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Aligning business and healthcare in India

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Contents 12 18

24 COVER STORY Hospitals are adopting strategic cost cutting measures to stay afloat

BULLETIN 10 This month's important news

TECHNOLOGY 26 A few leading hospitals share


details about their unique PET CT.

INFRASTRUCTURE 18 Appropriate furniture selection

COMMENT 34 One needs to adopt an inter-

helps reduce patient anxieties, integrate patient-centered care into every corner of a facility’s environment.

personal approach with patients.

OPINION 24 Medical educational institutions around the world are making efforts in transforming the way education is delivered, says Prashant Mishra.



TREND 36 Home healthcare startups are bringing in the most advanced care at the patient’s doorstep.

IT 39 Medical data is one of the most sensitive information cyberattackers can steal.




Astute strategies The unswerving efforts of the Government to shackle the private healthcare sector with stringent regulations have never been this acute, not in the last two decades. After the NPPA capped the price for stents and orthopaedic implants, the Government has demanded the prices of drugs and consumables to be capped as well. If stifling regulations shrinking profit margins were not enough obstacle to growth, the implementation of the New Minimum Wages Act in a few states has increased the cost of manpower substantially. While healthcare is perceived to be a highly profitable venture, the truth is many hospitals are bleeding and devising strategies to trim cost and stay afloat. Our cover story focuses on these innovative methods that mega groups have been compelled to devise to improve on operational efficiency. Going forward, as the Government further plans to tighten the noose around private healthcare, it are these pragmatic strategies that would help the organisations tide over the current crisis. But how many small sized private healthcare set-ups in tier III cities would still survive or investment would be pumped in such locations is anybody’s guess! The Government think thank needs to understand the complexities of running private healthcare set-ups, that most affording patients prefer over public set-ups, and adopt a far more moderate approach to regulating cost of care in private set-up.

Rita Dutta Editor

JULY 2018 • VOL 6 • ISSUE 10

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Jiva Ayurveda partners with Airtel under BharatNet programme Jiva Ayurveda has partnered with Bharti Airtel under the flagship BharatNet programme of the Department of Telecommunications (DoT) to make quality healthcare services available to patients in rural India. Under the partnership, Airtel and BharatNet have already set up three Broadband Experience Centres in three villages in Uttar Pradesh viz: Ghazipur, Gorakhpur and Varanasi. Airtel has committed to partner with BharatNet in up to 30500 Gram Panchayats. Airtel will provide 100 mbps connectivity to these Broadband Experience Centres. Through the Centres, villagers in rural settlements will get access to digital and web-based services such as online health consultations, online banking and ecommerce. Airtel and BharatNet have partnered with Jiva Ayurveda for online health consultations. Dr Partap Chauhan, Director, Jiva Ayurveda said, “Jiva Ayurveda is a leading Ayurvedic treatment service provider company which runs the largest telemedicine centre in the world for Ayurveda. We are pleased to partner with Airtel and applaud the efforts of DoT in this breakthrough and ambitious initiative of BharatNet. Connecting the 2.5 lakh Gram Panchayats will ensure that affordable, quality healthcare becomes accessible at the complete grassroots level.”

Dr Partap Chauhan

CANCON 2018 sets guidelines for head and neck cancer

SMT’s biodegradable polymer coated stent study

The second edition of CANCON 2018 witnessed participation from over 250 delegates and faculty, who deliberated over a period of two days on ‘Improving Outcomes in Head and Neck Cancer – Oncological, Functional and Beyond’. CANCON-2018, organised by Cytecare in association with The Foundation for Head & Neck Oncology, Association of Otolaryngologists India Bangalore Chapter, and others, saw deliberations on establishing consensus guidelines for improving outcomes in head and neck cancer. Dr Vikram D Kekatpure, Senior Consultant, Head and Neck Surgical Oncology, Cytecare Cancer Hospital, said, “There is a need to develop consensus guidelines for a holistic approach to improve outcomes for head and neck cancer patients, with greater emphasis on functional rehabilitation and quality of life.”

SMT (Sahajanand Medical Technologies Pvt. Ltd.) has announced the successful clinical study result of their Biodegradable Polymer Coated Supralimus SirolimusEluting Stent(S-SES) in India. The result came from an observational and retrospective study that was carried out in 346 patients with a follow-up compliance of 94.5% (327 patients). The aim of the study was to assess sevenyear clinical outcomes of biodegradable polymer coated Supralimus Sirolimus-Eluting stent at Shree BD Mehta Mahavir Heart Institute, Surat. The principal investigator of the study, Dr Atul Abhyankar, Interventional Cardiologist, said, “The present study is the first ever longest study conducted on biodegradable polymer coated SES." The interesting part of this study is that there is a high percentage of follow-ups of patients which has shown satisfactory and sustained seven-year clinical outcomes suggesting long-term benefits of biodegradable polymerbased SES, he added.




Anil Kumble launches diabetes campaign former cricketer and Padma Shri awardee - Anil Kumble along with the team of DMDSC, Dr V Mohan, Dr Ranjit Unnikrishnan and Dr RM Anjana took the pledge to defeat diabetes. “Unfortunately there’s a lot of diabetes cases everywhere in India,” said Dr V Mohan, Chairman & Chief Diabetologist, Dr Mohan's Diabetes Specialities Centre. “We are taking ‘Let’s Defeat Diabetes’ initiative to every part of the nation to spread Anil Kumble took the pledge to defeat diabetes. awareness, as diabetes is taken very lightly in our country, despite the fact that it is the The power to defeat diabetes lies in our seventh leading cause of death in India. The hands. With this message, India’s leading progression from pre-diabetes to diabetes diabetes experts, Dr Mohan’s Diabetes can be stalled successfully if the individual Specialties Centre (DMDSC) launched adopts a simple BLUE formula i.e. Blood ‘Let’s Defeat Diabetes’ - a public initiative Checks, Lifestyle changes, Understanding that aims at educating the individuals in your food and Exercise. With proper treatKarnataka about diabetes. This initiative ment plan and lifestyle modification, paencourages people in the state to undertients can live a long and disease-free life.” stand their risk of diabetes and take the Commenting on this initiative, Anil pledge to adopt healthy practices that Kumble said, “India is at high risk for helps in defeating diabetes not just for diabetes and we need to address this imthemselves but for others around them. mediately. Every one of us needs to take Extending their support to the cause, steps to manage it.”

Global Hospitals, Mumbai, completes 250 liver transplants The liver transplant team from Global Hospitals, Mumbai, has successfully completed 250 liver transplants over a span of four years at their facility. The multi super specialty tertiary care hospital currently performs three to four transplants in a month. “Global Hospitals, Mumbai provides a comprehensive set of treatments and diagnostic procedures for the treatment of various disorders related to liver. We are staffed with team of globally recognised liver and pancreas surgeons, nurses and technicians. We have the best facilities for

all endoscopic and colonoscopy procedures. Working with other specialists, our doctors provide consistent and seamless treatment to all the patients suffering from various liver diseases,” said Manpreet Singh Sohal, Regional COO, Global Hospitals. Currently, India is at a stage where organ donation awareness needs to done at a community level. Liver diseases are one of the least recognised causes of mortality in India. Experts are of the opinion that less than 10% adults and less than 8% of children are in need of liver transplants.

First anti-aging centre Smart Metabolic Anti-Aging Centre, a futuristic and preventive healthcare centre, based in Saket, is the latest addition to New Delhi’s buzzing wellness and healthcare landscape. A unit of Gujarmal Modi Hospital & Research Centre (GMHRC), the anti-aging centre is a first-of-itskind metabolic and functional wellness clinic in India, focusing on reversing metabolic damage caused by aging. Heralded as a one-stop solution to age-related and lifestyle diseases that are common today, the centre specialises in reversal of diseases like diabetes and also fat loss through a holistic yet non-invasive approach. Its treatment methodology has been designed to deliver tangible results in just two weeks. The latest offering from GMHRC led by Dr BK Modi (also Founder-Chairman, Smart Group), follows his mantra of “helping people be Happy, Healthy and Wealthy beyond 100”.




Cut Cost, Grow Stronger Hospitals are adopting innovative strategies to bring about operational efficiency and counter the erosion of margins due to price capping BY RITA DUTTA





he private health sector in India has come under intense scrutiny in recent times for lack of transparency in pricing. To course correct, the Government has been taking several steps to usher in transparency in pricing and make healthcare more affordable, whether it is capping price of stents, implants and other consumables. The Delhi government has proposed regulations that would restrict hospitals and nursing homes from marking up prices of several medicines and consumables over 50% from their procurement price in a move to curb alleged profiteering. The DOP report has observed that high trade margins enjoyed by distributorshospitals/ retailers are the main reason for cost escalation of drugs including medical devices. It has been notified that margin escalation has largely happened between the Price to the Hospital & MRP (the price at which the hospitals buy and then sell the medical device to the patients). According to experts, the headwinds affecting healthcare profitability in the current times are probably the highest in the last two decades. Says Dr Lloyd Nazareth, COO, American Oncology Institute, “There is an erroneous perception in Government and the general public that healthcare organiations are highly profitable. Many large organisations are struggling to get fair returns on capital.” Many big private healthcare organisations such as Fortis Healthcare have reported losses quarter on quarter. Says Ashish Bhatia, COO (North & East), Fortis Healthcare, “The creation of a healthcare infrastructure is expensive, gestation periods for recov-

ery are typically long, about 5-7 years for an operational breakeven and 15 years for recovery. Estimated investment approaches 1 crore per bed including all the facilities and expertise as per globally accepted standards. There are no special tax benefits for private hospitals. There is no formal industry status for us to enable us to advocate for our concerns and put forth suggestions or recommendations.” According to him, there is no large scale profit for hospitals as is widely believed. “For the sake of argument, one might say that the revenues of private healthcare delivery service have multiplied over the years but overall profitability margins are extremely low, given the multiple costs incurred. It is to be noted that healthcare service prices in India over the last decade have also remained muted, lower than inflation and much below those in the neighboring countries of Singapore, Thailand and Malaysia,” says he. Despite the rising costs of healthcare services, private hospitals continue to be a convenient target, even as return on capital employed (ROCE) is between 10%-20%. This is just enough to plough back into the business – high upfront capital investments, gestation period and turnaround time – despite optimising efficiencies. Today, 68% of hospitalisation in urban areas and 58% in rural areas are through private establishment – in the absence of public health services providing quality care, the gaps are filled in by private health care service providers. “But popular public perception is that the over-reliance on private hospitals allows them to charge substantially more than Government hospitals. But this would be true for other sectors as well. The Government is playing the role of a strict controller rather than an enabler. Regulating hospital prices in a generalised manner might put the hospital chains in smaller towns out of business, which will end up denying patients required care,” says Bhatia. Hospitals are facing high cost pressure on various fronts. Firstly, in a growing economy,

Rajit Mehta, MD and CEO, Max Healthcare

Ashish Bhatia COO (North & East), Fortis Healthcare

1. There is no large scale profit for hospitals as is widely believed.




2. Hospitals are having a serious look at manpower utilisation.

the number of well trained specialists and super-specialists coming out per year is inadequate for the needs of the economy. Due to this shortage, there is great pressure on doctor costs. “One is not able to open hospitals in many tier III and tier IV towns simply due to non-availability of critical specialists. This shortage is artificially created, as there is ample scope to increase the number of training positions in the country,” says Dr Lloyd. There is compensation pressure in most other verticals of the healthcare industry including nursing, technicians and other support staff. In some states, the minimum wages are revised substantially every six months, but the same states revise Govt Scheme tariffs only every three to five years. GST and weakening Rupee are likely to put pressure in equipment as well, lament experts. Steps to Reduce Cost Operational transformation that can lead to 8 to 15% increase in topline can happen by reducing manpower by 7 to 22%, materials cost by 12 to 20% and other costs by 20 to 30%, says P Neelakannan, Group COO, KIMS. The key steps adopted to reduce cost




and enhance operational efficiency without compromising on quality are: Centralised Services: Many hospitals have been centralising service to reduce cost of operations. Max Healthcare, for instance, has been engaged in centralising HR, finance, and some other departments through automation. It is scouting for a Shared Resource Centre in Delhi NCR where these share services would be housed. Says Rajit Mehta, MD & CEO, Max Healthcare, “We have already centralised many functions like billing, collection, clinical protocols and these have reduced manpower cost substantially.” Even cancer care specialist, HCG, uses centralised services to reduce manpower cost. Says Dr Ajai Kumar, chairman, HCG, “Centralising the use of physicists for radiation treatment has saved us from hiring a group of physicists per centre and brought about operational efficiency.” The group has a pool of 40 physicists who are used as a part of centralised services. Right-sized Hospitals: Hospitals will have to be right sized in terms of square feet per


operational bed, IP room sizes and spend per operational bed. With the exception of a few markets, experts feel, there is no potential to create lavish or five star hospitals. “As a rule of the thumb, I recommend a 12-15% reduction in cost per bed and sq ft per bed as one moves from a tier 1 to a tier 2 city and similar 12-15% reduction as one goes from a tier 2 to a tier 3 city. With a bit of innovation in design, material used and type of equipment procured one can create viable projects which can provide quality healthcare. Many hospital designers and planners are not focussed on this and, as a result, so many projects are simply non -viable from day one,” says Dr Lloyd. No frills Hospitals: According to experts, the revenue that the hospitals are making is just enough to invest in technology but not enough to upgrade infrastructure for go for fancy interiors. Several groups are going back to the “No frills hospital” concept. “This is rather unfortunate as so much was happening in the area of hospital design, aesthetics and many hospitals were comparable to international hospitals in terms of service levels. The policy of premium setting by insurance companies is focussed in most part on only having lowest pricing by hospitals and the lowest premium for the customer,” says Dr Lloyd. Supply Chain Management: At a time when there is only so much that one can do to keep manpower costs under control this is an area where most organisation can get substantial benefit by focussing on efficiencies in supply chain. There are ample examples of organisations that have improved EBITDA by 3-5% by a strong focus in this area. Standardisation of formularies and supplies across the entire network can bring enormous procurement efficiencies across these networks. Also, standardisation of use of material for common procedures can bring great benefit.” I have seen large organisation where between centres of the

3 same network costs of material per angiography vary between Rs 1000 to Rs 4000, angioplasty from Rs 5500 to Rs 15,000 and cardiac surgery from Rs 22,000 to 35,000, dialysis from Rs 400 to Rs 700. These are standard high volume procedures and standardised material usage and cleaning and sterilisation techniques can bring great value to organisations,” says Dr Lloyd. Working capital needs to get unlocked by tracking inventory holding days. In a mature hospital, as a rule of thumb, one should keep inventory holding between 25-35 days. Holding above this guzzles working capital and holdings below this probably indicate that one is not ordering Economic Order Quantities and one can face problems of Stock-Outs. “One needs to have an efficient system for regular tracking of non-moving stock and dead stock. Most hospital administrators are frightened to deal with the problem of dead stock as it will mean some write off from their books. As a result, the dead stock is often kept alive, sometimes for many years so that it has zero value when finally written off,” points put Dr Lloyd. Service Mix Optimisation: Several groups are paying more attention than ever beforeon specialities that have a higher ARPOB. “Rather than offering a holistic mix of services, we need to emphase on services that generate more revenue. And we need to price as per our expertise,” says Neelakannan. Working Capital Management: At a time

P Neelakannan Group COO, KIMS

3. Supply chain is one of the key strategies to reduce cost.




when a significant part of the business of most organisations is Credit Business from Insurance, Corporates and Govt Credit Schemes, organisations need to focus greatly in this area. There are many large organisation where working capital can be as high as 30-40% of their entire debt. Most organisations under resource their receivables teams both in numbers as well as calibre. “A crack team at each location headed by a fairly senior finance professional can make significant differences in accurate billing with maximisation of revenue collectible, reduce discharge to bill submission time, vigorously follow up on payables, reduce bill returns for clarifications and reduce disallowances,” says Dr Lloyd.

Dr Lloyd Nazareth COO, American Oncology Institute

4. Hospitals are going for on-line prescriptions to prevent revenue leakage.

Restructuring Debts: Some groups negotiate hard with existing lenders to give a better rate of interest or switch over to a competitor that gives a better rate. KIMS, for instance, keeps at looking at reworking interest rates of existing lenders. “A penny saved is a penny earned,” says Neelakannan. Effective Manpower Utilisation: With 40 to 45% of topline being manpower cost, its effective utilisation is a key area. After implementing the new minimum wages act




in healthcare, hospitals in a few states are spending a few crores every month mainly on nurses. According to experts, if one analyses most jobs, one sees that large part of the roles and functions of that job can be pushed to employees, one and even two levels lower. It is useful if every organisation in a structured and calibrated manner analyses each job and look for opportunities to do this to reduce manpower costs. If done in a structured manner, one can train internal candidates take on higher roles. This activity most often creates career progression for internal candidates who can be retained at a lower cost as compared to lateral hires. To counter the effects of high manpower cost in nursing, KIMS Hospitals has started employing several patient care assistants who help the nurses with non core work like mobility, bathing, and others for patients. According to a study done in KIMS, it was found that 35-38% of nursing time was spent on non core areas. Hiring these patient care assistants has sustantially reduced the spend on nursing. Hospitals have also been cautious about hiring when a vacancy is created. They prefer hiring internally or maximising the use of existing manpower. It is getting increasingly difficult for


5 hospitals to get adequate numbers of junior and middle grade doctors. "Having in house programmes for post graduate programmes, Fellowships and Certificate programmes go a long way in creating a more stable and more affordable pool of doctors who man the emergencies, ICUs and wards," says Dr Lloyd. As doctor cost contribute to 16 to 22 % of overall manpower cost, some hospitals that had full-time consultant are re-looking at doctor utilisation. “We are looking at a fee for service model as a part of the package for doctors,” say Neelakannan. Manpower costs in housekeeping and security personnel even if outsourced keep spiralling due to frequent six monthly increase in minimum wages in some states. It is important to focus on bringing efficiencies in these areas by using automation and central transport pools of staff. “I find that a ratio of about 0.8 housekeeping staff per occupied bed acts as a good benchmark for the number of housekeeping staff required in a hospital at maturity. In most organisations one finds that security staff are deployed without

giving due thought to the actual purpose of their deployment,” says Dr Lloyd. Plug Revenue Leakage: To plug revenue leakage from pharmacies, many hospitals are issuing digital prescription. “The prescription is not hand written. One has to collect the prescription from the pharmacy and this prevents revenue leakage in a major way,” says a senior leader. As many patients are discouraged to stand in long queue to procure medicine, Max Healthcare has started delivering medicine to the patient’s doorstep without any further charge. The group is also using digital prescription. To prevent revenue leakage in terms of low IP conversion, hospitals are taking help of IP counselors to explain tariff to patients. Doctors guide patients to these IP counselors who explain various packages with the patient. “The IP cousnellor calls up the patient to follow up and understand his concerns. If cost is a prohibitive factor, we try and re-work the package to suit his budget,” says Neelakannan.

Dr BS Ajai Kumar Chairman and CEO, HCG

5. There are many large organisation where working capital can be as high as 30-40% of their entire debt.





New-age furniture Experts opine on the shift from comfortable to connected furniture BY TEAM HR

H 1. Paediatric divisions have evolved into a fun and frolic like environment.


ospital furniture, when rightly designed, aids mobilisaton of patients, enhances mobility of transport, and reduces the workload of care givers. And when poorly designed, it can cause discomfort and even risk to patients like entrapment and bed sores, which result in prolonged hospitalisation. And non-ergonomic furniture could result in occupational injuries including back injuries and related problems for caregivers. Below is expert opinion on the evolving trends in hospital furniture:


Sudheera Mure Associate DirectorInteriors, KGD Architects


hoosing the right furniture is important to create an environment that invite, comfort and heal. Uncertainty is a shared experience for patients and healthcare facilities can be unsettling places for them. From the moment they arrive,


throughout their stays and on follow-up visits, patients are making assumptions about the care they would receive and are seeking reassurances. Healthcare environments play a critical role in how patients interpret the quality of their treatment and view their overall experiences. By creating a healing, nurturing environment, a healthcare facility can enhance its patient-centric care. It can ensure each patient’s comfort, privacy, dignity and respect and help build lasting patient relationships. Appropriate furniture selection helps reduce patient anxieties, integrate patientcentered care into every corner of a facility’s environment and create an uplifting, healing spaces for patients. It increases efficiency of the staff performance and restorative for workers under stress. If furniture is uncomfortable, then it’s likely the one thing that patients will remember about their entire healthcare experience. It causes discomfort and longer recovery period, leads to loss of trust about the quality of service offers by the hospital and has an impact on overall experience. Before choosing furniture, one should look at safety. Easy use without staff as-

sistance as well as quality, modality, ease of maintenance, built to withstand the rigors of 24/7, optimising patient care areas footprint, breathable fabrics that offer antimicrobial and stain-resistant properties and evidence-based design are some of the traits one should look at while selecting furniture. With time, hospital furniture has evolved and contributed towards making healthcare facilities into more welcoming than inhibiting environments. Every day, healthcare teams provide tender care, promote health and wellness while addressing other realities of healthcare—the demands of changing demographics, increased consumer expectations, heightened environmental concerns while assimilating emergent technologies. In response, healthcare construction and furniture needs are rapidly evolving. The facilities of yesterday look nothing like the facilities of today, and that surely will look nothing like facilities of tomorrow. Earlier, waiting rooms used to look and feel like holding pens, designed to seat most patients in as little room as possible and provided a few physical or emotional comforts. Lack of privacy due to chairs was lined up in orderly rows from end to end,

2. Besides comfort, furniture shall meet age-old requirements such as durability and ease of cleaning.





3. IP rooms with basic furniture have been replaced with multi-purpose furniture.

preventing patients from being able to look at one another. Some would sit, some stand, but no one looked comfortable. In present hospitals, these spaces offer a smooth transition from physical pain and emotional uncertainty to vital information and relief. Group seating with integration of landscape, privacy panels, individual hand rests makes the patient/ visitor more comfortable and no longer waiting periods is called as painful. Private rooms were modest and simple area just catering for patient’s privacy, treatment and recovery, but not anymore. These have evolved into places of residential aesthetics, zones of comfort enabling faster healing, soothing and make patient experience like home. At the same time, the furniture needs to meet age-old requirements such as durability and ease of cleaning. In modern healthcare, the family is integral to healing process. From the limited access available earlier, these places have transformed into family-friendly facilities with comfortable waiting areas and private lounges. IP rooms with basic furniture have been replaced with multi-purpose furniture/ space enablers, integration of modularity and storage solutions without compromising efficiency. In the era of nuclear families, a patient’s family is no longer confined to immedi-




ate ones like spouse/ children/ parents but includes extended multi-cultural families as well as friends as a patient’s care-giving community. In response to these needs, healthcare facilities are actively incorporating designs to accommodate newer family dynamic, cultural push factors and psychosocial influences that enable increased family involvement in patient care. This shift impacts the types of furniture required in various locations – such as waiting areas and patient rooms. The role and the positive impact family members can have on their loved ones during healing process is immeasurable. As a result, healthcare institutions have transformed into hospitality, rest and recuperation zones in tune with the needs of new-age patients. This has resulted in the introduction of living-room like furniture such as sleepers, gliders and recliners. The paediatric divisions used to be zones without many add-ons and this has evolved into fun and frolic like environment with interesting furniture with bright and vibrant shades and play areas, enabling children to forget about the illness. Gynaecology room furniture has progressed from functional to comfort furniture to minimise stress and discomfort due to longer waiting hours. Most facilities currently do not focus on dedicated furniture for bariatric patients. In the past, occasional severely obese patients were handled on an ad-hoc basis with existing hospital equipment, reinforced as needed. Keeping the sensitivities of this class of patients, facility and furniture designs have evolved to provide ultimate goal for bariatric patients- which is independence and strength. With newer custom design approaches, bariatric patient and accompanying visitors’ reluctance to use standardsized weaker furniture has given way to an uninhibited use of waiting and patient zones furniture, providing well needed comfort. Patients and visitors seating arrangements have been replaced from row-based


to cluster based to enable social interactions. Seat which are too low make it difficult to stand without assistance. Seating furnitures are being provided with grasp points on front of the arm, providing a stable platform or push point. A seat that pitches forward assists patients with a safe exit from the chair. Newer and efficient designs of furniture for support staff enables increased efficiency in the demanding work environs. Some of the current work furniture trends are task seating, desk seating, height adjustable tables, integrated filing and storage cabinets, etc.

Sameer Joshi AVP – Marketing (B2B) Godrej Interio


ospital acquired infections (HAI) accounts for almost 80,000 deaths world over per year. With overcrowding rates being high in India, the percent of cases reported in India is higher as compared to many other countries. Healthcare furniture can play a role here in limiting the HAI. In addition to basic function of supporting the patients healing and facilitating caregiver activities that help heal patients, hospital furniture can assist limiting incidence of HAI. With patient care and safety as top priority, one should attempt to fight the use of bacteriostatic additives in our ICU products. What we also observe that caregiver fatigue is major cause of medical errors. A well-designed furniture can play role in lessening the efforts needed by caregivers, thereby reducing the fatigue. Godrej Interio has been working on integrating newer technology in hospital furniture that saves the caregiver time and effort from their everyday activities. The Indian market is developing and rap-

4 idly maturing when it comes to healthcare. Earlier focus of healthcare furniture design was on basic functionality. Cost was also essential element of design. Healthcare needs to be affordable. For instance, majority of hospital beds in India are manual sheet beds. This is with contrast to developed markets where majority are motorized beds with electronic controls. So, I would say cost and functionality was the main driver of the furniture design. This has evolved with focus shifting to patient care and caregiver comfort coming to centre stage in furniture design. Poorly-designed products are also a leading cause for HAI. The poorly designed hospital furniture can impact patient’s safety including patient fall and injuries. It also has a major impact on caregiver comfort and wellness, thereby can contribute directly to medical errors. Similarly, health workers commonly complain of injuries while lifting or moving patients. These issues can be tackled with due consideration when designing products with features like a zero-transfer gap or motorised functions in ICU beds. In some cases, the above hazards could even be fatal, which is why this is an Industry with very stringent regulations, norms and standards for furniture designing. The global standards being followed while designing hospital furniture are Harmonized Standards- IEC 60601-2-52 for safety & essential performance, EN ISO 13485: 2012 medical devices for quality mgmt. system,

4. Poorly-designed hospital furniture can impact patient’s safety including patient fall and injuries.




5 EN 908:2008 for graphical symbols, ISO 14971: 2012 for risk management of medical device, IEC 60601-1:2005 for medical electrical entrapment. The trends in hospital furniture has moved over years from good furniture to comfortable furniture. It is now moving to connected furniture. Trends over the years have evolved in a pattern that leads to caregiver efficiency by using newer technology like sensor for weight management, remote healthcare, finer electronics, cloud technology, etc. A connected hospital would use these and more. A connected hospital would have wireless technology that integrates all the medical devices in the hospital, leading to accurate patient records and real-time data analysis. This would also reduce time required for caregivers in maintaining patient’s records, and these gained efficiencies can be utilised for providing quality care to patients.

5. The OPD usage at maternity hospital mandates comfortable, spacious seating for pregnant women and mothers with newborn.


Dr Mudit Saxena CEO and MD Ovum Hospitals


urniture in hospitals has become an integral part of the value proposition in patient care. It sets the level of expectation amongst patients the moment they step into the lobby of a hospital. Apart from de-


fining the positioning, it also plays a major role in the outcome and comfort level of the patient during his stay. An inpatient spends maximum time on a bed at a hospital which accounts for over 95% utilisation during his or her stay. The outpatient area is utilised by a large number of patients and their attendants visiting the facility. They use services at consultations, lobby, phlebotomy, physiotherapy etc. While the inpatient area caters to 24 hours of patient comfort and monitoring, the outpatient area witnesses a huge turnover of customers in limited space and time. The furniture design and specifications differ for each area. The inpatient area focuses on beds with their accessories required for patient care, various patient-positions and maneuverability. The attendant cot has to be equally comfortable. The outpatient area demands furniture which should not only be durable and strong, it needs to be comfortable and aesthetically in sync with the ambience. This area serves as waiting zone and the furniture design should ensure that the personal space of patients is not encroached upon. Some of the key criteria to focus on while procuring furniture would be the department where it would be used, the warranty on product and maintenance required for the upkeep of the furniture. Areas like ER and others require quick transfer of patients along with multiple attachments, hence the beds or trolleys have to be sturdy, efficient in design as well as light to handle by caregivers. This is applicable for the inpatient beds, too. The furniture design needs to ensure that there are no sharp edges. Sometimes, the elevators turn into limiting factor because of poor designing. This may affect the size specifications of patient trolleys and cots. The delivery of furniture on time is critical for running smooth operations. Apart from that, we need to focus on the


warranty and after sales support for the furniture. The availability of spares may become a challenge, resulting in certain expensive and critical furniture pieces to be inoperative. The supplier credentials as well as payment terms and conditions are very important. Peer review serves as a good source of information for benchmarking and procuring furniture. Some manufacturers may extend a period of trial for a few pieces of furniture to assess the functionality of their product. This feature is very common at airport lounges where many sellers display their products as part of sales strategy as well as to showcase the durability of their product. Many a times, the buyers get carried away with some unique features of the furniture which would be rarely used. This leads to needless investment and exceeding the budget. The furniture for different areas and specialties differ. In general, for OPDs, the seating needs to be comfortable and spacious – for patient and their accompanying attendants. It should respect a patient’s personal space and should allow easy accessibility to maintain and manage it. Shifting and cleaning of the furniture is a regular feature undertaken at outpatient areas. In orthopaedics and physiotherapy areas, seat sizes are larger to accommodate patients with support. Same is observed at birthing centres addressing the needs of pregnant women. Some special requirements are desired for lactation needs and baby care of newborn. The paediatric centre usually caters to a younger age group with colorful furniture and accessible seating. At present, OPDs at many hospitals and centres are focusing on soft seat sofas and lounge chairs. Beds for bariatric centre are designed differently. They need to withstand weights above 250 kgs and are wider in size. For orthopaedic units, beds need special attachments. Similarly, ICU and HDU beds have elevation modalities and additional attach-

6 ments features. At many daycare centres like dialysis and chemotherapy units, beds have been replaced with foot elevating relaxing chairs - lazy boys. Ovum Hospitals offers Maternity, Gynecology, Neonatal, Paediatric and IVF care. The OPD usage mandates comfortable, spacious seating for pregnant women and mothers with newborn. So, the furniture design has to keep newborn needs in mind such as lactation rooms and baby diaper change rooms. For paediatric age group, we prefer colorful, safe and accessible seating. The inpatient rooms have appliances like microwave and refrigerator. The bed for mothers are spacious to accommodate the newborn with call bells etc attached to the bed. The elevation of these beds are electrically controlled. The rooms have a provision to accommodate a bassinet for a new born. The NICU for newborns requires warmers and incubators. All these equipment need to have warranty and safety features. The future of furniture in healthcare will focus on space saving designs with multipurpose functions. Already voice controlled features have been introduced in room amenities. The same is expected to extend to furniture - to bring down costs on nursing and hospital assistants as well as ease of functionality.

6. Furniture in hospitals has become an integral part of the value proposition in patient care.




A paradigm shift Medical educational institutions around the world are making efforts in transforming the way education is delivered BY PRASHANT MISHRA


T 1. Investment in a robust research pipeline acts as the driving force for any academic institution.


he quality of education in a country is a strong indicator of the economic and social development. Education is an area driven and influenced by public policy, and affects the entire human capital of a nation. This is all the more true for medical education. The quality of medical education in a nation influences not only the state of the healthcare workforce, but also the population healthcare and development indicators. Medical educational institutions around the world are making efforts in transforming the way education is delivered by redesigning curriculum and incorporation of current learning technologies. A few of the challenges that beset medical education today are outlined below: Research Output A study published in 2016, tracked the


research output from 579 Indian medical Institutions between 2005 and 2014, and compared the results with some of the most prestigious medical centres in the world. It was found that only 4.3% of the institutions produced more than 100 papers a year. Around 57.3% of the medical colleges did not have a single publication during this period, thus highlighting the state of medical research in the country. Investment in a robust research pipeline acts as the driving force for any academic institution, spearheading innovation, creation of new technologies and intellectual property. Sub-optimised research efforts compromise funding and manpower both, amongst other things. Inadequate research publication skills such as inappropriate research designs, unrepresentative samples, incorrect methods of analysis, and faulty


interpretation all adversely affect the quality of research. Doctors in India have to manage multiple demands on their time: clinical responsibilities, administrative duties, handling a high volume of patients, leaving them with very little time for research. However, research and publishing are important activities in the life of a clinician. Continuous Medical Education Continuing medical education remains one of the most important sources to maintain and update clinical competence and learn about therapeutic advances. CME acts as a support system to help clinicians to continuously improve their practice and offer better care to their patients. Online CME platforms offer a multitude of benefits, including flexibility in time and place over traditional CME interventions. The availability of online, learner-centred CME tools helps clinicians diagnose their learning needs and choose the learning pathway most appropriate for them. However, it is important that doctors exercise their option to learn from accredited CME providers. Learning from credible, reputed and accredited healthcare providers provides credibility to the learning content and ensures the clinicians of the authenticity of learning materials. Clinical Decision Support Systems In a study published in 2016, it was observed that if medical error was a disease, it would be the third largest killer in the US. A Harvard University study in 2013 estimated that 5.2 million injuries occur across India each year (out of the 43 million globally) due to medical errors and adverse events. In another study, it was pointed out that primary care consultants in India allocate around two minutes per patient consultation. Synthesising expert opinion, evidence and incorporating patient considerations at the time of patient consultation might be cumbersome, but is important nonetheless.

2 In this situation, to offer optimum medical care to patients and avoid any adverse event, it becomes essential that clinicians utilise tools and resources right at the point of care. Clinical Decision Support Systems (CDSS) aid supplement clinical decision making—in which the characteristics of an individual patient are matched to a computerised clinical knowledge base and patient-specific assessments or recommendations are then presented to the clinician or the patient for a decision. The Way Forward The need for imparting fair, value based medical education is greater than ever before. The use of accredited learning resources, reputed international course interventions for supporting research and incorporation of evidence in clinical decision making would help support the cause of medical education in a long way.

Prashant Mishra is Managing Director, India & South Asia with British Medical Journal.

2. The need for imparting fair, value based medical education is greater than ever before.




User Speak A few leading hospitals share details about their unique PET CT BY TEAM HR


ET-CT imaging system is moving toward low radiation and better imaging. By identifying body changes at the cellular level, PET

may detect the early onset of disease before it is evident on other imaging tests. Here’s a look at the PET CTs of a few leading hospitals:

Aster Medcity Type of PET CT being used: The group uses Time of Flight (ToF) PET CT with 16 slice from Philips - Philips TruFlight Select at Aster MIMS, Calicut and Aster Medcity, Kochi. Procedures for which PET CT is used: • Whole body PET CT Scanning using FDG • PSMA PET CT scanning using Gallium 68 • Ga-68 DOANOC PET CT for Neuroendocrine tumours • Simulation procedures for radiotherapy planning Number of patients that use PET CT on a monthly basis: Around 175 Type of isotope used: Fludeoxyglucose , FDG (F 18) and Gallium 68



Steps to ensure quality of clinical outcomes by using PET CT: Staging and care of plan, during treatment interim PET CT, change protocol based on it Eg: lymphoma, end of treatment - evaluate the efficacy of chemo/RT . plan for continual treatment, follow ups. Says Gopinath M, Chief Medical Physicist, RSO & Senior Manager Operations, Aster Medcity, Kochi, “PET CT has an important role in the entire course of treatment starting from staging and developing a plan of care, to know the response during treatment and post treatment and for follow-ups.” Onsite or Offsite Cyclotron: Offsite. “We have a Cyclotron facility in Ernakulam (Molecular Cyclotrons) and in case of non availability, we procure from Bengaluru,” says Gopinath. Precautions taken to ensure safety of personnel manning the department: a) Continuous training on safety aspects Sensitising, Awareness and safe handling b) Qualified staff c) Personnel Radiation Monitoring services d Personnel Radiation Protection Equipments e) Facility Design - Fume Hoods / Delay Tanks / CCTV Monitoring/ Structural Shielding etc f) Spill management mechanisms and


personnel decontamination facilities like eye wash/ shower etc g) Access control to the Nuclear Medicine Facility - Double lock mechanism h) Strict adherence to Regulatory guidelines and protocols (AERB / IAEA ) Trained personnel manning the department: a) Nuclear Medicine Physician: MD in Nuclear Medicine Dip NB in Nuclear Medicine Diploma in Radiation Medicine Fellow in European Board of Nuclear Medicine b) Medical Physicist and RSO L III MSc in Radiation Physics / RSO L III certi-

fication from AERB PG Dip in Radiation Physics c) Nuclear Medicine Technologist DMRIT (Diploma in Medical Radiation Isotope Technology) B.Sc MRIT Suggestion to make PET CT more affordable: Says Gopinath, “Having a cyclotron in the city or nearby areas reduces consumable cost and ensures more equipment utilisation. To improve utilisation, one can make referral pattern with peripheral hospitals than increasing the number of PET CT units in same city. Also, R&D in developing indigenous PET CT reduces the capital investment."

American Oncology Institute Type of PET CT being used: Discovery IQ 3-Ring 16-Slice PET CT, manufactured by GE Healthcare. The 1st PET CT of the group, Discovery-600 from GE installed, was installed in Hyderabad in 2011. According to Nilesh Gupta, Zonal Director, American Oncology Institute, “Currently, we have five installations of these PET CTs in South Asia and about 8-10 more will get installed at various locations over the next 18 months.” Number of patients that use the PET CT on a monthly basis: About 300. Type of isotope used: Major consumption is of 18F-FDG (>95%) & few units of 18F-NAF. On-site or off-site cyclotron: “We do not have cyclotron either onsite / offsite,” says Nilesh. Procedures for which the PET CT is used: “In our institute, PET/CT is mainly used for performing oncologic whole body PET/CT studies (more than 90 %) for patients with diagnosed cancer. We also perform studies for diagnosing and understanding clinically challenging non-oncology diseases including PUO, vasculitis, sarcoidosis etc,” says Nilesh. It is performing FDG PET/CT, which is a proven diagnostic modality for:

1. Accurately staging the cancer and thus impacting the treatment plan in up to 15-45 % of patients (depending on type of cancer) as compared to conventional imaging 2. Better assessment of response to treatment 3. Identifying recurrence of cancer at early stages 4. Long-term surveillance of patients who received treatment for cancer 5. Diagnosing certain rare clinical conditions




in non-oncology patients that otherwise are not identified by conventional modalities (CT, MRI etc) Precautions taken to ensure the safety of personnel in the department: The departments are manned with personnel who are well-trained in radiation safety standards. They are equipped with all essential radiation safety equipment (radiation monitors, Lead aprons, lead bins, lead shielded doors etc.). “Also, we ensure that policies for standard operating procedures are followed strictly while handling radioactive material and radioactivity administered patients. An institutional radiation safety committee is constituted and meetings for appraising the safety status and updating the SOPs are

held at regular intervals,” says Gupta. Trained personnel manning the department: The departments are headed by a qualified and trained nuclear medicine physician, who supervises the work flow of the department. It also has: 1. A qualified radiation safety officer for supervising the safety and regulatory aspects, 2. Two trained technologists for performing the PET/CT studies and 3. Additional support staff trained specifically for handling patients scheduled for PET/CT (including a patient coordinator, dedicated nursing and housekeeping staff).

AMRI Hospitals Type of PET CT being used: Fluorodeoxyglucose (FD)PET-CT from GE at the Dhakuria unit of the group. It was first installed in 2011 which was first in Kolkata. Later, it was re-installed in October, 2014. PET CT is used for: For different type of oncological indication like staging, response assessment, detection of recurrences and re staging. However, in recent years, it has gained considerable attention in non-oncological purpose like detection for pyrexia of unknown origin, assessment of dementia



and cardiac viability. Number of patients that use the PET CT on a monthly basis: Around 100 patients. Type of isotope used: Fluorodeoxyglucose (FDG) On-site or off-site cyclotron: It has an offsite cyclotron at Rajarhat, Kolkata, established by a joint venture of EKO and Siemens. The cyclotron serves all the centres in Kolkata. Precaution taken to ensure the safety of personnel and the facility in the dept: Says Dr Anirban Mukherjee, Nuclear Medicine, AMRI, “The department has a dedicated radiation safety officer for nuclear medicine who ensures proper operation from radiation point of view. Regular training of staffs and concerned personnel has also been taken by the physician associated with the department.” Suggestion to make PET CT more affordable: Says Dr Mukherjee, “Decreasing the cost of FDG, the main isotope used for PET-CT, will help decrease the cost of PETCT. Also increase in the number of patients will help in decreasing the cost of the procedure.”

Embracing modern thinking

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Advancements in PET CT PET-CT designs have evolved due to improvements in performance of individual CT and PET components and enhanced software integration, says Rajib Karmakar



1. Asia-Pacific held the largest share of the market in 2016, followed by North America.


hat is driving the growth of PET CT market? The rise in incidence and prevalence of diseases, both malignant and non-malignant, infectious, Alzheimer, and cardio vascular diseases drive the market. In addition, the growth of geriatric population that is susceptible to taking medications for their wellbeing is expected to fuel the growth of the market. However, the high cost of PET-CT scanner is anticipated to restrict the market growth By geography, the global PET-CT scanner device market is segmented into North America, Europe, Asia-Pacific, and LAMEA. Asia-Pacific held the largest share of the market in 2016, followed by North America.


In addition, Asia is anticipated to be the fastest-growing regional segment during the analysis period. The key factors that drive the growth of the market include increase in pool of patient population, growth in prevalence of infectious and chronic diseases, and rise in government investments for the development of better healthcare facilities and R&D. Asia-Pacific is expected to emerge as the area with maximum growth potential due to the focus of key players in the emerging economies and improvements in healthcare infrastructure. Increase in Prevalence of Diseases In the past few decades, increasing prevalence of diseases cases have reached an


Large Pool of Geriatric Population The global geriatric population has increased significantly and is vulnerable to various diseases and disorders, such as cancer, Alzheimer, HIV, and cardiac disorders. Geriatric population is particularly vulnerable to various diseases and has a high incidences of acquiring diseases compared to other age group. The escalation in rate of the geriatric population is expected to raise the demand for diagnosis, thereby driving the PET-CT scanner device market. Technological Advancements Technological advancements in PET-CT scanner result in added features such as high image resolution and contrast, time-of-flight acquisition, improved large field-of-view imaging, low FDG dose and faster acquisition. For instance, in 2014, Philips developed the world's first and only digital PET-CT scanner Vereos PET CT systems, which enables scans within 5 mins, gentle system warm-up, automatic standby for reduction in power consumption, and have Guardian Program that predicts system issues before they occur and lowers cost related to unplanned downtime by 43%.

alarming proportion due to rise in morbid lifestyle. It is estimated approximately 46.8 million people worldwide were living with dementia in 2015. And this number is anticipated to increase to 74.7 million in 2030. According to the WHO, approximately 36.7 million people were reported living with infection (HIV/AIDS) worldwide in 2016. The high-tech imaging technology of PET-CT scanner provides early detection, accurate staging and localisation, and precise treatment and monitoring of the diseasesthereby giving patients a better glance of treatment outcome, disease detection, as well as avoid unnecessary procedures. This is anticipated to boost the market growth in the future.

How the PET CT technology has evolved? In the past years, PET/CT designs from all vendors have evolved, mainly because of improvements in the performance of the individual CT and PET components and enhanced software integration. The need for high-speed CT, driven mainly by the cardiology market, has seen the original two- or four-slice scanners replaced with 16, 40, 64 and 128 slices/rotation models, and also developments in PET crystal and hardware have resulted in improved lesion detection, efficiency and accuracy. PET CT design is continually being innovated. The newer technology enables more precise measurements of metabolic processes and data quantification, including assessment of neurologic disease, malignant, non malignant, infectious and cardiac perfu-




The newer technology of PET CT enables more precise measurements of metabolic processes and data quantification, including assessment of neurologic diseas infectious and cardiac perfusion and viability." sion and viability. In the past years, Time Of Flight (TOF) technology for PET is designed to enhance image quality by reducing image artifacts, providing higher sensitivity and lesion localisation (location of annihilation). Most recently, a new generation PET CT scanner has been designed based on detector technology, detector material and data acquisition methods called Digital PET CT system, utilising DPC (Digital Photon Counter) photodiode detectors that will further improve technical performance. The resulting images help clinicians better detect and locate lesions to increase diagnostic confidence and preserve healthy tissue during treatment with lower FDG dose and faster acquisition time. The hybrid technology has widely been accepted by oncologists, cardiologist and neurologists all over the world, thereby validating its excellent technical performance, clinical utility and scientific potential. So much so, in fact, the main imaging vendors in the market are no longer producing standalone PET scanners and, consequently, only PET CT machines are now sold new into the market. As a consequence of the great improvements in technology and growing evidence that a PET CT examination demonstrates superior diagnostic performance over separate PET and CT exams that are interpreted side by side, there has been significant growth in the usage of PET CT in



clinical practice. PET CT is the full-performance dualtechnology medical imaging modality. As such, it opens up a whole new dimension of possibilities for technological development in medical imaging. In which areas, is PET CT being used? PET scans are most commonly used to detect malignant and non malignant disease, infection imaging, cardiac viability and perfusion imaging (non-invasively) and brain disorders. The majority of these PET scans are performed to evaluate cancer using the glucose analog fluorine-18 fluorodeoxyglucose (F-18 FDG). In most cases, cancer cells are more metabolically active and divide more rapidly than normal tissues. By using radiopharmaceuticals that target physiological parameters such as glucose metabolism, PET enables imaging and quantification of cellular function and tumor detection. This approach has several potential advantages over anatomical modalities such as computed tomography (CT). CT imaging relies on size and architectural changes to diagnose malignancy, which limits sensitivity and specificity. How does one ensure quality of clinical outcomes by using this diagnostic procedure? PET CT is the full-performance dual-technology medical imaging modality in one umbrella and PET CT procedure covers whole body scan of the patients which includes from brain to mid thigh, the PET gives functional information of tissue while CT gives anatomical information of same tissue. On fusion of function, information image over anatomical tissue images results in dual function and exact location is obtained in one go and help in improving diagnostic accuracy and outcome which is quite difficult with standalone modality like CT, MRI and PET. What kind of trained personnel should man the department? PET CT scans require unsealed radiation


emitting isotope medicine (radiotracer) FDG, and from radiation safety point of view, always trained staff can work in such a facility. In India, regulatory body AERB, responsible to issue license to run such facility under the safety control, and regulations demand the presence of a full-time nuclear physician (DRM, DNB or MD in Nuclear Medicine), qualified NM Physicist (MSc Nuclear Medicine) and RSO (MSc Nuclear Medicine) approved by the AERB and entire facility should register under ELORA AERB with individual radiation professional identity number. What are some of the key challenges that a PET CT centre usually face? The key challenges that PET CT facility usually face are: 1. Infrastructure: There is a dedicated layout plan for PET CT facility from the AERB, the construction of such facility requires huge investment and step wise approval, and a mild deviation in the plan results delayed approval for machine installation. 2. Qualified man power: Qualified manpower is mandatory, otherwise the AERB won’t give license to run the facility and to procure FDG from the regional medical cyclotron centre. 3. Availability of FDG medicine: PET CT examination requires FDG medicine to perform scan and FDG is a radioactive medicine with half life of 110 min (it become half of its original value in every 110 min). The FDG preparation needs dedicated medical cyclotron machine which is three to fur times costlier than PET CT scanner, putting a cyclotron along PET CT is not viable due to cost reason, that is common in government setup but not in private set-up. There is a number of commercial cyclotron facility in different parts of India and every cyclotron facility supply FDG to 10 to 20 PET CT centres under the supervision of the AERB. Due to limited number of such cyclotron facility, many parts of India does not have

2 any PET CT centre especially in remote and rural areas. 4. Cost: One of the big challenge is cost, as a PET CT scanner itself very costly equipment and then there is infrastructure cost, qualified man power and running cost. 5. Regulatory policies: The AERB regulatory policies are very strict and violation as such results in license cancellation and it requires renewal of licenses and NOC on a yearly basis for any change in the practice cause delaying in license. What measures can be taken to make PET CT more affordable? In the recent past, a number of PET CT facilities has come up in different parts of India, and this has resulted in reducing cost. As per the current scenario, the PET CT cost is almost similar to MRI and CT angiography procedure,. Earlier, this was three to four times. Many new radio tracers which do not requires any cyclotron are coming to clinical practice and this might replace the FDG by about 50 to 60%, as NM researchers are claiming that every PET CT facility would be able to prepare medicine in-house and that is going to make the technology more affordable.

Rajib Karmakar is Business Manager, Computed Tomography & Advanced Molecular Imaging, India Sub Continent, Philips Healthcare.

2. Major imaging vendors in the market are no longer producing standalone PET scanners and, consequently, only PET CT machines are now sold new into the market.





Re-building trust While doctors see innumerable sufferings on a daily basis, we must try to treat patients with more compassion and empathy BY DR SHANKAR NARANG

D 1. It is important to adopt a more inter-personal approach with each patient.


o you completely, whole-heartedly trust your doctor? If this question was asked to a random number of people today, chances are a majority of them would reply in the negative. Unfortunate as it may sound, the erosion of trust between patients and doctors (and the medical system in general) is a glaring reality today. Reports of malpractices by medical professionals, lack of due diligence, and a growing perception that hospitals are out to extort money are some factors responsible for this trust deficit. The ability to heal and save a life puts a humongous responsibility on the shoulders of doctors. A minor oversight or a little error of judgment that can cause forgivable losses


for other professionals, can lead to loss of life when it comes to a physician. Physicians are even required to take an oath of ethical practice when they begin their careers. This practice dates way back to the Hippocratic Oath written between the third and the fifth centuries BC. Historically medicine was considered as one of the most noble professions and doctors perceived as gods of healing. Not so, any more! The Erosion of Trust In recent years, the field of medicine has witnessed a significant shift in India. With the emergence of corporate hospitals, there is a growing perception that doctors today are operating less for public service and more for


earning big bucks. Out of reach of a majority of common people as they are, the ‘five-star’ hospitals do not just charge for medical treatment but also for the ‘luxurious’ facilities they offer to patients and their attendants. The turn towards investigation-based treatment where doctors prefer to conduct a series of investigations before arriving at the diagnosis also, in a way, fuels the belief that physicians order many diagnostic tests just to help fill the hospitals’ coffers. Add to it daily news reports of malpractices, corruption, illegal dual practice and professional negligence, and the recipe for the trust deficit is complete. The Medical Council of India was recently disbanded and replaced by another organisation, following serious accusations of misconduct and incompetence. In fact, the Parliamentary Committee established to analyse the functioning of the Medical Council of India, in an seriously indicting comment, stated that ‘the instance of unethical practice continues to grow due to which respect for the profession has dwindled and distrust replaced the high status the doctor once enjoyed in society’. If the statutory body responsible for overseeing of medical education and ethical standards of doctors is indicted and thrown out, it would hardly inspire confidence among the people. Another seemingly minor, yet significant development has been the abundant availability of information on the Internet that often seeds doubts into the minds of patients viz a viz their medical condition and treatment. Asking ‘Dr Google’ during a treatment has become a common practice among patients, and contributes to them doubting the doctor’s prescription or ability to diagnose. In a nutshell, the trust-shaped hole in the doctor-patient relationship is a real concern today, and needs to be addressed with utmost honesty. Here is what we can and must do: Adopt a More Inter-Personal Touch Unlike a few decades back, patients are more aware and armed with a lot of information. Doctors must take this into account while

2 treating an individual. Here, it is important to adopt a more inter-personal approach with each patient. The requirement to accommodate more patients everyday, we must give sufficient time to hearing out patients. At the same time, effort must be made to explain the line of treatment being adopted, as also quell any doubts they have. Explain, talk more, listen attentively, even if you know the patient’s doubt is unfounded. More importantly, assure them with words and body language that they are safe in your hands. Be More Compassionate: While doctors see innumerable sufferings on a daily basis, we must try to treat patients with more compassion and empathy. Being empathetic allows you to treat a patient with dignity and this inspires confidence. It is equally important to be empathetic to a financially week patient and try to help him/her out in managing costs. This can be done by prescribing only generic drugs to such patients, as also by tying up with crowd-funding initiatives to seek financial aid. Rebuild Institutional Trust The corporates houses that are investing in the field of medicine must also pay attention to the need for catering to the middle and low income class as there is an imminent need to set up more and more no-frills hospitals. This will also help rebuild trust in the institution of medicine.

Dr Shankar Narang is Chief Operating Officer with Paras Healthcare.

2. Explain, talk more and listen attentively, even if you know the patient’s doubt is unfounded.





Redesigning healthcare Home healthcare companies are laboriously working towards bringing in most advanced care to the patient’s doorstep BY RAJIV MATHUR

1. Home healthcare startups have come up with quality service models facilitating medical services at the doorstep.



ndia has one of the lowest hospital bed to patient ratios in the world – 0.9 to 1,000, which is less than one third of the World Health Organisation norm of three beds per 1,000 patients. If you factor out the urban skew, the ratio deteriorates significantly to 1 bed per 6,000 patients! Add to this worrying scenario of the relatively high cost of high quality hospital


care (although quite competitive by global standards), and you have the makings of an exponential and growing need for affordable care @ home. Today, wellness and life-span are two metrics of a developed nation. Enabled by cutting edge medical technologies; R&D advances; remote diagnostics; robotics and artificial intelligence the face and shape of


critical care @ home is set to undergo a sea change. And that change – especially in the Care @ Home space - is being driven by start-ups. These startups are not just facilitating medical service delivery to patients across the country, but are helping in cutting down the cost of treatments, diagnosis and care@ home services. Other streams of healthcare startups include online pharmacy, medical tech, hospital automation, mobile health, telemedicine and many more.


ven after the Indian government’s extensive plans and projects for healthcare in India viz. NAM (National AYUSH Mission), IMI (Intensified Mission Indradhanush), PMSMA, National Health Mission, the Indian healthcare segment is severely ruptured. The anticipated results aren’t achieved by the Government and the medical care segment is still staggering. People are forced to rely on private hospitals for healthcare and treatments which is growing ever expensive by each day. The paradox prevailing in the Indian healthcare sector is its expensive line of treatment in spite of the country’s portrayal as a ‘medical tourism hub’. Private hospital contributes almost 74% of the total hospital in the country and the healthcare facilities are immoderately high to bear for the larger segment of the society. This critical situation is well handled with the introduction of innovative concepts and quality services by the home healthcare startups in India. Home healthcare startups have come up with quality service models, facilitating medical services at each doorstep and making it reasonably affordable for most of the population. Implications of the latest technological innovations and IT solutions give the extra edge to home healthcare startups and helps patients with the best treatment and medical assistance right at their home. Whether it is critical care or primary care of patients suffering from diseases, chronic or old-age, home health-

care startups provide dedicated medical care with medical electronics, doctors and nursing staff at the home where the patients can have safe treatment with homely comfort and family around them. The Indian healthcare segment is expected to grow at a CAGR of 16.28% and reach $372 Billion by 2022. In terms of revenue and employment, the sector has unsurpassable potential which needs right direction and proper exposure. Only less than 10% of the population have access to medical insurances in the country and the out-of-pocket private payments account for nearly 3/4th of the total medical expenditure on healthcare. These statistics are sufficient enough to express the stark contrast between the costs of private medical services and public earnings of the population. The recent entries of home healthcare startups have paved a new path that brings the latest medical facilities available at home for patients, and it doesn’t weight heavy on the pockets as well. The idea of making affordable treatment and care available at home, with ultramodern technological aids can ably revolutionise the healthcare and hospital industry in the country.

2. Some of them provide complete home health care services including hospital to home transits, doctor visits, coordination with the hospital, 24/7 nursing staff and medical attendant, and medical equipment.







3. The patientcentric service models developed by these ventures will ease the burden on the existing medical infrastructure.


ome of the startups have foresighted the gap between the medical facilities and home outreach and come up with the most innovative, practical and pocket-friendly solutions. They unify the elements required for critical care, medical expertise, medical equipment and along with the technological integration they succeed in providing hospital equivalent facilities at home. Just like the turnkey solutions of different business domains, these startups under the guidance of skilled entrepreneurs and visionary leaders, provide complete home health care services including hospital to home transits, doctor visits, coordination with the hospital, 24/7 nursing staff and medical attendant, and medical equipment. A dedicated network of doctors, physiotherapists, nursing staff, medical assistants and medical practitioners accounts for the prompt and the best-in-class services by home healthcare startups. Apart from the adept services and advanced facilities, they adroitly help to bring down the expenditure, by segregating the medical


services from hospital charges, which are affordable and economical. Home healthcare startups are laboriously working to bring in the most advanced technologies like telemedicine, Teleradiology, HIS (Hospital Management Information), EMR (Electronic Medical Records) and Intensive Medical Care and Monitoring Machines at the patient’s doorstep. The future of medical treatment and health ailments cure seems bright with the entry of home healthcare startups and the promising services offered by them. The patient-centric service models developed by these ventures will not only ease the burden on the existing medical infrastructure but also provide access to affordable, high quality critical care@home services to those in need.

Rajiv Mathur is Founder of Crititcal Care Unified (CCU).


Understanding cyber security threats In the world of cybersecurity, ‘prevent to protect’ is considered the most important maxim BY SEAN SULLIVAN


he now infamous WannaCry attack infected more than 2,00,000 businesses across the globe a year ago. One of the most prominent victims was the National Health Service (NHS) of the United Kingdom. In just moments, the attack took 45 NHS hospital groups offline and hindered about 20,000 appointments. Although no fatalities were reported, the largest ransomware attack in history was a clear signal that healthcare industry may not be prepared for increasingly advanced cyberattacks. In the world of cybersecurity, ‘prevent to protect’ is considered the most important maxim. We have to analyse the attackers’ Tactics, Techniques, and Procedures (TTPs) and pre-empt attack vectors or those vulnerabilities could potentially be used to

1 compromise a system or a network. Despite our increased awareness of network security, cyberattackers have time and again come up with new and more evolved tactics to counter the cybersecurity establishments. The Hitachi Payment Services hack, for instance, which subsequently affected about 32 lakh debit cards in India, used a malicious code that concealed its traces after every successive exploit. This made the code virtually undetectable. Imagine an attack like spreading from hospital to hospital. The results could be deadly. Vulnerability of Healthcare Systems Before we delve further, let us try and understand why the healthcare industry’s IT systems are so vulnerable to cyberattacks. Modern technologies have introduced

1. WannaCry attack infected more 2,00,000 businesses across the globe a year ago.




2. A single-point vulnerability can not only compromise the targeted system, but can also enable a cyberattacker to gain access to the broader network.

multiple layers of convenience, information accessibility, and functionality. For instance, medical records and patient history have become easily accessible thanks to digitisation. Unfortunately, this accessibility also amplifies the attack surface, creating easy targets for cyber criminals. An existing network vulnerability, or weak network node, could be used by a cyberattacker to gain access to vital private data. In addition to such prevalent vulnerabilities, multiple healthcare systems today are often being integrated with IoT technology. Technology that connects everything to the internet is exploding but it’s also bursting with unpatched vulnerabilities. There have been 70,000 known Common Vulnerabilities and Exposures (CVEs) discovered and many more that have not been identified yet. The Mirai Botnet Attack or Dyncyberattack-- which caused service disruption of leading technology giants such as Amazon. com, Twitter, Airbnb, Netflix and PlayStation Networks among others -- was driven by compromised IoT-enabled devices such as network cameras, baby monitors, and residential gateways. The use of IoT technology in absence of adequate counter measures is




a security concern that will only get worse. In India, cybersecurity risks directly threaten economic development. Digitisation of medical records is still at an early stage in the country, especially amongst government institutions, but the initial steps are often being taken without ample concern for vulnerable perimeters, advanced TTPs, and exploitable attack vectors. A single-point vulnerability, say within an IoT-based system, can not only compromise the targeted system, but can also enable a cyberattacker to gain access to the broader network and navigate within it easily. And these attacks can be launched from almost anywhere around the globe. Malicious insiders can also breach Electronic Health Record (EHR) systems. Unauthorised access has to be expected in India’s large-scale hospitals, which have a long history of security lapses. Recently, a 19-year old medical aspirant was booked for impersonating as a doctor for five months in one of the nation’s renowned medical institution. The person had established himself as a doctor and made acquaintances across departments and participated in multiple events ranging from strikes to marathons


during this ‘fake’ tenure. His original identity was revealed only after fellow doctors became suspicious at a hospital event. Today, medical professionals are also taking advantage of remote technologies that enable them to monitor and control individual medical systems. These systems can also fall prey to such cyberattacks. There are cases in which telnet servers have been found running with weak password credentials. These credentials can be discovered through trial and error or by using brute force techniques. The healthcare industry falls in direct line of sight of DDoS attacks that overwhelm systems until they’re inoperable. DDoS attacks often also leave residual elements such as viruses and malwares that can further mar the integrity of a network. Tackling DDoS attacks, which at present average at around 10GB peak rate, is becoming increasingly difficult in the light of terabitlevel attacks that have lately stated to the surface. The Dyn cyberattack that we’d earlier discussed was a terabit-level attack. This year alone, GitHub and Arbor Networks confirmed two terabit-level attacks. Web application attacks, similarly, can compromise backend data and potentially reveal damaging information. These threats are terrible when they target sensitive data but when they target IoT devices directly responsible for patient care, they could be life threatening. Why Healthcare is Targeted Medical data is some of the most sensitive information cyberattackers can steal. Ransomware compromises a device or a system and prevents its access through encryption and demand ransoms for decryption and giving access. Hospitals infected with this threat often end up paying. Why? Any organisation that experiences a cyberattack faces bad press but ransomware is even more dangerous for an institution’s reputation. In these attacks, sensitive customer or operational data can be compromised and seized and that makes it impossible to

3 conduct day-to-day processes. Stolen information can also be sold over the dark web, putting the identities and personal security of the affected people at a considerable risk. And as India integrates an array of services linked to the Aadhaar database, these attacks may even risk national security. The Indian healthcare industry, as of now, is worth more than $160 billion and will reach over $280 billion by 2020. This makes the nation’s healthcare industry a massive target for global cyberattackers. India, as a nation, is experiencing rapid digitisation and such transformation is more evident amongst government bodies which are late to the IT revolution. The speed of digitisation will certainly leave multiple vulnerabilities in the bureaucratic infrastructure. Advanced cyberattackers are aware of these developments and hunting for weaknesses. Even if cybersecurity staff is able to find and fix a majority of vulnerabilities, cyberattackers can still wreak havoc. Understanding the threats growing along with a growing hospital network infrastructure is imperative. If we are not able to improve cybersecurity within the healthcare industry, we’ll not only experience significant financial losses but can ultimately also experience loss of life. And that’s a risk no one can take.

Sean Sullivan is Security Advisor at F-Secure.

3. Medical data is some of the most sensitive information cyberattackers can steal.




Knowledge sharing platform The seminar was attended by pathologists, physicians and clinicians



1. Dr. (Col) Arun Harith addressing pathologists at TSS Delhi.


ransasia BioMedicals Ltd., India’s leading In-vitro diagnostic company, recently organised a scientific seminar in East Delhi on the latest advancements in biochemistry and hematology for laboratories. Titled Transasia Scientific Seminar (TSS) Ace, this pioneering academic initiative aims at encouraging the exchange of technical know-how among doctors. The seminar focused on biochemistry and hematology - two of the most critical areas for in-vitro diagnostics. The session on ‘Effective Use of Database Systems by doctors’ by Dr (Col) Arun Harith (Sr Consultant & Head of DepartmentBiochemistry, Medanta Medicity, New Delhi) highlighted the growing need of database for improving test outcomes. On the other hand, Dr (Col) Jyoti Kotwal (Chairperson & Prof.- Dept. of Hematology, Sir Gangaram Hospital, New Delhi) spoke on ‘Clinical Utility of Advanced Hematology Parameters.’ She emphasised on how the latest automation in hematology helps in enumeration of the different parameters such as IPF, Ret He, Immature Granulocytes, NRBC, etc. and how these parameters help in early diagnosis of diseases. The sessions were chaired by Dr Meera Sikka, Head of Dept.- Pathology University College of Medical Sciences. Transasia offers the entire range of semi and fully automated analysers and reagents in biochemistry and hematology. The latest in clinical chemistry is a fully automated, random access clinical chemistry analyser,


XL 1000 with a throughput of 1040 tests/ hr. It offers a host of key features such as sample clot detection, permanent hard glass cuvettes and four channel direct ISE measurement, among others, making it an ideal choice for high volume labs. The seminar received an overwhelming response with full-house participation. The over 70 attendees comprised pathologists, physicians and clinicians from reputed Government institutions such as Delhi Cancer institute, IHBAS, Swami Dayanand Hospital, Rajiv Gandhi Super Specialty Hospital, Hegdewar Hospital, LBS Hospital and private institutes such as MAX Healthcare, Kailash Healthcare Ltd., Yashoda Super Specialty Hospital, Dr Lal PathLabs, Metropolis, SRL Diagnostics, etc. Speaking on the occasion a spokesperson for Transasia Bio-Medicals Ltd, said, “There is an alarming burden on the society from both communicable and non communicable diseases in India. Around 70% of the treatment decisions are based on lab results. Yet, less than 30% of the Indian population has ever got their blood test done. The major chunk of the 70% population is in the smaller towns. At Transasia, we are committed to reaching out to the pathologists and clinicians in every nook and corner of the country, so that they are well equipped to cater to this population. TSS Ace is a unique platform that empowers the pathologists with the technological advances and encourages exchange of scientific updates, backed by expertise and experience." Over the years, TSS Ace has grown in popularity and has become Transasia’s identity. It has been well accepted as a successful forum and benefits more than 800 pathologists and clinicians annually.


A new milestone Apollo Hospitals celebrates life with over 1,500 BMT patients


pollo Hospitals, India’s first multispecialty chain of hospitals, reached a new milestone with over 1,500 successful Bone Marrow Transplant (BMT) procedures conducted on patients across the Apollo Hospitals Group. The 1,500 patients treated at Apollo BMT units have come from all over India including Chennai, Mumbai, Delhi, Kozhikode, Gujarat, West Bengal as well as from foreign countries like Oman, Bangladesh, Sri Lanka, Tanzania, Dubai, UAE, and Mauritius. Apollo Hospitals, Chennai was the first hospital to conduct India’s first cord blood transplant and unrelated transplant, and the 1500 BMT landmark carried out successfully across the group hospitals endorses the success of these high end procedures for both children and adults with survival rates comparable to western centres. Bone marrow transplantation saves the lives of patients with blood cancer and serious blood disorders like thalassemia major, aplastic anemia and primary immune deficiency. Commenting on this milestone, Dr Prathap C Reddy, Executive Chairman, Apollo Hospitals Group said, “I am glad that our team has helped over 1500 patients from across India as well as abroad to celebrate life and win over life threatening conditions through a Bone Marrow Transplant. For us, this number is just one milestone

on our journey of healing. Though we have come a long way from the first successful BMT at Apollo in 1995, there are many more patients who are in need of BMT. It is extremely important that people come forward for bone marrow donation and help save more lives.” Sharing his thoughts, Dr Ramesh Nimmagadda, Director, Medical Oncology, Apollo Cancer Centre said, “Our patients come to us with a sense of hope and it is with joy and a sense of fulfilment that we are celebrating over 1500 lives on this occasion. It is not just a milestone that our team has achieved here, but more than that it is an occasion to celebrate the courage, determination and spirit of the patients whose age ranges from 6 weeks to 68 years! Innovation, technology, teamwork and dedication at the hospital have enabled us to take the lead in BMT.” Equipped with highly qualified BMT team, and stringent infection control norms which are critical for BMT patients, BMT treatment is available across the Apollo Hospitals chain at Chennai, New Delhi, Hyderabad, Ahmedabad and Kolkata. Apollo Hospitals was the first corporate hospital in India to perform the procedure in 1995. Today, the BMT procedure performed at Apollo for over 40 different conditions have resulted in over 1500 people celebrating life.




Preclinical PET-MR workshop PET-MR has proven to be highly effective in health research


n interactive preclinical PET-MR workshop with demonstrations of a new 7T integrated PET-MR multi-modality imaging system from MR Solutions and presentations from participants was held in Dijon recently. The Cancer Center Georges François Leclerc (CGFL) organised the event in partnership with the UK based PET-MR supplier MR Solutions to launch a new user group in preclinical PET-MR. The event was very well attended by around 60 users from the MRI imaging communities across the world - Europe, Asia and the United States. Many were existing PET-MR users who shared their experiences with the group. PET-MR has proven to be highly effective in health research. The workshop focussed on key areas including the benefits of using PET and MR imaging of tumours, hearts and brains in rodents for oncology, cardiology and neurology research. There was also much discussion on the use of multimodality tracers in PET-MR and optical imaging to improve visualisation results. The benefits and differences between several of the latest preclinical imaging



techniques was examined including simultaneous PET-MR and sequential PET-MR. This combination of options has been increasingly taken up by labs across the world as MR Solutions’ multi-modality scanners become the machines of choice. Multi-modality imaging combines MRI for the exquisite structural and functional characterisation of tissue with the extreme sensitivity of PET imaging for metabolism and tracking of uniquely labelled cell types or cell receptors. Professor Alexandre Cochet, head of the Department of Nuclear Medicine at the CGFL commented, “The development and use of advanced technologies such as preclinical PET / MRI requires a great deal of collaboration between users. This workshop has fulfilled our expectations as it has led to the formation of a new user group to advance PET-MR imaging, with support from MR Solutions.” Fabrice Chaumard, Director of Sales and Marketing at MR Solutions, added, “We have always been driven by the demands of the leading researchers and we are really grateful to The Cancer Center Georges François Leclerc for hosting this really stimulating meeting. There is no doubt that these meetings have a significant role to play in improving imaging which translates into better research.” The CGFL and MR Solutions are partners in the Integrated Magnetic Resonance and PET Preclinical Imaging (IMAPPI) consortium which validated a first prototype of sequential PET-MRI in 2012-2014. MR Solutions is the world technology leader in preclinical, cryogen-free MRI scanners with multi-modality capability and continues to roll out technical innovations to advance imaging capability. The company has offices in the UK, North America and Asia as well as a network of agencies across the world.



Affordable diagnostics Providing new means of affordable access to diagnostics is no small task BY ARUNIMA PATEL


pertinent problem currently faced by Indian healthcare industry pertains to the access of diagnostic healthcare in rural India. There is utter lack of good and well functioning licensed laboratory services in rural India. Laboratory services that are present in the rural India are marred with shortages of pathologists, technicians, biochemists, and other staff members. Rural India has one-fourth the doctors and diagnostic facilities as compared to urban areas and this is a huge issue with the chronically ill, who require complex and expensive long-term monitoring and treatment strategies. Diagnostic testing is one of the most important segments of the medical field. Diagnostic laboratory testing results are applied for almost 60-70% of medical treatments

in India. India is home to about six lakh villages with 70% of India’s population living in rural areas, yet out of the approx one lakh diagnostic laboratories in the country, majority of them cater to metros and tier 1 cities. As per a survey, there are only around eight diagnostic labs per 100,000 people in India and diagnostic facilities have a very low reach in small towns and villages. Attracting and retaining trained medical professionals in diagnostic facilities is a major challenge for rural public health facilities. Apart from scarcity of qualified health staff, laboratory setups of the health centre are not well equipped to support the accurate investigations for diagnosis of diseases. Rural people have to go to urban cities to access diagnostic services, where better diagnostic facilities are available. To

1. Attracting and retaining trained medical professionals in diagnostic facilities is a major challenge for rural public health facilities.





2. Ninety per cent of research and development in diagnostics are done in western markets.


prevent the spread of diseases and reduce the mortality rates, the focus should be on the infiltration of healthcare and diagnostic services in rural India. Ensuring that all citizens have access to quality diagnostics must be a fundamental responsibility and an essential economic function for any government. Diagnostic facilities must be accessible, affordable and responsive, both to the constantly changing medical and clinical needs of patients as well as to the broader demographic, social and cultural dynamics in the modern world. Providing new means of affordable access to diagnostics, however, is no small task. There are certain factors that need to be addressed. Affordability: Services of specialists must not only be accessible, but also affordable. Indians have a high willingness to pay for quality diagnostics that are reasonably affordable. There is growing healthcare consumer awareness in India, so demand will continue to grow if care is affordable and accessible. Certified diagnostics: Because of the centuries old dependency on quacks and healers, Indians choose not to trust institutional care and scientific diagnostic services. To gain their trust it is important that certified well-regulated and audited lab services should be promoted in these areas. Convenience: Lack of services in rural areas increases dependency and high volume in laboratories of nearby cities, as most of


the population choosing diagnostics are directed there. The challenges faced is to reach and get himself tested form a major reason for not choosing to go for tests, thereby making his condition worse. Allocations for regulation: In order to ensure that quality diagnostics reach people through programme verticals, budgetary allocations to diagnostics is much needed. Currently, the diagnostics industry comprises largely of unregulated players. Accreditation is not mandatory and hence the onus of accuracy, quality or reliability of a test reports lies with a lab. Making allocations for such regulation in the budget can empower national bodies like NABL to play a bigger role in regulating the most basic function of healthcare. Tax relaxations and subsidies: The support from government in the form of tax relaxations is limited. There are tax exemptions for preventive diagnostic tests below Rs 5000, which do have a positive impact on the demand side of the diagnostic market; however, more such interventions are required on the supply side, so as to reduce the costs of delivering diagnostic tests. Currently, the taxation levied on necessary chemicals and technology increase the test costs, thereby making it inaccessible to most people. If the costs for life-saving diagnostic tests have to be brought down and its benefits are to trickle down to the common man, reduction on taxation of lab chemicals would have a much more visible effect. Public-private partnerships: Government collaboration with private players to bring quality diagnostics to towns and rural areas can be beneficial. Sufficient incentives and subsidies should be given to be able to sustain a presence in these areas, while offering the best of services..

Arunima Patel is Managing Director with iGenetic Diagnostics.

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Healthcare Radius July 2018 issue  
Healthcare Radius July 2018 issue