health and medical expenses on the vulnerable sections of our society and stated that as many as four crore people plunge into poverty each year due to expenses on medical treatment. He also found the fact that almost 80 per cent of the expenditure on healthcare by people is out of pocket. The President also admonished that the health services for the poor cannot be poor health services and opined that the progress in the health sector is key to securing India a prominent standing in the world. He also stated that the nation’s productivity has a direct relation with the health and wellbeing of its citizens. Economic growth that does not go hand in hand with reduction in avoidable mortality and ill health is neither sustainable nor desirable. The President asked AIIMS to take the lead in propelling India to the frontiers of innovative solutions in healthcare, discovering new cures, harnessing existing and emerging technologies for affordable healthcare, and exploring new paradigms for preventing disease and creating wellness. He said that AIIMS should be a powerhouse of biomedical research and a role model for others. AIIMS must rise to be one of the 10 best medical universities in the world by the year 2020. EH News Bureau



n an attempt to deal with the growth of menace of diabetes, Diabetes Endocrinology Nutrition Management and Research Centre (DENMARC) and BD are forming an Association of Diabetes Educators (ADE) to educate people about the different aspects of managing diabetes. It was launched at the recently held first annual conference of Association of Diabetes Educators in Mumbai amidst several renowned endocrinologists, educators and experts. “The association has 200 registered diabetes instructors so far to and we are looking forward to add more by the coming year. We are happy to have BD as our knowledge partner who will help educators to come


together on a platform and establish the profession of diabetes educators. ADE’s research will focus on building the evidence base for diabetes education and proving the value of the diabetes educator’s intervention in primary healthcare setting,” said Dr Hemraj Chandalia, Diabetologist and Director of DENMARC. Diabetes educators are healthcare professionals who will educate people with and at risk for diabetes and related conditions to achieve behaviour change goals which would lead to better clinical outcomes and improved health status. Educators of ADE will present their research and clinical work in the quarterly journal to reach out to a larger group of peo-

ple. This organisation underlines support sites in traditional settings, and will also expand programme options for diabetes care professionals and experts. This association will offer improved support for community-based settings such as physician offices, pharmacies, specialised clinics and centres. “We are happy at the formation of Association of Diabetes Educators in India as it will significantly try to improve the public health thereby reducing the financial burden on the country’s healthcare system. Diabetes educators play a pivotal role in empowering patients to adhere to effective treatment and mobilising diabetes educators will empower people with diabetes to take charge

of their own disease,” said Manoj Gopalakrishna, Managing Director, BD India. The eligibility criteria to be a part of ADE is to be a graduate in Nutrition or Nursing (BSc and above) or the incumbent has to be a pharmacist (B-pharm or above) with a minimum three months of practical experience in counselling people suffering from diabetes or two years of practical experience in any healthcare setting. A medical professional (MBBS, MD) recognised by Medical Council of India who has demonstrated abiding interest in diabetes education shall be admitted after due scrutiny by the Executive Council of ADE. EH News Bureau


Menopause doesn’t cause weight gain: IMS Study The hormonal changes at menopause are associated with a change in the way that fat is distributed tudy reveals that menopause changes the way that fat is distributed, leading to more belly fat. To mark World Menopause Day which fell on October 18, the International Menopause Society (IMS) has developed a state-of-the-science review on weight gain at the menopause which is published in the peer-reviewed journal, Climacteric. The review reveals that going through the menopause does not cause a woman to gain weight. However, the hormonal changes at the menopause are associated with a change in the way that fat is distributed, leading to more belly (abdominal) fat. Thus the evidence points out that absolute weight gain is determined by non-hormonal factors, rather than the menopause itself. The key finding was that the way fat is deposited


changes at the menopause; studies indicate that this is due to the drop in estrogen levels at that time. After the menopause, women experience a shift in their fat stores to their abdomen. According to review leader, Professor Susan Davis, Monash University, Melbourne, Australia, “It is a myth that the menopause causes a woman to gain weight. It’s really just a consequence of environmental factors and ageing which cause that. But there is no doubt that the new spare tyre many women complain of after menopause is real, and not a consequence of any changes they have made. Rather, this is the body’s response to the fall in estrogen at menopause: a shift of fat storage from the hips to the waist”. Dr Duru Shah, Member of the Board of the International Menopause Society and Past

President of the Indian Menopause Society was also a part of the study. According to Dr Shah, “This article to which I have contributed is written by a group of Board members of the International Menopause Society based on various scientific studies reported in international journals. This article takes away the myth that menopause leads to obesity. What is clear from the scientific data is that fat gets redistributed to the abdominal with increased Cardiovascular disease. Hence, cardiac problems are usually seen in women following menopause and not before menopause”. The review notes that increased abdominal fat increases the risk of future metabolic disease, such as diabetes and heart disease, in postmenopausal women. It also noted that, contrary to popular opinion, estrogen therapy (HRT) does not

cause women to put on weight. There is good evidence that HRT can prevent abdominal fat increasing after menopause. Professor Davis continued, “What this translates to in real terms is that women going through the menopause should begin to try to control their weight before it becomes a problem, so if you have not been looking after yourself before the menopause, you should certainly start to do so when it arrives. This means for all women being thoughtful about what you eat and for many, being more active every day.” The IMS is calling for women to be more aware of the problems associated with excess weight, and to take early steps to ensure that they don’t gain excess weight after the menopause. EH News Bureau NOVEMBER 2012

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NABL accreditation for Asian Institute of Medical Sciences


sian Institute of Medical Sciences (AIMS), has been granted NABL status in a record time since inception. Speaking on the occasion, Dr NK Pandey, Chief Surgeon, Chairman and MD, AIMS said, “The very recent National Accreditation Board for Testing & Calibration Laboratories (NABL) accreditation for AIMS is testimony to the fact that we maintain and adhere to the highest possible standards in laboratory tests as in all other testing and diagnostic facilities.” Dr Ramesh Chandna, Director, Quality and Laboratory Services, AIMS said, “The NABL accreditation will benefit patients and also make them aware that we have certified approval for precision, accuracy and timely delivery of reports. In addition to NABL accreditation, we have a well constructed internal as well as external quality assurance programme.” Highlighting the USP of the laboratory services he said, “Many a time, during critical surgeries, when the patient is being operated the surgeon needs to decide the course of action fast. The strategy, for example, for patients undergoing suspected cancer surgery can be decided only when the test results for a biopsy come in, revealing whether a tumour is benign or malignant. We are the only hospital in Faridabad to have this facility of frozen section. In thirty minutes, our lab gives results regarding the diagnosis whether the tumour is benign or malignant. In this way surgeons can minimise the number of procedures a patient has to undergo for diagnosis and most importantly know whether radical surgery is required on the patient or not.” He further elaborated, “We are the only lab in Faridabad using chemiluminescence technology for diagnosis of both infectious and non-infectious diseases. The technology employed is far superior to other technologies like ELISA and rapid testing.” EH News Bureau



Kartavya Healtheon launches its disease management services for HIV patients It is also in the process of rolling out day care centers and family doctor services to address the needs of primary healthcare in major cities of India artavya Healtheon, a chronic disease management company has launched a HIV disease management services in India. With its unique concept of ‘Health back’, this programme will offer patient management service to individuals suffering from HIV by focusing on disease awareness, medication adherence and maintaining healthy lifestyle. The programme is designed to target the elements that support the best clinical and financial outcomes: the right healthcare provider, the right medica-


tions, the right care and the right lifestyle. HIV/AIDS is now viewed as a chronic disease, in which patient management is an integral component. Kartavya Healtheon’s servicing team ensures that each individual is given assistance and support on a regular basis through telephone calls, SMS, pill reminder machines and even personal visits by field based counselors. It addresses issues of therapy compliance, medication adherence, prevention, disease awareness and management.

Vikram Srivastava, CEO and Co-Founder, Kartavya Healtheon says, “We educate and support HIV positive patients to seek early, preventative care in order to prevent HIV transmission and stay compliant to treatment. DM plays a vital role here as it helps to overcome the scepticism and strengthen the courage of the patient so that he lives a normal life rather than living a HIV life.” “Our call centre’s multilingual professional staff will assist callers in providing proactive ways to improve and maintain physical,

emotional and psychological well-being and support the member to take ownership of their health. They will also provide wellness, lifestyle and medication management information to the patient to ensure compliance and thereby curbing unnecessary costs,” added Srivastava. Kartavya Healtheon is also in the process of rolling out day care centres and family doctor services to address the needs of primary healthcare in major cities of India, in the near future. EH News Bureau

Max Super Speciality Hospital, Patparganj launches speciality institutes These institutes would heighten the study and research in the areas of cardiac sciences, neurosciences, oncology, renal sciences and trauma services ax Super Specialty Hospital, Patparganj has launched five institutes within the hospital, each with a specialised area of focus. The newly launched Institutes are the Max Institute of Cardiac Sciences, Max Institute of Neurosciences, Max Institute of Renal Sciences, Max Cancer Centre and Max Trauma Centre. The institutes were inaugurated by Arun Jaitley, Member of Parliament and


Leader of Opposition at Rajya Sabha and Analjit Singh, Founder and Chairman of Max India. The idea behind the launch of these institutes is to heighten the study and research in each of these areas of focus so as to benefit individuals and enable better understanding and cure of diseases. Each of these institutes will be headed by senior doctors and specialists known for their expertise in their respective areas.

Analjit Singh, Chairman, Max India Group said, “The new speciality areas would not only provide medical care for cardiovascular, renal, neurological, cancer and trauma ailments, but would also pioneer research in these critical areas. Other than people from East Delhi, these new centres would even cater to the increasing inflow of patients from contiguous and nearby cities of Noida, Ghaziabad, Meerut, Moradabad, Hapur and

Haldwani.” Rahul Khosla, MD, Max India said, “The opening of these new Centers of Excellence at Max Super Speciality Hospital, Patparganj is in line with our strategy of deeper presence in the Delhi-NCR region. These specialties would play a significant role in taking forward Max Healthcare's Academic-Medical Centre Model.” EH News Bureau

BCCI has a new Vice President Dr Alok Roy has become the first individual from healthcare to be elected for this position r Alok Roy, Chairman, Medica Superspecialty Hospital, was unanimously elected as the Senior Vice-President of Bengal Chamber of Commerce and Industry (BCCI) at the institution’s 158th Annual General Meeting held at its headquarters in Kolkata on September 28, 2012. This is the first time that an individual from the healthcare


industry has been elected for this post. This prestigious institution is a chamber of commerce based in West Bengal, India. Established in 1853, it is the oldest such institution in India, replacing the former Calcutta Chamber of Commerce, which was merged into the new organisation. The Chamber’s vision is to be the most valued partner

of commerce, industry, academia, professionals and governments for achieving responsible economic growth as well as accomplishing their societal and environmental needs. The organisation has its headquarters at the former Royal Exchange in BBD Bagh, Kolkata, which was once the residence of Robert Clive, the first Governor-General of India.

The members include corporations and industries of all sizes, professionals, divisions of large multinational corporations and service industry organisations. Dr Roy brings with him his vast experience in building and running healthcare units, and BCCI stands to gain immensely by his wisdom and knowledge. EH News Bureau NOVEMBER 2012



Bharat Family Clinic to invest Rs 150 crore for primary family clinics


ohns Hopkins Medicine International (JHI) and Bharat Family Clinic (BFC) have signed a memorandum of understanding (MoU) to establish a large network of outpatient primary care clinics across India. As per the agreement, Johns Hopkins faculty and experts will advise Bharat Family Clinics on the development of clinical programmes and assist with the facility design and operation of the new chain of primary and secondary care clinics across India. A network of nationwide clinics will be launched over a 10-year period with the first one scheduled to open in November. Pradeep Handa, MD, Chairman of Bharat Family Clinic said,“This initiative is an important step toward transforming primary health care services in India. We believe that this can be best accomplished through the delivery of quality medical and wellness services in an environment of compassion, comfort and care. We are planning to open 60 to 70 clinics in next four to five years with investment of Rs 150 to 200 crore.” The new facilities will incorporate the outpatient primary care procedures and protocols of Johns Hopkins Community Physicians, and will feature state-of-the-art diagnostic equipment and highly trained teams of healthcare providers. The BFC clinics will offer consultations with physicians and will provide diagnostic, laboratory testing, and pharmacy and ambulatory care services. Areas of speciality will include general internal medicine, obstetrics and gynecology, pediatrics, dermatology, endocrinology, gastroenterology and otolaryngology. Steven J Thompson, CEO of Johns Hopkins Medicine International said, “We are delighted to partner with Bharat Family Clinics through this project. We also hope that this project will make significant impact on the delivery of preventive and primary care in India and beyond.” EH News Bureau




Fortis Memorial, a quaternary care hospital, to be launched in Gurgaon Fortis Memorial Research Institute to offer advanced multi-clinical, holistic treatments for complex medical problems ortis Healthcare has announced its vision for its next generation hospital, the ‘Fortis Memorial Research Institute (Fortis Memorial), expected to open shortly in Gurgaon, India. Commenting on the new concept, Malvinder Singh, Executive Chairman, Fortis Healthcare, said, “A comprehensive institute, it is aimed at delivering cutting edge medicine in line with the best in the West. No effort has been spared and every conceivable detail looked into, in the setting up of this next generation hospital, positioned as the healthcare destination facility, in Asia.” The Fortis Memorial is expected to be a one stop, multi-super speciality quaternary care hospital providing medical excellence. Great attention has been paid to detail, evident in the excellence in design, infrastructure, latest technology, supe-


rior functionality and compassionate care delivered with a motive to heal. Shivinder Singh, Executive Vice Chairman, Fortis Healthcare, said, “The new Fortis Memorial Research Institute marks a paradigm shift in our interpretation of the idea of holistic patient care and our quest for excellence. All our efforts are directed at radically improving clinical outcomes with a warm and friendly experience.” He added, “The facility has been designed with great sensitivity, keeping in mind the anxiety and stress that patients and their families undergo and intuitively addresses these emotions. The overall ambience and facilities support total healing with an emphasis on complete cure and effortlessly strings together wellness into the healthcare mainstay.” In its first phase, Fortis Memorial will have 400 top

doctors and more than 1,000 nurses to provide the best treatment and care. It is the first hospital in its category to house a full-fledged stem cell lab for cutting edge medical treatment and also offers robotic surgery and organ transplantation for patients. The Fortis Memorial utilises and showcases the latest technologies in use for healthcare. Some of the milestone technologies at the hospital will include the first pilot project for precision radio-surgery in the world bringing together the cutting edge expertise of two medical technology giants – Elekta and Brain Lab. The precision radio-surgery system is the first such collaboratively created installation in the world involving both companies. Separately, Philips Medical systems has also entered into a long-term arrangement with Fortis Memorial to develop new

technology and methods to treat complex medical conditions. Other state-of-the-art technologies deployed at the hospital include the 3 T digital MRI, 256-slice CT scan, advanced brain suite, BiPlane cath-lab, time-of-flight PET CT, digital mammography, e-ICU, fibro-scan, voice modulated integrated operating rooms and an open diagnostic lab. Holistic health facilities like a swimming pool for hydrotherapy, a fullyequipped gymnasium and spa for health and wellness, several Art ‘n’ Health programmes to recuperate, a mini theatre to de-stress, retail therapy outlets for immediate needs and a food court providing a choice of dining options to replenish energies would also be offered at Fortis Memorial. EH News Bureau


Extend Nutrition enters the Indian market with Plans to channelise their products through xtend Nutrition, a leading US brand is set to enter the Indian market with its range of food products that are meant to help control diabetes and avoid blood pressure swings. The company will join hands with, a known e-health store. will be the exclusive authorised online partner in Extend Nutrition’s venture into the Indian e-healthcare arena. Speaking about the development, Prashant Tandon, MD and Co-Founder, HealthKart said, "India is known to be world's diabetes capital. With e-health scene rapidly catching up here, I am sure this partnership will be prolific in many ways." According to the Indian Council of Medical Research, nearly 150 million people in


India have either diabetes or pre-diabetes, and that number is steadily on the rise. By 2030, over 400 million Indians will be impacted by the disease. Kevin Dalrymple, President, Extend Nutrition, said “ provides us a unique home delivery distribution model that allows our products to reach the millions of people in India that struggle with diabetes and blood sugar management every day. Dr Francine Kaufman, MD, former president of the American Diabetes Association and a world renowned endocrinologist, is the inventor behind Extend Nutrition’s science-based products. She developed a complex carbohydrate formula using uncooked corn starch, protein and fats. The

formula has been clinically tested and proven to help control blood sugar for up to nine hours. Covered by 17 international patents, these snack products by Dr Kaufman have undergone six clinical studies and are part of a fast-growing diabetic food brand in the US. Extend Nutrition products metabolise slowly, resulting in stable energy for six hours during daytime and for up to nine hours during nighttime. This also reduces blood sugar swings to help keeping cravings and fatigue at bay. The product range includes bars, shakes, drizzles and savory crisps. They are an exciting substitute to all indulgent snacking options. They are available in a variety of flavours including: Chocolate Delight, Peanut Delight, Apple

Cinnamon Delight, Mixed Berry Delight, Honey BBQ, White Cheddar, to name a few. Three proven effects of these products are that they a) reduce calorie consumption at the next meal by an average of 21 per cent, b) effectively reduce morning hyperglycemia by an average of 28 per cent and c) help to reduce nighttime hypoglycemia up to 75 per cent. Extend Nutrition’s products also help provide energy to overcome a skipped meal, help to control hunger and improve recovery from exercise. For this reason, they can be effectually used by those who are weight conscious, fitness enthusiasts, people on the go, kids and adults alike. EH News Bureau NOVEMBER 2012


New launch

Insystt launches a healthcare web-app


nteractive System Technologies (Insystt) has designed and developed a healthcare automated web application which allows consumers to keep track of information on real-time availability of medicines or drugs at any given location within India. This service is free-of-cost for users, pharma manufacturers, distributors, medical retail shops or pharmacies and individuals like medical practitioners. The company plans to introduce the operational services within Mumbai and expand the same stage-wise throughout the country. It is an automated healthcare web application, which through a series of questions provides the users with personalised medical information, related to them and their symptoms. It assists individuals in ensuring the availability of lifesaving medicines and grants information on real-time accessibility of medicines in the vicinity as well. It also helps to book appointments with any doctor for any date and time from every location pan India.This feature is conclusively costless and being multilingual profits every cast, creed and community of the society, and as well as the remote and rural sectors of India with no limitation to accessibility. This facility is obtainable on mobile technologies. Medical professionals can now validate and align daily schedules consequently and initiate online updates of diagnosis for the ready reference from anywhere at any given point of time. Medical shop owners or medical distributors get complete exposure of business with minimal investment. Pharma companies, with the help of this application track the availability of brands real-time and get facts and figures for an individual or multiple brand range as showcases the real-time availability of medicines and hence sees an increase in business profitability. EH News Bureau


Indraprastha Apollo hospital launches ‘Go Pink, Get Screened’ campaign It is an initiative to commemorate Breast Cancer Awareness Month and spread awareness that early detection is crucial to conquer breast cancer n the occasion of Breast Cancer Awareness Month, Indraprastha Apollo Hospitals has started an awareness campaign ‘Go Pink, Get Screened’, which highlights the fact that early detection of breast cancer can help fight the deadly disease. Every year, October is commemorated worldwide as Breast Cancer Awareness Month to increase and spread awareness about its prevention, early detection and treatment. Through its campaign, Indraprastha Apollo Hospitals and Apollo Hospitals Noida is also providing a discount on various breast checkups at the hospital premises. Dr Ramesh Sarin, Senior


Consultant, Surgical Oncology, Indraprastha Apollo Hospitals, said: “Detection in stage I holds almost 90 per cent chance of cure, while detection in stage III has minimal chance of cure. Cure rates in the west have improved entirely because of a generation of mass awareness leading to early detection and treatment. The most important means for this is awareness about the disease and self-discovery, rather than accidental discovery, as presently happens in many cases. Learn to do breast self-examination. It can happen to anyone. Talk about it. Breast Cancer is different from most other concerns as it has non-toxic treatment available to cure.”

Dr Harsh Dua, Senior Consultant, Medical Oncology, Indraprastha Apollo Hospitals, said: “Monthly self-examination, monthly check-up by doctors and regular screening helps to reduce mortality due to breast cancer. Screening can help in diagnosing breast cancer early. Early detection of cancer increases the chances of a successful treatment.” Dr Sapna Nangia, Senior Consultant, Radiation Oncology , Indraprastha Apollo Hospitals, explains, “Early breast cancer detection via screening mammography is the most effective way to reduce mortality from the disease. Many young women ignore the initial

signs, such as a breast lump or an unusual discharge. It is advisable women get themselves checked once they reach 30 years of age, instead of 40. Women younger than forty require a clinical breast examination for screening.” It is estimated that by 2025, breast cancer cases will double, leading to an alarming rise of such cases in women. By regularising breast cancer screenings, the early signs can be diagnosed well in time and treatment can be initiated promptly. Some early signs of cancer include lumps, sores that fail to heal, abnormal bleeding, persistent indigestion, and chronic hoarseness. EH News Bureau


Exercise more beneficial on an empty stomach The research was conducted by the scientists at the University of Glasgow xercising before breakfast is better than exercising afterwards according to new research by scientists at the University of Glasgow. Dr Jason Gill and Nor Farah of the Institute of Cardiovascular and Medical Sciences conducted a study to compare the effects of exercise performed before and after breakfast on fat loss and metabolic health.


Ten overweight men who were not regular exercisers took part in the study. Each man underwent three trials, one to two weeks apart, involving performing no exercise then eating breakfast; walking briskly for 60 minutes before eating breakfast; or doing the same walk after eating breakfast. Participant were given lunch three-and-a-half hours

after breakfast and the amount of fat their body burnt, and the levels of fat, sugars and insulin in the blood were measured over an eight-and-a-half hour period on each occasion. The results indicated that both timings of exercise increased fat burning over the day and improved the metabolic profile in the blood. But, exercise before breakfast

resulted in greater fat loss and larger reductions in the level of fat in the blood. The research paper, ‘Effects of exercise before or after meal ingestion on fat balance and postprandial metabolism in overweight men’ is published in the latest edition of the British Journal of Nutrition. EH News Bureau


Indian Paradox: 46 per cent children suffer from malnutrition while 30 per cent are affected by obesity Both problems are affected by factors like environment, dietary patterns and socio-economic status least 46 per cent of Indian children up to the age of three still suffer from malnutrition. This was reported in a study by the British-based Institute of Development Studies (IDS), which incorporated papers by more than 20 India analysts. Dr Ramen Goel, renowned Bariatric Surgeon and Past President of All India


Association for Advancing Research in Obesity said, “Malnutrition amongst children in India is not only related to poverty, even children who can afford two meals a day, eat mostly carbohydrates and transfats. This nutrition ignorance arise out of lack of awareness in their parents, teachers and society at large.”. At the same it was also

revealed that more than 30 percent of children in India is affected by obesity. Causes associated with childhood obesity include: environment, lack of physical activity, heredity and family, dietary patterns, socioeconomic status etc. Dr Ramen Goel observed, “We are seeing larger number of children with weight of over 100 kg visiting

our clinic. The irony is that most of these kids have gained weight for no fault of theirs, since they are not decision makers either at family, school or societal levels.“ Thus it was seen that a paradoxical situation exists in India wherein children of the country are battling both malnutrition and obesity. EH News Bureau





IRIA 2013: Official meeting ground for Indian radiologists It promises to be an event that will bring together distinguished international and national radiology experts he Indian Radiology and Imaging Association (IRIA) is organising its 66th annual conference from January 4-7, 2013 at Daly College, Indore, Madhya Pradesh. The event will be hosted by the Madhya Pradesh State Chapter of IRIA. The annual conference of IRIA has become the official meeting ground for the Indian radiologists to exchange their professional experiences, discuss the recent advances, know about the state-of-the-art technology in radiology and imaging sciences and educate the young radiologists and residents. IRIA has been growing continuously by integrating new developments and involving more and more


Last year’s visitors being informed about IRIA 2013 radiologists, not only from India but from all over the world. An excellent scientific and educational programme covering various fields of diagnostic imaging, interven-

tional radiology and molecular imaging, is being prepared to meet the expectations of the visitors to IRIA 2013. It promises to be an event that will bring together dis-

tinguished international and national experts from the radiology field, who will present their experience on topics covering all spectrums of radiology. In this regard, a comprehensive scientific programme is also designed. This event will be an opportunity for the participants of all sub-specialities to attain knowledge about cutting edge technology. In addition, this event will be an ideal forum for networking and building lasting relations with participants from different parts of the country.

Highlights of the scientific programme: ● ●

A galaxy of National and International faculty Accreditation by M.P. Medical Council and

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Royal College of Radiologists Symposia on Radiology Journalism PG Teaching Course by American Institute for Radiologic Pathology, a programme by the American College of Radiology Pre-conference workshops Daily plenary sessions Orations, debate and image interpretation sessions by International faculty. "Meet the Professor" sessions for residents and students ESR Presents, AOSR Presents, Case of the Day Posters, Exhibits, Competitive Scientific Papers


'Patients First' at RSNA 2012 RSNA 2012 with its theme of 'Patients First' has a lot of sessions, presentations, exhibitions and activities in store for the delegates expected to come from across the world he Radiological Society of North America (RSNA), an international society of radiologists, medical physicists and other medical professionals with more than 50,000 members across the globe, hosts the largest medical meeting in the world, drawing 60,000 attendees annually. This year, the 98th Scientific Assembly & Annual Meeting of the Radiological Society of North America, will be held from November 25 – 30, at the McCormick Place, Chicago, US. The theme for RSNA 2012 is “Patients First”. From lectures and special sessions focussed on the speciality's hottest topics to presentations of cutting-edge research and the latest in radiology informatics, learning opportunities in every sub-speciality would be in abundance at RSNA 2012. Science, education programmes are expected to raise the bar at RSNA 2012. New research, evolving techniques and technology, expert updates on healthcare policy and the latest in patient-tailored care are included on the rich roster of offerings this year. Along with an overall up-tick in abstract submissions, RSNA’s science and education com-



mittee chairs reported stronger international participation, an increase in technology-driven sessions and a steady focus on keeping

“Patients First.” RSNA 2012 attendees can choose from a wide range of education exhibits and scientific sessions, refresher

courses, self-assessment modules (SAMs), applied science, integrated science and practice sessions and workshops encompassing every sub-speciality. George S Bisset III, MD, is the President of RSNA 2012, Houston, Texas. Honorary Membership in RSNA will be presented for significant achievements in the field of radiology to Giovanni G Cerri of São Paulo, Brazil; Mukund S Joshi of Mumbai, India, and András Palkó of Szeged, Hungary. In addition, RSNA will honour two individuals at the event for their contributions to research and education. A James Barkovich of San Francisco, for his outstanding work in research and Marilyn J Goske of Cincinnati for outstanding work in education. Other features at RSNA 2012 are: Brazil Presents: RSNA’s continuing series highlights discoveries, techniques and practical clinical applications from investigators in Brazil RSNA DxLive: A fastpaced expert-moderated sessions where participants test their knowledge against that of their colleagues using mobile devices. Nuclear Medicine/MI Campus: Courses, exhibits and presentations featuring

nuclear medicine/molecular imaging are housed together for focused study. Mock Jury Trial: Witness the process of a medical malpractice trial in a case of overexposure to ionising radiation. CIR Spanish ProgrammeEmergency Radiology: A series of presentations for the Spanish-speaking radiologic professional, with available English translation. Resident & Fellow Symposium: This programme will help trainees make informed decisions in their careers For Hospital Administrators: The Hospital Administrators Symposium addresses compliance and coding, radiology reimbursements and anticipated technology advances Radiologist Assistants Symposium: Four interactive refresher courses on Sunday designed to meet the educational needs of radiologist assistants (RA) as defined by ARRT. RSNA also publishes two top peer-reviewed journals: Radiology, the highestimpact scientific journal in the field, and RadioGraphics, the only journal dedicated to continuing education in radiology. EXPRESS HEALTHCARE



Hospital Build & Infrastructure India 2012 It promises to be a power packed three-day technical conference where the stake holders of the hospital infrastructure industry would be sharing their views and opinions with the delegates ospital Build & Infrastructure India 2012 (HBII), a threeday exhibition and conference which will offer a direct access to the latest opportunities in the Indian hospital infrastructure and healthcare market is slated to be held on December 14-16, 2012 at Bombay Exhibition Centre, Mumbai. HBII 2012, this year, is set to be the largest strategic gathering of investors, commissioners, backers and managers of healthcare-related building projects with key players and exhibitors in planning, design, construction, operations, management, supply and refurbishment. The event aims to highlight issues that are essential to hospitals, nursing homes, architects, builders, project managers, consultants and manufacturers to remain compliant, competitive and sustainable. Concurrent platforms have been engineered to reward, demonstrate and educate industry professionals on the latest technological advances. One of the major initiatives for the HBII Conference 2012 is a three- day technical conference for industry professionals to benefit from the experience of renowned global industry leaders. The conference will deliberate on key issues related to hospital design and planning, innovations as well as engineering aspects to look for when building or upgrading small as well as large healthcare units. In addition to the speaker presentations, it will include attractive panel discussions, from internationally acclaimed companies and influential healthcare personalities from India which will serve as an excellent catalyst to the entire conference agenda. Categories of awards ● Leaders in HealthcareWinning Strategy in the new regionalised multinational healthcare market place ● Hospital Build, Design and Upgrade- Designing and building safe, functional, effective architecture & infrastructure ● Quality of Care- Leap over the quality chasm through redesigning healthcare quality model




Few of the speakers include ●

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Dr Chandrasekhar R, Chief Architect - DGHS, Department of Health, Govt. of India Dr Ramakanta Panda, Vice Chairman & Managing Director, Asian Heart Institute Dr Rana Mehta, Director, Healthcare, PWC India Dr Sujit Chatterjee, LH Hiranandani Hospital Vishal Bali, CEO, Fortis Global, India/Singapore VP Kamath, Chief Operating Officer, Wockhardt Hospitals Dr Rajiv Kumar Jain, Director (Health and Family Welfare), Ministry of Railways, Government of India Raju Narayan,CEO, Parkway Group Dr Mahesh Reddy, CoFounder and Director, Nova Speciality Surgery Ameera Shah, Managing Director and CEO, Metropolis Healthcare Dr Vishal Beri, Chief Operating Officer, Hinduja Healthcare Dr Girdhar J. Gyani, Member, Governing Board, National Accreditation Board for Hospitals & Healthcare Providers Dr Shakti Gupta, Head, Department of Hospital Administration, Academy of Hospital Administration Dr.Sameer Khan, Chief Operating Officer, Nova Medical Centers Dr Anupam Karmakar, General Manager, Operations, Jaslok Hospital Dr. Yash Paul Bhatia, President, Indian Healthcare Quality Forum Gaurav Malhotra, Managing Director & Chief Executive Officer, Patni Healthcare Joy Chakraborty, Director Administration, Hinduja Hospital, Mumbai

Growing stronger and bigger with participation from leading companies Leading companies, products and technology from India and abroad at HBII will provide the necessary thrust to the industry, striving to meet the rising demand for new and better healthcare facilities.

Several leading companies like Tata Motors, Godrej Interio, Sio Vassundhara International, STH Architect, Portalp International, Modular Concepts, Tahpi , Mehta Tubes Limited, Zebra Technologies, Hospaccx India TM, Allarch India, CR Medisysytems, Attune Technologies, Draeger, Alvo, Ram Metal Industries, Knauf RAK FZE, Linet, Hospaccx India Systems, Mindray, Bluestream Manufacturing Services, Agora Climate Control Systems, Aeropure Systems, Light & Magic Automation, Eubiq India, Archetype, American Institute of Architects, Bioni Paints India, Medica Synergie, Helix Corporation, Cosign India, RMG Polvinyl, Tata Consultancy Services, Redsun Communication, Meditek Engineers, Medimek Industries, Pratiba Medinox, HLL Lifecare, Piercing Systems, Studex, CAEM India, Inpro Corporation, Medirail India, The Best Interiors, Airox Technologies and many more are expected to have their presence at HBII 2012 since it will be a major healthcare event to develop and consolidate connections in healthcare infrastructure business within India. HBII will cover the whole spectrum of healthcare infrastructure segment with products ranging from architecture and design, construction, flooring, ceilings, lighting, ambulances, medical equipments, OT medical systems, healthcare IT, lights and pendants, HVAC, hospital curtains, doors etc. for the healthcare industry. Companies and individuals interested in exploring and studying the burgeoning Indian healthcare market now have an established platform to meet and learn from the key stake holders from major healthcare facilities of India. The only trade show of its kind in India, HBII will provide everyone in the hospital supply chain an unmatched opportunity to network, upgrade knowledge, source, sell, share ideas and technology, partner, ALL under one roof. For more information contact Tel: +91 22 4048 1710 NOVEMBER 2012


MEDICALL 2013 Gujarat MEDICALL 2013's focus is on taking Indian medical technology to the next level

f one has to pick from a list of successful events which have created a stir within a short span, MEDICALL would turn out to be a winner. Not only is it India’s premier medical equipment expo, but it has emerged as, and earned the envious reputation of being, the first real 'supermarket' for hospital equipment and supplies. With India on the fast track to economic growth its healthcare industry is expected to grow from its current $36 billion (approx), growing at 15 per cent CAGR, the Indian healthcare industry will be a $280 billion by 2022. In this context the role of MEDICALL assumes even greater significance. This is evident from its awesome and comprehensive range of


exhibits that include hospital information system, solutions, surgical and examination furniture, rescue and emergency equipment, to diagnostic/laboratory OT equipment/dental/ophthalmology equipment, medical disposables and cleaning equipment. MEDICALL has grown as a brand and continues to draw the highest percentage of hospital owners, doctors, medical directors and purchase heads in addition to being a proven and highly successful platform for attracting affluent producers, dealers and suppliers. The fact that its previous hosting attracted over 430 exhibitors and over 8000 quality visitors mostly from the its core target group, speaks volumes about the credibility of the event.

Now in its 10th edition, MEDICALL 2013 Gujarat will be hosted from February 810, 2013 at Ahmedabad. It will bring together the best in the business of ICU and operation theatre equipment, refurbished equipment, trolley, wheel chairs, cots and other furniture, hospital linen and laundry, hospital charts and stationary, office automation equipment, printers dealing with pamphlet and file designing, communication equipment, medical disposables etc. Special products at display will be ambulance, mannequins and other teaching aids for nursing, hospital management software, energy saving equipment, hospital flooring, housekeeping equipment, nurses alarm system, liquid oxygen and central pipeline,

physiotherapy equipment, autoclave and steriliser. Gujarat is the venue of choice because the state government is taking several initiatives to make Gujarat a global healthcare destination. Through use of latest technical equipment, increased health insurance, major corporate investments and services of highly skilled medical personnel, the Gujarat healthcare sector is poised well for a sustained boom. Medexpert, the organisers of MEDICALL, are a reputed name in events and trade shows for the healthcare industry. Medexpert are totally committed to making the exhibition experience of exhibitors both profitable and efficient by maximizing return on their investment. The total number of

exhibitors will be 300 companies for the second time at Gujarat—mainly medical equipment manufacturers. With such an impressive showing, the organisers expect close to 5000 quality visitors from India including those from countries like India, Srilanka, Bangladesh, Africa, Nigeria, Ghana. Thus, MEDICALL 2013 promises to be bigger and more incisive in terms of content and participation. In turn, it will provide a big fillip to the healthcare in general and medical equipment industry in particular. Medexpert also is organising show in Srilanka from March 15-17, 2013 and Chennai from August 2-4, 2013. For more information visit


International Fellowship on Health Technology Assessment The event will offer training on selection and use of health technologies for optimum results mrita Institute of Medical Science is organising first International Fellowship on Health Technology Assessment from December 9-16, 2012. It is being organised in association with Joanna Briggs Institute of Evidence Based Medicine, University of Adelaide, Australia and faculty from University of Toronto as well as University of Liverpool. IIT Madras is the technical collaborator for the event. The Fellowship is empanelled with NABH. Experienced international and national faculty have agreed to participate and share their expertise during this week long international fellowship programme, which is first of its kind in the country. The objective behind organising this fellowship was to impart training to the future torch bearers of healthcare professionals on the basics of impact assessment (IA) in selection and use of health technologies by methodological approach, systematic reviews to measure clinical effectiveness, economic modelling and harm-benefit assessment through an integrated patient



safety approach. Health technology assessment (HTA) is a multidisciplinary activity that systematically examines the safety, clinical efficacy and effectiveness, cost, cost-effectiveness, organisational implications, social consequences, legal and ethical considerations of the application of a health technology—usually a drug, medical device or clinical/surgical procedure. It acts as ‘a bridge’ between evidence and policy-making and seeks to provide healthcare policy-makers with accessible, useable and evidence-based information to guide their decisions about the appropriate use of technology and the efficient allocation of resources.

Rationale for HTA The cost of new technologies, the allocation of available resources and the ethical questions involved are topics of major concern to policy makers, health care practitioners, and researchers.

Technologies examined at HTA 1. Medical and surgical procedures and other inter-

ventions and techniques 2. Devices, drugs, instruments, and other equipment 3. Structure and organisation of healthcare services 4. Supportive services to the healthcare processes

Importance of HTA to healthcare decision-makers In contrast to the licensing processes for drugs and medical devices, which assess quality, safety and efficacy, HTA focuses on ‘the value’ (clinical and economic) of the technology relative to current (or best) clinical practice—the so-called ‘fourth hurdle’.

What are the goals? Ultimate aim: Potentiate the capacity of a health system to reach its goals ● Respond to people’s expectations by providing high quality essential services on the basis of efficacy effectiveness cost and social responsibility ● Provide financial protection against the cost of ill health ● Improve the health of the population it serves

HTA broadly focuses on two questions: 1. Clinical effectiveness: how do the health outcomes of the technology compare with available treatment alternatives? 2. Cost-effectiveness: Are these improvements in health outcomes commensurate with the additional costs of the technology. HTA can help policy-makers decide which technologies are effective and which are not, and define the most appropriate indications for their use. HTA can reduce or eliminate interventions that are unsafe and ineffective, or whose cost is too high compared with the benefits. That said, to date, most international HTA activity has been directed at quantifying the use of new and expensive pharma products. Technology is a key driver of healthcare costs. Health technology assessment (HTA) plays an essential role in modern health care by supporting effective decision making in health care policy and practice. There is a

vibrant and growing community around the world of those who undertake and use HTA. HTA's mission is to support their work in promoting the introduction of effective innovations and effective use of resources in healthcare.

Specific parameters ● ● ● ●

Technical properties and safety Efficacy/effectiveness Efficiency (cost effectiveness; cost benefit) Impact on health system: health related, organisational and economic Social acceptability (Ethical and social aspects)

Contact Dr Sanjeev Singh, Organising Secretary, HTA & Medical Superintendent Amrita Institute of Medical Sciences Tel: +91-484-6681234 Ext 1836, 1835 Email: sanjeevksingh@aims. / Website: EXPRESS HEALTHCARE



Management Development Program (MDP) on Nursing Leadership The Management Development Program (MDP) on nursing leadership which covered different aspects of nursing and its importance was very well received by those who attended it early 60 nursing delegates from 20 hospitals across Mumbai and Navi Mumbai gathered at the Management Development Program (MDP) for Nurses, conducted by MBA Health and the hospital faculty and students on October 6, 2012, at Padmashree Dr DY Patil University Department of Business Management in CBD Belapur, Navi Mumbai. The sessions were conducted by Phalakshi Manjrekar, Director-Nursing, Hinduja Hospital and Dr Swati Kambli, Principal– College of Nursing, Dr DY Patil University. Beginning the session, Manjrekar threw light on 'Leadership Communication', its significance and importance to nurses. “Clear communication is the most important key to a business leader’s success. So to grow as a leader and manager, you must learn how to be an effective, compelling communicator,” informed Manjrekar. Group activity with


change management were held wherein delegates were exposed to management games and helped to understand how to accept and embrace changes in the business environment. Role play was conducted by students of Padmashree Dr DY Patil University Department of Business Management to emphasise the practical aspects of the nursing profession. The second session was steered by Dr Swati Kambli who gave her valuable insights on management process and supervision in nursing. She mentioned, “Supervision is an accepted management principle in any complex human undertaking, that is, any undertaking in which several people work together needs unification and coordination” Speaking on the importance of nursing, Dr R Gopal, Director and HOD – DYPDBM said, “A great Nurse Manager is an acknowledged leader, an advocate for her patients, staff and hospital. She is a powerful agent for change, a

respected member of the nursing administrative team and a good fiscal manager. It's not easy to balance the competing demands of patients, families, visitors, physicians, unit staff, etc but an effective nursing manager is flexible and organised enough to address everyone’s needs in a systematic way.” Dr Nitin Sippy, National Convener, MDP said, “Nurses are like neurons in a hospital and nursing management is the central nervous system of hospital administration. This workshop used various pedagogies like case studies, evaluation of existing business plans, etc.” Overall, the Management Development Program (MDP) for nurses was a huge success. The topics in the entire programme ranged from various aspects of nursing and many new ideas were mentioned. The audience particpated completely in the question and answer spells held after every session, thereby making it a thoroughly interactive programme.

Dr Nitin Sippy

Dignitaries with Audience


52nd Annual State Conference of IRIA, AP State IRIA's AP State annual conference was a very informative event with a mix of several interesting segments he 52nd annual state conference of IRIA, AP state was organised at KREST, Hyderabad on the October 13-14, 2012. The annual conference attracted more than 200 delegates from all over the state. The conference was held under the leadership of Prof Kakarla Subba Rao, Chairman KREST and Dr T Mandapal, President of IRIA, AP state with Dr N Eshwar Chandra as the organising secretary. The theme of this year’s conference was ‘Chest & Abdominal Radiology’ The scientific programme included lectures from international, national and local faculty. Dr Zafar H Jafri from Oakland University William Beaumont School of Medicine, USA delivered two lectures on imaging of renal cell cancers and imaging of diseases of ureter. He also conducted a very interesting and much appreciated ‘Sanrad Quiz’ for post graduates. Out of a total of 38 teams which had applied, six teams were shortlisted for the finals after a preliminary screening test. The radiology quiz cases included some common cases and some very rare and interesting syndromes and presentations. Dr Harsh Mahajan from New Delhi, Dr Bhavin Jankharia from Mumbai and Dr Arjun Kalyanpur from Bangalore were part of the distinguished national faculty.




Dr Arvind Chaturvedi, Director of Radiology at Rajiv Gandhi Cancer Institute, New Delhi delivered the prestigious ‘Roentgen Oration’ of IRIA, AP state chapter for the year 2012. He dealt at length on a common topic, ‘Imaging in Lung cancer—current standard’ which was widely applauded. The scientific poster exhibition attracted over 40 good quality exhibits from student and senior delegates. Attractive prizes were awarded to the top three posters. A small but elegant trade exhibition was organised wherein multinational and local

companies displayed their products and gave information to the visitors. Major imaging companies like Sanrad, GE, Philips, Carestream had displayed their latest products and solutions. Dr Harsh Mahajan, president of IRIA was the chief guest at the inaugural function on the morning of October 13, 2012. An updated telephone directory of IRIA AP State, which was the result of painstaking efforts of Dr K Prabhakar Reddy, was released by Dr Harsh Mahajan during the inaugural ceremony. Life time achievement award for the year 2012 was presented to Dr UV Krishna Murty for his unstinted support and longstanding active association with the organisation. He is well known for his ‘radiological poetical skills’ and his presence is a must for all official functions of IRIA.. In the evening, a felicitation programme was organised to honor senior radiologists and trade partners. Senior professors Dr R Venkateswar Rao, Dr C Hundiwala, Dr R P Deshpande, Dr Loka Pandurangam, Dr Sreedhar Marar were felicitated in the evening function. Members of trade who had a long association with IRIA, AP state, KD Vakil, Sreekant T, DV Reddy, Kannababu and Vaidesh Harnoor were felicitated. NOVEMBER 2012


EVENTS UPDATE Workshop for nursing professionals

EyeStrat12 CHENNAI

Health Technology Assessment

Date: November 22-23, 2012

Date: December 1, 2012

Date: December 9-16, 2012

Venue: Department of Critical Care and Department of Nursing at SPS Apollo Hospitals, Ludhiana

Venue: The Raintree Hotel, Anna Salai, Chennai

Venue: Amrita Institute of Medical Science

Summary: A two-day workshop for nursing professionals will share best practices and knowledge with nursing professionals across the region. Contact details: Abhijit Singh Project Leader – Strategic Initiatives Satguru Partap Singh Apollo Hospitals Sherpur Chowk, GT Road, Ludhiana – 141003

HOSPIFINMARK Date: November 24, 2012 Venue: Dept of Business Management, Dnyanpushpa Niketan Sector-4 CBD Belapur, Navi Mumbai Summary: The 4th National Conference on Health and Hospital Management will have a panel discussion, which will be held on 'varietal branding and marketing opportunities for small to medium sized hospitals, nursing homes, diagnostics, day care centres,etc. Participant profile: Hospital promoters, directors, hospital administrators, CEOs, owners of nursing homes, labs, radiology centres, healthcare management consultants and students. Contact details: Dr Dushyant Patel: 9920043092 Dr Tapasya: 9022337383

Summary: A one-day conference on strategic management and marketing for eye hospitals & ophthalmic professionals. The event will be organised by AMEN & Pranav Healthcare. Participant profile: Eye hospital promoters, CEOs/COOs, administrators, managers, executives, healthcare management consultants, ophthalmologists Contact details: Mob: 09035189824 / 25 Website:

PeopleHosp CHENNAI Date: December 5, 2012 Venue: Hotel Marina Towers, Egmore, Chennai Summary: A one-day conference on strategic human resource management for hospitals Participant profile: Hospital/Healthcare promoters, CEOs/COOs, administrators, HR managers, HR executives, healthcare management consultants Contact details: Mob: 09035189824 / 25 Website:

HospiArch VIZAG

HospiArch 2012 DELHI

Summary: Amrita Institute of Medical Science is organising first International Fellowship on Health Technology Assessment in association with Joanna Briggs Institute of Evidence Based Medicine, University of Adelaide Australia with faculty from University of Toronto& University of Liverpool. The technical collaborator is IIT Madras. The Fellowship is empanelled with NABH also. Participant profile: Hospital and healthcare administrators and CEO's, MS, COOs, decision makers, finance officers, medical professionals, fresh graduates in medical/bio-medical/pharma/ Hospital management Contact details: Dr Sanjeev Singh Amrita Institute of Medical Sciences +91-484-6681234 Ext 1836, 1835 Email: / Website:

FICCI Health Insurance Conference-2012 Date: December 10, 2012 Venue: FICCI, New Delhi Summary: Federation of Indian Chambers of Commerce & Industry is organising 5th FICCI Health Insurance Conference, on the theme 'Getting Behind the Numbers.'FICCI’s endeavour, through this conference, is to identify key areas where data analytics can be meaningfully used and its benefits to achieve objectives of growth and expansion of the health insurance sector for both the private and government sponsored health insurance schemes.

Date: December 8, 2012 Date: November 24 and 25, 2012 Venue: Vizag Venue: Hotel City Park, Kapashera, Gurgaon (near toll plaza), New Delhi Participant profile: Hospital/ healthcare promoters, CEOs/COOs, administrators, managers, executives, healthcare management consultants Contact details: AMEN, No. 233, 6th Main, Rajeevgandhi Nagar, Near Lourdes School, Nandini layout Bengaluru - 560096, Karnataka Ph: 09035189825 Website:


Summary: A one-day conference on hospital planning, design and architecture will be organised by AMEN & Hospaccx India Systems Participant profile: Hospital/healthcare promoters, CEOs/COOs, administrators, managers, executives, Healthcare Management Consultants, Architects Contact details: Mob: 09035189824 / 25 Website:

Participant profile: Participants in the conference would include representatives from the health insurance industry, life insurance industry, non- life insurance industry, healthcare providers, MHIs, NBFCs, insurance brokers, agents, clinical experts etc. Contact details: Sidharth Sonawat/Sudhiranjan Banerjee FICCI Federation House, Tansen Marg New Delhi-110001 Tel: 011 23487246, 23487220, 011 2373 8760– 70 (Extn. 246/220) Fax: 011 2332 0714, 011 2372 1504 E-mail:,



Strategy Hazard identification and risk analysis Deepak Venkatesh Agarkhed, GM-Clinical Engineering, Facilities & Quality,Takshasila Healthcare & Research Services, gives an insight on the need , importance and benefits of hazard identification and risk analysis of the medical equipment in a hospital Page 31 MAIN STORY

The Great Indian Healthcare Factories-I: Narayana Hrudayalaya In the first of a series of articles on ‘The Great Indian Healthcare Factories’, featuring stories in healthcare that are exemplary and worth emulating, Gp Capt (Dr) Sanjeev Sood, Hospital Administrator and NABH empanelled Assessor, chooses Narayana Hrudayalaya and traces the reasons that contributed to its success

r Devi Shetty’s vision for affordable healthcare led him to start the Narayana Hrudayalaya ('Temple of the Heart') in Bengaluru in the year 2001. Since then there has been no lookingxe back and the Group has now expanded into ‘health cities’, a series of larger-than-usual centres specialising in cardiology, eye, trauma, orthopaedics, neurosciences, dental and cancer care; comprising of 16 hospitals and 5700 beds. It expects to expand the chain to 30,000 low cost beds by 2020 and is also looking at creating three or four health cities around the US border. What makes this venture tick and achieve efficiencies that others can only envy? To answer this question, one has to examine the visionary leadership, strategic management, organisational culture, unique business model and other key attributes of Narayana Hrudayalaya.


Man behind the mission


Hospital Administrator and NABH empanelled Assessor



Dr Devi Prasad Shetty, Founder and Chairman of Narayana Hrudayalaya, is a medico-entrepreneur and a philanthropist crusader with a missionary zeal –all rolled into one. Influenced by the philosophy of Mother Teresa, he blends compassion with care and has a vision to provide quality healthcare for the masses worldwide. Known for his unconventional ideas, Dr Devi Shetty has innovative solutions for most of the ills afflicting the Indian healthcare sector. He believes that if each one of the 800 million Indian mobile subscribers, contribute Rs 10/as premium out of their monthly bills to a micro insurance health scheme, their healthcare needs will be taken care of. To achieve this, the

government needs to perform the role of the insurance provider rather than being healthcare provider. To overcome the shortage of medical manpower, he suggests that the government should open 100 medical colleges with upgraded district hospitals every year for the next five years. Narayana Hrudayalaya also plans to adopt 2000 children every year from rural West Bengal and other states and mentor them to become doctors by offering soft loans. He also believes in empowerment of paramedical staff and involving them in delivery of care. He proposes an equitable distribution of world class healthcare for the masses at an affordable cost. Recently awarded with the Padma Bhushan, Dr Shetty has been called as the 'Henry Ford' of heart surgery and ‘King of Hearts’ for having performed over 15,000 heart surgeries. The RBI has asked banks to emulate Narayana Hrudayalaya - to increase their relevance to consumers.

Creating focused factories of healthcare One of the startegies of Narayana Hrudayalaya has been to focus on a limited number of core competencies and bring in factory-like efficiencies in each hospital. This is the best way to compete effectively, by dedicating to a manageable set of services with greater standardisation, rather than being multi-purpose. The core competencies, precisely defined by the organisation’s strategy and its humane approach, is backed by its technological and economic strengths.

Size does matter Narayana Hrudayalaya has adopted a unique principle of economies of scale for

lowering healthcare costs and increasing accessibility. It has created ‘health cities’ with huge capacities in terms of infrastructure. Today, these hospitals perform about 12 per cent of all cardiac surgeries in the country; the maximum number of dialysis than any hospital chain in India at the modest cost of Rs 400; highest number of surgeries on children in the world; and the highest amount of bone marrow transplants at Mazumdar Shaw Cancer Centre in India. By handling greater volumes, the organisation has been able to hone its physicians towards greater proficiency levels, and also negotiate better prices for inputs directly from vendors. This helps to streamline the organisation’s workflows, processes and build systems with better efficiency and cost–effectiveness.

Achieving best outcomes Since the super specialists at Narayana Hrudayalaya hospitals see large volumes of cases and perform no more than two to three types of procedures, they excel in their domain. Most of these hospitals attain clinical and quality outcomes that are among the best in the world.

Reaching the grassroots To meet the healthcare needs of the masses, Narayana Hrudayalaya had launched a micro health insurance scheme, Yeshaswini eight years ago in collaboration with the Karnataka State Government. The scheme now has close to four million farmers as members contributing Rs 12 per month. It covers the expenses of 1650 different varieties of surgeries. In the first 20 months of scheme, 85,000 farmers had free medical treatment, 22,000

had free surgeries, and another 1400 had heart surgeries. Dr Shetty also founded ‘Arogya Raksha Yojana’, a joint venture of Narayana HrudayalayaPL, Biocon and ICICI to provide free OPD consultation, cashless surgical facility, and diagnostics at discounted rates.

Reining in costs by all means To rein in their costs and provide quality yet affordable care, Narayana Hrudayalaya critically examines its entire supply chain and processesfrom cost of land, technologies used and manpower employed; so as to get the best value for money. Narayana Hrudayalaya partners with the Governments and real estate owners to get land at subsidised rates and procure medical technology at lease or convince the vendors to park their machines in the hospital instead of outright purchase and buy consumables from them, thus saving on capex. Thus, Narayana Hrudayalaya is able to commission largescale projects and scale them up across the country. “The focus is how can you scale faster and deliver cheaper while adhering to the highest standards of clinical outcomes,” says Shetty. To attract and retain the best manpower, Narayana Hrudayalaya pays compensation at par with the best. However due to longer work hours, lower TAT and downtime; they are able to perform more surgeries per day, thus reducing the cost per procedure.

Hybrid and dynamic pricing At Narayana Hrudayalaya, approximately 40 per cent of patients pay a reasonable price for their treatment, a small percentage - those who

continued on page 32 NOVEMBER 2012


Hazard identification and risk analysis Deepak Venkatesh Agarkhed, GM-Clinical Engineering, Facilities & Quality,Takshasila Healthcare & Research Services, gives an insight on the need, importance and benefits of hazard identification and risk analysis of the medical equipment in a hospital he ever evolving role of technology in healthcare services now allow hospitals to diagnose faster, with greater accuracy than ever before and increasingly in a manner which is least invasive. It allows hospitals to treat better and help patients recover faster. Most of the processes in high risk clinical areas of a hospital like the operating room, intensive care area etc., involve usage of medical equipment. But faulty medical equipment or use of equipment in a manner other than in which it was intended to may lead to serious disability or death of patient. Few examples are wrong delivery of drug through non calibrated infusion pump, and patient suffering from a burn injury due to loose contact with patient plate while using electrosurgical equipment inside operating room. The NABH accreditation standard ROM 6a, mandates that top management of hospitals should ensure proactive risk management across the organisation. As per NABH accreditation standard FMS 1a, the hazard identification and risk analysis


(HIRA) exercise is to be conducted by hospital and it should take all the necessary steps to eliminate or reduce such hazards and associated risks. It is mandatory to monitor adverse events and near misses in the hospital, as per NABH accreditation standard CQI 4f. The failure mode and effect analysis (FMEA) is one of the tools that can be used for performing HIRA on processes involving medical

equipment Establish the risks and the consequences of these failure modes ● Identify and implement mitigation strategies for the effects ● Assess the success of the mitigation strategies ● Implement modifications to hospital procedures as appropriate A hospital-patient related process is any repetitive action that involves transformation ●

● ● ●

● ●

Table 1: Numerical Effects Scoring Severity (S)

Occurrence (O)

Detectability (D)

Major : 3

Frequent : 3

Low : 3

Moderate : 2

Occasional : 2

Medium : 2

Minor: 1

Rare : 1

High : 1

equipment. The FMEA, like any other process improvement methodology, is a team activity wherein relevant members from different departments will be involved. The goals of FMEA are as follows: ● To identify the failure modes in the process involving medical

of inputs i.e. resources like clinicians, medical equipment, materials into an output i.e. desired service like patient being diagnosed for specific problem. Process mapping will help to identify the major steps in any process. The road map for implementation of FMEA is as follows: ● Select a process or sub

● ●

process involving medical equipment List the potential failure modes i.e. how it may fail List the potential effects of the failure Estimate the severity number (S) i.e. a numerical measure as given in Table 1 of how serious is the effect of the failure on the patient List potential causes or mechanisms of failure Estimate the occurrences number (O) i.e. a numerical measure as given in Table 1. It is a measure of probability that a particular failure mode will actually happen Estimate the detection number (D) i.e. a numerical measure as given in Table 1. It is a measure of probability that a particular failure mode would be detected by process members Compute the risk priority number (RPN = SxOxD) Determining corrective and preventive actions i.e. mitigation strategies for the effects including list of individual responsible for

completing the action Prioritising actions based on the RPN ● Recomputed RPN after corrective actions to hospital procedures as appropriate are computed The scoring for S, O and D can be taken in a scale of one to 10, but during the cross function teams' brainstorming session it was noticed that lot of disagreement was happening between the members of group on arriving at a score for any sub process. Hence, it was decided to take numeric measures for S, O and D in the range of one to 3. ●

FMEA Case Study The following FMEA case study was done to eliminate the possible failure modes in the use of defibrillator in a hospital. Defibrillators apply an electric shock to establish a more normal cardiac rhythm in patients who are experiencing ventricular fibrillation or another shockable rhythm. The defibrillator is a lifesaving equipment used in emergency situations and any failure/wrong use while applying electric shock can

FMEA Computation table Worksheet of defibrillator using external paddle Steps of usage of defibrillator

Potential failure mode

Effects of failure: Description

Effects of failure: Severity

Effects of failure: Probability of occurence

Effects of failure: Detectability

RPN Number

Significance of failure

Causes of failure

Switch on defibrillator

Unit not working

Can't use unit

Major (3)

Occassional (2)

Medium (2)



a) Batteries not charged due to:

Mitigating strategies

1) Power cord of unit was disconnected

Nursing: Adopt shift-wise visual inspection of defibrillator as part of crash cart checklist and weekly testing unit on test load

2) Defective power cord

Clinical Engineer: Regular preventive maintenance and calibration

3) Forgot to switch on power outlet

Nursing: Adopt shift-wise visual inspection of defibrillator as part of crash cart checklist and weekly testing unit on test load

4) Less functional power

Nursing and Engineering team

b) Unit malfunctioning

Clinical Engineer: Regular preventive maintenance and calibration

continued on page 32 NOVEMBER 2012



S|T|R|A|T|E|G|Y continued from page 31 Apply conductive gel on defibrillator paddle

Improper conductivity between the patient skin and unit

Electrical arc generation leading to burn on patient

Moderate (2)

Ocassional (2)

Medium (2)


Paddle surface not clean

Nursing: Cleaning of paddle unit after every usage unit

Conductive gel is old

Nursing: Shiftwise visual inspection

Wrong conductive gel usage

Nursing: Shiftwise visual inspection and SS adoption

Excessive or low gel application

Nursing/Clinician: User training

Select desired energy

Selection knob being loose or non functional

Improper or non selection of energy

Major (3)

Rare (1)

High (1)



Hardware malfunctional

Clinical Engineer: Regular preventive maintenance and calibration

Position paddles on patient's chest and deliver shock

Loose connectivity of paddle cable from unit

Improper or non selection of energy

Major (3)

Rare (1)

High (1)



Hardware malfunctional

Clinical Engineer: Regular preventive maintenance and calibration

Position paddles on patient's chest and deliver shock

Improper selection of position of paddle on surface

Insufficient energy delivery or electric arc

Moderate (2)

Ocassional (2)

High (1)



User Training

Nursing/Clinician: Increase frequency of user training including refreshers

Position paddles on patient's chest and deliver shock

Improper force exerted between patient skin and unit

Insufficient energy delivery

Moderate (2)

Frequent (2)

Low (3)



User Training

Nursing/ Clinician: Increase frequency of user training including refreshers

lead to first or second degree burns or death of the patient. The process of using a defibrillator with an external paddle whenever code blue is initiated in a hospital is shown in the FMEA computation table. The failure mode for each sub process is tabulated along with effect of each failure, its severity, occurrence and detectability. The possible cause of failure and mitigating

strategies is also filled. The rating for S, O and D are fixed based on detailed brainstorming session between nursing team, clinicians, head of emergency department and clinical engineering. The risk priority number for each failure is calculated to understand which sub process needs priority focus. As we can notice, the following sub process needs improvements.

1) Switching on defibrillator 2) Positioning of paddles on patient chest and deliver shock 6) Application of conductive gel on paddle The team assigned the relevant members to work on mitigating strategy. The hospital team, based on FMEA study, revisited process on maintenance of life saving equipment including defibril-

The Great Indian Healthcare Factories-I...... continued from page 30 want the comforts of private rooms - pay a premium, the majority pays less than the market rate and 10 to 20 per cent pay virtually nothing. For the indigent patients, the hospital's charitable trust raises money to help compensate for the material costs of their treatment, thus, dissociating healthcare from affluence. At Narayana Hrudayalaya in, Bengaluru, 40-60 per cent of paediatric heart surgeries are done free of cost. Narayana Hrudayalaya follows a




dynamic pricing policy, wherein it daily examines the profit and loss account and monitors the average realisation per procedure and profitability. Then, it works out how much concession they can afford to offer the next day without impacting the margins adversely.

forecasting demands and eliminating wastage. Within the ‘Health City’, various specialties share expensive imaging equipment and other facilities like laser, cyber knife and blood bank,. They are run round the clock instead of 7-8 hours daily, thus increasing asset utilisation.

Best inventory management

Reaching out to the last mile

Narayana Hrudayalaya bulk purchases all medical stores and consumables, at discounts, directly from the manufacturers and manages all inventory efficiently by

A distinctive rural healthcare service, “Hrudaya Post”, was launched with Karnataka postal circle to enable rural heart patients to scan and send their medical records to

lator and improved on timely preventive maintenance and calibration. The frequency of training and visual inspection process during daily rounds also increased. The team decided to review the sub process again after three months, based on the corrective action taken and to revisit the RPN number. The RPN score for step 1, 2 and 6 came down to 6, 4 and 8 respec-

tively, after implementing the corrective measures on ground. The FMEA for defibrillator helped the organisation to strengthen internal processes and to avoid the potential defect in process, which could have affected patient care. Similar studies can be done in other areas where medical equipment is involved, as part of the HIRA exercise.

Narayana Hrudayalaya for consultation. After perusing, the hospital would revert with a detailed report and advice to the patient, within 24 hours, free of cost. This arrangement saves time and money needed for visiting consultants.

working in a filmless and paper light environment. Thus, by embracing best practices and business principles in cost containment, rationalising manpower utilisation, adopting innovative pricing, Walmart’s inventory management practices, the scale of Ford Motors, efficiency of McDonald and Toyota; Mayo Clinic’s professional excellence, Mother Teresa’s compassion and dynamic leadership of Dr Devi Shetty, it has woven a great success story that is truly Indian and worth emulating and replicating as a benchmark.

Leveraging technology Through telemedicine and other ICT applications, Narayana Hrudayalaya automates processes and shares medical expertise with remote parts of India and other countries. It has migrated to digital radiology for better throughput and image quality, while


Hospital Infra MAIN STORY

Flooring facts Hospital flooring today is not only about cleanliness but also aesthetics, design sustainability and durability. Right flooring is essential to efficient hospital functioning says M Neelam Kachhap

ospital designs in India are moving from traditional and institutional to a more stylish, functional and patient friendly look. Although, flooring is an integral design aspect in hospitals, it is often considered a mundane-seeming topic and does not attract much attention and time while planning. However, right flooring is essential for efficient hospital functioning. Hospitals are complicated buildings, as different floors have varied needs ranging from high-traffic corridors to supporting frequent movement of machinery to providing a welcoming homelike area for patients. In addition, floors in hospitals are desired to have superior cleaning and maintenance qualities. Furthermore, they need to be able to cope with heavy traffic from equipment like wheelchairs, trolleys and X-ray machines and meet standards for smoke, fire and slip resistance – without relinquishing aesthetic qualities as a key design feature



of the building. In recent years, the variety of products available to meet these needs has grown exponentially. Style, durability, maintenance, sustainability, and choice of materials are all major areas of consideration when specifying, installing, and maintaining healthcare flooring.

Flooring is important Right flooring at a healthcare facility is not only functional but looks beautiful and soothes the frayed nerves of patients as well. Thus balancing aesthetics and functionality is crucial while designing hospital floors. “Right flooring is an important aspect of planning any healthcare facility. Having right flooring is about combining health and safety requirements without losing sight of the aesthetics and the emotional needs of the patient. Proper flooring

adds to the overall ambience soothing the patient’s state of mind,” says R Kurup, Chief Marketing Officer, H&R Johnson (India). “It is very important for a healthcare facility to strike a balance between aesthetics and functionality of the space. Hospitals/clinics need to have floors which are not only natural- looking but most importantly it needs to be slip and germ-resistant, soft, low on maintenance and high on durability,” he adds. Planning for hospital floor should get much time and attention as it is almost a permanent component of the building, and redesigning and rebuilding would have economic repercussions apart from all the inconvenience for the staff as well as patients. Gaurav Saraf, Joint Managing Director, Square Foot says, “Flooring plays a critical role in healthcare facilities. As per JCI norms, EXPRESS HEALTHCARE


H|O|S|P|I|T|A|L|I|N|F|R|A in all critical areas and patient areas you need seamless flooring. In India, the government is not stringent on these norms. Flooring cannot be replaced everyday so hospitals should pay more attention to flooring.”

Flooring considerations Earlier hospital designs were dull and only took care of the functionality aspect but today hospitals are improving the flooring designs through colour and aesthetic appeal. “Historically, hospitals and healthcare facilities were only focussing on offering medical services. And so most healthcare facilities had a typical style of flooring which was the vinyl tile. Recent studies have revealed that the emotional component of patients affects the success of medical treatment. The outcomes improve when the healthcare environment is comfortable and homelike,” informs Kurup. Adding to this Saraf says, “Earlier all hospitals used to be grey, black and mundane in terms of colour and design. Today, colour therapy is used in a big way and all hospitals use bright colours, borders, special designs for paediatric wards etc.”

Consumer calls Nowadays, flooring systems are available in a range of attractive colours with optimal flooring solutions that retain a very attractive appearance throughout the life span of the healthcare facility. “Today, consumers prefer premium quality products which have high functional attributes. Flooring, with anti-skid, anti-stain and germ free attributes, are considered as a perfect melange of aesthetics, functionality and hygiene,” says Kurup. New hospitals are also looking at novel materials and green flooring options which are LEED certified and eco-friendly. “Today people understand that hard flooring like stone, marble, tiles cannot be used in hospitals and you need hospital speciific flooring. We have more than 800 colour options of vinyl flooring and designs available for use in hospitals. Some hospitals are also looking at using eco friendly flooring or green flooring in the vinyl flooring or linoleum ranges,” says Saraf.

Ideal options for hospitals Most suitable flooring solutions for hospitals have qualities like water-resistance, slip-resistance, durable, stain-proof, and fire resistance. Anti-skid material is critical for the safety of both patients and hospital staff.



“The most preferred flooring options for hospitals are antiskid tiles and germ-free tiles. The scratch-free tiles offer high degree of abrasion resistance while germ-free tiles offer protection from various disease-spreading bacteria. Scratch-free tiles also come with added USP like antiskid, stain-proof and easy to maintain features. The germfree tiles inhibit the growth of germs, bacteria, fungus and other microbes that come in contact with the tile,” affirms Kurup. Stain-resistant solutions are important for flooring which is used in areas where the spilling of blood, body fluids, iodine-containing solutions and other similar materials is common. Waterresistant flooring solution, apart from other things, helps in cleaning. “Most customers are looking for easy-to-clean, water-resistant flooring options for hospitals,” offers Alok Goel, CEO, NITCO. “Wooden finish tiles; polished, glazed and vitrified tiles; mosaico; naturoc and digital printing tiles are also in demand these days,” he adds. However, wide consensus is being formed to use ecofriendly products in hospital floor design. “Generally, you use vinyl flooring in hospitals. All our products are green products and earn

LEED points. For specific safe areas like ramps etc., we have specialised safety flooring which is non slip. All products for healthcare are designed keeping in mind functionality, safety and maintainance etc. Laminate is not an ideal solution for healthcare facilities except maybe in some areas like suite rooms, and recreational areas,” highlights Saraf. Durable flooring solutions are designed to withstand high traffic in the room, which therefore eliminates the constant need of having to repair floors which prevents the disruption of patient care arising from repair work. “Ceramic tiles have grown to a sizeable chunk today. The key product range includes ceramic wall tiles, ceramic floor tiles, vitrified tiles and industrial tile. They cater to varied taste sand requirements of customers. Tiles are high on durability, easy to install and easy to maintain. These tiles are available in a wide variety of designs, textures and surface effects,” says Kurup. Different considerations come into play while selecting flooring solution for hospitals. The need is to look for solutions that save cleaning time and maintenance on the floors as well as provide aesthetic appeal.


IT@Healthcare 'SATO Blood Safety Solution, tracks the logistic of blood bags from the donation centre to the bedside' SATO Healthcare, a leader in barcode and RFID solutions for the healthcare industry, has recently launched its automated blood bag tracking and management solution that ensures fast and efficient delivery of blood from donation center to bedside transfusion. Lim Yee, MD, SATO International Asia Pacific updates Raelene Kambli on the importance of a blood bag tracking system and SATO's new products category in this field

Page 36 REPORT

VC funding strong in healthcare IT Q3 2012 saw VC funding of $194 million flow into the healthcare IT sector, but not a single deal featured India this quarter. The Indian IT industry is yet to make their presence felt in this sector which is in great demand globally


he Mercom Capital Group report on funding and mergers and acquisition (M&A) activity for the Healthcare IT (HIT) sector during the third quarter of 2012 revealed that venture capital (VC) funding in HIT continued to be strong with $194 million going into 37 deals in Q3 2012. The strong uptrend that started in Q3 2011 has continued for five quarters in a row, according to Mercom. Fifty-eight different investors participated in these funding rounds with First Round Capital, Great Point Partners and West Health Investment Fund participating in multiple deals. This quarter no Indian company made it to the healthcare IT VC funding or M&A activity list, proving that the Indian IT industry is yet to make their presence felt in this sector which is in great demand globally. In Q3 2012, Health Information Management (HIM) companies received the most funding as a technology group with $101 million in 20 deals, followed by mobile health companies with $39 million in seven deals and social health network companies with $26 million in four deals. Within HIM, clinical decision support companies accounted for the highest number of deals by technology with three deals, followed by business and clinical intelligence, document management, population health management (PopHR), practice management solutions and radiology information system (RIS) companies all with two deals each. “Financial activity continues to be strong in the HIT sector with a healthy number of early-stage deals,” explained Raj Prabhu, Managing Partner, Mercom Capital Group. “Mobile


health and social health

network companies had a

strong showing this quarter.” EXPRESS HEALTHCARE



'SATO Blood Safety Solution enhances the visibility of blood logistics’ Lim Yee MD, SATO INTERNATIONAL ASIA PACIFIC


ATO Healthcare, a leader in barcode and RFID solutions for the healthcare industry, has recently launched its automated blood bag tracking and management solution that ensures fast and efficient delivery of blood from donation center to bedside transfusion. Lim Yee, MD, SATO International Asia Pacific updates Raelene Kambli on the importance of a blood bag tracking system and SATO's new products category in this field

What are the challenges associated with the blood bag tracking process? There are two key challenges: i. Tedious manual process which is time consuming ii. Slow speed in the process from the point of collection to when the right patient receives it Currently, blood service authorities in many countries have spent a large amount of time and resources to establish safe management systems that use barcode technology. This process still has many manual processes along the chain which are time consuming and expensive practices for assuring the safety of patients.

The top funding deal this quarter was the $25.5 million raise by Telcare, a mobile health company that uses cellular machine-to-machine technology for diabetes and other chronic illnesses. Other top deals included $20 million raised by Connecture, an online health insurance process automation company focused on health insurance exchanges, followed by $17 million raised by Doximity, a professional social network for physicians. Clinipace, an eClinical technology provider of real-time access to the healthcare information raised $13 million, and finally Streamline Health Solutions, a provider of enterprise content management and business analytics solutions for healthcare organisations and SoloHealth, a healthcare technology and data analytics company raised $12 million



Why should hospitals and blood banks have a blood bag tracking system ? By having an efficient blood bag tracking system in place,complete traceability from the donation centre to the patient is ensured. Also, this will allow real time monitoring of the blood at each level of the supply chain for inventory control and safety control in terms of temperature.

How can a blood bag tracking system increase efficiency and patient safety? A blood bag tracking system such as the SATO Blood Safety Solution, tracks the logistic of blood bags from the donation centre to the bedside with rich safety features such as real time location monitoring, route management, time management, access control, and temperature recording with RFID technology. It also enhances the safety of transfusion at bed side with the electronic matching system of patients and blood bags. This cuts down on the time that the entire process takes and enhances patient safety.

How can one ensure fast and efficient delivery of

blood from donation center to bedside transfusion with the help of a blood bag tracking system?

provide enough information will not be useable and will be disposed.

By automating many of the current manual processes and thereby improving efficiency, speed and traceability.

How would you differentiate SATO's Blood Safety Solutions from the rest of your competitors?

Tell us about SATO's latest solutions in this regard. The SATO Blood Safety Solution enhances the visibility of blood logistics from donation centres to bedside transfusion with the use of both RFID and 2D code technology. This improves the efficiency and speed of matching the blood type to the right patient, thus saving lives and money.

What are its unique features and benefits of this system? Our solution is the first of its kind in healthcare to offer real-time location tracking and patient safety features, with RFID tunnel readers, RFID smart fridge and traceability software. Thus the major benefits of the system are efficiency, speed and traceability. The solution improves the efficiency of the operation and reduces wastage. For example, a blood bag that fails to

Healthcare Information Management (HIM) VC Funding Q3 2012 (By Sub Technology) Scheduling, Rating & Shopping - $1.1M, 1 Deal

Medical Imaging - $4M, 1 Deal

Clinical Decision Support $19M, 3 Deals

Medical Device Data System (MDDS) - Und*, 1 Deal

Business and Clinical Intelligence - $11M, 2 Deals

Health Insurance Exchange - $20M, 1 Deal Health Information Exchange - $6M, 1 Deal

Document Management $14M, 2 Deals

Electronic Health Record $1M, 1 Deal Coding - Und*, 1 Deal

Population Health Management (PopHR) $2M, 2 Deals

Radiology Information System (RIS) - $11M, 2 Deals

Practice Management Solutions - $13M, 2 Deals

* Undisclosed

Source: Mercom Capital Group, llc

each. There



strength in M&A activity in the sector as well, providing

investors and companies with plenty of viable exit

There are no competitors currently. Existing solutions are either partial or with traditional barcode technology and not competitive in term of efficiency and reliability.

Is the system cost-effective? How? It entirely depends on how many donations centres, how many blood service centres, how many transportation vans, and most importantly how many blood donations are made in the country that is implementing the solution.

How would you like to market this system? What are the strategies you would be adopting to reach out to your customers? There are some countries in the Asia Pacific region that promote themselves as a medical hub and the potential is huge for this solution to take root.

strategies. There were 37 M&A transactions in Q3 2012 amounting to $3.2 billion, of which only 10 transactions disclosed details. Among the top M&A transactions, Roper Industries acquired Sunquest Information Systems, a provider of diagnostic and laboratory software solutions to healthcare providers, for $1.4 billion. One Equity Partners acquired M*Modal, a provider of clinical documentation services and speech understanding solutions, for $1.1 billion, Science Applications International Corporation acquired maxIT Healthcare, a healthcare IT consulting firm, for $473 million. Thomas Bravo acquired Mediware Information Systems, a provider of clinical software solutions, for $195 million. EH News Bureau NOVEMBER 2012

Knowledge ‘Uncontrolled diabetes ultimately results in increased cardiovascular risk’ Three eminent doctors explains the co-relation between diabetes and obesity, how bariatric surgery can help and their research work on this topic Page 39 MAIN STORY

Diabetes management – future trends T Dr Shashank R Joshi, President, Indian Academy of Diabetes & Consultant Endocrinologist, Lilavati Hospital and Bhatia Hospital, Mumbai elaborates on the future trends in diabetes management and opines that frequent diabetes monitoring and intensive management is on the rise


President, Indian Academy of Diabetes & Consultant Endocrinologist, Lilavati Hospital and Bhatia Hospital, Mumbai


here has been a considerable rise in the prevalence of diabetes across the world. As per the World Health Statistics 2012, one in every 10 adults is diabetic, with the figure increasingly rising among the youth due to unhealthy lifestyle and lack of exercise in their daily routine. The rising trend of weight gain, coupled with lack of physical exercise and high level of mental stress in school-going children acts as a precursor of future diabetes in them at a younger age, particularly in those children who also have a family history of diabetes. More than 346 million people worldwide are currently suffering from diabetes; and this malady is predicted to become the seventh leading cause of death in the world by the year 2030. Unfortunately, India has one of the largest number of diabetic patients in the world (62.4 million people live with diabetes in India and there are 77.2 million people with pre-diabetes). It is estimated that every fifth diabetic in the world would be an Indian. The disease is such that it cannot be cured, making it all the more important to actively manage it. According to the World Health Organization, every year, 35 million people die because of diabetes. 80 per cent of these diabetes deaths worldwide occur in low- and middle-income countries with people aged between 35 and 64 years. While there is one person in the world dying of diabetes every ten seconds, two new diabetic cases in the world are being identified every ten seconds. Additionally, by the year 2025, there will be seven million new diabetic cases in the world. Currently, India is facing an epidemic of diabetes, with a high prevalence in urban

areas. Over the past 30 years, the prevalence of diabetes has increased to 12-18 per cent in urban India and three to six per cent in rural India, with significant regional variations. Moreover, impaired glucose tolerance (IGT) is a mounting problem in India and another 14 per cent of the Indian population has pre-diabetes in India, a harbinger of future diabetes. The need to better manage and control the rapid rise of this disease has led to innovations in diabetes monitoring and management therapies to assist patients and physicians in tackling the chronic disease with more scientific and accurate results. People with Type 1 diabetes and many people with Type 2 disease require treatment with insulin to control blood sugar and reduce the risks of complications, including blindness, heart disease and nerve damage leading to amputations. The main aim of diabetes treatment is to achieve blood glucose in order to prevent acute and chronic complications, improve quality of life and avoid premature diabetes associated deaths. Research in the field of

diabetes has taken two main directions: innovations aimed at improving current management methods, and exploring radical new approaches. Improvements in current therapy include making glucose monitoring and insulin delivery less invasive and more patientfriendly, and many significant advances have been made in this context over the past two decades. Among these have been the development of improved glucose monitoring techniques and minimally-invasive techniques for sampling blood. New, fast-acting forms of insulin have also been introduced along with novel, and more accurate, ways of insulin delivery through the use of insulin pumps. There has also been considerable research in non-injection dosage forms for insulin, such as inhalable insulin, although many products have not been granted approval and require more clinical data. Once approved, these could herald a new era in insulin therapy.

Recent trends in diabetes monitoring and diagnosis Blood sugar of a person

without diabetes is maintained by the body within a normal range irrespective of the amount of food that is consumed by a person. In patients having diabetes, blood sugar spikes within an hour after any meal. This process goes on throughout the day. So the blood sugar of a person with diabetes is continuously changing every minute of the day throughout the person’s life. Patients may use glucometers to check blood sugar, but this gives the value of blood sugar only at the particular time when the test is done. However, since blood sugar levels of a patient are changing from minute to minute, checking simply with blood glucose meters may not be sufficient. However, a more effective way to monitor sugar levels and understand how the blood sugar is changing throughout the day is with the help of a technology called continuous glucose monitoring system (CGMS), which is now also available in India. CGMS is done with a monitor (like iPro 2 etc.) that is attached to the abdominal wall. It reads the sugar levels of the person EXPRESS HEALTHCARE



every 10 seconds and keeps a record every five minutes so that we can get 288 readings per day during the CGMS study period. This data is uploaded on a computer and it is clearly visible in the form of a graph which anyone can understand. The patient gets to see how his or her blood sugar has moved after each and every meal of the day. This gives the person a clear idea as to how much the blood sugar has risen after a particular meal. The patient can then take corrective measures regarding food intake. The doctor can make out how a particular patient’s blood sugar is changing throughout the day. There are plenty of patients who have high blood sugar at odd times of the day which is not detected by the routine tests like fasting blood sugar and PPBS (blood sugar after food) or who are unaware that they may be experiencing low blood sugars at night. With this information the doctor can modify the treatment to get better control of blood sugar throughout the day. For patients who are suffering from gestational diabetes and patients with diabetes who are planning pregnancy, it is absolutely vital that the blood sugars are very tightly controlled throughout the pregnancy. The consequences of poor control can be grievous to the mother and foetus. So, in patients with diabetes who are planning pregnancy it is extremely useful to get a CGMS done and get a correct picture of the blood sugar pattern. Low blood sugar, especially at night, may go unnoticed and this is clearly picked up by a CGMS study. Glycosylated haemoglobin (HbA1c) is a very useful test to detect how well blood sugar is controlled over the previous three months. However, HbA1c indicates the average blood sugar and so it does not give a correct picture of how much fluctuation occur. In fact, if a patient has frequent low blood sugar, it could result in low HbA1c (because HbA1c denotes an average value) and a false sense of security to the patient and doctor, even when the blood sugar is often high and is actually poorly controlled. CGMS is a useful tool to detect this disease. Another new upcoming diabetes monitoring approach is the use of implantable chips. A microchip can detect the amount of glucose in a per-



son’s blood and will then transmit this information to a wireless scanner where it can be easily read by the patient. All it will require are some basic instructions, and monitoring one’s own glucose level with this product will be simple and accurate. This innovative little device serves as an alternate for the aid of glucose monitoring.

Recent trends in diabetes management Insulin therapy is one of the cornerstones of diabetes management, and its efficacy in early and late-stage diabetes is well-established. Yet, the first choice of doctors in India for most diabetics has so far been to attempt sugar control through oral anti-diabetics (OADs), diet control, exercise and lifestyle changes. One of the key reasons for delaying control through insulin is the resistance and fear in patients, of taking injections daily, particularly self-administering the same. For Type 1 diabetes where insulin is required to manage the condition, the traditional diabetes management is done by delivering insulin through multiple daily injection (MDI) through devices such as insulin pens and insulin injections. These devices are also available in india and help in self-management of diabetes. An excellent alternative to multiple daily injections is insulin pump therapy. By using an insulin pump, patients can match their insulin to their lifestyle rather than trying to adjust their lifestyle to their body's response to insulin injections. People of all ages,who require insulin to manage their diabetes, can get benefit from this novel therapy. Insulin pumps are being more commonly used because of their unique ability to continuously infuse insulin, closely mimicking the behaviour of physiological secretion from a normal pancreas. Just as a healthy pancreas delivers insulin automatically, every seven to ten minutes throughout the day, an insulin pump matches the natural rhythm of a healthy pancreas, which is nearly impossible for people using traditional injection therapy. In brief, insulin pumps consist of: (a) the pump (computerised battery operated device); (b) a disposable reservoir to hold insulin; (c) a disposable infusion set, (including a soft plastic cannula to be inserted just below the skin). The insulin pump is

a small mechanical device that is worn outside the body, often on a belt or in a pocket. The pump delivers insulin directly into the body through the soft, flexible cannula under the skin. Patients generally refill their pump with insulin every two to three days. Scientific evidences from published studies have also proven the added benefit of insulin pumps in improving quality of life, normalising sugars in recalcitrant diabetes, improving sexual function, and relieving the intractable pain of neuropathy. Pump therapy allows people with diabetes to adjust insulin intake easily and maintain glucose levels within a near-normal range. An insulin pump is an excellent tool for helping improve glycemic control. Tight glycaemic control is central to good health, as proven by numerous studies, including the landmark diabetes control and complications trials (DCCT). In that study, patients who maintained near-normal glycaemic control significantly reduced their risk of long-term complications. The risk of diabetic eye disease decreased up to 76 per cent, nerve disease was reduced up to 60 per cent, and kidney complications were reduced up to 56 per cent. A pump can help patients avoid hyperglycaemia (high blood sugar), which can cause long-term complications and lead to ketoacidosis (causing coma or death if left untreated), and hypoglycaemia (low blood sugar), an acute condition that can be dangerous, particularly while sleeping. With a pump, people can also be more flexible. Patients using longer-acting insulin with injection therapy must follow rigid schedules of insulin injections, meals and snacks, whereas patients using an insulin pump can program insulin delivery when they eat, and adjust or stop insulin delivery for exercise or other needs. Patients using pump therapy can eat what they want, when they want - something almost unheard of in patients treating their condition with traditional insulin injections.. Pumps are also beneficial for patients who are unable to manage their diabetes or related complications. Currently, approximately 500,000 people worldwide are using insulin pumps to manage diabetes; however, despite India’s claim of educational achievement and economic progress, the bene-

fits of insulin pump therapy have reached only a fraction of people with diabetes, who rightly deserve such innovative therapy. Advanced insulin pump technology like MiniMed VEO, is one of the new insulin pumps in the world that can automatically shut-off the supply of insulin, if the patient’s glucose levels drop too low, protecting against dangerous, and potentially life threatening, hypoglycaemia (low glucose suspend). The insulin pump, when used with an integrated glucose-sensing technology, monitors the patient’s glucose levels 24 hours a day and can actively protect the patient against the risk of a hypoglycaemic event becoming severe, even while the person is asleep. This new therapy also has a range of simple alerts to help patients act to keep their glucose level stable, providing the best possible chance of staying safe and avoiding highs and lows. This new technology, which is now also available in India, gives greater freedom in eating and sleeping. At the same time it takes the stress and fear out of diabetes management for its capacity to protect against the dangers of hypoglycaemia. The reasons for the poor utilisation of insulin pump therapy in India include lack of awareness among doctors and patients, affordability concerns, lack of proper diagnostic infrastructure, and lack of reimbursement. As a greater number of doctors in India begin to be more aware of such advance therapies, they will be able to educate more Indians on the causes, prevention and management of diabetes. The success of insulin pump therapy depends on selection of the right candidate, extensive education, motivation, and implementing the sophisticated programmes with skill. So far, while diabetes does not have a cure, diabetes management with the help of education, correct diet and exercise, medication (oral hypoglycaemic agents and/or insulin), glucose monitoring, and modern technology have made managing diabetes better and simpler. However, finding a permanent cure for the disease will be one of the greatest breakthroughs in medical science. Some animal studies have shown promising results and there seems to be hope for curing diabetes in the future. NOVEMBER 2012


‘Uncontrolled diabetes ultimately results in increased cardiovascular risk’ DR DAVID E CUMMINGS





r David E Cummings, Professor of Medicine from the University of Washington, Dr Shashank Shah, Director of Laparo Obeso Centre, and Director, Department of Laparoscopic and Bariatric Surgery at Ruby Hall Clinic, Pune and Dr Jayashree Todkar, the Consultant General and Laparoscopic Surgeon at Poona Hospital and Ruby Hall Clinic, Pune explains the corelation between diabetes and obesity, how bariatric surgery can help and their research work on this topic, in conversation with Raelene Kambli

How is diabetes in India different, why is it a challenge and what could be done to tackle this situation in India? Why are Indians prone to diabetes? Diabetes in India is different due to multiple reasons: Higher body fat: Except for fat, all other components like bone mass density, etc., are less in Indians, as compared to Caucasians. Hence, though Indians appear thin, they actually have a high percentage of fat in their bodies. This is an Indian paradox and is known as ‘The Thin-Fat Indian’. Indians have a higher percentage of fat in their bodies due to a thrifty genotype or thrifty gene hypothesis. Over the generations, Indians suffered from malnutrition or under nutrition and therefore, genetically their bodies were designed to store fat, in order to fight malnutrition. However, in the current scenario, this genetic makeup has evolved as obesity, in India. High incidence of central obesity: Indian obesity is seen predominantly in the belly. For eg., for a BMI of 35, an American will appear overall large. However, an Indian at a BMI of 35 will have thin limbs but a prominent belly. Hence, they may not fall under the definition of obesity or morbid obesity. However, fat is the largest endocrine organ in the body and it secretes various hormones and peptides required for various body functions. Therefore, high concentration of fat in abdominal area can cause high blood pressure, cholesterol, heart disease, diabetes, etc. Hence, abdominal obesity

makes Indians more susceptible to diseases like diabetes and CVDs, etc., as compared to Caucasians, who have overall obesity. Hence, higher body fat percentage due to thrifty gene hypothesis and high incidence of central obesity make Indians genetically predisposed to developing Type 2 diabetes. Due to these genetic reasons, Indians also experience the onset of cardiovascular diseases, atleast 10 years

plant, amputations, etc., every year. Available pharmacological treatments are neither able to control the progression of type II diabetes nor are they able to prevent the complications caused by the disease. If one looks at the current Indian studies, the best medical care is being offered to the patients and yet most of them suffer from uncontrolled diabetes. Over the period of time, uncontrolled diabetes ultimately

Higher body fat percentage due to thrifty gene hypothesis and high incidence of central obesity make Indians genetically predisposed to developing Type 2 diabetes

earlier and at a lesser BMI, as compared to other ethnicities in the world. Therefore, India has become the diabetes capital of the world.

results in increased cardiovascular risk as well.

According to current guidelines, at what BMI levels does a patient qualify for a bariatric surgery?

During RYGB, a small pouch is created in the upper part of the stomach, separating it from the rest of the stomach. This restricts the intake of food as the person tends to feel less hungry. Secondly, a small part of small intestine, the duodenum, is bypassed, by connecting the smaller, upper part of the stomach directly with lower part of the small intestine. Since duodenum is a part of the small intestine that is responsible for absorption of calories and nutrients in the body, this surgery leads to weight loss in obese patients, post RYGB surgery. However, it must be noted that the larger part of intestine is intact to absorb nutrients and there is no evidence of malabsorption in the patients who have undergone this procedure. RYGB has shown to result in complete remission or better management of type II diabetes. Hence, clinicians believe that this surgery induces hormonal changes in the body and is not

The standard consensus by the National Institute of Health, US, permits bariatric surgery for any person with BMI of >40, without any comorbidities, or any person with BMI >35 along with any one uncontrolled co-morbidity. The new Asian guidelines, published in the Journal of Association of Physicians India, has lowered these levels for Indians, to BMI level of >37.5 without comorbidities, or to BMI of >32.5 with any one uncontrolled co-morbidity. Dr Shashank Shah was a core faculty member of this committee, which proposed the new Asian guidelines in 2009.

Why was there a need to look for alternate treatment options for treating Type II diabetes? A large number of diabetics in India die of kidney failure, wounds, heart

Tell us more about the Roux-en-Y-Gastric Bypass (RYGB) surgery?

merely a weight-loss surgery, but can also be a possible treatment for type II diabetes.

How does RYGB lead to better management of Type II diabetes? Initially, it was thought that the small stomach size was responsible for weight loss in patients opting for RYGB surgery. Since the stomach size decreased after the procedure, it was believed that the patient would eat less frequently and hence, lose weight. Hence, bariatric surgery was initially thought to be a weight loss surgery only. However, in more recent times, it is being understood that RYGB is a metabolic surgery, which changes a person’s hunger and satiety pattern, thereby affecting the glucose production and absorption in the body.

Can you tell us more about the Comparison of Surgery vs Medicine for Indian Diabetes (COSMID) study on which you are working together? COSMID study is being conducted in Pune. When it gets completed, it will serve as the Level 1 evidence for comparison of surgery vs medicine in management of Type II diabetes and will furnish details for any scientific body to for new guidelines for Type II diabetes treatment. A randomised controlled trial (RCT) is the highest level of evidence for all medical investigations, as the investigating surgeons do not decide the course for treatment for the selected patients, in this case, choice of treatment through RYGB surgery or medication. Till date, only three RCTs have been conducted across the globe to compare the results of surgery vs. pharmacological treatment for management of Type II diabetes. These trials have been conducted in US, Italy and Australia. COSMID is the fourth such trial, being the first and the only one of its kind in entire Asia. The results of the third and most recent trial, termed as Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) Study, were published in The New England Journal of Medicine in March 2012. EXPRESS HEALTHCARE


K|N|O|W|L|E|D|G|E Who would be funding this research in India? US Metabolic Council and Worldwide Metabolic Council will be funding this research in India.

What about the guidelines for conducting clinical trials in India? In India, the guidelines for clinical trials are laid down by the Indian Council of Medical Research (ICMR) and Independent Review Board (IRB)/Ethics Review Committee. COSMID has been passed by ICMR and ethics committee, and is registered under the WHO.

How long will this study take? The study results will be out in the next two to three years’ time.

Are there any side-effects of the surgery or do the patients have to take any precautions? There are guidelines for patients in terms of diet, etc., which they are able to follow much better after surgery. Because there is rerouting of intestines, there can be



deficiency of Vitamin B12, iron, calcium, and other minerals, due to malabsorption in the body. However, all of this can be consumed in the form of multivitamin pills or tablets, which the patients don’t find a major challenge. Minor nutritional supplements for lifetime are preferred options by diabetics, as compared to consuming supplements plus antidiabetic, cholesterol-lowering medicines and insulin for the rest of their lives.

How critical is this study in the Indian context? Would these study results be applicable to Indians across the globe? In order to apply findings of STAMPEDE, the third RCT conducted in America, to Indians, we need to study the efficacy of surgery vs medicines as a treatment option for Type II diabetes in Indians. This is because, typically, people of Indian ethnicity have a different set of genes, body composition, distribution of fat and genes that make the cells, which produce insulin, relatively poor. There are downsides and

Case study: Impact of RYGB surgery in managing diabetes This study was done to find the impact of Roux-en-Y Gastric Bypass surgery in managing Type II diabetes in patients. It is a pilot study, a prospective study of RYGB for Type II diabetes mellitus in Asian Indians With BMI of < 35 kg/m2 The sample size of the stydy was 15 patients, not graded morbidly obese, suffering from Type II diabetes. ●

● ● ● ● ● ● ● ● ● ●

The patient profile was as follows: BMI 22–35 kg/m2 (WW 40, 35 +comor; India Asian concensus assi of phy India (AAPI) 35-32+diab “Overweight” to “Obese” by Indianspecific WHO criteria Type II diabetes mellitus (DM) Confirmed with Abs, C-peptide, FHx Severe diabetes Mean duration: 9 years. They shoud be in severe need of treatment. 80 per cent on insulin (the rest on oral DM meds) HbA1c: 10.1 per cent Other features Dyslipidemia: 93 per cent Hypertension: 60 per cent

risks to the surgery as well. Hence, in a randomised trial , one has to be very ethical and follow all rules and regulations. However, it is a relatively safe surgery. The chances of mortality within

All patients underwent RYGB. The results were phenomenal. In the first month, average blood sugar level of all patients was about 100 and by nine months it was 89, which is completely normal. In the first month itself, 80 per cent of the patients were off all diabetic medication, by thethird month and thereafter, all of them were off diabetes medicine. As per the data on these patients after three to four years, most of the patients are still non-diabetic or minor diabetic.This was a small study but the results were extremely compelling. Hence, Dr Cummings and Dr Shah submitted the results of this study to get the grant for a top quality randomised controlled trial, to study the full balance of risks and benefits of surgery vs medical and behavioural therapy in diabetes patients who have a BMI of 25-35 and would not qualify for surgery by body weight but have a need for alternate treatment to treat their Type II diabetes. This RCT, which is currently underway has been named as Comparison Of Surgery vs Medicine in Indian Diabetes (COSMID)

30 days of surgery is 0.2 per cent, while for gall bladder surgery, which is the most common operation, chances of dying are 0.3 per cent. Yes, these study results will be applicable to Indians

in the entire world. Although environmental changes have an impact on the human body, genetic make-up remains the same and plays a larger role in people acquiring such diseases.



‘IDF predicts that the number of people with diabetes will rise to 552 million by 2030’ Professor Jean Claude Mbanya PRESIDENT, INTERNATIONAL DIABETES FEDERATION


ndia is the uncrowned 'Diabetes capital of the world' and this silent killer is one of the major healthcare on the country's horizon. Hence, International Diabetes Federation (IDF) has chosen India as the focal country for its activities on this World Diabetes Day that falls on November 14. Professor Jean Claude Mbanya, President, IDF talks to Lakshmipriya Nair about the IDF's focus this year, the various activities planned and the steps that can be implemented to curb diabetes in India. IDF's focus for this World Diabetes Day is “Diabetes education and prevention'. So what's in store on this front for this year? This year's World Diabetes Day campaign is a global call to action for protecting the health of our future generations. It aims to convey the urgency with which the diabetes epidemic must be approached and focus on the changes in our behaviour, from the individual to the multinational-corporation level, that will help to protect the future of individuals and communities. In order to reduce the impact of diabetes, basic knowledge on the prevention and optimal management of the disease much reach the hands of people with diabetes, those at risk and our healthcare providers. Policy makers must also be made aware of the socio-economic benefits of our messages, and spurred into action by an informed general public. Young people are the driving force behind our activities to promote and disseminate our education and prevention messages this year, which address three issues of concern for the diabetes community: the importance of the right diabetes education for all; how the way we live is putting our health at risk; and the stigma and discrimination that many people with diabetes around the world still face. With children and adolescents at the centre of the campaign slogan


- Diabetes: protect our future IDF has widened its scope to engage individuals and organisations outside of the diabetes community that are active in promoting healthy living. We want diabetes to be included on everyone's wellness and nutrition agenda. New this year is our "Pin a Personality" campaign which aims to get the blue circle - the global symbol for diabetes awareness - more widely recognised outside the diabetes community. The concept is simple: we encourage anyone and everyone to take a picture of a well-known person wearing a blue circle pin. Launched in April, the campaign has proved very popular among the IDF network with over 200 personalities from around the world currently featured in our online gallery. This initiative complements our on-going and ever popular Blue Monument Challenge and other activities aimed at getting everyone to 'Go Blue for Diabetes'.

Tell us about the activities that are planned specifically for India, seeing that it is the focal country for this year's campaigning? IDF is partnering with local associations on a nationwide campaign that will have its main events in three cities: Chennai, New Delhi and Mumbai. A monthlong series of activities targeting health professionals and the general public including surveys, screening drives, and walkathons - will be highlighted by the showcase event ‘Diabetes Blue Fortnight’. This is the country's largest awareness campaign that will bring together the government, medical fraternity, associations and organisations working around diabetes, media, corporate organisations and the general public on a single platform to facilitate exchange and growth of knowledge. The event hopes to highlight solidarity towards the cause of reducing the diabetes burden in India. Activities include: ● Doctors 4 Diabetes Care, an opportunity for doctors

and medical professionals to pledge their commitment to spread diabetes awareness, inform people about preventive and management measures and encourage family members of people with diabetes to go for regular and frequent screening A diabetes screening drive in several cities across India, at hospitals and clinics, government and corporate offices, community centres and other venues, to promote the importance of early detection and treatment of diabetes. The lighting in blue over 30 landmark Indian monuments which include the Swaminarayan Akshardham Temple, Old Fort; Qutub Minar and Humayun Tomb in Delhi; Sidhuvinayak Temple in Mumbai; Victoria Memorial Hall in Kolkata and Shaniwada Fort in Pune.

Tell us more about the 'Go Blue' campaign of IDF. Blue became the colour for diabetes awareness following the passage of United Nations Resolution 61/225 in December 2006, which recognised World Diabetes Day as an official UN day. Blue is colour of the blue circle, the symbol of World Diabetes Day and of the global fight to curb the global epidemic and improve the lives of people with diabetes. The aim of IDF is to see coordinated global celebrations for World Diabetes Day with the colour blue used to rally the diabetes community around an easily recognisable and impactful theme and display unity for a common cause. Activities around the colour blue include the Blue Monument Lighting Challenge and Blue Fridays, where everyone is encouraged to wear blue in their home, school or workplace to raise diabetes awareness.

It is said that Indians are more vulnerable to Type II diabetes? Why is it so? How can it be brought under

control? Diabetes can be found in every country in the world and without effective prevention and management programmes the burden will continue to increase globally. Type 2 diabetes makes up about 85 to 95 per cent of all diabetes in high-income countries and may account for an even higher percentage in lowand middle-income countries such as India. Type 2 diabetes is now a common and serious global health problem, which, for most countries, has developed together with rapid cultural and social changes, ageing populations, increasing urbanisation, dietary changes, reduced physical activity, and other unhealthy behaviours Since obesity and diabetes represent one of the biggest public health challenges of the 21st century, IDF has adopted the following position, in line with the recommendations of the World Health Assembly of May 2004: ● All-embracing strategies focusing on prevention and education at every level must be designed ● Healthy dietary patterns need to be encouraged at an early age ● Physical activity should form a central part of both childhood and adult lifestyles ● Clear food labeling and a reduction in portion size are crucial factors in encouraging a healthy diet ● Children should be protected from advertising, which promotes inappropriate (and unnecessary) consumption of energy dense (high calorie) food and drink To prevent Type 2 diabetes, IDF promotes the regular screening of people who are overweight or have a first degree relative with Type 2 diabetes and ethnic high-risk groups as well as everyone over 65 years. IDF also advocates taking the following practical steps to prevent the development of diabetes and obesity from childhood: ● Creation of suitable footpaths, designed tracks and road schemes that




allow safe walking, cycling and the use of play areas around the home and school Change in school curriculum to encourage children to participate in sports and physical activity Implement policies to control access to energy dense food and drinks, whether at home, on the way to school or at school itself A ban on all forms of marketing of foods and drinks directed at children at school and on radio, TV and other avenues Simple and understandable displays of the composition and energy density in all eating establishments Monitoring food consumption patterns and the prevalence of diabetes in the population IDF encourages those with

will rise to 552 million by 2030. Type 2 diabetes accounts for up to 95 per cent of diabetes cases, and the rise in Type 2 diabetes appears to be mainly related to the increasing prevalence of overweight and obesity worldwide. Furthermore, the rising level of childhood obesity worldwide and the subsequent onset of Type 2 diabetes have profound implications for the future.

What are the causes for Indian children being more vulnerable to Type-1 diabetes? How can it be brought under control? At present, Type 1 diabetes cannot be prevented and we do not know the exact causes. The environmental triggers that are thought to generate the process which results in the destruction of the body’s insulin-producing cells are still under investigation.

In India, a lack of resources and government investment in NCDs often hinders initiatives to bring diabetes under control responsibility for the provision of healthcare services to guarantee that all steps are taken to ensure that these measures are met. Governments can make a significant contribution by encouraging lifestyle changes and investing in health programmes. However, a comprehensive approach is needed to tackle the global epidemic of diabetes and obesity successfully. IDF therefore promotes the active collaboration of member associations, public health authorities, the pharma industry and the food and drinks industry to achieve the best possible results in tackling the dual, overlapping problems of diabetes and obesity.

Kindly elucidate on the corelation between obesity and diabetes? Obesity and diabetes currently threaten the health, well-being and economic welfare of virtually every country in the world. According to recent estimates of the International Obesity Task Force, up to 1.7 billion people of the world’s population are at heightened risk of weightrelated, NCDs such as Type 2 diabetes. IDF predicts that the number of people with diabetes



Today, there is no cure for diabetes, but effective treatment exists. If you have access to the appropriate medication, quality of care and good medical advice, you should be able to lead an active and healthy life and reduce the risk of developing complications. Good diabetes control means keeping your blood sugar levels as close to normal as possible. This can be achieved by a combination of the following: ● Physical activity: A goal of at least 30 minutes of moderate physical activity per day (e.g. brisk walking, swimming, cycling, dancing) on most days of the week. ● Body weight: Weight loss improves insulin resistance, blood glucose and high lipid levels in the short term, and reduces blood pressure. It is important to reach and maintain a healthy weight. ● Healthy eating: Avoiding foods high in sugars and saturated fats, and limiting alcohol consumption. ● Avoid tobacco: Tobacco use is associated with more complications in people with diabetes. ● Monitoring for complications: Monitoring and early

detection of complications is an essential part of good diabetes care. This includes regular foot and eye checks, controlling blood pressure and blood glucose, and assessing risks for cardiovascular and kidney disease.

How can the patients themselves take charge and prevent a debilitating disease like diabetes from taking control of their lives? A good diabetes education is key and also the points mentioned above.

A recent study by WHO established that people suffering from diabetes are more susceptible to TB. Can you elaborate on this situation is likely to aggravate India's disease burden? People with diabetes are at higher risk of developing tuberculosis (TB) than those without diabetes. Tuberculosis, an infectious disease of the lungs, affects 9.4 million people and kills 1.7 million worldwide every year. 1 TB is a major public health problem in many lowand middle-income countries, where the number of people with diabetes is also rising rapidly. Regions, such as India who are most heavily affected by tuberculosis are also those that have some of the highest numbers of people with diabetes and will experience the biggest increases by 2030. Not only does diabetes contribute to a person's risk of developing tuberculosis, but it also makes it more difficult to treat those who have both diseases. A review looking at the impact of diabetes on tuberculosis treatment found that people with diabetes are more likely to fail treatment and more likely to die during treatment compared to those without diabetes. The link between tuberculosis and diabetes requires interventions that address both diseases. For example, screening for tuberculosis in people with diabetes and screening for diabetes in people with tuberculosis could offer opportunities to increase detection and prevent diabetes or tuberculosis-related complications. A recent review showed that when people with diabetes were checked for tuberculosis, more people were found to have previously undiagnosed TB than in the general population. This was also true of people who had tuberculosis, and were checked for diabetes, in which many more were found

to have previously undiagnosed diabetes than in the general population. People with diabetes who have good glucose control are less likely to develop tuberculosis. In addition, tuberculosis treatment leads to decreasing blood glucose levels suggesting that integrated management of tuberculosis in people with high blood glucose could lead to better diabetes control. Effective management of both diseases requires the same elements including early detection, providing guided standard treatment, and having an effective drug supply. The same principles can be applied to both diseases and help many people affected by tuberculosis and diabetes. Setting standards on these simple priorities could lead to effective detection and treatment for diabetes as has been seen in global tuberculosis control.

What are the major obstacles that hinder the initiatives to bring diabetes under control? Each country faces its own particular challenges. In India, a lack of resources and government investment in NCDs often hinders initiatives to bring diabetes under control. In a lot of cases, diabetes research cannot be translated into low income/low resource settings. Diabetes awareness is low and at the same time stigma attached to the disease is high! Without a substantial people’s movement, pressing for change on all levels, it will be very difficult to inspire any kind of change.

What are the immediate steps that India should implement to curb the growing threat of diabetes? India needs to implement the following steps: ● All-embracing strategies focussing on prevention and education at every level must be designed ● Healthy dietary patterns need to be encouraged at an early age ● Physical activity should form a central part of both childhood and adult lifestyles ● Clear food labelling and a reduction in portion size are crucial factors in encouraging a healthy diet ● Children should be protected from advertising, which promotes inappropriate (and unnecessary) consumption of energy dense (high calorie) food and drink.


Radiology Rooting for refurbished CT scanner machines

'... better, faster and affordable solutions in clinical imaging'

Som Panicker, Vice President, Sanrad Medical Systems

Bernd Montag, Global CEO, HIM Division, Siemens Healthcare

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USG in breast cancer: the old and the new Dr Arjun Poptani, Sr Radiologist, Rockland Hospital elaborates on the various usages of ultrasound in the detection and diagnosis of breast cancers with dense tissue he traditional role of ultrasound in imaging of the breast is to further evaluate masses or asymmetries and to help differentiate a solid mass from a cyst. In breast cancer, it has been used as a diagnostic follow-up to an abnormal screening mammogram. The addition of ultrasonography to mammography increases sensitivity for small cancers but decreases specificity. Ultrasound (US) is also used to provide guidance for biopsies and other interventions. It is the first line of imaging in a woman who is pregnant or less than 30 years old with focal breast symptoms or findings, where both the sensitivity of ultrasound and negative predictive value for malignancy were 100 per cent. US of the axilla also detects suspicious lymph node metastasis, especially in the obese. Results of a recent clinical trial from American Radiology Services Inc, conducted at the John Hopkins Institute and published in JAMA 2008, showed that addition of US to mammographic screening of the breast will yield an addition-


Pseudonodular hypoechoic lesion compatible with a microcystic mass on B-mode sonography. The colour elastogram shows homogeneous elasticity in the entire lesion (score 1). Cytologic diagnosis: fibrocystic changes

al 1.1 to 7.2 cancers per 1000 high-risk women. However,

this study also reported a higher incidence of false pos-

Comparison of ultrasound imaging techniques for breast lesions Sensitivity (%)

Specificity (%)

Accuracy (%)









* Conventional B-mode sonography: category 4 and over, diagnosed as malignant. â&#x20AC; Real-time tissue elastogrpahy: score 4 and over, diagnosed as malignant


itives leading to more number of biopsies/cytology in the screened population. The use of US to guide core needle biopsies (CNBs) from a breast lesion for diagnosis of nonpalpable lesions is faster and better tolerated by some patients than stereotactic mammography. The use of US requires that the lesion can be well visualised by ultrasound and confidence that the ultrasound finding and mammographic finding represent the same thing. With US-guided core needle biopsy, passage of the needle through the lesion can be directly visualised and confirmed; as a result, fewer samples (usually three to five) are needed to provide diagnostic material. If the lesion is better visualised mammographically and is difficult to reproduce reliably on US, then stereotactic guidance is the preferred method. More recent uses of US in the management spectrum of breast cancer have been in the area of interventions during neoadjuvant chemotherapy and breast conservation surgeries for patients who have large or locally advanced tumours for which neoadjuvant (induction) chemotherapy is considered, careful anatomic localisation is critical to ensure that the surgeon can localise the area of tumor after neoadjuvant therapy. Typically, the lesion is measured both clinically and through ultrasonograpy, reported in terms of size, the "o'clock" location on the breast surface, and the disEXPRESS HEALTHCARE


R|A|D|I|O|L|O|G|Y tance of the lesion from the nipple. The use of radioopaque clips placed at the time of biopsy to localise the primary tumour in case there is a complete clinical and radiographic response to induction therapy can also be tried under sonographic guidance. Ultrasound is useful in evaluating the local extent of breast cancer and can identify additional tumour in the same breast thereby altering surgical management (mastectomy verses breast conservation) in up to 18 per cent of women. Ultrasound is appropriate in evaluating implants in a woman with contradictions to MRI or where MRI is not available. It can be used to check the integrity of a silicone implant capsule. Leak of silicone to the surrounding breast tissue causes a typical "snowstorm" appearance. Similarly, intracapsular rupture can be diagnosed on ultrasound by a characteristic "stepladder" appearance.

Newer modalities of USG Real time tissue elastography: Conventional uses of mammography for breast screening over the years have put forth some interesting caveats. For example, in Japan where the average age of diagnosis of breast cancer is a woman in her 40s, the specificity of mammography as a single tool of screening is unacceptably less, because the breast tissue is quite dense in this age group. Also, the global trend of breast cancer diagnosis is at present towards a younger population of women, who are mostly in their 30s, where simply getting a mammogram done wonâ&#x20AC;&#x2122;t be sufficient as a screening tool. All this has created a need for a tool which can add to, and increase the specificity of mammography, and if necessary which can also be used as a standalone modality of screening or diagnosis. Elastography was described at the beginning of the 1990s by Ophir et al. In 1997, Garra et al published the first clinical study showing the potential of elastography in the detection and characterisation of breast lesions. But it was only after 2004 that it became possible to use this technique simul-



taneously with conventional sonography, thanks to new equipment with probes that allowed both real-time B-mode sonographic and elastographic studies. Ultrasonography works as an essential tool in diagnosing breast cancer, especially in women with dense breasts and in detecting small cancers of the breast. In recent years, realtime tissue elastography has come up in a big way as an auxillary tool in the evaluation of cancer of the breast. This method uses colour evaluation of the degree and distribution of tissue strain, induced by tissue compression with an ultrasound device. Compared with conventional B-mode sonography, it scores a lot higher in specificity, so much so that it might replace histological proof of some breast lesions in the near future. It can also be useful in the preoperative assessment of the margins in breast cancer. Further development of ultrasound elastography is expected. Method: Real time elastography visualises the degree and distribution of strain induced by light compression in a real-time manner when artificial light compression is applied to breast tissue. Results are noted when soft tissue receives greater strain, while stiff tissue receives less (Shiina et al., 2002). The images are classified into five patterns (Itoh et al., 2006, Tsukuba Elastography Score, Itoh, 2007). Interpretation: Scores from one to three showing green images of strain with and without tense blue images are judged to be benign. Scores four and five showing blue images are diagnosed as malignant. Score 1. Strain in the entire hypoechoic area Score 2. Strain not seen in part of the hypoechoic area Score 3. Strain only in the peripheral areas and not at the center of the hypoechoic area. Score 4. No strain in the entire hypoechoic area; and Score 5. No strain either in the hypoechoic or surrounding areas

the other hand, to achieve negative margins in the operating room, the usefulness of ultrasound with its easy portability and improvements in technology is well known (Henry-Tillman et al., 2001). Furthermore, ultrasound is superior in specificity but inferior to MRI in sensitivity (Tamaki et al., 2002). Considering the above facts, application of ultrasound elastography to assess the extent can be considered in both pre and intraoperative setting.

Ultrasound tomography

Well-circumscribed solid nodule with small intranodular cystic areas compatible with fibroadenoma on B-mode sonography. On the color elastogram, a mosaic pattern is shown (score 2). Cytologic diagnosis: fibroadenoma.

Poorly defined solid nodular image with a posterior acoustic shadow and irregular echogenic halo compatible with carcinoma on B-mode sonography. The color elastogram shows stiffness in the entire lesion and an area of the surrounding tissue (pattern 5). Histopathologic diagnosis: invasive ductal carcinoma.

Solid nodule with indistinct margins and a sonographic suspicion of malignancy (BIRADS 4). The color elastogram shows stiffness in the entire lesion with homogeneous red distribution, representing maximum hardness (score 4). Histopathologic diagnosis: invasive ductal carcinoma.

Preoperative assessment of margins in breast cancer With increasing awareness and use of breast conservation surgery, evaluation of the margins of excision of a lesion has become one of the important parameters of management. A precise grasp of the degree of invasion into the breast tissue and the

presence and degree of the extensive intraductal component is important to assess margins of excision. As a tool for preoperative assessment of the extent of cancer, 3D MR mammography which utilises MRI is superior to mammography or ultrasound (Esserman et al., 1999; Nakamura et al., 2002). On

A recent study from Karmanos Cancer Institute, Detroit, US by Duric et al describes the construction and use of a prototype tomographic scanner and reports on the feasibility of implementing tomographic theory in practice and the potential of US tomography in diagnostic imaging. Method: Data were collected with the prototype by scanning two types of phantoms and a cadaveric breast. A specialised suite of algorithms was developed and utilised to construct images of reflectivity and sound speed from the phantom data. Results: The basic results can be summarised as follows: (i) A fast, clinically relevant US tomography scanner can be built using existing technology. (ii) The spatial resolution, deduced from images of reflectivity, is 0.4 mm. The demonstrated 10 cm depth-of-field is superior to that of conventional ultrasound and the image contrast is improved through the reduction of speckle noise and overall lowering of the noise floor. (iii)Images of acoustic properties such as sound speed suggest that it is possible to measure variations in the sound speed of five m/s. An apparent correlation with x-ray attenuation suggests that the sound speed can be used to discriminate between various types of soft tissue. (iv)Ultrasound tomography has the potential to improve diagnostic imaging in relation to breast cancer detection.



Rooting for refurbished CT scanner machines Som Panicker, Vice President, Sanrad Medical Systems elucidates on the advantages of using refurbished Equipment and addresses the means to reduce radiation risks in these machines e all need to agree with the fact that any X-ray generating machine, no matter small or big, old or new, makes for a radiation risk if it is not maintained or monitored for radiation safety. But at the same time, we cannot agree with the propaganda that all the radiation hazards are mainly caused by imported, used X-ray tubes and CT machines brought from US, Europe or Japan to India, and conveniently forget that there are thousands of old X-ray equipment which are more than 10-years old, both in government sector and private hospitals in India, which are neither monitored nor maintained due to various reasons. We should not forget that many of these high end equipment like CT scanners are not fully manufactured in India till date and the cost of new medical equipment are extremely high, making it very unreasonable to charge the patients for these high end services . There is a very acute shortage of qualified personnel for making quality assurance and test reports in this field. Very often the diagnostic medical centres and hospitals have to wait for several months to get approvals, and also bear the brunt of certain officials who are hand in glove with agents to demand bribes and favours for providing licenses. Under such prevailing circumstances, Atomic Energy Regulation Board (AERB) has authorised and issued licenses to qualified and trained personnel to do Q/A tests for X-ray equipment which is a great relief to the medical centres and frees the system from the monopolistic attitude of the state DRS officials. As a qualified person



Vice President, Sanrad Medical Systems


working with diagnostic imaging equipment for many years, I would like to highlight few important aspects that justify the import of refurbished or used CT scanners in India. They are as follows: 1. Government of India permits import of any used medical equipment with residual life of more than eight years. 2. Medical equipment do not have an expiry date and these equipment can be used as long as it is serviced and maintained efficiently to produce good quality images and performance within specifications 3. Due to very high costs of new and imported medical equipment, the costeffective but used medical equipment are the only feasible solution to provide high-end diagnostic services at low costs in remote and rural areas of the country. 4. X-rays are produced by secondary emission. Their use is very effectively controlled by electronic circuits and mechanical devices which limit the spread and scatter of X-rays. As these X-ray tubes get older, the radiation emitted keeps reducing and ultimately the tubes get fused after which they need to be replaced. 5. AERB is a regulatory body which provides training, testing and inspection for all types of radiation equipment at site. They also approve sites for installation of equipment and guide the doctors and hospitals on the specific use of such equipment. 6. Unlike radiation produced from nuclear isotopes and other materials used in nuclear medicine as well as cancer treatment equipment like Gamma camera, Linear Accelerator, Cobalt Therapy etc, X-ray radiation is much safer and






less harmful when used for diagnosis under controlled situations. X-rays are the main source of diagnostic medical imaging of patients, and the effective use of these equipment (old or new) by trained professionals are safe and harmless to the patients when used as per the allowed radiation limits and dosage. The use of latest technology in developed nations has become a trend, and most of them replace equipment within a span of four to five years. The cost of such upgrade to technologically advanced equipment do not hinder their services to patients, as most of the patients are covered by medical insurances or government policies. As these replaced equipment have a large percentage of residual life left over, it is wise to make good use of it in other countries where they lack such facilities greatly. Hence these imported used equipment play a great role in the development of rural clinics and medical centres. They also facilitate rapid growth of high-end medical services by providing economical solutions to the needy patients. Indian engineers use their skills and intellectual ability to make excellent use of these medical equipment for safe and effective patient diagnosis therapy, saving a lot of foreign exchange for the nation. They also provide alternative solutions to the dictum of some vendors who overcharge the customers and make huge profits from services and sales of new medical equipment. Average life expectancy of good medical equipment is approximately 15 years with proper service and maintenance conducted at regular intervals. All X-

ray equipment are calibrated at regular intervals to ensure production of good quality diagnostic images. 12. Even in countries like US, Japan, Korea etc., the use of second hand medical equipment are permitted and is considered as a viable alternative to new equipment. Most of the high-end medical equipment have CE/FDA/TUV certification thus proving to be safer for use in medical diagnosis. 13. Radiation hazards are caused only due to misuse or abuse of equipment and not because it new or old or imported. To ensure that good quality diagnostic images are produced, all X-ray based medical equipment need to undergo similar tests and periodic maintenance, irrespective of whether it is a used machine, a brand new one, locally manufactured or imported. 14. Finally, we should work towards encouraging local manufacturing of high-end medical equipment like CT, MRI etc by offering tax cuts, incentives, subsidies etc. It is our governmentâ&#x20AC;&#x2122;s lack of policy, and illogical as well as difficult tax structures that make investments in medical equipment manufacturing an unattractive idea. China has gone a long way ahead in this arena and we should learn from their manufacturerfriendly policies. It is better to encourage more investors to start manufacturing these high-end medical equipment in India, thereby reducing the overall cost of such equipment. It would also create an alternative to expensive imports from US, Europe and other foreign countries. The author can be reached at EXPRESS HEALTHCARE



'Siemens will come up with better, faster and affordable solutions in clinical imaging' Bernd Montag, Global CEO, Healthcare Imaging & Therapy Systems Division, Siemens Healthcare discusses current imaging trends, factors driving the imaging market, Siemens Healthcare's plans for the Indian imaging market and more in an interaction with Lakshmipriya Nair How has imaging in healthcare evolved over the years?

Bernd Montag Global CEO Healthcare Imaging & Therapy Systems Division Siemens Healthcare

Let me just touch on three aspects: Quality, speed and accessibility. Talking about quality, earlier, clinical images were pictures of shady grey, thus very difficult to read. 3D imaging, functional imaging or visualising molecular information was unthinkable. Today, we are close to delivering a ‘digital copy’ of the patient, showing structures of less than one millimetre in high resolution and 3D. But I’m not only talking about reading images, we also offer equipment for image-guided therapies. For example, our angiography system, Artis zee enables surgeons to perform minimallyinvasive interventions such as trans-catheter aortic valve implantation (TAVI) through image-guidance, replacing conventional invasive surgeries. In terms of speed, we are currently living a world, where our flagship CT Somatom Definition Flash is performing a heart scan in a split second. Ten years ago, we would not have even dared to dream of this. Finally, accessibility has significantly improved. Today, millions of people in the emerging markets like India have access to clinical imaging, which is also a result of more affordable imaging solutions. And this trend will continue, Siemens will come up with better, faster and more affordable solutions in clinical imaging.

What are the disease and patient trends shaping the imaging industry, in India and globally? According to the United Nations, average life expectancy in India, during the 1950s, was less than 40 years. By the year 2000, life expectancy had gone up to an average of 64 years. By



the mid of this century, Indians will live more than 75 years. So you can say that within 100 years, average life expectancy in India will have almost doubled! This is pretty impressive and outstanding globally, even if the trend of living longer is of course a global one. This increase in life years comes with a change in disease patterns: With growing age the likelihood of chronic diseases in the area

C-arm. Another example, which I just touched on, is the world’s fastest CT scanner, Somatom Definition Flash, which has been installed at quite a few health institutes in India. Biggest growth, ofcourse takes place in the middle segment. Our MRI system, Magnetom Essenza, explicitly addresses this market and due to its great priceperformance-ratio it is now the best selling MRI system

The task for the imaging industry is to help doctors provide high quality diagnosis at the earliest possible stage, leading to efficient and effective therapies of cardiology, oncology and neurology increases. So the task for the imaging industry is to help doctors provide high quality diagnosis at the earliest possible stage, leading to efficient and effective therapies.

How has India's imaging market grown in the past decade? Global market growth in the last couple of years was between three to five per cent per year and India’s was definitely higher.

Which of your division’s products are most attuned to India's healthcare needs? We would not be the market leader in India, if most of our products were not suitable for the local market. For instance, our factory in Goa very successfully targets the special requirements of our Indian customers. In the high-end segment we see a great demand for our products. For example, we have sold Artis Zeego, a cath lab with the world’s first robotic

in India. In the course of Siemens Healthcare’s twoyear innovation and competitiveness programme, Agenda 2013, we explicitly target further innovation in the middle segment to increase accessibility for our products. Since the beginning of the Agenda 2013, we introduced a CT, an MRI, an X-ray and an ultrasound system that offer a very compelling balance between image quality and investment budget. We may see more of this at the RSNA Congress.

Tell us the rationale behind the Siemens and HCG collaboration to set up a Centre of Excellence for cancer care. Any more such collaborations in the pipeline? The idea behind this is to give some kind of an organisational framework to our collaboration with one of our leading customers in Asia. At the end of the day, Siemens Healthcare is translating customer requirements based on clinical needs into products

and solutions. The better we understand these requirements, the more successful we can be in this translation. We believe both sides are winning in such collaborations: Our customers give us ideas based on their clinical expertise, and we present our ideas based on our technical expertise on how clinical work-flows could be improved. So, this is truly a winwin-win-situation: The customers win through our input, we win through customer input and most importantly, the patient wins! We have a number of Centres of Excellence around the globe.

What are the unique opportunities and challenges in Indian healthcare market vis-à-vis the global market? Due to its sheer size, the Indian market is a challenge in itself. This applies of course to the number of people and to the fact that India is a continent. Besides, the diversity of the Indian market is quite unique. On one hand, you have high-class hospitals with the same requirements as any teaching hospital in the US or Germany. On the other hand, there is a vast and fast growing market for entry and midlevel products. We try to serve both markets with innovations that cater for quality, effectiveness and price-efficiency. We have more than 1,000 software developers in Bangalore, who contribute in achieving our business goals. I have just been there and was truly impressed by the quality and speed of our teams…

What are the learning lessons for India from the global market? I believe there is no specific one or two specific lessons, India can learn from the global market. India NOVEMBER 2012

R|A|D|I|O|L|O|G|Y certainly has great potential for the development of almost all industries. However, like most countries in the world, India too is facing the challenges of the current economic environment. The Indian Government is very ambitious to establish a modern healthcare system for its vast population. This is an effort that deserves the highest respect. Siemens has deep roots in India and we would feel honoured to help India on its way to implement an efficient and effective healthcare system.

What are the immediate policies or steps to enhance access to affordable imaging solutions in India? Government rules and laws are always the result of the specific circumstances in the respective country, so it’s difficult to tell as a foreigner, what should be done. In general, what has proved to be efficient and effective is open competition and a predictable, stable, longterm business environment making it possible to plan and invest in business activities.

The Indian Government is very ambitious to establish a modern healthcare system for its vast population. Siemens would

third less at cost than its predecessor. And as I already said, we may see more in the line of accessible innovations at this year’s RSNA congress in the US.

way to implement an efficient and

What are Siemens Healthcare Imaging & Therapy Systems Division’s future plans for India?

effective healthcare system

The direction for our business in India is clear

feel honoured to help India on its

north. We are ready to grow! We are very confident that we can do this with our unique offering in the highend segment and we will develop more and more products for the fast growing midlevel market. Talking about partnerships I can only say: I am open for discussions – any time!

Direct Conversion accelerates Digital Radiography. Your next-generation total solution from Fujifilm.

How can your division play a role in alleviating the concern of healthcare access in the country? Just one year ago, our Siemens’ President and CEO, Peter Loescher proudly donated another Sanjeevan mobile clinic, this time to Medanta, one of India's largest speciality institutes located in Gurgaon. The previous one was donated to Smile Foundation in Madhepura, Bihar. Sanjeevan mobile clinic was an initiative started by Siemens India to help improve the accessibility and affordability of healthcare services in the interiors of India. Apart from our corporate citizenship programme, we are fostering our R&D efforts to come up with highly innovative and at the same time more cost-efficient imaging equipment. Last year, we introduced our digital Xray system Multix Select DR, which is about one NOVEMBER 2012

FDR AcSelerate is proof of Fujifilm’s never-ending quest for superb image quality and technological innovation in digital radiography. Working at the heart of AcSelerate is our newly developed direct conversion Flat Panel Detector (FPD) which directly converts X-rays into electric signals for enhanced DQE and MTF performance, allowing dose reduction. This new FPD along with Fujifilm’s renowned image processing technologies Image Intelligence™ delivers images of refined quality, while the first class ergonomic design of AcSelerate being both automated and intuitive provides ultimate comfort for both patient and technologist – all for diagnostic confidence. Fujifilm has long been an industry leader in Computed Radiography, Women’s Healthcare, PACS, and now with FDR AcSelerate, we present the same cutting-edge solution for every step of radiographic exams from exposure to study, operability and maintenance with unsurpassed reliability.

More Details for FDR AcSelerate

FDR AcSelerate (Model: FDR200)

This equipment is a Class 2 laser product (IEC60825).




Trade & Trends FUJIFILM: Enhances the quality of patient’s life

‘Myrian is used by more than 2000 users every day’

Fujifilm continues to work hard to provide the Indian consumer with the best products and services Page 49

Patrick Mayette, Co Founder and General Manager, INTRASENSE Page 51

Drying cabinet from Periclave Periclave's new Drying cabinet has been designed to ensure simple and fast drying of instruments hospitals, pharmacies and other places where instruments might be processed

oru Bhathena’s Division – PERICLAVE has introduced the Drying Cabinet for surgical instruments, glassware, respiratory therapy items, linen etc. The Periclave Drying cabinet, a professional heavy duty industrial dryer series of


machines with CE marking. The unit has a large door opening for easy and quick loading and unloading. It has been developed for the on premise market, and is suitable for hospitals, pharmacies and other places where instruments might be processed. The design allows for top performance at lowest possible operation cost and investment. The electronic control centre ensures that maximum productivity is obtained. The system meets all modern requirements for effective treatment of instruments with low power consumption. Its new drying system allows total use of electric energy and reduces consumption so saving energy. This versatile

system is known for its ruggedness and yet silent, controlled vibration less operation. This inimitable hot air blowing completes drying in shortest process time.

Main features The Periclave Drying cabinet series utilises high quality material such as Stainless Steel SS 304 quality in vital parts in contact. It has a stainless steel SS304 inner and outer body for long life with easily removable fittings. The drying cabinet is designed to dry surgical instruments and metal ware, respiratory tubes or other tubing, face masks, anaesthetic bags and other equipment used in hospital, laboratory or pharma industry. The shelves

are removable, hence can be altered and placed as per size of the load to be dried. The cabinet is insulated with 50mm approved type insulation for protect from heat dissipation. Mechanical door latch is fitted with high temperature with standing silicone door gasket to ensure effective sealing when the door is closed. Drying cabinet is a high capacity drying cabinet designed to dry surgical instruments, utensils, glassware and anaesthetic respiratory therapy equipment. Simple to operate, the unit has an adjustable temperature range of 70 – 90 ºC and drying time range of 0 – 99 minutes. The key advantages

of this series are the simplicity of the electronic based controller system, which saves time and energy in the finishing operation.

Contact: Zoru Bhathena Periclave House , 63-A, Kandivali Co-op Industrial Estate, Charkop, Kandivali (West), Mumbai – 400067

Biozeal’s brilliant offerings BioZeal has a range of eclectic equipment with great features to serve the healthcare segment

brands among doctors because of its accuracy, reliability and its efficiency, even in low perfusion index. It is available in both handheld and table top monitor type

iozeal is an authorised dealer for Wipro GE Healthcare. Some of its products include a pulse Oximetre (Ohmeda), which is one of the most preferred

Features of Tuffset (Handheld Pulse Oximeter) ● Small and lightweight for simple, one-hand operation ● Rubber grip offers secure handling ● Intuitive features require minimal training ● Backlit with large LCD displays and easy-to-read numbers for excellent visibility ● Low battery indicator




Features of Trusat (Tabletop Pulse Oximeter) ● TruSignal enhanced SpO2 delivers improved performance during clinical motion and low perfusion ● Backed by a full, three-year warranty ● Up to 30 hours of uninterrupted battery life (up to 20 hours with TD option) and a fast, full battery recharge in only 3.5 hours. Note: Continuous use of backlight can significantly affect the battery life. ● Small, lightweight design. Only 2.76 lb (1.25 kg) ? less than half the weight of most bedside oximeters

Alarm limits are always visible and saved between uses Pulse bar waveform

For more information about the company and its products contact Jimmy Makhija Mobile: + (91)-9768156266

Address: C- 23, Santmira CHS, Kanya Nagar, Kopari Colony, Thane - 400 603, Maharashtra, India Email:, NOVEMBER 2012

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FUJIFILM: Enhances the quality of patient’s life As a firm believer in patient centric solutions, Fujifilm continues to work hard to provide the Indian consumer with the best products and services

ujifilm is always committed to pay precise attention to the rapidlygrowing Indian economy. Anchored by an open, fair and clear corporate culture, Fujifilm is determined to remain a leading company with the leading-edge technologies. To remain a vigorous company, and exercising pioneering leadership, we hone our innovations consistently. We boldly take up the challenges of developing new products, services to gain customer trust and provide them the ultimate satisfaction.

our product line, that makes your X-ray diagnosis easier and more efficient. To address the customers' needs the products that they have come up with in Computed Radiography are: FCR PRIMA FCR CAPSULA X FCR CAPSULA XLII FCR XG5000 FCR PROFECT ONE FCR PROFECT CS

Fujifilm’s latest offerings in the healthcare industry are as follows:

patient. Fujifilm’s advanced DR products deliver productivity gain for radiologists, while maximising image quality.


Computed Radiography Digitalisation has realised high efficiency and accurate diagnosis in clinics and hospitals. It has also brought about high-quality images and stable X-ray imaging eliminating the need for dark room processing. The imaging process is clean and diagnosis can be made efficiently. In 1983, Fujifilm brought ‘Digital’ to the world of analog X-ray diagnosis by launching the FCR 101, a digital product that used the FCR (Fuji Computed Radiography) technology. Since then, Fujifilm have been at the primacy of digital imaging by developing this technology further and by announcing various follow-on products which have contributed to improving the efficiency of diagnostic imaging and quality of medical care. Since then, they have added many new products to


Fuji Digital Radiography Fujifilm Digital Radiography System is for high-quality imaging. Digital radiography (DR) provides immediate imaging results for the operator and less waiting time for the

FDR AcSelerate The X-ray room of the future! A streamlined solution with dynamic speed and sharp images. Building upon our longstanding digital expertise and superior diagnostic image processing technology Fujifilm have accumulated over the years and has developed a new Flat Panel Detector (FPD), offering remarkably high X-ray conversion characteristics and this, in hand with an innovative X-ray unit of superb operability, gives healthcare industry the AcSelerate. This new product is the latest edition to Fujifilm’s Digital Radiography (FDR) product line.

FDR D-EVO FDR Devo is an extremely light, easy-to-use, swift, effi-

cient workflow & extensive free position exposure device. Fujifilm overcame the traditional process of integration and introduced to the very new X- con free technology. It gives one panel solution, Unparalleled speed improving workflow, ISS technology FPD, supports various positioning by tabletop exposure along with compatibly sized DR cassette, that’s only 2.8 kg* in weight.

Digital Mammography (FFDM) Over a period of time Fujifilm has earned the acclaim and trust of healthcare institutions worldwide. Company is committed to provide the best solutions to support the pink ribbon campaign. Fujifilm strives for the best possible image and system quality in order to provide the optimum clinical environment for Mammography applications. With innovation and great potential Fujifilm steps toward total solution in digital Mammography. To take their innovation further ahead they have introduced FFDM AMULET.

Amulet Amulet is designed with comfort and efficiency in mind for all women. Fujifilm ensures ease of use, optimised work flow, comfort and peace of mind during examination along with patented direct conversion flat panel detector technology for true 50-micrometer imaging precision.

Digital Portable System FCR GO2 - Gathers smile everywhere - anytime, anyplace Mobility as you like itThe dual motor drive allows free and smooth steering, with speed adjustment capability and gives superb mobility even in tight spaces. Designed to be silent, you can comfortably move the unit at night time. Positioning as you need it- The telescopic arm adjusts easily to the precise, desired

position for high quality images. Lightweight cassette make you smile- The rugged, lightweight IP Cassettes, in a variety of sizes, add to the precise positioning you need to deliver high performance in areas with limited space such as at the bedside. Various size IPs and cassettes fill a variety of studies.

Synapse (PACS) Fujifilm's next-generation medical imaging and information management system, SYNAPSE allows the archiving and distribution of vast amounts of image information from all modalities, managing it all with a single system. With the first comprehensive picture archiving and communication system (PACS)with next-generation web technology, SYNAPSE utilises the latest Wavelet compression technology for on-demand compression and access of large files quickly and easily regardless of location. SYNAPSE has revolutionised the management of radiology imaging services, supporting image diagnosis with high-quality images, numerous image processing features and easy operation, affording exciting new possibilities in this rapidly evolving medical field.

Fuji Dry Chemistry System Speedy and reliable point of care testing: Opening a new horizon for a more precise POCT world. Fully automated analyser based on dry technology for more convenient and reliable on site performance, featuring remarkable turnaround time response and wider network system capability. For all clinical settings, ranging from small clinics to large hospitals.

Printing Solution Outstanding performance, remarkable efficiency and superb quality of our printing solution fulfill all the medical imaging needs. The verity of products of Fujifilm in this segment includes DPX 7000, DPX 4000, DPX Lite & DPX PRIMA.



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Teleradiology solution and inter centre connectivity using OsiriX Dr Roshan Shetty, Pinnacle Imaging, Mumbai shares his experience with OsiriX and narrates how Shreeji Scan helped him to customise the product to meet his requirements



any of us must be aware of the fact that today, “OsiriX is the most versatile platform for a cost effective reporting workstation at much affordable price”, in the field of medical imaging. In this article I am focusing on much the less explored area of OsiriX known as “inter centre connectivity and tele-radiology environment” with MAC OS. Unfortunately, since last decade no other Apple authorised vendor or professional solution provider in the country has been able to understand and cater to the demands of today’s radiology and imaging needs. Finally, now in 2012, Shreeji Scan Services has taken the initiative and come up with a solution that could change the course of telereporting, that too with APPLE platform and its virus free environment. It is the least explored area of OsiriX, because of lack of technical know-how of the people who provide services for APPLE and OsiriX in India. But in Mumbai, I have come across two enthusiastic youngsters from Shreeji Scan Services who have taken up this challenge and come up with an out-of-the-box solution of providing inter-centre connectivity and Teleradiology using OsiriX. This is a great feat and achievement for Shreeji Scan Services, thanks to their dedicated research to meet my expectation of tele-reporting on Apple platform. I would like to inform all APPLE fans in India, who inspite of using Apple for so many years, were forced to switch to Windows platform for tele-reporting, as no such solution was available on APPLE platform, that finally the wait is over. I would further wish to inform all Apple loving fans from Medical Fraternity, that finally we have a tele-radiology solution, which works with MAC OS. Thanks to Shreeji Scan Services for coming up with such a wonderful solution for Apple lovers, especially in India.


Recently, we added a auxiliary centre in place, approx two km away from my main setup in Juhu, Mumbai. I was using one of the conventional server based tele-radiology software and had a server hosted in my own centre. But the solution was not feasible because it did not give me connectivity to view images on my I-Phone or I-pad, and the download time was too much, and finally the output was compressed images upon successful download. My objective was that from my auxiliary centre, I should get real time DICOM images physically transferred to my OsiriX server located at my main centre. Also, I should get access to images on iPad/iPhone or laptop desktop when I am out and emergency hits either of my setup, as it is located in one of the renowned cardiac setups in Mumbai. So, one day I called these guys from Shreeji Scan Services, from whom I had bought an Apple OsiriX workstation an year ago. I put forward my requirements to them, and to my surprise after a span of 15 days they came to me, saying that they had come up with a solution, by which I could get real time DICOM images transferred to my Osirix Workstation in my main centre, as soon as a scan is done in my other centre which is approximately two km away from main centre, and that too automatically, without the intervention of my technician. Further I could even access images, which were present on my OsiriX Server, remotely on iPhone and iPad or any apple or windows laptop. Even I can download DICOM files locally on windows desktop/laptop and open them with any free DICOM viewer available on the Internet. To me it sounded illogical and overambitious in the first instance, and plus there was a risk involved amounting to few lakh rupees, but seeing the confidence of these youngsters, I decided to give it a try, and as per my expectation,

here we stand today with a solution that could change the course of tele-reporting, that too with APPLE platform and its virus free environment. I still remember them saying that “Sir, we have started new and this is going to be first of its kind setup in India also, but somebody will have to trust us, and we would want to try and fail rather than not taking risk of attempting”. This thing touched me a lot, and moreover there was my own desire to to come up with an Apple-based solution for tele-radiology and inter-centre connectivity. So, I kept full faith in Shreeji Scan Services and decided to proceed with the project. Frankly speaking, even my close friends told me that I was taking a risk of Rs 7.5 lakhs! But for me it was an adrenaline-pumping thing, as technology has always been my passion and moreover I did it out of my love towards Apple and these youngsters, who were very sincere. I made my expectations clear to them, I informed that they will have to give me a total solution, from choosing ISP to setting infrastructure and training my staff. I also told them that it should continue working in the same way for a long time, even after its one year warranty. Not only that, I should be able to print report remotely and automatically to both the centres without the need for human intervention at that end. Finally, the project started in the last week of July. First, OsiriX server was installed at my main centre (the configuration of the server is unbeatable and most powerful than any other Windows server in the country). Secondly, we installed iMac with minor upgrades at auxiliary location as the client machine for auto upload and local viewing. Finally, we chose a local cable ISP and fortunately his specifications matched our technical requirements. Then, we configured the point-to-point connectivity between these two

points using reliable and economical CISCO solution. We set up a web-server connectivity and inter-centre connectivity with the help of static IP’s. We used mail print solution because it saved us investment in costly IP printer and static IP plus additional security. Within a week, my whole new solution was ready and it is working flawlessly since nearly three months now. The following objectives were achieved with the help of this endeavour: 1) Automated image transfer from auxiliary centre to main centre, without human intervention. (separated by approx. two km) 2) WEB access on i-Phone/iPad and Windows desktop at my home 3) Advanced post processing at each end possible (Auxiliary main centre and at home) 4) No security compromise in any of the place and no more irritating virus issues 5) No recurring cost except for internet connectivity cost 6) Remote printing of reports to any place without using costly IP Printer 7) Auto workload distribution to other junior doctors from server 8) Digital signatures with due security 9) Sharing studies with referring physician on demand Finally the wait for Applebased tele-radiology solution is over, thanks to Shreeji Scan Services and their dedicated effort to understand the needs of today's radiologists and provide them with acustomised solution as per their needs. I hope that this cost effective solution keeps helping not only the radiologists in metros like Mumbai, but also at remote places. I hope that Shreeji Scan Services, would continue the good work, and always focus on the innovation and customisation trend, that they have started, rather than focusing on only selling standalone OsiriX Workstations.


T|R|A|D|E & T|R|E|N|D|S

‘Myrian is used by more than 2000 users every day’ Patrick Mayette, Co Founder and General Manager of INTRASENSE informs about his company’s association with Modi Medicare, Myrian - a multimodality workspace launched by his company, its various features and applications; as well as the changing dynamics of the Indian radiology market Can you tell us about Intrasense and its association with Modi Medicare?


Co Founder and General Manager of INTRASENSE

INTRASENSE has been closely working with the company Modi Medicare, and its CEO Jigish Modi, for more than two years. Modi Medicare’s expertise on our Myrian platform means high service quality for our Indian customers.

Tell us about Myrian and its applications for radiologists, surgeons and clinicians in their daily practice. INTRASENSE develops a new generation of advanced software solutions for the review and analysis of medical images. Our Myrian platform is a full-fledged multimodality workspace with a user-friendly interface and features not only high level functions, but also powerful protocols to optimise clinical workflows and boost productivity. A comprehensive set of original clinical modules are available as options for liver, lung, colon, vessels, breast, heart, vessels and brain. The XL-ONCO module is the most advanced oncology follow-up application on the market. These applications are a key asset for radiologists, surgeons, oncologists and specialists: ● They improve the efficiency of image reading and the accuracy of diagnosis ● They support surgery and therapy planning and assessment ● They allow the early and accurate evaluation of a treatment

What is the USP of Myrian? Myrian is the first true multimodality workstation in the market with the capacity to combine, compare and process images from several modalities simultaneously.

How has been the overall market response to Myrian in the Indian market? Indian market is a huge market and we have seen very good response on very specific needs as liver postprocessing diagnosis at the

Myrian is the first true multimodality workstation in the market with the capacity to combine, compare and process images from several modalities simultaneously. Myrian also adapts itself to the exact needs of each user and hospital This is essential to allow the comprehensive analysis of patient information, particularly in chronic diseases. Myrian is also a very versatile and customisable platform that perfectly adapts itself to the exact needs of each user and each hospital. It seamlessly fits in the hospital information system (PACS, RIS, modalities) to enhance its capacity. Its modularity allows step-by-step investment. It is available in workstations as well as in application server configuration.

Today, we can see a very large scope of opportunities, from equipping PACS companies with advanced visualisation software to answering to global tenders with server base software.

Can you share with us some significant achievements over the last few years, global or in India?

How are you poised for growth in the near future?

Today, INTRASENSE serves over 500 customers including prestigious university hospitals in over 25 countries. Myrian is used by

market.The high-level of medical education and massive investments in the healthcare infrastructure are strong drivers for growth


PRO (Basic CR/DR Workstation) ADVANCED (Double oblique MPR/ MIP, CPR, etc.) EXPERT (3D Workstation) EXPERT VL (3D With Volumetry W/s) XL-REGISTRATION (Elastic Registration) XL-4D NAVIGATOR




What are the opportunities and bottlenecks in the Indian radiology market for your business?

beginning. With all the new equipment on CT and MRIs, India has overcome many high challenges and is now targetting very high-end modules such as Brain MR and Cardiac MR.

We believe that India is a high potential


more than 2000 users every day. Our outstanding technology and our fast growth have allowed us to introduce the company on the NYSE Euronext market in February 2012. This is a key asset to accelerate the development of our platform and our presence in strategic markets such as India. We believe that India is a high potential market. The high-level of medical education and massive investments in the healthcare infrastructure are strong drivers for growth.

Our platform is very well accepted on the global market and regarded as a competitive alternative or complement to modality vendors’ workstations as well as a smart way to enhance existing PACS installations. With three major product launches every year, we move fast to offer state-of-the-art technology to our users. Myrian XL-ONCO for cancer therapy evaluation or Myrian XP-LIVER for liver surgery planning are considered as the best solutions in their categories. On October 15, 2012, we will launch Myrian XP-BREAST, the most advanced breast MRI viewer on the market, with outstanding reading performance and smart clinical workflows and post-processing features. Combined with high quality services, these solutions will continue to drive our global growth and market leadership as the most innovative visualisation software company.



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Quality administrator From medical technologist to the ISQua international assessor, Neeraj Lal has traversed a long path in a short span of 15 years to establish himself as one of the most reliable, efficient and respected hospital administrators in Gujarat. He takes a stroll down memory lane, with M Neelam Kachhap ablo Picasso once said 'action is the foundational key to all success'. In healthcare, success comes after years of toil and hard work. At the hospital, success is even more elusive for those who are not doctors. For Neeraj Lal, CEO, BAPS Shastriji Maharaj Hospital, Vadodara, success came after much struggle and tough grind. This small town boy has helped set up many leading healthcare organisations in Gujarat and steered them to success. After finishing schooling from Roorkee, where his father worked (IIT Roorkee) and where he was brought up, Lal graduated in medical technology from Post Graduate Institute of Medical Education and Research, Chandigarh. A good student, he won the Aikat Memorial gold medal for best outgoing student in PGI in 1996. However, life as medical technologist was difficult as there were very few job opportunities. This was 1996, and the era of successful corporate hospitals was about to begin. Apollo hospitals had just started their hospital in Delhi. Luckily, Lal got a job at the Indraprastha Apollo Hospital and this career move stirred him towards hospital administration. “Although, I was busy and had a lot to learn, I wanted to do something more,” says Lal. On the insistence of then HOD Dr Sangita Rawat and his father, Lal joined Tata Institute of Social Sciences, Mumbai to gain a Masters degree in hospital administration. His administrative career began in 2001 at the Shri Krishna Hospital & PS




Medical College, Karamsad, Anand as senior executive. He then moved to UN Mehta Institute of Cardiology & Research Centre, Civil hospital, Ahmedabad as CEO. “My first interaction with government officials and secretaries was at UN Mehta hospital. I learned government policies and protocols there,” explains Lal. His next big assignment was with SAL Hospital & Medical Institute, Ahmedabad where he worked as senior manager operations. “At Sal hospital, I implemented HIMS and RFID technology for ease of operations,” he recounts. After a brief stint at Sterling Hospitals, Ahmedabad and Vadodara as head, business development his next halt was Shalby Hospitals, Ahmedabad. “I lead the team at Sterling and Shalby Hospitals for

elment of PSU, private sector corporate, national and international insurance companies,” Lal proclaims. At Shalby Hospital, Lal spent five years in various senior administrative roles. “I left Shalby as Senior Vice President. I headed the operations, quality, academics and strategic alliances. I was instrumental in getting NABH,NABL,ISO and various awards in healthcare including prestigious Rajiv Gandhi National Quality Award, FICCI Healthcare Excellence Award and Emerging India Award for the hospital. I even started academics in the hospital and courses like DNB Ortho (first in Gujarat), Fellowship in Pain Management and Critical Care Medicine,” he says. At the same time he was also the accreditation coordinator for NABH and

NABL and a certified internal auditor for ISO 9001:2000. Getting the title of Assessor for International Society for Quality in Healthcare Care- ISQua Surveyor on the International Accreditation Programme (IAP) based in Ireland (2011) was the proudest moment of his life. “Quality in healthcare is my passion and that cultivated my further interest to get involved in Global Healthcare Quality System in order to contribute to the Indian accreditation and quality enhancement as quality to me is a journey and constant improvement,” he affirms. “I think quality is the vehicle which passes through each and every corner of the hospital. After gaining experience in each and every aspects of hospital administration, I thought of entering NOVEMBER 2012

L|I|F|E in healthcare quality in 2005 and did some course, workshops with WCI, JCI and finally applied for ISQua as International Surveyor from India. They accepted my request and profile during January 2011 and made me ISQua international assessor for three years. Dr Gayatri Vyas Mahindroo, DirectorNABH and Dr Girdhar Gyani, CEO-NABH was instrumental in guiding and mentoring me for ISQua,” shares Lal. He is also associated with various institutes and universities for teaching programmes in hospital manage-

ment as visiting faculty and external examiner. Some of these are Ahmedabad Management Association (AMA), All Indian Institute of Local Self Govt (AIILSG), Ahmedabad, CM Patel College of Nursing, Civil Hospital, Gandhinagar, Jotiba College of Nursing, Bhandu, Hemchandracharya North Gujarat University, Patan and IIPH Gandhinagar Other than administrative duties, Lal does not forget his social duties. Apart from helping various small clinics and dispensaries streamline their operations he also finds

Mixed Bag Your motto in life- To excel, higher and higher for healthcare delivery system Your first day at work- At Apollo Hospitals corporate office in Delhi. I remember climbing stairs up to 8th floor as lift was out of order The first time you fired somebody- Cannot say Your happiest moment -When I got married to Neha 2007. Three things you cannot do without- Neha, self-confidence and news paper One trait that you would like to change about yourself –I would like to get rid of little bit of anger sometimes Your first vehicle- My father gifted me a second hand Bajaj Super scooter after I got my first job and which is still with me parked in my garage One parental advice that you remember- Even if you grow to a higher level in your career, always stay connected and communicate to your old teachers, friends and associates.

Neeraj Lal with his family

time to teach underprivileged children through the Teach India programme, an initiative by The Times of India. His family consists of wife Neha Lal who is General Manager with GCS Medical College, Hospital & Research Centre in Ahmedabad and three and half year-old son. “My strength is my wife, who has given me encouragement

throughout my career and equally responsible to make my profession life memorable as a whole. We have worked together in many hospitals in same areas.” Lal like to spend off-duty time playing badminton, reading business magazines and listening to all-time hits of Kishore Kumar.

People Steve Doswell joins Ekohealth as Chief Market Development Officer


teve Doswell has joined Ekohealth Management Consultants as Chief Market Development Officer. Doswell has been COO of America Online (AOL), Canada and GM of Ericsson Canada. Of special relevance for Ekohealth is Doswell’s impressive history of working with start-ups in similar stages which Ekohealth is in now, and helping to develop them into commercial successes. Steve has already done this for three North American startup companies. All three of these companies were successfully sold to major North American corporations. His last company developed technology to allow for remote dispensing of prescription medicines through ‘ATM-like machines’ . Thus, Doswell is well connected to the healthcare sectors in India and South Asia markets. Dr Akash S


Rajpal, MD and CEO, Ekohealth said, "We are confident that Steve Doswell's rich experience will ensure that Ekohealth successfully progresses to next level." “Steve, being a senior industry leader, in North America was invited to review our social impact projects at NASA. He was quite impressed with Ekohealth's positioning, road map results to date and indicated an interest to work with me in making Ekohealth a central player in Indian healthcare. He has amazing past success stories with startups raising millions of dollars leading to IPOs. His interest in Ekohealth, his excitement with the model and his belief that I was in right place at right time was a great boost to my confidence. Steve has a great feel for the state of Indian healthcare from his time opening up South Asia, includ-

ing India for the PharmaTrust remote dispensing systems. I am exceptionally pleased that he has come on board. I am sure his presence will boost the company’s leadership and enable us to take the vision of affordable health and ethical healthcare facilitation forward to commercial success”, he further added.

Dr Akash Rajpal recently won the prestigious Ramanujan Bose Social Impact Award for 2012 by NASA Singularity USA for his Ekohealth initiative. Giving his views on the Indian healthcare market and his vision for Ekohealth's expansion plans, Doswell expressed a keen desire to be a part of the progression of healthcare in the country, “India has excellent private health facilities and physicians. However, the established systems of referrals and pricing of medical procedures hinders economic efficiency. Additionally, patients in India seem to be considerably less willing to consider alternative treatments, seek second opinions from physicians, compare prices of procedures and substitute generic for brand drugs than patients in North America, Europe and other regions of

Asia. All of these factors represent artificial barriers to economic efficiencies in matching supply to demand and realising the benefits of competitive forces. As a result, patients in India are clearly paying a higher cost of healthcare then they would under a more open economic environment. I think that it is fabulous that Ekohealth is working to provide its members with the tools and information to precisely tear down these barriers and to empower patients to make decisions which will reduce healthcare costs without negatively impacting quality. I absolutely believe that this is a great model for India and I see no reason why virtually every Indian citizen who desires to use private healthcare services, whether having health insurance or not, would not be a member of Ekohealth.”




People Trivitron Healthcare gets new director of Innovation & Education


rivitron Healthcare recently appointed Dr GS Bhuvaneshwar, an acclaimed researcher in the development of medical devices such as tilting disc heart valve prosthesis as its Director of Innovation & Education. The “Valve man”, Dr Bhuvaneshwar, joins Trivitron Healthcare with an objective to lead the company’s new initiatives in innovation and education. He also aims to strengthen the company’s manufacturing base, thereby helping them to become India’s leading medical device company. He will be housed in the new R&D center in Science Park in IIT Madras and will also be overseeing all the R&D collaboration initiatives between IIT Madras and Trivitron Group. Prior to joining Trivitron Healthcare, Dr Bhuvaneshwar headed the Biomedical Technology

Wing of Sree Chitra Tirunal Institute for Medical Sciences & Technology, Trivandrum since 2000. He had been associated with the Biomedical Technology Wing since its inception in 1976. Commenting on the occasion Dr GSK Velu said, “Being part of Chitra Heart Valve and several other indigenous medical devices innovation and commercialisation over the past three decades Prof Bhuvaneshwar brings along with him deep knowledge in medical devices R&D and product commercialisation process. He will be heading all the R&D initiatives in Trivitron with specific focus in Cardiology, Imaging, Diagnostics, CLSS and Ophthalmology. Trivitron Healthcare would not have got anyone better to lead the Innovation and indigenous initiative to drive the vision of improving access

and affordability of medical technology products with specific focus in cardiology, Imaging and In-Vitro Diagnostics.” With Dr Bhuvaneshwar’s leadership, Trivitron group is planning to bring in multiple medical technology devices, medical instruments, in-vitro products through domestic innovation initiatives in collaboration with reputed Indian academic institutions and MNC medical technology companies. Trivitron is working towards original patent, IPs in the areas of primary health, focused in retinal screening device, innovative cardiac positioning system to aid the cardio-thoracic surgeons, Anti-Biogram device for rapid culture sensitivity testing and few other innovation initiatives in association with academic and medical research institutes.

Dr Sanjay Oak takes over as VC, Padmashree Dr DY Patil Vidyapeeth


r Sanjay N Oak has assumed charge as Vice Chancellor of Padmashree Dr DY Patil Vidyapeeth (Deemed to be University) from October

3 this year. He began his duties by receiving the University Mace (Gyan Dand) from the Ex Vice Chancellor Dr James Thomas in a ceremony held at the Vice Chancellor's Office. On this occasion, Dr Oak said, “After a long innings of 26 years in the public sector, I opted to take the reins of a deemed to be university. This is a momentous occasion and a very thoughtful decision. It will be appropriate to say that the decision has come to me from the head rather than from my heart. Having witnessed and experienced, various issues in health and educational sectors, I feel that the educational process should be student-cen-

tric. Learning is a continuous process and should not end by mere acquisition of a degree. Padmashree Dr DY Patil Vidyapeeth is not going to be my “workplace” but it has become my “home”. The environment of Vidyapeeth will now be full of seminars, symposia, workshops and guest lectures by eminent scholars. We shall lay emphasis on “Learning Together And Growing Together”. Ours is perhaps the only campus which can take pride in the fact that we have an International Stadium next door. The innovative courses in sports need to grow still further and our Vidyapeeth will give a boost to it. I close my address

by offering my heartfelt regards to the Governor of Tripura, Padmashree Dr DY Patil and pledge that I will serve the Vidyapeeth with interest, integrity and ingenuity and keep the Vidyapeeth’s flag flying high.” Dr R Gopal, Director, Dean & HOD – Dept of Business Management said, “With the new leadership of Dr Oak, we will not only scale the 4th National Conference on Health & Hospital Management (HOSPIFINMARK – Hospital Finance & Marketing, November 24 2012) but also introduce many new healthcare industry-beneficial courses. Thus, we hope to rise beyond

skies under the new flagship.” “We are highly honoured to have such great leaders. They are a continuous motivation for us and they force us to activate each grey cell within us,”said Dr Nitin Sippy, Assistant Professor and Course -InCharge – Health & Hospital Management. Dr Nandita Palshetkar, Member of Board of Management and renowned gynaecologist and IVF specialist attended this occasion at the University Nerul Campus, along with all directors, trustees and professors and faculty members who welcomed Dr Oak to the University.

Duru Shah: Empowering the women of India


r Duru Shah, Scientific Director at Gynaecworld, became the first Indian gynaecologist to be bestowed with the international FIGO Distinguished Merit Award in Rome. She received this prestigious award during the opening ceremony of the World Congress of the Obstetrics and Gynaecology held in October, 2012. FIGO is the International Federation Of Gynecology & Obstetrics instituted for more than 20 years now.The award is awarded to only three deserving candidates globally, once every three years. Commenting on this latest achievement, Dr Shah said, “This award means a lot to me.



I feel both honoured and blessed to be India’s first recipient to receive this prestigious award. It is a sign that my work is appreciated and this gives me the impetus to do more.” Dr Shah is reputed to be an ethical gynaecologist for over three decades. She is also known as the female crusader of the healthcare sector and has spearheaded successful women's health programmes, mainly in the hinterlands of India. Being the President of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), in 2006, she also initiated many social programmes like ‘Growing up’ - the urban adolescent empowerment project

which educated approximately five million girls in India on adolescent reproductive and sexual health, ‘Kishori’- the urban slum-based adolescent empowerment programme in Dharavi and a rural maternal health programme - ‘Save the Mothers’ . Academics is another area that interests Dr Shah. She has been the Chairman of the Indian College of Obstetricians & Gynecologists, the academic arm of FOGSI. She has initiated educational programmes such as the ‘Satellite School’ in association with the Indian Space Research Organization at FOGSI, the Post Graduate Review Course at ICOG, and the Post Graduate Quiz at the

Indian Menopause Society. She is presently working as the Director of “E-Tutorials” a web-based educational programme for post graduate students in ObGyn. She has authored more than 100 publications. A peer reviewer for many journals, she is also on the editorial board of ‘TOG’ by the Royal College of Obs & Gyn, the ‘Climacteric’ by the International Menopause Society and ‘Menopause International’ of the British Menopause Society. Dr Shah’s passion has always been preventive health, especially in young girls and women, with combating sexual abuse, especially in young girls,

being a new focus area. Her overall aim is to empower Indian women as they are the ‘mothers of tomorrow's children’ and thus she feels her efforts ‘really take care of our future’.







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