JUNE 2012

Healthcareexecutive

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Healthcareexecutive

Vol 1 Issue 5 | June 2012 | `100

A i d i n g s m a r t b u s i n e s s d e c i s i o n s

GLOBAL

PRACTICES

Assessing the

impact of

mHealth tools

pg 58

LEADERS SPEAK Local production

of medical gadgets pg 44

DEBATE Is hi-tech

health more expensive?

pg 52

CHALLENGES Errors due to technology pg 22

MEDICAL TECHNOLOGy

Faster,saFer,better

At your side at the hospital: Dräger.In the fast-paced, cost-intensive and technology-driven field of acute care medicine, you have to face

the most complex challenges every day. Technology solutions from Dräger offer more than just direct

value for your patients and support for your clinical team. They help you to enhance cross-departmental

or even hospital-wide management activities. It is our passion to develop Technology for Life to improve

quality and reduce the cost of care.

4 | June 2012 Healthcare ExEcutivE

Dear Friends,Medical science has progressed by leaps and bounds in the past two decades or so, and many more wonderful developments are in the offing. This has made life more comfortable for patients, imaging technology enables pin point accuracy of diagnosis while doctors have become more effective in managing seriously ill people. In this respect, India is not much behind the rest of the world; leading international experts in various clinical specialties regularly visit India and their counterparts from within the country regularly participate in major interna-tional conferences.

However, advances in science and their applications to medicine and health-care are coming into our lives at breakneck speed and the period of obsolescence of technology is getting shorter every year. This applies particularly to high end medical equipment such as CT or MRI or PET/CT or even to a cathlab suite. Hence it is extremely important that hospital managements take the decision to purchase or upgrade their equipment with a great deal of thought and consider-ation, and not merely for the sake of status. Further, a purchase decision should be need-based and not just because something new has come into the market. Hospitals of all sizes and categories also have to ensure that the decision to replace or upgrade their equipment is economically viable and ensure that an adequate work load would follow.

Another option becoming quite popular is that of renting high end medical equipment instead of outright purchase. In this case, the company offering the equipment would continue to own it and the client or user would pay a fixed rent. This has two distinct advantages. Firstly, the client organisation does not have to make a huge payment upfront, and is thus saved from the headaches and expenses of raising funds. Secondly, outdated equipment is no longer a worry because the hospital concerned can always rent a more advanced version of a machine whenever they need to.

The need for all these mechanisms would be much reduced if the government were to accord infrastructure status to the healthcare industry, thus making cheaper funds available. Also, the prices would come down substantially if some of the equipment were manufactured in India.

Coming to the public sector, a common observation is that the public hospitals have a budget and well-defined procedure for purchase of heavy equipment but no arrangement for maintenance, storage and utilisation. This should change without further delay.

Sincerely

[email protected]

HealthcareexecutiveA i d i n g s m a r t b u s i n e s s d e c i s i o n s

Healthcare ExEcutivE June 2012 | 5

Dear Readers,There is no denying that medical science and technology has made huge advances in the past few decades, and the future holds even greater wonders that would make it possible to restore people to health in a shorter time and to a greater extent than even before. Our cover story in this issue draws attention to some of these technologies including robotics and stem cell research, bio-absorbable coronary stents and portable diagnostic equipment.

Among the most significant is telemedicine which plays a crucial role in tak-ing these advances to the rural and semi-urban population in India where they are needed the most. Along with this are miniaturised ultrasound, ECG machines, baby warmers and even handheld glucometers or blood pressure instruments that can be carried to far away locations. These are the keys to the society’s biggest demand – widening access to healthcare facilities to include huge segments of the populace that are currently left out of the system.

Another burning issue is the ballooning of healthcare expenses, partly on account of newer medical technologies. One solution to the problem is judicious use of the latest gadgets, only for those patients who really need it. What is also likely to make a big difference is the indigenisation of manufacture of medical devices, consumables and other similar products. The reason why the prices of medicines in our country are among the lowest in the world is that a majority of them are manufactured within India. There is no reason why the story of medical devices should not follow a similar course. Besides, if many more people can afford an angioplasty or a hip re-placement, and the required implants can be produced within the country, their prices and even the doctor’s charges could come down drastically. It would be a virtuous cycle from which everyone stands to gain. And if this sounds like a fairy tale, just think of what happened to mobile phones during the past decade.

We are at the cusp of an exciting era as far as healthcare is concerned and wel-come you to join us on this journey towards a better tomorrow.

Sincerely,

[email protected]

HealthcareexecutiveA i d i n g s m a r t b u s i n e s s d e c i s i o n s

Editor in chiefDr. Vivek Desai

Publisher Narendra Karkera

General Manager Ganesh Lakshmanan

Editorial Editor Dr. Sumit Ghoshal

Deputy Editor Jayata Sharma-Sand

Sr. Correspondent Arunima Rajan

Marketing & SalesHead Sales Deepti Khanna

Marketing & Subscriptions Isha Khanolkar, Maninder Singh

Art & DesignGlowrt Design HouseCover Design - P. Jadhav

Print and ProductionPrinted by Abhishek Ostwal and Published by Narendra Karkera on behalf of Hosmac India Ltd., 120 Udyog Bhavan, Sonawala road, Goregaon (E), Mumbai – 400 063. Disclaimer: Views and opinions expressed in this magazine are not necessarily those of HOSMAC India Pvt. Ltd., it’s Publisher and/or Editors. We, at HOSMAC India Pvt. Ltd. do our best to verify the information published but do not take any responsibility for the absolute accuracy of the information. HOSMAC India Pvt. Ltd. does not ac-cept the responsibility for any investment or deci-sion taken by readers based on the information provided in the magazine. HOSMAC India Pvt. Ltd. does not take responsibility for returning unsolici-tated material sent without due postal stamps for return postage. No part of this magazine can be reproduced without the prior written permission of the Publisher. HOSMAC India Pvt. Ltd. reserves the right to use the information published in the magazine in any manner whatsoever.


CONTENTS

NEwS08The latest in the world of health-care. The section covers both national and international news of your interest. Read it to stay updated.

ChallENgES22Innovation in medical technol-ogy has improved patient lives but it indeed has added up the complexities within the health-care delivery system leading to medical errors.

BriCk & MOrTar26 A Hybrid Operating Room with its excellent imaging capabilities

allows orthopaedic surgeons and traumatologists to efficiently carry out interventions such as hip, spine or femur.

CaSE STudy30 Teleradiology has impact on all significant aspects of healthcare namely access, quality, timeli-ness, cost, communication and training. It has made a difference in healthcare delivery systems in a very positive manner.

COvEr STOry36We have tried analysing the 10 best technologies that changed the way healthcare has been delivered in the past couple of decades. These are the technolo-gies that have saved millions of lives worldwide and have proved

that the human mind can reach unimaginable heights of excel-lence where medical technology is concerned.

lEadErS SpEak44Indigenous medical technology manufacturing and innovation is the key to bring cost effective medical technology solutions specific to India and emerging markets of the world.

u aSk50Pavan Behl, Director & GM, SonoSite India answers the com-mon queries faced while tackling medical technology. Does he have the answers to your questions? Have a look and find out.

dEBaTE52Has technology made healthcare more costly? Or should we focus more on its benefits and not at the cost involved? Read to know more.

glOBal praCTiCES58The section focuses on testing the impact of mHealth tools on maternal and child healthcare. How do we know mHealth tools are actually changing health outcomes for the better?

pOrTraiT64Transforming cancer care by bringing core clinical services

JUNE | 2012

Volume 1 Issue 5


to one central place, Dr. BS Ajai Kumar seeks to change the landscape of Oncology Care in the India.

FOCuS68Aravind Eye Care System has strived to provide eye care of the highest quality at the lowest expense possible. Besides, it also makes medicines and trains people in eye care.

BOOk rEviEw74There are books that stand the test of time and enthrall the read-ers for centuries, across genera-tions. The Art of War written during the 6th Century BC by Sun Tzu remains relevant even today, because war and business are similar in many ways.

happENiNgS75A listing of various events from across India and all around the world.

JOBS76A section that captures the best of jobs available currently in the healthcare sector.

CEO pagE78While you are reading this, Dr. OM Manchanda of Dr. Lal Path Labs is probably skiing in Alaska with his kids. This is how he maintains his work-life balance, by taking out time from work for his family. Besides, he is a die-hard fan of renowned singer, Kishore Kumar.


National

NEWSThe long drawn out conflict between that TPAs (third party administrators) responsible for processing health insurance claims of most people, and the 7,000-member Association of Medical Consultants (of Greater Mumbai) has just got a lot more complicated.

The reason is that the Brihan-mumbai Municipal Corporation (BMC) has withheld the renewal of registration of a majority of the 2,000-odd nursing homes in the city since March 31, 2012 on the grounds that the nursing homes are not compliant with a newly promulgated set of fire-safety norms. Using that as an excuse, several TPAs have rejected the claims of a grow-ing number of health insurance policy holders, thus putting them in a piquant situation.

Since the BMC action has resulted from an order of the Maharashtra state government, a similar state of affairs is likely to develop in other major towns as well, but a precise idea of the extent of the problem is not yet available. Efforts to contact the Pune-based MD India, one of the largest TPAs in the country, failed to elicit any response.

At the root of the dispute is the approach of the fire safety depart-ments of various municipalities in Maharashtra which expect small nursing homes to comply with the same standards as the large stand alone hospitals. “The larger hospitals are usually housed in separate buildings while the smaller ones are often part of residential apartment buildings. Clearly the same requirements cannot apply to both categories,” says Dr Niranjan Agrawal, former president of the AMC, adding that discussions were underway with the Director, Fire Services, government of Maharashtra. This might take a month or two, or even a little more, and the AMC leaders have demanded that their members who own nursing homes

should be issued with some kind of provisional registration till then.

This is merely the latest twist in the ongoing tussle between nursing home owners and other healthcare providers on one hand, and the TPAs and insurance companies on the other. On May 17, the AMC posted on its website (www.amcmumbai.com) a letter to all its members, which reads as follows: “We call upon you to abstain from providing any kind of cashless services (GIPSA, corporate, private included) to any patient, in the larger interest of our community. This is a request to all consultants, not only from nursing homes but also the corpo-rate or trust hospitals.” GIPSA is the short-form of General Insur-ance Public Sector Association, the umbrella body comprising of General Insurance Corporation of India, with its four subsidiaries. In January 2011, it made a decision to appoint a common TPA for all the health insurance schemes issued by the public sector com-panies.

The letter further points out that the insurance companies have been requesting the AMC to call off the boycott, but they are not ready to empanel more than 300 nursing homes (belonging to AMC members). They also want to negotiate separately with each individual hospital, so that they can drive a hard bargain, an approach that the AMC is striving to counter.

The AMC on its part has embarked on an initiative to arrive upon a “scientific” mechanism through which the cost of various healthcare services in different parts of the city can be calculated. “This will take some time, as the association has communicated to its members from time to time over the last two years,” Dr Agrawal said.

Till that time, the long drawn dispute is quite unlikely to come to a final conclusion.

AMC tussle over health insurance worsens

The Indian ECG equipment market has emerged as one of the most profitable in the patient moni-toring sector, marking a compound annual growth rate (CAGR) of 12.6 percent from 2010 to 2017. The market showed no signs of slow-ing down even during the global economic downturn with the stress ECG/TMT market generating $9.1 million in 2010, at a growth rate of 11.1 percent. However, it is the 6/12-channel ECG equipment market, with a remarkable CAGR of 21.6 percent that is expected to power the market ahead.

According to a recent analysis report from Frost & Sullivan titled, “Overview of the Electrocardio-graph (ECG) Equipment Market in India,” finds that the market earned revenues of $26.5 million in 2010 and estimates this to reach $60.7 million in 2017.

The market is benefitting from the rising incidence and aware-ness of cardiovascular diseases, escalating public expenditure on healthcare services, increas-

ing demand for high-end equity systems, and rapid technological advancements.

“End users have shown a marked preference for equipment with more accurate measure-ments,” says Frost & Sullivan Re-search Analyst. “This has created a wider market for high-equity ECG systems (6 and 12 channel ECGs) market, but shrunk the channel ECG market.”

Despite the overall vast market potential, participants will face some road blocks while trying to penetrate the rural markets. The inadequate access to healthcare facilities and competition from the low-cost domestic market will peg back participants that are looking to establish a toehold in the Indian market. The competition between domestic and major market partici-pants has even led to price wars in the single-channel and 3-channel ECG market segments, which have, in turn, eroded the profit margins of prominent market participants.

ECG market zooms by 12.6 percent


Cloud computing in India will get a huge boost from a new five-year agreement between the Banga-lore-based Narayana Hrudalaya (NH) and HCL Infosystems Ltd, which will help the leading heart care organisation to place its entire HIS (Hospital Information System) on a cloud computing platform.

The solution would reduce capital and operational expendi-tures for Narayana Hrudayalaya and will enable the hospital to provide faster access to healthcare for its patients such as facilitating faster patient registrations. The implementation will also enable hospital staff to quickly complete their administrative tasks thereby freeing their time to provide healthcare.

HCL blu Enterprise Cloud’s Infrastructure as a Service (IaaS) solution is being deployed across 22 NH hospitals and has been already rolled out in Bangalore, Ahmedabad, Jamshedpur and Jaipur. The other centres are in the process of being hooked up to the central system.

Elaborating on the deploy-

ment, Harsh Chitale, CEO, HCL Infosystems said, “We would like to thank Narayana Hrudayalaya for deciding to partner with us in their transformational journey. Cloud computing has come to de-fine the way businesses function today and keeping in line with the present times we are committed to providing the best in class En-terprise Cloud Services. Our cloud solutions are highly customized as per the needs of organizations and focuses on addressing busi-ness needs of clients.

We bring the best available technologies from different partners to achieve an optimal solution for our clients.” On the occasion Dr. Devi Shetty, Founder, Narayana Hrudayalaya said, “We are delighted to partner with HCL Infosystems who is not only a long standing ICT company in India but also amongst leading cloud enterprise solution provid-ers today. With this deployment we look to maximize our ef-ficiency and scale up our services. We are sure that our HIS on cloud will be a path breaking initiative in the Indian Healthcare Industry.”

Though poliomyelitis has largely come under control in India dur-ing the past few years, it could raise its ugly head once again if public health authorities and others involved in the various anti-polio campaigns become complacent, according world re-nowned philanthropist Bill Gates. The former CEO of Microsoft has warned during a recent visit to India that while polio remains widespread in Pakistan, the danger of the disease spreading quickly among Indian people would be quite imminent.

Gates attended a Rotary International function in Mumbai where he was felicitated for his

contribution to the control of polio all over the world. On his three-day visit to India, he is also expected to meet top officials of the central government as well as industrial leaders for discus-sions on future philanthropic programmes.

Responding to his observations, Rotary International India chapter assured all help to Pakistan in eradicating polio. Dr Rajendra K Saboo, past president, Rotary International said, “If need be, we will be ready to offer assistance to polio stricken victims of Pakistan offering them polio corrective surgeries in India or in Pakistan through our network.”

Polio hazard from Pakistan Narayana Hrudalaya, HCL tie-up on cloud computing

Bilcare Technologies, a business unit of the Pune-based Bilcare Ltd, which is a research and technology company focused on next-generation anti-counterfeit-ing, security and brand protection solutions for different industries, has now reached an agreement with the Council of Scientific and Industrial Research (CSIR) for a brand new technology known as nonClonableID. The collaboration is part of the CSIR’s New Millen-nium Indian Technology Leader-ship Initiative (NMITLI) Scheme.

One of the most important applications of this technology

would be in the field of counter-feit medicines, a major challenge not only for the pharmaceutical industry worldwide but also gov-ernments and regulatory bodies tasked with detection and control of fake drugs.

In this context, product ac-countability and traceability has been recognized as a critical need for providing quality medical products. The issue covers not only detecting counterfeits or eliminating illegal duplicates but more importantly to also ensure that medicine of genuine origin is consumed by the patients.

Bilcare, CSIR to join hands

Dr. Devi Shetty (Right)


Piramal Healthcare Solutions, which sold out a large chunk of its business to Abbott Healthcare in May 2010 for a massive $ 3.7 billion (Rs 17,000 crore) approxi-mately, has turned its focus back towards the conventional pharma-ceuticals business. Last month, it decided to acquire the US-based Decision Resources Group (DRG) in a $ 635 million deal, which provides high quality web-enabled research, predictive analyses, and consulting services to the global pharmaceutical industry. DRG has a sales turnover of about $ 160 million and has clocked a compounded annual growth rate (CAGR) of almost 20 per cent for the past five years.

DRG is focused on three distinct segments of the $ 5.7 billion global information management industry, namely, Biopharma, Market

Access and Medical Technology. The Biopharma unit provides reports, databases and advisory services on drug utilization trends and forecasting in a variety of therapeutic areas; the Market Access unit provides database and

analytical services that healthcare companies to assess current and future opportunities for their products and the Medical Technol-ogy division provides actionable insights and data on the medical device markets. These services are created with the help of a network of 125,000 healthcare professionals (mostly doctors) and a number of proprietary databases.

Commenting on the acquisi-tion, Piramal Healthcare chair-man, Ajay Piramal, said, “The global healthcare industry is facing several challenges including rising research costs, lower drug approval rates, mounting regula-tory pressures, and increasingly complex reimbursement models. The need for specialist informa-tion is critical and the demand is growing. DRG’s portfolio of products is widely regarded as the

gold standard of information.” He also noted the fact that nearly 300 analysts with a string track record in their respective fields would now be a part of the Piramal fold.

In the past two years, Ajay Piramal had made several invest-ments in fields unrelated to life sciences even though he assured the Indian investment community repeatedly that he had no intention of abandoning the life sciences sector. Hence, even as he bought a minority stake in Vodafone and made investments in real estate, which is his family’s traditional business, drug industry watch-ers were waiting to see when his words would be backed up by some real action. That time seems to have come. Besides, the new acquisition would synch very well with the Piramal group’s relatively small drug discovery arm.

BGS Global Hospitals, part of the Global Hospitals Group, announced the launch of an in-novative Stereotactic Radiosurgery procedure which takes just four minutes to treat brain tumours.

Stereotactic Radiosurgery is a specialized technology of reaching the tumour (a focal point) in the brain through three dimensional measurements and calculations. This is done by a special instru-ment called Stereotactic Frame which will give the coordinates to reach the target tumour and radiation is delivered to the tumour without damaging the neighbour-ing structures. The procedure involves delivery of a single, high dose of radiation to a small and critically located brain tissue through the intact skull.

Dr. N. K. Venkataramana, Vice-Chairman and Chief Neurosur-geon, BGS Global Hospitals said, “Stereotactic Radiosurgery offers a great advantage in treating benign tumours as well as brain tumours located in critical areas without an open surgery. This method has become the standard of treatment

all over the world for the Arterio-venous Malformations of the brain wherein surgery is of high risk. In addition, people with multiple med-ical problems who are otherwise not fit to undergo neurosurgery now have an option of Stereotactic Radiosurgery. Today’s refined technology has made it acceptable to neurosurgeons worldwide by providing comparable and safe results. In addition, this technol-ogy has brought down the time of treatment to just four minutes by

providing enormous amount of patient comfort. Safety, speed and accuracy are what neurosurgeons can achieve today in Stereotactic neurosurgery through this modern technology. Stereotactic Neurosur-gery is a team work by Neurosur-geons, Physicists and Radiation Oncologists. BGS Global Hospitals hopes to make a real change in the field of Neuro-Oncology and serve the needy ones better in the future.”

“Varian TrueBeam STx is today the most powerful radio surgical

technology in the world. By being the first in India to have this equip-ment the BGS Global Radiosurgery Program is better able to treat a wide range of brain & spine tumors. In addition BGS Global Hospitals is well positioned to treat a number of exciting future clinical applications including epilepsy, depression and stroke,” observed Professor John R. Adler, pioneer in stereotactic radiosurgery from California, who was present at the launch ceremony.

Four minute surgery for brain tumours

Piramal acquires US biopharma company


On the occasion of World No Tobacco Day on 31 May, WHO is urging governments to beware of the tobacco industry’s interference in tobacco control programme. As countries move to meet their obligations under the WHO Framework Convention on Tobacco Control (WHO FCTC), the tobacco industry is becoming more aggressive in its attempts to undermine the treaty by acting against the policies contained in it.

The industry is targeting the youth through increased advertising budgets in several countries of the WHO South-East Asia Region. One in ten school students are offered free samples of tobacco products. The tobacco industry has sued central and lo-cal governments over the pictorial warnings on cigarette packets claiming that they infringe on the industry’s rights to use their legally-registered brands and free-dom of speech. The Global Adult Tobacco Survey shows that health warnings are effective and a large number of tobacco users noticed the warnings and thought of quitting. Similarly, lawsuits have been filed against smoke-free laws

against the Ministries of Health. The apex courts later rejected these contentions and upheld the regulations.

“Governments must protect people’s health from tobacco use and be vigilant about the tobacco industry’s interference in tobacco control measures” said Dr Samlee Plianbangchang, WHO Regional Director for South-East Asia. ”WHO will enhance its support to government initiatives to fight the tobacco industry” he added.

India and Indonesia are among

the top ten tobacco leaf produc-ers in the world. In addition the Region is one of the largest producers of smokeless tobacco products. Ninety percent of global smokeless tobacco users live in the Region. Sale of smokeless tobacco products in India increased by over 25% between 2005 and 2010.

Ten out of 11 Member States in WHO’s South-East Asia Region are party to WHO FCTC and nine counties have adopted comprehen-sive tobacco control legislations. Many countries have established

smoke-free public places and banned cigarette advertisements. Sale of tobacco to minors is prohibited in most Member States. Global Tobacco Surveillance has been implemented in ten Member States and nationwide Global Adult Tobacco Surveys have been conducted in Bangladesh, India, Indonesia and Thailand.

Nepal recently prohibited smoking and chewing tobacco in public places, mandated graphic health warnings and provisions for health funds from tobacco taxation. Thailand has declared all public places 100% smoke-free and banned display of cigarette packs at sale counters. Eight cities were declared smoke-free in Indonesia in spite of the strong influence of the tobacco industry.

Though tobacco and tobacco products are in the sensitive list in South-Asia Free Trade Area (SAFTA), the ASEAN Free Trade Agreement (AFTA) aims to eliminate tariff barriers within the Region including tobacco. Tobacco companies in the Region are tak-ing advantage of these liberal cross-border trade areas to the best of their advantage.

WHO alarm over tobacco usage

Special days being set aside to focus attention of particular medi-cal disorders are hardly a novel idea. However, the last week of the month just gone by appears to have had more than its fair share of such commemorative occasions.

First in the series was World Thyroid Day on May 25; then came World Multiple Sclerosis Day on May 30 and finally World No-Tobacco Day. A related event, though not connected with any specific medical condition was World Medical Transcription Week celebrated from May 21-26.

On World Thyroid Day this year, the Indian Thyroid Society has released a text book which will give the medical fraternity comprehensive information about this hidden disease, which often

goes undetected and undiagnosed. The Indian Thyroid Society will be distributing 1500 copies of the textbook to medical colleges across India. Indian Thyroid Society president Dr. R V Jayakumar says, “Recent studies have shown an alarming increase in thyroid disor-ders across India. We would like to persuade every adult in India to go for a regular thyroid checkup.”

Similarly, on the occasion of World Multiple Sclerosis Day on May 30, Multiple Sclerosis Society of India (MSSI) Mumbai Chapter organised a seminar and panel dis-cussion on “Living with MS “at S P Jain Auditorium, Bombay Hospital. The dialogue was centered around the everyday issues and struggles faced by MS patients and their families at work & public places.

Expert panel will includes – Medi-cal Fraternity, Legal Advisory, Finance personnel, CSR representa-tive, Celebrities, Insurance Profes-sional & Social Activists. This will be followed by a prize distribution ceremony, ‘MS Victor Awards’ and formation of a human chain.

According to Mrs Sheela Chitnis, National Vice President & Vice Chairperson, MSSI Mumbai Chapter, “World MS day is the only global awareness raising campaign on multiple sclerosis. The goal is to provide the public with more information about MS and increase awareness of a disease that ma-jorly affects the young population of the country.”

CBaySystems, India’s largest clinical documentation solutions provider, hosted a series of employ-

ee focused activities to celebrate Medical Transcription Week (MT Week) from 21st to 26th May, 2012. Organized under the aegis of the industry’s nodal body - Association for Healthcare Documentation In-tegrity (AHDI), MT week is a mark of tribute to the community of global healthcare documentation specialists who are passionately committed to creating high quality medical records and working with healthcare organizations .

Speaking on the occasion, Mr. Dinesh Kumar, Managing Director, CBaySystems said, “Serving as a second set of eyes on patient health records, healthcare docu-mentation specialists have played a pivotal role in assisting doctors raise the bar of healthcare delivery to patients.”

Spate of ‘health days’ in May

Human lung made of thermocol


Talwalkars Better Value Fitness Limited, one of the largest fitness chains in India with 120 gyms across 62 cities, has introduced a state-of-art fitness studio called Nu Form. The Nu Form fitness studios allow full body exercise workouts using the EMS or Elec-tric Muscle Stimulation method.

EMS is a full body training with electrical stimulation. In this method the muscles are stimulated so that the workout is much more efficient. Thus the training which one does is much more intense and faster than conventional weight training. Strengthening, toning and a super-effective workout in a short time span are the main out-comes of an EMS workout.

The training intensifies the human body’s natural process wherein the central nervous system constantly sends electrical impulses to control muscle action and thus reaching deeper muscle layers which are hard to activate through conventional training. The wide range of benefits from EMS training are weight loss and fat removal, strength and endur-ance, relief from backache, im-proved blood circulation, enhanced muscle formation and stimulation, improved mobility, muscular imbalance correction and body toning. It also helps athletes who desire a strong, athletic build for themselves in terms of sports training.

New fitness regime from Talwalkars

Indians now have an ally in the fight against painful and unsightly varicose veins, with a new minimally invasive medical technology called the VNUS Clo-sure™ procedure. The procedure offers patients fewer side effects and a faster recovery when compared to certain alternative treatments.

The VNUS Closure procedure is a clinically proven, minimally invasive procedure that treats varicose veins and their underly-ing cause, venous reflux, with little or no pain. It requires a small incision at the insertion site and the vein is sealed with radiofrequency heat. Dr. Sriram Narayanan, Consultant Vascular Surgeon, Tan Tock Seng Hospital, Singapore, said at a recent press conference arranged by Covidien,

“Varicose veins are a common problem in India and are on the rise due to less active lifestyles. Minimally invasive surgery, such as the VNUS Closure procedure, offers a fast, safe and effective way of treating varicose veins. It combines the speed of laser treatments with the favorable treatment profile of radiofre-quency heat. Not only have we seen patients benefit from a better cosmetic outcome, which includes

minimal bruising, but they can also typically resume normal ac-tivities within one day, as opposed to 6 months earlier.”

Dr. Rajiv Parakh, Chairman, Division of Peripheral Vascular & Endovascular Sciences, Medanta - The Medicity, said, “We are proud to offer a new kind of surgery that continues to transform the minimally invasive arena, result-ing in even better experiences for patients.”

This new procedure can cover 7cms of area at one go, as opposed to the earlier 0.5cm by laser treatment. The procedure will cost somewhere around Rs. 90,000-95,000.

The promoters of this procedure argue that the cost is still less than earlier procedures because the hospital stay has been reduced to one day.

Varicose veins are most often swollen, protruding veins that occur in the legs, ankles and feet. Venous reflux disease is the un-derlying cause of varicose veins, and develops when the valves that keep blood flowing out of the legs and back to the heart become damaged or diseased. This may cause varicose veins as well as pain, swollen limbs and leg heaviness.

Covidien offers new therapy for varicose veins

Skin analysis machine from Dr Batra’sDr Batra’s Positive Health Clinic Pvt. Ltd has introduced a state-of-the-art skin analyser machine (SAM) to objectively quantify and measure treatment outcomes for skin patients. A unique diagnostic tool, SAM offers a technological advantage in treating skin prob-lems by providing a complete visual analyses and diagnoses of skin ailments.

“The skin analyser augments the doctor’s observations by visu-ally analysing and diagnosing

various skin disorders. Whether it is acne (pimples), psoriasis, atopic dermatitis (eczema), lichen planus or vitiligo (white patches), among others, the machine produces a comprehensive report about the patient’s skin status, the nature of the disorder, rate of measurable improvement and progress via the homeopathic treatment. SAM also recommends skincare do’s and don’ts” says Dr Mukesh Batra, Founder, CMD, Dr Batra’s Positive Health Clinic Pvt. Ltd.


Fortis Escorts Heart Institute (FEHI), a fully dedicated cardiac care facility recently the launch of India’s first Fortis Acute Stroke Treatment (FAST) program with the intent of providing finest Stroke Treatment at Par with International Standards. The hos-pital has formally announced its toll-free helpline number: - 1800-200-3060 for stroke victims, which can be accessed from all mobile services providers & landlines in Delhi and NCR.

This is for the first time in India that a hospital has devised Stan-dard Operating Procedure after benchmarking it with the interna-tional practices for the treatment of Stroke patients. The standard practices at Fortis Escorts Heart Institute (FEHI) ensures that the patient is treated with pre set timelines as timely intervention is the key in stroke for better patient survivability and outcomes.

Analysis of community surveys from different regions of India shows a crude stroke incidence rate of about 203 per

100,000 population above 20 years of age, with a recent study in eastern population report-ing 504 per 100,000 population Most studies carried out in India show that about 10% to 15% of strokes occur in the population below 40 years, which is a higher proportion compared with other countries.

A top official of the Planning Commission has exhorted the healthcare industry to take les-sons from the infrastructure area, particularly in the manner in which public-private partnerships are designed and operated.

“Infrastructure projects were in shambles once. But they have come up recently because there’s a model framework in place and the government paid the atten-tion that the sector demanded. We need to pick up lessons from infrastructure and see if can be replicated in healthcare,” said Gajendra Haldea, Advisor to Deputy Chairman (Infrastructure), Planning Commission, Govern-ment of India.

He was speaking at a confer-ence – ‘Public Private Partnership: Policy Framework’ organised by Confederation of Indian Industry

(CII) and International Finance Corporation (IFC) - a member of theWorld. Bank Group, organized in Mumbai recently.

Thomas Davenport, Director, South Asia, IFC said, “The Indian

challenge in healthcare is unique. It demands scale and simple, rep-licable models that can be custom-ised to unique local requirements. The responsibility of the private sector is to standardise PPP while

the government needs to expand opportunities for private sector growth in the sector.” In India, among other interventions IFC helps structure and design PPP transactions to support-providing basic services including health-care to underserved and low income segments.

Dr Vivek Desai, Chairman, CII Western Region Healthcare Sub-Committee & Managing Director, Hosmac India, said, “Success of the PPP model in Indian health-care will require a two-pronged strategy. One is to have a model, broad framework for the PPP agreement which needs to be a win-win one that will benefit all the parties. Secondly the revenue models need to be put in place without which it is difficult for healthcare to give returns on investments.”

The Medical Students’ Associa-tion of India (MSAI) also known as IFMSA India (International Federation of Medical Students’ Association) will host IFMSA’s 61st General Assembly in August in Mumbai.

IFMSA India has won the bid to host this prestigious Assembly, the focus of which will be Uni-versal Health Care, only months after being adopted by the IFMSA as the 100th member of the Federation. The General Assem-bly in Mumbai will welcome 1000 delegates from 104 countries to be a part of this esteemed initiative.

Mr. Pratap Naidu, President of IFMSA India said, “The support that we received from our country to get India the membership was outstanding. The organization is only getting bigger and better and now that India is included in the IFMSA, it’s only gotten us more respect and responsibility.

“The hard work put in by the entire team of IFMSA- India has totally paid off. We are over-whelmed with joy to host this

event,” Naidu added.IFMSA is an international

organisation comprised of future physicians that are interested in global health issues. IFMSA is recognized by both the United Nations and the World Health Organization (WHO) as the international forum for medical students.

Throughout its history, numer-ous students have been active in the member organisations of IFMSA, collectively representing more than 90 countries across the six continents.

Every year, nearly 8,000 stu-dents participate in the exchange programs of IFMSA; thousands more design projects, attend con-ferences, and plan events in such areas as human rights and peace, medical education, reproductive health and HIV/AIDS, and public health.

Its mandate is to train medical students at an early age to become advocates for health issues that they will face later as practitio-ners.

India to host global students’ conference in August

‘Health must learn from infra PPPs’

FAST treatment for paralytic stroke


Health insurer Highmark recently announced it has hired long-time healthcare and insurance industry veteran William Winkenwerder, Jr., MD, as the company’s new president and CEO.

Winkenwerder takes the reins at Highmark at a critical junction for the health insurer, as it looks to acquire struggling West Penn Allegheny Health System amid a rancorous contract stalemate with the region’s top health system University of Pittsburgh Medical Center. In Winkenwerder, Highmark appears to have found a new leader who has experience in both the healthcare and insur-ance industries to lead it through this complex transition.

“Given Bill’s extensive experi-ence in public service, as well as his credentials as a physician and healthcare executive, he clearly has all of the attributes that we were looking for in a new CEO,” stated J. Robert Baum, Highmark’s chairman of the board. “His outstanding track record in the healthcare industry, along with his business expertise and strategic vision, make him uniquely qualified to lead our efforts going forward.”

Since 2007, Winkenwerder has headed the Winkenwerder Company in Alexandria, Va., which provides consulting services for clients including 3M

– Helath Information Systems, Harris Corporation and Johns Hopkins Medicine. Prior to that, he served from October 2001 to April 2007 as Assistant Secretary of Defense for Health Affairs in the U.S. Department of Defense. With the DoD, Winkenwerder led the Military Health System, which comprises more than 132,000 personnel and provides healthcare service to more than 9.5 million people through the TRICARE program and 70 mili-tary hospitals worldwide.

“Highmark and its employees have a longstanding history of meeting the healthcare needs of millions of people. While there are many challenges ahead, I’m excited about the many oppor-tunities we have in front of us – including our plans to create a new, integrated delivery system,” Winkenwerder said.

UAE among top 20 in healthcare spending

UAE’s health sector has con-solidated its position as one of the world’s top 20 in terms of spending per capita. The average spending of $1,200 per person per year is commendably high by international standards, and it is envisaged that this will set off a chain reaction that yields ripple benefits for the local health fraternity.

Among the benefits is the fact that increased spending by patients gives hospitals the finan-cial clout to attract the world’s sharpest medical talents. This is exemplified by the UAE’s premier institutions such as Saudi German Hospital-Dubai, which has lured professionals from Germany and other European pacesetters.

Another facet of increased spending is that institutions can now afford to equip their depart-

ments and wards with state of the art apparatus. This spans from diagnostic equipment to laborato-ry test facilities, operating theater machinery, life support systems and more. The net result is that rather than opt to make expedi-tions for treatments in the US and Europe, UAE patients now prefer to get treated locally.

More patients now acknowl-edge that local institutions are equally adept - and, in the case of the afore-mentioned Saudi Ger-man Hospital-Dubai, sometimes even superior - to their American and European counterparts.

Dr Mohaymen Abdelghany, CEO of Saudi German Hospital-Dubai, was greatly enthused by the trend of increased spending, “This is a massive vote of confi-dence by patients, because they are voting with their pockets.

International

Philips launches ‘HealWell’ healthcare lighting solution Royal Philips Electronics recently showcased its innovative HealWell patient-room lighting solution. Philips’ HealWell is a lighting solu-tion for hospitals designed to help care providers enhance the healing environment in patient rooms. As a global leader in Lighting, Philips combines their expertise with their knowledge of lighting’s impact on health, to provide the benefits of natural daylight in the patient’s room. Healwell is designed to auto-

matically manage a daily rhythm of light, similar to the course of light on a sunny day, promoting the sleep-wake rhythm. In the afternoon and evening, the light levels decrease gradually, enabling patients to relax and prepare for sleep, elevating wellness and patient recovery.

In addition, Philips recently also lead an educational workshop on ‘Sustainable Lighting Solutions for a Healing Environment’.

Highmark names William Winkenwerder as new CEO


New Sheikh Khalifa Medical City wins Sustainability award

Abu Dhabi Health Services Company (SEHA) won the Best Sustainable Development Award at the Cityscape Real Estate Awards – MENA for its Sheikh Khalifa Medical City (SKMC) development. Cityscape, one of the region’s leading real estate exhibition companies, seeks to highlight key innovations and developments in the real estate industry. Chris Speller, Cityscape’s Group Director, awarded the distinction to SEHA in a ceremony recently held at the Yas Viceroy Hotel in Abu Dhabi.

“We are profoundly honored to receive this award as a tangible recognition of our commitment to innovation and sustainability,” said Saif Fadhel Al Hameli, Chief Officer, Facilities and Construc-tion Division of SEHA. “We were granted this distinction along with

the projects architecture firms ICME, TILKE and SOM They have designed several important projects in the country we are delighted to have them onboard as we continue to build SEHA into a world-class healthcare provider.”

Envisioned as a ‘city within a city’, SEHA’s SKMC goes beyond the typical somber design of medi-cal centers and creates a bustling community featuring vibrant public spaces and a distinct char-acter. Encompassing over 300,000 square meters, SKMC will include three distinct hospitals – a general hospital with a Level 1 trauma center and tertiary women’s and pediatric hospital. The primary design challenge was creating distinct identities for each of the three hospitals while maintaining a unified look.

HAAD signs deal with South Korean hospitalsThe Health Authority – Abu Dhabi (HAAD) recently signed a hospital service agreement with four South Korean hospitals. The agreements with CHA Gangnam Medical Centre, Ewha Woman’s University Medical Centre, Severance Hospital and Wooridul Hospital aim to raise the quality of healthcare services provided in Abu Dhabi through knowledge exchange and expertise, and improving medical personnel qualifications on both sides.

Zaid Al Siksek, CEO of HAAD, signed the agreements in the pres-ence of Mohammed Al Hameli,

Chairman of HAAD and Chemin Rim, Korean Minister of Health and Welfare (MoHW) during the

Medical Korea in Abu Dhabi Workshop. The workshop was held to present the excellence of Korean medical technology and to raise general awareness on Korea’s advanced medical services including organ transplantation, cancer and cardiovascular centres, among others.

“This agreement signing reflects the strong business ties between the UAE and the Republic of Korea in all areas and specifically in the healthcare sec-tor,” said Al Hameli. This brings the number of agreements signed between HAAD and Korea to

eight following the Memorandum of Understanding signed by the two parties in March 2011. In No-vember 2011, HAAD also signed hospital service agreements with Samsung Seoul Hospital, Seoul National University Hospital, Seoul St. Mary’s Hospital, and ASAN Medical Centre in Korea. According to the Ministry of Health and Welfare (MoHW) of Korea, the number of patients admitted at Korean hospitals from abroad has been increas-ing. Middle East patients alone reached 1,821 last year, a 91 % increase from 949 patients in 2010.

New 42” healthcare-grade LCD display for patients Panasonic, a provider of profes-sional display and digital signage solutions, recently announced a new high definition, 42”, healthcare-grade display, the TH-42LRH50U. The new display is UL 60065 Annex Q certified to ensure hospital safety standards are met for patient and waiting room use. The display is also fully compatible with pillow speaker in-terface systems, allowing for easy integration with existing in-room patient entertainment systems.

Combined with the 32” TH-32LRH30U, Panasonic now offers a family of healthcare-grade profes-sional LCD displays that deliver the reliability and superior image quality the company is known for. The TH-42LRH50U features low failure rates for a professional display solution with a low total cost of ownership and a high return on investment.

The new TH-42LRH50U features a fast boot time of three seconds (versus the conventional seven seconds). The display’s SD Memory Card slot permits system-wide cloning of settings to

a large number of units resulting in significant installation cost savings. The displays are also equipped with essential functions for hospital installations, such as initial input/channel/volume and maximum volume settings.

The TH-42LRH50U LCD incor-porates the Pro:Idiom® digital rights management system elimi-nating the need for a separate set-top box to deliver protected HD programming. The Panasonic Concierge Service Program, which is also included, provides on-site

service and support for the warranty term.

“With the

addition of the TH-42LRH50U LCD, we now offer hospitals and other medical facilities a choice in healthcare-grade displays to meet their patient room needs, all of which are UL60065 Annex Q Certified,” said Scott Thie, Direc-tor, Healthcare, Panasonic System Communications Company of North America. The new display features a wide viewing angle of 178º to ensure clear images from virtually anywhere in the patient room.


Smart Healthcare tech gets Euro 40 million order Royal Imtech N.V, a technical services provider in and outside Europe, recently announced its first success in the Netherlands for ‘Smart Healthcare’: an inte-grated technological approach in the care market. ‘Smart Health-care’ involves providing a hospital with a customised comprehensive plan for an intelligent, green, cost-effective approach that integrates the hospital’s total energy and sus-tainability requirements, technical infrastructure, technical main-tenance requirements, medical equipment and instrumentation, as well as ICT solutions.

The IJsselland Hospital in Ca-

pelle a/d IJssel is the first hospital in the Netherlands to make the change to this total approach as based on this ‘Smart Healthcare’ formula. For Imtech, this means a 40 million euro order. René van der Bruggen, CEO Imtech, said, ‘Technology is becoming more and more important in care and cure. A technological total approach can reduce a hospital’s operating costs, improve its operations, and upgrade its technical maintenance. This applies to both the hospital property and all the medical equip-ment. Technology also helps to increase the energy efficiency of health care buildings and to make

health care even more sustainable. Imtech is an important player in the care market. With our new ‘Smart Healthcare’ formula we

anticipate well in the need for extensive technical integration. This first order opens the way to a pro-active market approach.’

ZirMed® a preeminent provider of revenue cycle technology and information for healthcare providers, recently announced it received recognition from Health-care Informatics for inclusion on the magazine’s 2012 HCI 100 companies listing.

The 2012 Healthcare Informat-ics 100 ranks the leading 100 companies by revenues derived from healthcare IT products and services earned in the U.S. The annual ranking is based on rev-enue information from fiscal year 2011, and provides readers with

information about vendors active in the healthcare IT market.

“We are very pleased to be recognised for the sixth year in a row by Healthcare Informatics’ influential HCI 100 ranking, a mark which indicates our stabil-ity in an industry full of change,” said Tom Butts, CEO of ZirMed. In reaction to moving up 6 spots to #73 on the list compared to last year, Butts continued, “It is nice to be recognised for our continual growth as we serve more clients across the healthcare spectrum.”

ZirMed in top 100 healthcare informatics firms

Starcare wins JCI in 1st year

In a remarkable recognition of its commitment to provide quality healthcare at affordable cost to the people of Oman, Starcare Hospi-tal in Muscat has achieved JCI Ac-creditation from Joint Commission International, USA, the world’s most respected accreditation body for Hospitals, within first year of its opening. The Starcare team was praised by Mohammed Saif Al Nabhani, Director General of Private Health Establishments, Ministry of Health, Sultanate of Oman at recent function attended by dignitaries from the Govern-ment, Corporate and Medical community.

“We are proud of Starcare Hospital and the team for this historical achievement and ap-preciate them for providing the quality healthcare services to the people of Oman. Ministry of

Health is bringing lot of remark-able changes to strengthen the public and private health sectors in Oman,” said Mohammed Saif Al Nabhani.

Staffed with high caliber, multi lingual medical and sup-port personnel, the hospital is already the preferred choice of the nationals and as well the expatriate community. With more than 35 specialties, Starcare now offers the complete healthcare solutions and is arguably the best equipped private hospital in Oman to handle cases of trauma and emergencies. The employee friendly, professional environment motivated every team member to undertake JCI Accreditation within 12 months as a challenge and their determination, team work and commitment of the management paid off.

Libyan team visits Dubai Healthcare cityRecently, a high-ranking delega-tion from the Libyan Ministry of Health visited Dubai Healthcare City (DHCC) to raise awareness about the status of the Libyan healthcare sector and engage in dialogue with healthcare institu-tions in the UAE.

Headed by the Libyan Deputy Minister of Health, His Excellency Dr Omran Turbi, the delegation comprised Dr Amal Naagi, the Ministry’s Head of Medical Ex-hibitions, Dr Ashraf Shembesh, Director of Medical Services, and Dr Fauzia Tushani, Director of

Media Relations. During their visit, the visit-

ing officials hosted a seminar on ‘Opportunities in the Libyan Healthcare Sector’ to highlight the revolution’s impact on healthcare services in the country and under-line the requirements that were urgently needed for rebuilding the system. Dr Ayesha said, “DHCC is pleased to support the Libyan Ministry of Health. The seminar served as a strategic platform to increase cooperation between the Libyan Ministry of Health and the healthcare community in Dubai.

ConvaTec announces acquisition of Trio Healthcare International

Clorox plans to touch $300 million mark

ConvaTec, a world-leading devel-oper and marketer of innovative medical technologies for com-munity and hospital care recently announced the acquisition of Trio Healthcare International Limited, a privately-owned UK-based company with an innova-tive range of accessory products for ostomy care.

Trio Healthcare International products, which will be added to the ConvaTec ostomy care portfolio, include Niltac™ sting free medical adhesive remover

and Silesse™ sting free skin bar-rier, both featuring the company’s advanced silicone technologies, and Diamonds™ Gelling Sachets with ActiveOne™ odor control.

“The Trio Healthcare Interna-tional range of products signifi-cantly enhances our portfolio of ostomy care accessories, offering advanced solutions for increased security, comfort and discretion,” says Jorgen Hansen, Senior Vice President of Global Market-ing, Business Development and Innovation, ConvaTec. “We look

forward to bringing the benefits of these innovative products, alongside our advanced ostomy systems and best-in-class adhe-sives such as ConvaTec Moldable Technology™, to more customers around the world.” Currently, Trio Healthcare International products are available in more than 20 countries around the world and, as a central part of the expanded ConvaTec portfolio of ostomy care accessories, will soon be available in many more markets.

IHH Healthcare, Asia’s largest hospital operator, plans to raise more than RM6 billion (S$2.4 billion) in an initial public offering in Kuala Lumpur. IHH Healthcare, controlled by Malaysia’s invest-ment arm Khazanah Nasional, will also have a dual listing in Sin-gapore with marketing scheduled to begin in July, sources said.

It plans to sell up to 360 million shares set at an indicative price of RM2.85 per share to so-called bumiputera investors, comprising ethnic Malays and indigenous people who are allocated pref-

erential shares by the country’s trade ministry, the people said. The offering comes amid a market rout that has led to several listings being pulled.

Recently, Clorox company Chief Executive Don Knauss announced plans to be fairly aggressive in buying assets to expand his company’s healthcare offerings as it looks to triple the size of that business over the next five years. The 99-year-old company is best-known for its namesake bleach, but its healthcare busi-ness - encompassing products like disinfecting spray, germicidal wipes and hand sanitizer - has been a small growth engine in recent years.

The business has grown to around $100 million in annual rev-enue from around $2 million over the past five years. He hopes to expand it to a $300 million busi-ness within five years, with about

half that growth coming from acquisitions. “You can certainly expect more activity,” Knauss said, noting that there are dozens of family-owned healthcare com-panies that focus on disinfection products, or products that prevent the spread of infection - offerings the company is looking to expand.

“Most of these companies that we’ve looked at are in the $10-to-$50 million range” of annual revenue, Knauss said. The company spent about $80 million to $90 million to buy two healthcare companies - Aplicare Inc and HealthLink - earlier in 2012. Internationally, Knauss said Clorox will also look for bolt-on acquisitions for its home care and laundry businesses in countries

where it already does business, especially in Latin America.

Clorox is trying to reshape its portfolio to align more with the consumer trends of health and wellness, sustainability, multicul-turalism and affordability. It has sold its auto care business and acquired various products sold to the healthcare industry as well as Burt’s Bees natural personal care products and Soy Vay Enterprises, which makes Asian marinades and dressings. Still, Knauss said the company was not inter-ested in making any drastic changes through

acquisition. “I think people typically overpay when they start talking about transformational acquisitions,” Knauss said.

WebMD Health has tapped for-mer Pfizer executive Cavan Red-mond as its new chief executive, ending a 4 months-long search after its former CEO suddenly resigned in January. Redmond, 51, joins WebMD from drug giant Pfizer, where he served most recently as group president of animal health, consumer healthcare and corporate strategy and as a member of its executive leadership team.

“Along with our experienced management team, I have great

confidence that Cavan will take WebMD to the next level,” the

company’s chairman, Martin Wy-god, said in a statement. “He has a successful track record in identi-fying and leveraging new revenue opportunities, driving efficiency and establishing sustainable growth platforms.”

Redmond has more than 20 years of broad experience in healthcare, including biotechnol-ogy, pharmaceuticals, consumer healthcare and infant nutritionals. He also has biopharmaceutical ex-perience in global strategic mar-keting and marketing research.

WebMD taps Pfizer Executive as CEO

IHH plans S$2.4b IPO



Every year, tens of millions of patients worldwide suffer disability or death

due to unsafe medical care. Nearly one in ten patients are harmed while receiving the healthcare in developed country and for developing country like India, China etc there are no proper statistics available. As per Institute of Medicine (IOM), more people in USA die of medical

error than breast cancer or AIDS. If we use the same statistics in developing countries like in India alone, almost one million people die every year due to medical error and iatrogenic incidences. The need of the time is to make the technology safer, reliable, dependable and effective in order to reduce the error within Health-care delivery system (HDS). Healthcare delivery system must

be designed in such a way that it eliminate the preventable errors and should report the errors which arises due to the complexi-ties within the HDS.

Statement of ProblemIn today’s world, healthcare deliv-ery system has gone really high tech, as we witness the complex surgeries been performed by the robots and many more. But the

medical error and death due to these iatrogenic errors are grow-ing at a phenomenal rate across the globe. Innovation in Medi-cal Technology has improved patient lives but it indeed had added up the complexities within the healthcare delivery system leading to medical errors. This research paper has identified that the problem of medical errors and mistakes arising within the

Technology and Error: A Part of Healthcare DeliveryThe need of the time is to make the technology safer, reliable, dependable and ef-fective in order to reduce the error, say Sanjay Saproo, Dr. Sanjeev Bansal and Anupama Pandita

Challenges


healthcare delivery system is because of the of lack of the fol-lowing elements, • Technology know-how • Training & Orientation • Medical Error reporting structure through SOP/ Protocol • Preventive and maintenance of the Medical Devices • Human factor Engineering in designing the Medical Devices

Discussion Patient, caregiver and technol-ogy are the three pillars of the healthcare deliveries which are interdependent to each other and results into the medical error.

The dictionary meaning of the caregiver is any individual, such as a physician, nurse, or social worker, who assists in the identi-fication, prevention, or treatment of an illness or disability. So the caregiver can be a doctor, a nurse, paramedical staff and the hospital management.

According to Daft (2004, 243), “technology refer to the work processes, techniques, machines, and actions used to transform organisational inputs (materi-als, information, ideas) into outputs (products and services)”. While technology in healthcare improves the patient outcome and safety at the same time it has given room to the medical error resulting into the patient injury or/and death. So a medical error is a bug within the HDS which re-sults into mortality or morbidity.

One of the simplest definitions of human error is that it is any action or omission that causes / results into an unwanted situa-tion that user neither foresee nor intend. Error is a generic term that encompasses all occasions in which a planned sequence of mental or physical activi-ties fails to achieve its intended outcome and the failure cannot be attributed to the intervention of chance.

Hospital Management and Policy makers Patient safety and patient

recovery fully depend upon the caregiver, while as caregiver in turn depend upon the available tools and technology within the system. If at any point of time something goes wrong between the human and technology this will results into the error or iatro-genic incidence which will lead to the injury or death of the patient. Patient being at the heart of the HDS will have a direct impact of any kind of failure or error which arises within the system from the technology or from the caregiver side.

Technology providers and manufacturers are working

hard and pumping billions of dollars into the R&D, to fight the disease with the electronics and get successful too to eradicate the disease. In turn when these latest technology devices are available for the usage by the end user over the patient, here the complexities start giving birth to the medical error and iatro-genic incidences. The reasons for complexities turning into the medical error over these devices are because the caregiver/user is not able to handle the technology fully due to lack of knowledge, training and orientation.

As per the WHO ten point

facts at least 50% of medi-cal equipment in developing countries are unusable or only partly usable. Often the equip-ment is not used due to lack of skills or commodities. As a result, diagnostic procedures or treat-ments cannot be performed. This leads to substandard or hazard-ous diagnosis or treatment that can pose a threat to the safety of patients and may result in seri-ous injury or death.

The most common approach to eliminating human error is to determine who committed a particular error and then train that person in the correct behav-ior. This strategy just fixes the blame--not the problem. Unfortu-nately, training alone is seldom effective in reducing errors. The need of the time is to have a proper understanding, adapt-ability, know-how between the man (Human) and Technology in order to save millions of patient from iatrogenic incidences.

Caregiver has always given the priority on the therapy side and had learnt the similar aspects in their medical schools but has been totally deprived from the technology side of the health-care which being the lifeline of the current healthcare delivery system worldwide. Education on the therapy side is not going to create anticipated improve-ment of clinical outcome if staffs remain having little knowledge on handle the technology aspects through proper training and orientation.

Training and orientation is otherwise available but the caregiver does not have much time to get acquainted with the latest technology or the hospital system lack the necessary pro-tocols which makes the training on these complicated devices mandatory or must attend for those who will be handling these devices.

In one of the white paper pre-pared by the American College of Clinical Engineering on “Enhanc-ing Patient Safety” the role of Clinical engineering, it has been

One of the simplest definitions of human error is that it is any action or omission that causes or results into

an unwanted situation that user neither foresee nor intend


stated that the error associated with the use of the medical tech-nology should be automatically attribute to the end user (http://www.accenet.org/downloads/AC-CEPatientSafetyWhitePaper.pdf)

The need of the time is not to isolate the end user from the system within which he is work-ing as 80% of the medical error is the “hospital system related error”. The caregiver / end user is a vital part in patient care and have to be in the center of the healthcare delivery system along with the patient and should acquire a complete knowledge of the correct usage of the technology through training and orientation.

With other high risk industries, rigorous safety procedures and hundreds of hours of training are put in place to prevent harm to human life, like aviation. There is a one in 100’000 chance of the traveler being harmed in the aircraft. In comparison, there is a one in 300 chance of a patient being harmed during healthcare delivery system. So it become quite obvious that we need to in-fuse the patient safety within the HDS and this can be optimised only when the healthcare work-ers receive the right training and skills. Further the system should be designed in such a way that the caregiver should be helped to have their knowledge up-to-date.

In any high risk systems like no matter how effective safety devices are, or the caregiver has the excellent skill and had been trained in highest standard, the accident are inevitable because the system’s complexity leads to multiple and unexpected interac-tions. Such accidents will happen regardless of the number of safety devices, the quality of the care provided, or the vigilance of the caregiver. As per the white paper, Can Technology Eliminate Human error 2006, Institute of Chemical Engineers, it is not possible to design technological systems to eliminate all human errors during the operation be-cause of the involvement of the

human component. It has further stated that even if systems can operate without human interven-tion, there is still possibility of human error at other phase of the lifecycle. The need of the time is not to turn the back to-wards these errors but caregiver need to report and document the said error for future references so that caregiver will not repeat the same. This will indeed lead to the root cause of such errors and it will bring the loopholes and weakness in the system on the surface resulting into the better patient outcome and safety. If we fail to do so, error happens to multiply and patient continue to suffer from these iatrogenic mistakes as it is well said that what cannot be measured cannot be managed.

Majority of errors goes unreported or down the drain because clinicians are fearful of litigation or of being severely reprimanded. Caregiver need to come out of this blame and shame to an open discussion over the medical errors. The need is to

put a reliable and error detection system in place within the HDS, called as protocols.

Further caregiver should fol-low the SOP (Standard Operating Procedures) to prevent the future errors. if the SOP’s are carried out every time, we can avoid the future mistakes by learning from the current mistakes if it happen as it is easier to find out the mistake in any set protocol of the HDS.

Protocols and SOP’s will also give patients the opportunity to identify their care pathways and to be part of the care path.

The new generation of the caregivers or any allied health professional has to sustain from the current complexities in the healthcare and have to make sure a safe, reliable, effective, timely delivery of the healthcare to the ailing patient who needs this the most. The present Healthcare structure is transforming from caring for patient into caring with the patient. In future patient will design their care and caregiv-ers/ healthcare professionals will

have to support them. This is a positive shift from a paternalistic doctor-patient relationship to a partnership. The patient and its close attendants should therefore be at the heart of all the patient safety strategies and programs. Health professionals and policy-makers must all work together to built a safer healthcare delivery system.

Technology know-how, train-ing and documented the error is not the end of the problem, proper maintenance of the Technology and preventive maintenance is also one of the factor for reducing the mortality and morbidity. Healthcare profes-sionals are more likely to blame themselves for any type of errors than they are to blame the equip-ment. Medical error happening from the break down of the devices or wrong diagnosis due to lack of proper maintenance should be the responsibility of the manufacturer and the service providers. Proper installation, periodically maintenance of the medical equipment and routine


calibration of the medical devices will ensure the reliability, ac-curacy and minimum chances of system break down which will result into the better patient outcome and patient safety.

Prevention is better than re-pair. Preventive maintenance of the medical technology devices is a proactive, periodic procedure performed on any electric and mechanical equipment to ensure it is operating according to manufacturer guideline and opti-mise its efficiency and accuracy. Nearly 5000 types of medical devices are used by millions of health care providers around the world, device related problems are inevitable. Inadequate maintenance of these devices will increase the risk of unexpected breakdown, life threatening errors, excessive repair cost and enhance the equipment down time and premature failure of the equipment. The World Health Or-

ganisation Medical Devices and equipment team described pre-ventive maintenance of the medi-cal equipment as essential tools for the error reduction and better patient outcome. As per the FDA, the most common errors reported are due to improper installation of the medical device accessories. Means proper installation of these critical devices are essential for their operation and patient safety. The new devices coming out of the manufacturer facility are passed through the highest standards of the quality control besides having the FDA and CE certified. With the passage of usage and lack of periodic pre-ventive maintenance and proper calibration of these high tech medical devices, it lead to wrong or inaccurate diagnosis and even sometime it results into com-pletely stoppage of the therapy leading to mortality or morbidity. The effective maintenance of the

these medical technology devices in developing countries like India, china become more essential as theses equipments are been imported from the developed country and are been made in dif-ferent environmental and climatic conditions.

Service providers who are responsible for the after sales service should ensure the proper backup service and spare support besides the periodical maintenance of theses high end Technology devices. For any manufacturer to reduce or elimi-nate human errors, it is necessary to consider the people who will use the device, the environment in which it will be used, the actions (or tasks) people will be doing that involve the device and understanding of the human error and use such information to reduce its occurrence in the use of medical devices.

According to Gosbee, ‘‘Human factor engineering is the disci-pline concerned with understand-ing human characteristics and how humans interact with world around them. The Human factor Engineering (HFE) while design-ing the medical devices must ensure that these devices should be designed in such a way that it should be user friendly, easy to service and maintain and should do a self calibration automatical-ly. Further these critical devices should provide a message to the end user for any fault, misdiag-nosis, routine calibration and preventive maintenance of the machine”. This will ensure a pe-riodical screening of the devices and increase the effectiveness and reliability of these complex de-vices ensuring the patient safety and reduction of the mortality and morbidity.

In conclusion With the adaption of the technol-ogy within the HDS, caregiver has to understand the usage of these medical devices through proper Training and orientations. HDS must work effectively in order to minimise the human and technology related error.

While errors and accidents are unavoidable caregiver follow the protocol to report these iatro-genic incidences in order to reduce further errors and mitigate its effects. Caregiver need to come out of the blame and shame game to an open discussion on these medical errors and should have a partnership with the patient who is the heart of the HDS. Caregiver must encourage the patient and its attendant to be a part of the HDS which will indeed will enhance the faith and the trust of the patient within the HDS.

The partnership is also required

between the healthcare workers, hospital management, service provider and manufacturer for proper maintenance of these tech-nology devices. Service providers must ensure the proper installa-tion and the periodical preventive maintenance of these devices for the reliability and effective usage in the complex environment.

Manufacturers need to keep in mind to use the human factor engineering while designing the-ses critical medical devices which should take into the consideration the human limitations and flaws for better patient safety and outcome.

About the authors: Sanjay Saproo, Dr. Sanjeev Bansal are from Amity University NCR, Delhi India, and Anupama Pandita is from Apollo Hospital Education and Research Foundation, Delhi

Prevention is better than repair. Preventive maintenance of the medi-

cal technology devices is a proac-tive, periodic procedure performed

on any electric and mechanical equipment


The two main pillars of healthcare are diagnosis and therapy, each with

its own requirements and its own limitations. Since time immemorial, they have been set distinctly apart even within the same hospital building – the CT scan or MRI department being in the basement or in a specially fortified section of the building, and the operating rooms on a different floor, correlated more with the ICU than the radiology department.

But as medical science gears up to face greater challenges, handle more serious patients, its practitioners have had to modify their instruments as well as their methods of working from time to time. The development of Hybrid Operating Rooms, in which the diagnostic modality is in complete sync with the operat-ing table, is one such form of adaptation. The most important benefit of this arrangement is that the patient does not have to be moved from the CT

Hybrid ORs: Future scenarioA photo essay depicting the latest global trend in hi-tech medicine, an operating room with complete facilities for diagnostic imaging

brick and mortar


machine to the operating table. As the diagnostic work gets over, the surgical team moves in and begins its work. This is particularly useful in situations like severe trauma, or congestive cardiac failure in which the very process of moving a patient from one location to another is fraught with risk.

Building a Hybrid OR is also a complex process. One major issue is asepsis during surgery, which has to be maintained throughout the diagnostic work as well. This means the HVAC systems have to geared accordingly. Besides, most of the subordinate staff working in the unit, whether from the surgical team or the radiology side, require special training so that they can work in unison.

Though this is a very recent development, having caught the imagination of cardiologists, trauma surgeons and others only in the past two years, there is already a growing demand for Hybrid ORs both in developed countries such as the US and UK, as well as in India. Responding to this demand, most of the leading manufacturers of heavy duty medical equipment, such as GE, Philips, Siemens and Toshiba have come out with a range of products designed to fit into Hybrid ORs. Most of the time, they have to collaborate with other companies such as Maquet and Steris, who are leaders in Operating Room equipment.

Steris, for example, is a market leader in the US for Operating Room infrastructure such as op-erating tables, lights, booms and communication equipment but it does not do medical imaging. Hence in March 2009 it entered a collaboration with GE, under which GE Healthcare would provide specialized X‐ray equipment and interventional technologies, while STERIS will supply custom‐designed HD 360° Suites featuring LED surgical grade lighting, video‐switching and visualization systems, and equipment man-agement solutions. Steris also


has a similar agreement with Philips.Maquet, another leading supplier of medical equipment, lists anesthesia and ventilation, ceiling units, operating tables, surgical assist systems and medical furniture as part of its product portfolio.

It offers complete solutions for operating theatres and intensive care units. It is strictly focused on the best possible treatment of patients and the greatest possible working comfort for the hospital team, according to one of its web pages. Maquet`s hybrid OR solution features modular, radiotranslucent surgi-cal tables synchronized with state-of-the-art angiographic systems all designed for use in sterile environments.

Interventionalists and Surgeons alike are now able to conduct a wide range of treat-ments and examine their results

using angiography in a single room without delay. MAQUET offers custom-tailored Hybrid OR products for a perfectly configured operating room - from a single source: from walls, OR lights and ceiling elements with integrated x-ray protection to operating tables, systems for OR integration (for image and equip-ment control), anesthetic devices and heart-lung machines. In this way, it sets up its fully integrated Hybrid OR in collaboration with manufacturers. In India, too, leading hospitals like Narayana Hrudalaya in Bangalore and Holy Family Hospital in Mumbai have started setting up Hybrid OR units, mainly for cardiac applications, and companies such as Maquet already have a pres-ence in India.

With Inputs & Photos from Bhavesh Bhatt, Maquet India.


Case study

Improvement of patient care through Teleradiology

The practice of Telera-diology, or the remote reporting of radiologic

scans, has grown at a dramatic pace since the beginning of the new millennium, and has made tremendous impact on patient care worldwide. Having been involved in teleradiology over the past decade, our experience

has shown us that in essence, teleradiology has impact on all significant aspects of healthcare namely access, quality, timeli-ness, cost, communication and training.

Teleradiology has proved to be a boon to the healthcare industry and has impacted the delivery systems in a very positive man-

ner. Listed below are 10 examples of how teleradiology improves patient care:

Acute Emergency Nowhere has teleradiology made greater impact on clinical patient outcome than in the emergency setting. In fact, the reason for the great boost in demand for

teleradiology services in the early 2000’s was directly based upon the need for emergency report-ing services by US hospitals. Up until that time a radiology scan performed at night in a hospital was interpreted by the clinician on site at the hospital. It was only seen by a radiologist the next morning, unless the clinician

Teleradiology enables better physician collaboration, communication and consultation – in turn leading to better patient care, says Dr. Arjun Kalyanpur


suspected an abnormality and called in a radiologist for a pro-fessional opinion. As Emergency physicians are not trained in CT interpretation, one can only surmise how many critical find-ings went undiagnosed till the next morning, in this scenario, and how many patients must have suffered the consequence. However around 1999, the US regulations changed, requiring that all studies needed to be interpreted contemporaneously by a radiologist for medico legal and reimbursement reasons.

Faced with a severe shortage of radiologists, that impacted most on night shift operations, radiology groups and hospitals began looking for alternatives and teleradiology presented a natural option. The need for such support very soon began to be felt in several other parts of the world where radiologist shortages prevail. At the same time, the technology applications such as multidetector row CT began to advance rapidly, so that conditions such as pulmonary embolism, aortic dissection, acute appendicitis and acute stroke could be detected immediately and noninvasively by CT. A num-ber of trauma-related indications

also were revolutionised by CT imaging, such as spinal injury, facial fractures, visceral and vascular trauma. It is in these areas that teleradiology plays a critical role. By transmitting the images to the location of the radiologist instead of having the radiologist physically come to the hospital, the report turnaround time is kept to a minimum. The use of broadband technology has made such rapid image transfer

possible. And mobile wireless 3G technology allows for interpreta-tion instantly by a radiologist from anywhere at anytime, even when on the go.

Having a centralised read-ing center further enhances the potential of such a process, using economies of scale and efficiency. In our organisation, thousands of examinations are interpreted every month for over 100 hospi-tals across the globe, with report

turnaround time as low as 15 minute for a stroke protocol CT performed diametrically across the world or 30 minutes for an indication such as suspected pulmonary embolism or aortic dissection.

Where there is no doctor presentThe second area in which tele-radiology makes a huge impact is in the setting of small towns

in remote parts of the country where radiologists are in short supply. Most radiologists are currently based in metropolitan cities, while on the other hand, the healthcare needs of the smaller towns are growing. As a result, imaging centers with CT and MRI scanners are coming up rapidly in these smaller locations; however there are either none or insufficient radiologists with expertise to interpret the imag-

ing studies. In such a situation, teleradiology offers significant benefit by bringing the images to radiologists who are available and competent to report the stud-ies. It is a fact that appropriate medical treatment cannot be pro-vided without accurate diagnosis, and teleradiology allows for an accurate diagnosis to be delivered to each and every citizen without them having to travel hundreds of miles in its quest.

Through our Telerad Founda-tion we have been supporting hospitals of the Ramkrishna Mission, in locations such as Ita-nagar Arunachal Pradesh. This hospital has the only CT and MRI scanner for the entire popu-lation of Arunachal Pradesh (1 million). Approximately 10,000 scans have been reported by our organisation for this hospital free of cost using teleradiology, with a link set up by our technology team via remote connection, without even a single physi-cal visit. Similarly, we support hospitals in Vrindavan UP, as well as hospitals in smaller towns in Jharkhand, Chhatisgarh, Bihar, Haryana and Tamil Nadu.

Asia is not the only continent to benefit from teleradiology. We currently provide services to cen-

Appropriate medical treatment cannot be provided without accurate diagnosis, and teleradiology allows

for an accurate diagnosis to be delivered to each and every citizen

without them having to travel hundreds of miles in its quest


Teleradiology workflow systems have physician-specific functions that

allow clinicians to tap into an imaging database conveniently

while performing their clinical duties, without interruption

ters in Tanzania and Nigeria, in locations where radiologists are in extremely short supply, allow-ing for timely report turnaround. Telesonography is another tool which has great potential benefit in remote areas but its growth in India is unfortunately currently restricted by PNDT regulations.

Reduced waiting time In countries like the UK, where the NHS was notorious for wait-ing times of weeks/months for outpatient reports, these times have been greatly reduced by the implementation of teleradiology. Allowing for the workflow to be evenly distributed to involve those radiologists who are less busy at any given time is a major productivity benefit of teleradi-ology. At multicenter imaging practices, teleradiology allows a radiologist at any one center to report simultaneously for all, so that no patient at any of the centers need wait for their report.

Our work with the Ministry of Health in Singapore has shown that teleradiology was able to reduce report turnaround time for Xrays at the Polyclinics run by the National Healthcare Group from 3 days to one hour. This has greatly benefited the people of Singapore who previously had to make two visits to the polyclinic — the first to see the doctor and the second to collect their report. Now at the same visit they can do both and receive their prescription as well, resulting in significant benefit in terms of workforce productivity.

Improved diagnostic qualityAs radiology has evolved, devel-oped and become increasingly complex, subspecialty radiology has become the order of the day. Teleradiology allows for the im-aging studies to be routed to the subspecialist who is most quali-fied and appropriate for the type of examination; be it a joint MRI, a PET-CT, or a mammogram. This results in enhanced quality of reporting. Within a group

of radiologists reading off the same PACS workflow engine, the worklists can be defined in such a manner as to allow each radiolo-gist to report only those cases in which they are specialised. In a large teleradiology practice such as ours, the subspecialists are able to support each other with consultations specific to their areas of expertise, such that in any situation, the highest quality is delivered for any individual report.

In the setting of emergency teleradiology, a genre of dedicat-ed emergency teleradiologists has evolved who have the skill set to

interpret a wide range of imaging modalities that are utilised in the emergency setting with the focus on providing the key information required for delivering appropri-ate urgent care and for making rapid triage decisions. Thus, the quality of reports is enhanced by the experience and expertise of

the radiologist operating in the emergency environment while at the same time the level of communication is also improved upon. Hence, critical value results are delivered verbally, instantly, to anywhere in the world, in the global teleradiology model.

Optimised physician utilisation By having a radiologist at a centralised reading center simul-taneously interpreting scans for a number of emergency depart-ments, maximum efficiency and rapid turnaround of reports is achieved 24x7. An interesting

variation on this model was de-veloped in the early 2000s, where the so-called nighthawk radiolo-gist was positioned diametrically opposite the globe to allow for a night shift to be transformed into a day shift. This was made possible by the deployment of ultrahigh speed international

broadband cable networks. Our organisation was among the first to pioneer this model with Board certified radiologists based in India, Israel, China and Europe reporting for the night shift of hospitals in the US.

This has two important benefits to patient care, namely a) the conversion of night to day improves the quality of service and of reports, as logically speaking, a radiologist working at 2 PM is clearly more compe-tent to deliver care than at 2 AM. Additionally, b) the productivity benefit engendered by converting night work to day means that the same number of radiologists can now be more productive interpret more studies, (as opposed to radiologists working nights who typically work one week in two) thereby benefiting more patients and shortening report turnaround.

This international teleradi-ology model was recognised and validated in an editorial published in the New England Journal of Medicine in 2006 as being of great value to emergen-cy health services in the US and other parts of the world. This is arguably the most potent benefit of teleradiology to patient care.


Lowers cost of patient care Teleradiology is a digital process – and therefore by definition film-less, which by itself reduces cost significantly in terms of avoiding film utilisation, processing and physical archival. The process of teleradiology is enabled by web-based intelligent workflow which allows images to be automati-cally routed to the location where they can be interpreted most rapidly and accurately, thereby enhancing patient care. An ef-ficient teleradiology workflow (such as Radspa, developed by TeleradTech, Bangalore) has been shown to increase radiolo-gist productivity and efficiency by a factor of 20% or greater, allowing more patient scans to be interpreted and more prompt diagnosis, both beneficial from the patient’s perspective.

A further benefit of teleradi-ology on patient care accrues from its economy of scale effect wherein a single radiologist can from a single location, interpret scans from multiple hospitals efficiently, obviating the need for redundant staffing by radiolo-gists at each individual institu-tion. This in and of itself has a tremendous impact on the cost of healthcare, as the cost of having a radiologist up all night at each of many hospital sites can be quite staggering. The support staff can also be scaled efficiently, including secretarial assistance in communicating es-sential results, and in terms of IT manpower utilisation, both also contributing to lowering the cost of patient care.

For better physician collaborationBeing a process that is conducted over broadband telecommunica-tions networks, teleradiology is in essence a communication tool, and it carries with it the benefits of enhanced physician to physician communication that in today’s world is an essential component of patient care. Organisations such as the US

Joint Commission mandate that all critical value exams (read: radiologic tests that have signifi-cantly abnormal results that may acutely impact on the patient’s well being in the emergency setting) must be communicated physician to physician in a timely and thorough manner.

In the teleradiology envi-ronment, as/when significant findings are detected, they are instantly communicated to the treating physician by means of telephone, e-fax, or via secure access to a RIS. Only 50% of radiology is interpretation of the image, the other 50% is the effective and timely communica-tion of its results. In the setting of acute stroke for instance, teleradiology allows for detection of acute CT findings and their communication to the neurologist within 15 minutes of the scan be-ing performed. This is therefore one of the critical enablers of treatment within the golden window, when brain tissue can still be effectively salvaged by

clot-lysing medication.Intelligent and collaborative

teleradiology workflows such as Radspa also allow for virtual consultations whereby radiolo-gists and physicians can view the same image of a scan contempo-raneously and discuss the find-ings. This can greatly assist in the clinician’s understanding of the extent of a patient’s disease and allow for more appropriate treatment planning. Similarly, intelligent and collaborative teleradiology workflows allow radiologists to consult each other and obtain second opinions from other experts, in real time, without delaying the diagnostic process significantly. This in itself can greatly enhance the quality of diagnosis and thereby of patient care.

Enables clinician image access Teleradiology is not for radiolo-gists alone but also for clinicians. Teleradiology workflow systems have physician-specific functions

that allow clinicians to tap into an imaging database convenient-ly while performing their clinical duties, without interruption. Thus the clinician can, during hospital rounds or while in clinic, view the scan of a patient who he/she has just finished examin-ing, using either a desktop work-station, or more recently a mobile handheld device such as an iPad. Instant access to prior studies for comparison of disease progres-sion is also enabled by teleradiol-ogy workflow systems, allowing for better clinical judgment. Recent developments in telera-diology workflow includes data mining and medical information systems, which assist in medical decision making and analysis of diagnostic data, which in turn enhances patient care.

Seamless integration between radiology information/intelli-gence systems (RIS) and hospital information systems (HIS) using HL-7 interfaces means that the data transfer between the clinical and the radiologic databases is


smooth and efficient, allowing for far more optimal clinical practice.

Surgical planning via remote 3D postprocessing An important corollary to radiologic reporting services is the remote 3D lab, which has lev-eraged information technology to supplement a scarce resource that of CT/MR technologists skilled in postprocessing of im-

age data. By transmitting the raw data images via teleradiology to a remote workstation, the labour intensive and time consuming postprocessing process can be moved offsite to a location where the skilled technologist is readily available, at lower cost to the healthcare system. The postprocessed imaging data is today an invaluable part of treat-ment planning, be it open surgery (example liver transplant) or

endovascular surgery (example aortic endovascular stent graft), or even radiation therapy. So in effect teleradiology allows high-end technical support services to be delivered efficiently and at a lower cost that the onsite model.

Enables next-gen E-training An integral part of any teleradi-ology workflow is to permit iden-tification of interesting teaching cases, and their subsequent ar-chival in a manner wherein they can be retrieved in an instant to develop training materials. And by the nature of their practice teleradiology service providers have a large catchment area for their radiologic scans, which makes for a greater variety of clinical material - for example in our organisation we are report-ing scans for patients in 15 countries across four continents, which leads to great variety in pathology and case material. And depending on the region

from where the scans originate, a greater than usual preponderance of complex and unusual cases tends to predominate, providing further value to students.

Conclusion In summary, the 10 factors listed above are the essence of how teleradiology today impacts positively on patient care. Yet what has been achieved is only the tip of the iceberg - with far more potential to be realised. More such applications should and will emerge in the years to come, as technology evolves and improves further. Given the nu-merous problems and challenges that healthcare faces today, teleradiology is a ray of light that illuminates its future and provides hope for overall better-ment of the healthcare delivery system.

The author is Chief Radiologist and Chief Pusher, Teleradiology Solutions Bangalore


COVERSTORY

Medical technology:

Faster, saFer, better

Technology has impacted human lives in ways that are unimaginable. It has sunk into our daily life so much that we do not even realise that we might not be able to survive without it! From mobile phones to laptops to i-pods and HD television, we are witnessing newer and hi-end technologies day by day. When humans can design outstanding technol-ogies merely for their entertainment, just think how much genius would go into evolving technologies that are capable of saving hundreds of lives!

Over the last couple of decades, we have seen a ‘technol-ogy revolution’ of sorts. Be it robotics or telemedicine or stem cell research, we have witnessed technologies that are simply breath taking. Our cover story this time tries to find out how these very advancements have impacted our lives, how have they changed the manner in which the business of healthcare is done, how it has brought a surge in the number of opportunities for healthcare professionals and how the industry is coping with the continuous inflow of latest tech-niques and technologies. And last but not the least; we have brought to you the 10 best medical technologies that have changed the face of healthcare forever, says Jayata sharma


there are numerous ways in which advancements in medical technology have

affected healthcare delivery. “De-spite consuming a low and rela-tively constant 2-5% of national health expenditure, medical technology has reduced hospital stay by an average of around 13 per cent,” says Dr. Dharminder Nagar, Managing Director, Paras Healthcare Pvt. Ltd.

This shift from in-patient to out-patient care provides substantial cost savings, as well as improved quality of life. Given the combination of a graying population and the current

economic climate, the value of these increased efficiencies can-not be overstated, in India as well as worldwide. Advancements in technologies have enhanced both, medical devices and healthcare delivery. Healthcare is an environment that faces a growing patient population, an overburdened clinical staff, and escalating expenses. “While the daily challenges vary, the mission of medical technology providers should stay the same; deliver better care while the hospital can be run as cost-effectively as pos-sible,” says Nikil Rao, President, Draeger Medical (India) Pvt. Ltd.

Over the last few years, medical technology has primarily focused on early and accurate diagnosis, faster and better treatment planning and effective follow up. Efforts are also being made to focus on safety and com-fort of both doctor and patient.

Imaging technology for instance is focusing on early detection and diagnosis, thus enabling higher chances of cure and correction. This also helps in using technology for preventive care rather than treatment after disease occurrence. It is now possible to detect minute lesions in the body with great precision and resolution with imaging technologies such as Ultrasound,

CT, MRI, PET/CT, etc. at an early stage.

In the field of Clini-cal chemistry and Blood analysis, technology plays a significant part. A drop of blood can now provide details of an array of diseases or symptoms that might strike a person in the coming future. Molecular diagnosis and lab automation have also proved to be blessings. “Once the staging of disease is clear, treatment planning becomes simpler,

especially in lifestyle diseases like cancer,

CVDs, stroke, etc. Open surgeries are getting replaced by minimally invasive proce-

dures, which come with huge benefits

to the patients and doc-tors as well. Less hospital stay, faster recovery, less trauma and infection, etc. are few benefits of technology advancements,” says D Ragavan, Sector Cluster Lead-South Asia, Siemens Healthcare.

In fact, in the last few years, technology has become more user-friendly and compact. Minia-turisation has helped in moving technology to the bedside, thus enhancing patient safety as well. “Patient safety has reached

greater heights with technology. Machines can now be easily disinfected and HAIs brought under control. In fact, even patients have become more tech-savvy and they come prepared to hospitals. Thus, technology is playing a major role in changing the way healthcare is delivered,” says Pavan Behl, Director & GM, SonoSite India Pvt. Ltd.

The application of technolo-gies has also increased. Earlier, ultrasound was used only in obs gyn but now its application is needed in an ICU, in the OT etc. The surge in medical technology has helped reach healthcare in re-mote areas as well. “Point of care diagnostics has enabled the reach of healthcare in tier II and tier III cities. Cardiac surgeries, liver transplants, oncology care, are now available at affordable prices all over India due to advance-ments in medical technology,” says Sandeep Sinha, Director, Healthcare Practice, Frost & Sullivan.

Need for additional trainingAs the technology landscape keeps changing regularly, hospi-tals and providers both have to strive hard to keep pace with it. While hospitals need to identify which areas need regular train-ing, providers have to keep de-signing newer training methods. While hospitals arrange seminars and workshops for this purpose, equipment providers so their bit as well. “Training our customers has always been an integral part of our approach and strategy. Since 2011, the Dräger Academy provides an overarching umbrella for all Dräger’s inhouse and external training courses with the mission to establish uniform quality standards worldwide. Hospitals also approach us for training programmes as well as updates and we do provide on-site training through our Application Specialist as and when required,” says Rao of Draeger. Similarly, Siemens is a global partner of excellence


in education. In India, they organise CMEs and user meets as knowledge sharing platform for their customers and industry at large. These help the practicing clinicians to get acquainted with newer technologies and also to exchange ideas and have a dia-logue with the experts. Recently, Siemens Healthcare brought the world renowned STAR program to India along with Bayer Zydus Pharma. Specialised Training in Advancements in Radiology (STAR) is an education program, which conducts lectures and workshops on cutting-edge devel-opments in the field of radiology.

Any new technology does require knowledge and skill enhancement of the healthcare professionals using that technol-ogy. “At BD, we train healthcare workers in the correct use of BD products and provide basic safety training, such as how to minimise exposure to blood borne pathogens. Training is often provided at customer sites when a BD product is introduced. For customers with more than one location, our team uses a ‘train the trainer approach to ensure proper training at each site,” says Rajnish Rohatgi, Direc-tor, Medical Surgical Systems, BD Medical.

In fact, recently BD in India collaborated with NABH to help hospitals and nursing homes

attain minimum standards of quality care so that they can apply for NABH accreditation. “We are working closely with hospitals to develop the skill of not only using our technology, but more importantly in building capabilities to reduce infection rates. In several cases, we have developed curricula for regional and national trainings with local partners to help develop and support the healthcare network,” says Rohatgi. One such instance is that of BD and FIND where the collaboration is to improve the diagnosis of tuberculo-sis in the developing world. The collaboration focuses on demonstrating the effectiveness of BD’s TB diagnostic technol-ogy in resource-limited settings, increasing access

to the technology through pricing agreements and strengthening TB laboratories.

Career opportunities Growing advancements in technology has also opened up better career avenues for health-care professionals. It creates a demand for newer opportunities in hospitals, diagnostic centers, with medical equipment manu-facturers, etc. Opportunities are usually found in areas like R&D, production, sales and marketing. “Technologies like the modern radiology innovations have opened up a lot of job opportuni-ties especially for the younger and more hi-tech generation of healthcare workers,” says Dr. Nagar. Advent of latest technolo-gies is also shaping our educa-

tion system. For instance, biomedical engineering

is gaining prominence as a separate stream

and many engineer-ing colleges in India offer this. This has helped

produce young engineers who have tremen-dous

potential in shaping their career

in the field of healthcare and contributing to the industry.

Also, the increased demand from India has compelled multi-national manufacturers to set up their R&D centers in India, which has given career opportunities to a lot of people. “Siemens took the lead in establishing a corporate technology centre at Bangalore to look at new concepts such as frugal innovation in healthcare. In the same premises, software development takes place in the development centre to create advanced software for global imaging business units. So en-gineers can choose a career of their liking in the field of R&D, manufacturing or marketing,” says Ragavan.

“Our work is dedicated to protecting, supporting and sav-ing lives. We therefore look to recruit employees with enthusi-asm, boldness and personality. In 2011 alone we hired about 650 people on a worldwide level. This includes staff under the safety and medical technology units,” says Rao from Draeger.

Technologies have definitely created more roles in a healthcare set-up. “We have been encourag-ing our staff to train in all kinds of technologies to give them space to grow. Our nurses are now also trained to be ICU technicians. Earlier, we didn’t have anything called a respiratory equipment technician, but now we do. In fact, biomedical engineering has come up in a big way. Previously, civil engineers used to handle the work but now most hospitals have a dedicated department for biomedical, thus increasing job opportunities by manifolds,” says Dr. Dilpreet Brar, Regional Direc-tor, Fortis Healthcare.

In fact, as treatment modalities are moving more towards non-invasive methods, it has reduced the burden on super specialised, experienced surgeons. “Now-a-days, even young surgeons can handle a lot of cases, especially with the advent of laparoscopic techniques. Doctors need not spend 10 years now mastering a specific technique,” says Sinha of F&S.


telemedicine is the use of telecommunication and information technolo-

gies in order to provide clinical health care at a distance. It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities. It is also used to save lives in critical care and emergency situations. Although there were distant precursors to telemedicine, it is essentially a product of 20th century telecom-munication and information technologies. These technologies permit communications between patient and medical staff with both convenience and fidelity, as well as the transmission of medi-cal, imaging and health informat-ics data from one site to another.

Early forms of telemedicine achieved with telephone and radio have been supplemented with videotelephony, advanced diagnostic methods supported by distributed client/server applications, and additionally with telemedical devices to sup-port in-home care. Telemedicine can be broken into three main categories: store-and-forward, remote monitoring and (real-time) interactive services.

Telemedicine has proved ex-

tremely beneficial for people liv-ing in isolated communities and remote regions and is currently being applied in virtually all medical domains. Patients who live in such areas can be seen by a doctor or specialist, who can provide an accurate and complete examination, while the patient may not have to travel or wait the normal distances or times like those from conventional hospital or GP visits. Telemedicine can be used as a teaching tool also. .A January 2012 report titled, “Global Telemedicine Market Analysis,” by RNCOS Industry Research Solutions, projects that the global telemedicine market will grow at a compound annual growth rate (CAGR) of around 19% from 2010 to 2015.

trivia: In its early manifes-tations, african villagers used smoke signals to warn people to stay away from the village in case of serious disease. In the early 1900s, people living in remote areas of austra-lia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the royal Flying Doc-tor service of australia.

Pet Ct

the fusion of PET and CT was done as research proved that the combina-

tion improved specificity, sen-sitivity, and accuracy. The first generation of PET/CT scanners included a single slice spiral CT integrated with a PET camera which utilised BGO (Bismuth germanium oxide) detectors. In fact, some of the early systems required two consoles to operate the system, one for the CT and one for the PET, and some of them incorporated a patient bore size that started at 70 cm for the CT and tapered to about 59 cm for the PET system. These types of systems were not patient friendly.

Today, nearly all vendors have overcome these shortcomings and now offer a variety of multi-slice CT configurations. All sys-tems are typically operated from one control console and have a consistent 70 cm bore which can accommodate RT pallets and pro-vide better patient comfort. The industry has made great strides in a short time. In fact, a recent report projects PET/CT utilisa-tion will grow 22% over the next five years and 55% over the next 10 years globally.

Also, PET/CT will become more affordable, substantially changing ROI projections. While the price range of these scanners

used to span from $1.8 million-$3 million, they’re now sold for $1.2 million-$2.3 million in the global market. The efficiency has also been on the rise. Earlier, a full body scan would require 45-60 minutes per scan, which is gradually decreasing to around 5-15 minutes.

In India, after the first PET/CT was installed at the Tata Memo-rial Center (2004), there has been a rapid growth of the modality. The year 2005 saw the inaugura-tion of two more PET/CT fa-cilities with on-site cyclotrons at Apollo Hospital, Hyderabad, and AIIMS, New Delhi. From stand-alone PET/CT systems with on-site cyclotrons, mostly in the government sector, the modality matured to an extent that, the majority of the PET/CT scanners and cyclotrons came up in the private setup; also, scanners situ-ated in different locations (and even different cities) could share the isotope produced from one cyclotron.

trivia: Invented by Dr. ron Nutt and Dr. David townsend, the Pet/Ct scanner was named the Invention of the Year in 2000 by time Magazine. In 2001, Pet/Ct was named Product of the Year by Frost and sullivan.

telemedicine


Molecular diagnostics

stem cell technology

borrowing from two new disciplines, genomics and proteomics, mo-

lecular diagnostics categorises cancer with the help of technol-ogy such as mass spectrometry and gene chips. Genomics is the study of all the genes in a cell or organism, while proteomics is the study of all the proteins. Molecular diagnostics determines how these genes and proteins are interacting in a cell. It focuses upon patterns – gene and protein activity patterns – in different types of cancerous or precancer-ous cells. Molecular diagnostics uncovers these sets of changes and captures this information as expression patterns. Also called “molecular signatures,” these expression patterns are improving the clinicians’ ability to diagnose cancer. Soon all cancers may be diagnosed this way.

By definition, it includes all tests and methods to identify a disease or the predisposition for a disease analysing Dna- or RNA of an organism. The way is paved by infectious disease testing and blood banking applications, but pharmacogenetic, predisposition

diagnostics and molecular cancer diagnostics applications will fol-low soon and post strong numbers in the years to come.

In addition, non-invasive or minimal-invasive procedures to obtain the material for those tests will facilitate the implementation. Cross-benefits like almost instant diagnostic results, more targeted therapies and shorter hospitalisa-tion times constitute higher costs

for molecular test in comparison to traditional analyses like micro-biology today. But molecular diag-nostics will help to abate cost for diagnosis, therapy and healthcare altogether in the middle-term.

The increase in the aging population and incidences of various chronic diseases are driving the demand of molecular diagnostics the world over. The genomic discovery has fuelled the

diagnostic marketplace because every gene-based therapeutic might need an accompanying (molecular) diagnostic test. At ap-proximately 30,000 genes for the human genome and with an esti-mated diagnostic significance of about 5%, the commercialisation of 1,500 gene-based tests can be expected. The industry is getting a push from every side and many factors collectively are fuelling the growth in this industry. Growing with a CAGR of 19 %, the global molecular diagnostics market is expected to reach US$15 Billion by 2014. Geographically, the US and EMEA markets are the most advanced in terms of adoption of molecular testing. India and China are major growing markets.

trivia: In 1949, Pauling and his colleagues introduced the term molecular disease in the medical vocabulary. the first seeds of molecu-lar diagnostics were pro-vided in the early days of recombinant DNa technol-ogy, with many scientists from various disciplines working in concert.

stem cell technology is a rapidly developing field that combines the efforts

of cell biologists, geneticists, and clinicians and offers hope of effective treatment for a variety of malignant and non-malignant diseases. Stem cells are defined as totipotent progenitor cells capable of self renewal and multilineage differentiation.

There are three sources of autologous adult stem cells: 1) Bone marrow, which requires extraction by harvesting, that is, drilling into bone (typically the femur or iliac crest), 2) Adipose tissue (lipid cells), which requires extraction by liposuction, and 3) Blood, which requires extraction

through pheresis, wherein blood is drawn from the donor (similar to a blood donation), passed through a machine that extracts the stem cells and returns other portions of the blood to the donor. Stem cells can also be taken from umbilical cord blood. Stem cells can now be artificially grown and transformed (differentiated) into specialised cell types with characteristics consistent with cells of various tissues such as muscles or nerves through cell culture. The classical definition of a stem cell requires that it possess two properties: self-renewal and potency. A number of adult stem cell therapies already exist, particularly bone marrow transplants that are used to treat

leukemia.Delhi’s AIIMS has a cardiovas-

cular stem cell group that does research on ways to tackle dilated cardiomyopathy, perhaps the 1st in the world. The center had also conducted a major multi-centre successful trial to look at the role of stem cells in repairing tissue damaged during acute heart at-tacks. Not just the heart, Hyder-abad’s LV Prasad Eye Institute had implanted cornea tissue grown from stem cells into the left eye of a middle-aged factory worker who had accidentally burnt it, leaving him blind in that eye.

In spite of numerous advance-ments, the Journal of Experimen-tal Medicine’s research (in 2010)

showed that transplanted cells that contain their new host’s nuclear DNA could still be rejected by the individual’s immune system due to foreign mitochondrial DNA. Tis-sues made from a person’s stem cells could therefore be rejected, because mitochondrial genomes tend to accumulate mutations.

trivia: In 1908, perhaps the term “stem cell” was proposed 1st time for scientific use by the rus-sian histologist alexander Maksimov (1874–1928) at congress of hematologic society in berlin. It postu-lated existence of haemato-poietic stem cells.


Minimally invasive surgery

Minimally invasive pro-cedures are performed through tiny incisions

instead of one large opening. Because the incisions are small, patients tend to have quicker re-covery times and less discomfort than with conventional surgery — all with the same benefits.

A minimally invasive procedure is any procedure (surgical or oth-erwise) that is less invasive than open surgery used for the same purpose. It typically involves use of laparoscopic devices and remote-control manipulation of instruments with indirect observa-tion of the surgical field through

an endoscope or similar device, and is carried out through the skin or through a body cavity or anatomical opening. This may result in shorter hospital stays,

or allow outpatient treatment. Minimally invasive surgery usu-ally has less operative trauma for the patient than an equivalent invasive procedure. It may be more or less expensive. Operative time is longer, but hospitalisation time is shorter. It causes less pain and scarring, speeds recovery, and reduces the incidence of post-surgical complications, such as adhesions. Patients with such le-sions on cosmetically or function-ally important areas such as the face gain great benefit from such techniques.

However, minimally inva-sive surgery is not necessarily

minor surgery that only requires regional anesthesia. In fact, most of these procedures still require general anesthesia to be adminis-tered beforehand.

trivia: a milestone was reached in 1881 in Vienna with the demonstration of the first gastroscopy by the surgeon Jan Mikulicz-radecki. It took a further 50 years until Georg Wolf and rudolph schindler (1932) introduced the first useful semi-flexible gastro-scope to the market ready for use.

robotics

robotic surgery, computer-assisted surgery, and robotically-assisted

surgery are terms for techno-logical developments that use robotic systems to aid in surgical procedures.

Robotically-assisted surgery was developed to overcome both the limitations of minimally invasive surgery and enhance the capabilities of surgeons perform-ing open surgery. In the case of minimally invasive surgery, instead of directly moving the instruments, the surgeon uses one of two methods to control the instruments: either a direct telemanipulator or by computer control. One advantage of using the computerised method is that the surgeon does not have to be present, indeed the surgeon could be anywhere in the world, lead-ing to the possibility for remote surgery.

In the case of enhanced open surgery, autonomous instru-ments (in familiar configurations) replace traditional steel tools, per-forming certain actions (such as rib spreading) with much smooth-er, feedback-controlled motions

than could ever be achieved by a human hand. The main object of such smart instruments is to reduce or eliminate the tissue trauma traditionally associated with open surgery without requir-ing more than a few minutes’ training on the part of surgeons. This approach seeks to improve that lion’s share of surgeries, particularly cardio-thoracic, that minimally invasive techniques have so failed to sup-plant.

The most popular da Vinci Surgical System comprises three components: a surgeon’s console, a patient-side robotic cart with 4 arms ma-nipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system. Articulat-ing surgical instruments

are mounted on the robotic arms which are introduced into the body through cannulas. The original telesurgery robotic system that the da Vinci was based on was developed at SRI International in Menlo Park with grant support from DARPA and

NASA. Although the telesurgical robot was originally intended to facilitate remotely performed surgery in battlefield and other re-mote environments, it turned out to be more useful for minimally invasive on-site surgery. The da Vinci is by far the most popu-lar in India; recently Mumbai’s Kokilaben Dhirubhai Ambani

Hospital acquired one. However, in spice being ‘wanted’ in India, not many hos-pitals have been able

to import it. Because of the hefty cost of the

robotic system it is not prov-ing cost-effective for all kinds of

hospitals and physicians, despite the benefits to patients, since there is no additional reimburse-ment paid by the government or insurance companies when the system is used.

trivia: In May 1998, Dr. Friedrich-Wilhelm Mohr using the da Vinci surgical system performed the first robotically assisted heart bypass at the Leipzig Heart Centre in Germany


Portable ultrasound

bio-absorbable stents

Portable or Point-of-care (POC) ultrasound technol-ogy has the potential

to transform the way in which critical care units (CCUs) function. By consolidating and speeding up healthcare delivery as well as minimising patient transports, such technologies can significant-ly improve patient safety, reduce costs associated in hospital stays and enhance healthcare quality.

However, the use of POC ultrasound is not limited to departments traditionally focused on clinical imaging. Diverse spe-cialties, such as anaesthesiology, critical care, emergency medi-cine, paediatrics, rheumatology, trauma, surgery, cardiology, etc. are relying on POC ultrasound for diagnosis and guidance of clini-cal procedures. It has also found its way into remote corners of the world where funds and facilities are limited. Smaller, more eco-nomical machines are required. POC units make the cost for ul-trasound technology affordable to more healthcare providers overall, including numerous hospitals and medical facilities throughout India.

The implementation of POC ultrasound technology by ap-propriately trained physicians results in improved quality of

care. It enables medical profes-sionals to perform precision-based procedures and treatments under direct, real-time ultrasound visualisation. Use of ultrasound guidance by physicians may improve success and decrease complications in regional an-aesthesia (nerve blocks), lumbar puncture, I.V. placement (central and peripheral vascular access), biopsies, thoracentesis, paracen-tesis, arthrocentesis, incision and drainage of abscesses, as well as localisation and removal of foreign bodies.

Portable ultrasound devices are pocket size, wireless, costing only $7,500 as opposed to usual ultrasounds costing from $40,000-$100,000. Although it has several benefits, the device is yet to pick pace in India due to certain rules under the PC PNDT Act.

trivia: the aDr 2130, designed by Marty Wilcox was the first portable ul-trasound unit commercial-ly available in the United states, being released in 1975. this unit weighed about 25 lbs, had 3 linear probes to choose from and used an oscilloscope for a display instead of a tv monitor.

although stenting had improved outcomes in patients undergoing

percutaneous coronary inter-ventions, permanent metallic implants had specific drawbacks that limited their unrestricted use. These included thromboge-nicity, permanent physical irrita-tion, mismatches in mechanical behaviour between stented and non-stented vessel areas, long term endothelial dysfunction, and chronic inflammatory local reactions. Additionally, their inability to adapt to growth was an obstacle for later surgical revascularisation. A solution to these issues came in the form of degradable implants that seem to offer some advantages. When bioabsorbable stents emerged on the radar of interventionalists in the last decade, some dared to dream that they might one day have a stent that would do its job, then disappear, eliminating the long-term use of dual antiplatelet therapy, without a subsequent risk of stent thrombosis.

In addition, bioabsorbable stents wouldn’t interfere with diagnostic evaluations using non-invasive imaging, such as MRI and computed tomography (CT). Equally important, the technol-ogy offered the promise of doing away with vessels loaded up with multiple stents, the so-called full metal jacket, which has the

potential to interfere with future coronary surgery.

Abbott was the first to introduce a thoroughly tested bio-absorbable stent. Abbott’s bioabsorbable everolimus eluting coronary scaffold is made of polylactide, a proven biocompat-ible material that is commonly used in medical implants such as absorbable sutures. As with a metallic coronary stent, Abbott’s bioabsorbable technology is designed to restore blood flow by propping open a clogged vessel, and to provide support until the blood vessel heals. Unlike a metallic stent, however, a bio-absorbable scaffold is designed to be slowly metabolised by the body and is completely absorbed over time.

However, there are still ques-tions looming over the wide use of these stents. Experts who have studied these stents are of the opinion they will probably work only in 10% to 20% of the population.

trivia: Puel and sigwart, in 1986, deployed the first coronary stent to act as a scaffold, thus 1) prevent-ing vessel closure during PtCa, and 2) reducing the incidence of angio-graphic restenosis, which had an occurrence rate of 30-40%.


total artificial heart and VaD

a total artificial heart (TAH) is a device that replaces the two lower

chambers of the heart. A TAH usually extends life for months beyond what is expected with end-stage heart failure. If you’re waiting for a heart transplant, a TAH can keep you alive while you wait for a donor heart. It also can improve your quality of life. However, a TAH is a very com-plex device. It’s challenging for surgeons to implant, and it can cause complications. However, a ventricular assist device (VAD) is something that’s seems to be a step better than TAH. VAD boosts the native heart by taking up over 50% of its function. In a young person, this device could delay the need for a transplant by 10–15 years, or even allow the heart to recover, in which case the VAD can be removed. Some VADs are intended for short term

use, typically for patients recov-ering from heart attacks or heart surgery, while others are intended

for long term use (months to years and in some cases for life), typically for patients suffering

from congestive heart failure. VADs need to be clearly distin-guished from artificial hearts, which are designed to completely take over cardiac function and generally require the removal of the patient’s heart.

Both devices are medical marvels and hence deserved a place in our list together! Another major advantage of a VAD is that the patient keeps the natural heart, which may still function for temporary back-up support if the mechanical pump were to stop. This may provide enough support to keep the patient alive until a solution to the problem is implemented.

trivia: the first Left Ventricular assist Device (LVaD) system was cre-ated by Domingo Liotta at baylor College of Medicine in Houston in 1962.

bio-implantsbioimplants are materials

of human, animal or me-tallic origin that are of-

fered after conservation or prepa-ration to the tissue replacem ent. On the basis of its origin, the infection security plays a large role next to the general demands on an implant. These implants use biomaterials that can interact with biological systems to coexist for longer service with minimal failure. Bio implants are widely used in repair, replacement, or augmentation of diseased or damaged parts of the musculo-skeletal system such as bones, joints and teeth. The fundamen-tal requirement of a biomaterial is that the material and the tissue environment of the body should coexist without having any unde-sirable or inappropriate effect on each other.

Common medical devices made of biomaterials include hip replacements, prosthetic heart

valves and the less common neurological prostheses and implanted drug delivery systems. These devices when placed inside the body are termed implants when they are intended to remain there for a substantial period of time, and as prosthesis when they are permanently fixed in the body for long-term application till the end of lifetime. Popular

metallic implants are usually made of one of the three types of materials: austenitic stainless steels, cobalt–chromium alloys and titanium and its alloys.

India has been ahead in the use of bioimplants especially with the increased popularity of cosmetic dentistry. Not just this, most hospitals in the country, including government ones, are

regularly using bioimplants for various joint surgeries.

The sheer possibility of developing a product that can be compatible inside the human body for an entire lifetime make bio-implants a pick for our list.

trivia: In 2009, LifeNet Health, a leading allograft bio-implant company, launched Vertigraft Cervi-cal bio-Implant (VG2C) with Preservon® technol-ogy for the 1st time. Pres-ervon® is a proprietary glycerol-based preserva-tion solution that allows allograft bio-implants to be stored in a fully hydrated state at ambient tempera-ture. this eliminated the need to freeze or freeze-dry bio-implants, doing away with lengthy thawing and rehydration times in operating rooms.


Leaders speak

Healthcare is about qual-ity, access, and one other vital factor - especially

in India - affordability. Most of India’s population is still strug-gling to come out of poverty, where cost can be a deterrent even if healthcare programs do reach them some day.

The coming decade will shape the future of healthcare industry with innovations in technology, financing and delivery models.

While hospitals will continue to be the mainstay of treatment for episodic acute care, there will be fundamental shift in nature, mode and means of delivery of care. Speciality centers, retail clinics, diagnostic centers, and wellness centers with simpli-fied processes and focus will improve the quality, service and convenience for the consumer. With rising life style diseases, preventive and chronic care will

gain more importance and play a major role in addressing medical needs. Advances in technology and medical research will make it possible to envision an entirely new healthcare system that pro-vides more individualised care without necessarily increasing costs. Healthcare will become increasingly personalised with the development and delivery of new treatments tailor-made to patient’s needs.

Is our healthcare vision flawed?Even though there is a bright future ahead of us, in reality is our vision for medical technol-ogy flawed? How did the Indian automotive industry become a self-sustaining industry? How did the Information Technol-ogy industry become a force to reckon with globally? How did the pharmaceutical industry turn a high-import country of drugs

Can medical technology emulate the IT story?Indigenous medical technology manufacturing and innovation is the key to bring cost effective medical technology solutions specific to India and emerging markets of the world, says Dr. GSK Velu


to one of the largest exporters of drugs in the world? By imple-menting such successful models, can the Indian Medical Technol-ogy industry grow and in the process, make India (a country that imports 71% of its medical devices) self-sufficient based on indigenous innovation?

What would be the country’s vision today, if you have numer-ous PhD scientists, a steady sup-ply of biomedical and electronics engineers, and medical device manufacturing facilities at its dis-posal? Would its vision change from what it was a year earlier, or would it remain the same? Could it be an untapped opportunity, knowing that the best people in the field, a supporting infra-structure, and an ecosystem of entrepreneurs raring to not only develop unique solutions for the local market but also put Indian medical technology industry on the global map?

India’s growing marketThe key products that comprise the medical devices industry include surgical appliances and supplies, surgical and medical instruments, electro-medical equipment, in-vitro diagnostic substances, irradiation appara-tus, dental and ophthalmic goods. Two main constituents make up the medical devices market. The services market involves product design and development services, product testing and certification services, product implementation services, product maintenance services, product upgrade ser-vices and Regulatory consulting services for medical devices. While the application market comprises Class I Devices, Class II Devices, and Class III Devices.

India’s medical equipment market—valued at $2.7 billion in 2008—is Asia’s fourth largest (behind Japan, China, and South Korea) and is projected to reach $6 billion by 2015. Domestic production supplies only 29 %of the market. Imports account for about 71 %.

Medical technology is seen as one of the three key drivers of increasing healthcare accessibil-ity. It is estimated that 35-40 % of a hospital project is allocated to medical technology. Therefore, it is imperative to devise ways to rationalise this cost by adopting some innovative methods includ-ing reducing the cost of medical technology research and develop-ment, encouraging indigenous production of medical devices, devising innovative ways of deal-ing with obsolescence, testing the new and upcoming business models of technology services etc.

There is a growing demand for quality healthcare service. The Indian population of 1.2 billion people is growing at a rate of 2.5 % per year. The growth in afflu-ence of 200-300 million middle-income consumers has increased the demand for healthcare services. Many in the growing “middle income” segment look for international quality medi-cal services in super-speciality hospitals.

This trend is likely to con-tinue for the next several years, thereby creating demand for a higher standard of healthcare. The changed demographic profile and the rise of lifestyle-related diseases have altered

the health seeking behavior of the consumer. There is a rise in lifestyle-related diseases such as diabetes, cardiovascular dis-eases, and diseases of the central nervous system. The growing de-mand for quality healthcare and the absence of affordable medical devices pose a challenge and certainly a great opportunity. In manufacturing medical devices - designing, prototyping, develop-ing, and marketing are areas for growth. Some of the best sales prospects in the Indian medical equipment market include cancer diagnostic, cardiac products, medical imaging, plastic surgery equipment, as well as polymerase chain reaction technologies, labo-ratory products, orthopaedic and prosthetic appliances. India is full of opportunities as most Indian healthcare institutes use foreign medical equipment.

Asia: the region of growthThe global market for medical equipment and supplies was val-ued at US$273.3 billion in 2011, equal to just over US$49 per capita. Orthopaedic devices hold the largest market share and car-diology devices have the highest growth rate in the medical device manufacturing industry.

The global medical device,

technology and equipment market is forecasted to be worth over US$348.6 billion by 2016, but where are the opportuni-ties? With an average CAGR of 9.6% and market value expected to exceed US$71 billion by 2015, the Asia/Pacific medical device sector offers significant commercial opportunities. The current medical infrastructure is less than adequate. According to World Health Organisation, there is need for 80, 000 hospital beds per year for the next five years to meet the local demand. A significant portion of these hospital beds will be in various specialties. With public-private participation, the industry is expected to grow to manage this demand. This has also brought a surge in demand for high-end medical devices and equipment as the specialty hospital facilities depend on the import of high-end medical equipment.

Where are the opportunities?The government has launched the National Rural Health Mis-sion (NRHM) 2005-2020 with an aim to provide quality medical care for rural Indians. Under this, NRHM has identified vil-lages having weak medical care delivery systems and is working


to improve the infrastructure in these locations. To meet the growing demand, one million beds will be added to bring the bed to a thousand-population ratio to 1.85 people. It requires a total investment of $77.9 billion, a large part of which will be from the private sector.

Small-scale industry that con-tributes over 40%of India’s GDP and provides majority of India’s employment can support the growth of the medical technol-ogy industry here. By develop-ing a joint roadmap, small-scale industries can develop second-ary products and services that involve parts sourcing, product maintenance, post-sales call centres, training, service delivery, and a host of other areas. By this synergy, both sectors can grow rapidly.

Local development key to fostering innovationFor the public and private sector to help meet the demand for medical devices, there is a critical need to foster an ecosystem that encourages stakeholders to invest and build technologies, medi-cal devices, and services. This ecosystem should closely involve and engage a broad spectrum of stakeholders from government bodies, new age entrepreneurs, and academia. While there is interest from all stakeholders to elevate Indian medical technol-ogy to global levels, the critical need is for a road map to develop a separate industry, transpar-ency in implementing programs, policy initiatives specifically directed at this sector,.

The Indian medical technol-ogy industry needs to innovate to meet the demand of the local markets. The potential for growth lies in creating a huge talent base, targeted government policies, a central regulatory body, collaboration between research bodies such as IIT, and establishing quality standards.

Some of the steps which the government can take include:

• Establishing MT manufactur ing Joint Ventures in India • To recognise MT as a separate and significant entity of Healthcare • To Form a Department of Medical Technology (like dept. of Pharmaceuticals) under Health Ministry or Sci ence & Technology Ministry. • Powerful financial incentives • Create our own supportive regulatory system• Supportive investment capacity (subsidised loans for

MT manufacturing / innovation)

Another key concern area is Indian medical technology inno-vation to bring out cost effective solutions suited to India and the emerging markets. Innovation in medical technology faces a lot of challenges which need to be ad-dressed by the government.

Combating the challenges The challenge in medical technology innovation space

can be addressed by creating a Medical Technology Innovation Eco-System which requires (1) an education system that nurtures creativity; (2) an R&D culture and value system which supports both basic and applied research and technology development; (3) an industry culture which is keen to interact with the academia; (4) government support; (5) a policy framework which encourages young people to enter scientific careers.

The Indian Medical Technol-ogy Innovation Eco System will include engineering, medical institutes, government (DST/DBT/ICMR) and domestic medi-cal technology companies. A col-laboration of industry-academia for innovative solutions will foster high levels of productivity. Creation of a central author-ity for holistic development of MT industry in India to driven on regulatory and commercial growth (Dept. of MT under Ministry of Health or Science & Tech.), share industry best practices and encouragement of overall development of industry are few of other notable steps to be taken by the government and others in the eco-system.

Some of the key recommenda-tions are mentioned below:Establishing an appropri-ate government channel focused on medical devic-es: Currently, medical devices are regulated as drugs under the Drugs and Cosmetics Act by the Drug Controller General of India (DCGI) of Central Drugs Standard Control Organisation (CDSCO), the central governing body of the country. A separate governing body that caters to the industry is required to oversee certification, approval, or moni-toring of medical devices. Manu-facturers face serious challenges in getting project approvals, and decisions can take as much as up to a year to get clearances. This has discouraged participants from entering this sector. With no direct relation to medical

Some of the most suc-cessful industries that have benefited from robust ecosys-tems are the Pharmaceutical and Information Technology industries.

The government set up several software technology parks in 1990. These parks make entry into the inter-national software industry simple. Companies in these parks can import goods duty free and for the first five years without corporate taxes. The park provides a single government contact for all procedures such as licenses, import certificates, etc. allow-ing Indian firms to avoid the bureaucracy of the central government. The Indian pharmaceutical sector has also come a long way, being almost non-existent before

1970 to a prominent provider of healthcare products, meet-ing almost 95 per cent of the country’s pharmaceuticals needs. From simple head-ache pills to sophisticated an-tibiotics and complex cardiac compounds, almost every type of medicine is now made indigenously. Indian govern-ment had framed a favourable policy to boost foreign invest-ment in the pharmaceutical sector. Tax holidays are of-fered to industrial operations established in specified Spe-cial Economic Zone or under developed areas, deduction of profits earned from exports, liberal depreciation allow-ances, deduction of capital R & D expenditure; and relief on all contributions to approved domestic research institutions are some examples.

Learning from other successful industries


devices, DGCI also faces serious challenges in understanding the requirements of the industry.

Specific policy initiatives: Lack of a clear policy for the industry has discouraged the private sector from participat-ing actively. Industry experts have long been asking for it to be recognised as a separate industry. Low import duties on raw materials and high duty on imported devices have helped China, Malaysia, and South Af-rica to develop low-cost medical solutions. To encourage invest-ment, financial incentives must be offered to local manufacturing units to offset the high capital required for new projects. .

Need for a dedicated regulatory body: Looking for successes in parallel industries within India can help create a model for developing the medical devices industry. The telecom industry has significantly gained from a dedicated regulatory body – TRAI. Its support has brought in tremendous growth in the telecom sector in a short span. Having a body such as TRAI overseeing all functions of the sector brought convergence of market players and govern-ment bodies to work together in making what the telecom sector is today – at over 600 million subscribers. The Indian medical technology industry requires a similar approach in establishing

a central agency that oversees all functions and addresses the specific needs of this industry.

Capitalising on the out-sourcing market dynam-ics: Outsourcing has helped medical device manufacturers reduce product development cost by 10% to 30%. The services outsourcing industry can gain from the entry of new medical device manufacturing companies to help established companies in outsourcing product manufactur-ing and maintenance in non-core areas of medical device manufac-turing.

Establishing India-specific quality standards and a device monitoring and certification body: The

current medical devices being imported to India are specifi-cally designed and developed to meet US & EU standards. These devices often require fine-tuning and further customisation when imported into India. While there are international standards such as ISO that certify the quality of these imported products, there is a critical need to establish quality control standards that meet India’s requirements. The design and development of these products need to adjust to the local market dynamics, for instance, a MRI machine that is big and heavy cannot be transported to villages that currently lack transportation and electrical infrastructure. What is needed is innovation from local manufacturing companies to design and develop medical devices that meets India’s current reality. Local manufacturing companies gain from closer ac-cess and depth of knowledge of the potential users of the devices from hospitals, doctors, and of course the sufferers. Including understanding the sensitivity of the largely inaccessible people who live in rural areas.

To sum- up, indigenous medical technology manufactur-ing and innovation is the key to bring cost effective medical technology solutions specific to India and emerging markets

Total Asian Medical Device Market, 2010 (US$ millions)

Dr. GSK VeluMD, Trivitron Group

of the world. Hence, significant efforts are needed for all partici-pants in the medical technology ecosystem to stimulate innovation in MT space so that opportuni-ties provided in the market can be capitalised by domestic MT companies and the consumers of healthcare services can be benefited.

The author is the Founder & Managing Director M/s Trivitron Group of Companies (the largest medical technology company of Indian origin). He established the Trivitron Medical Technology Park, South Asia’s first state-of-the-art medical technology manufacturing facil-ity and the Trivitron Innovation Center, a center of excellence for biomedical research & development and design.


Mr. Pavan Behl, veteran in the medical technol-ogy industry, joined

SonoSite India Pvt. Ltd. in Octo-ber 2005. Currently he is leading SonoSite India Private Limited as its Director & General Manager. Mr. Behl is a seasoned profes-sional and has rich experience in various aspects of the medical technology business.

With over 36 years of active

experience, Pavan Behl is a well-informed man who has a clear vision of taking his company to next level. SonoSite is the innova-tor and world leader in bedside and point-of-care ultrasound and offers high quality imaging per-formance in delivering to diverse specialties i.e anesthesiology, critical care, emergency medicine, pediatrics, rheumatology, trauma, surgery, cardiology and sports medicine

Mr. Behl’s leadership skills, integrity, high level of detail and work ethic are second to none. Together with his strong and efficient team of 32 employees in India, his efforts have been instrumental in company’s continuous high growth since its inception.

Prior to assuming position of General Manager at SonoSite, he has served multinational companies such as Becton Dick-inson, SpaceLabs Medical and

Guava Technologies and has been responsible for successfully establishing and managing their direct operations.

Pavan Behl feels his success is due to his attentiveness to details and his enduring & persevering personality.

Born in December 1953, Mr. Behl is an alumnus of Indian In-stitute of Management, Ahmed-abad and graduated from St. Stephen’s College Delhi in B.Sc. (Hons) Chemistry.

Q.Medical equipment is a major component of the budget in set-ting up a new hospital. What factors should be kept in mind when choosing the particu-lar items?A. The most important factor apart from budgetary constraints is the relevance of particular pieces of equipment for the

clinical specialties that the management would like to em-phasise. Every hospital has a few branches in medicine which it wants to concentrate on, because they cannot the best in their city in each and every medical discipline.

There is a tendency among some hospital managements to accept the bundle offers of an equipment vendor – that is to make all their purchases from the same vendor. The reason could be a price advantage or some facility in the terms and condi-tions written into the purchase contract. However, there may be no need to buy all the equipment at the same time as part of a bundle offer.

Besides, every vendor has its own strengths and weaknesses; they may not have the best available technology in every class of equipment. This puts the purchaser at a disadvantage if he

Medical equipment is a major part of the budget The choice of medical equipment, the timing of the purchase, the selection of the vendor are crucial issues for hospital managements. Pavan Behl, Director of Sonosite India Pvt Ltd, responds to our queries on these issues

U Ask


goes for a package deal.Another set of issues concerns

the support, education and train-ing that major equipment manu-facturers provide for the clinicians as well as other user groups. One also has to consider the cost of ownership, the terms of warranty, after sales service, etc.

Q. Which are widely used gadgets that a clinical specialist can transport with him from one medical centre to another?A. The important ones that have become available in the past few years include portable ultrasound and ECG machines, cardiac defibrillators, and even CT machines! The last gadget has become available in the US in the recent past and has proved quite useful in major trauma centres. The system typically requires about one third of the mAs used for conventional CT, due to a combination of a short detector-tube distance and high-efficiency solid-state detectors. It is mounted on wheels, so that it can be moved to the patient’s bed-side. Portable defibrillators were introduced as far back as the early 1960s, but gradual improve-ments in the design of defibrilla-tors, have led to the availability of Automated External Defibril-

lators (AED). These devices can analyse the heart rhythm by themselves, diagnose the rhythms disorders, and charge to treat. This means that no clinical skill is required in their use, allowing lay people to respond to emergencies effectively.

The value of portable ultra-sound is quite widely understood by now. It can be a lifesaver in medical emergencies such as severe trauma, or neonates who need immediate attention. Besides, even in areas that have good hospitals, portable ultra-sound machines can run on bat-tery power for up to three or four hours, which is extremely useful

in case of a power failure. Where time is of essence, portable equipment makes a lot of sense.

Further, the patient safety issues are easier to handle with portable ultrasound; the chances of hospital associated infec-tions, which are a major cause of concern worldwide, are much reduced with this technology. The systems are easy to use and learning curve is not much of a hurdle. Hence it allows the doc-

tors to focus on the patients as soon as possible.

Q. What are the major issues involved in sourcing of spares and consumables for hi-tech medical gadgets?A. The biggest problem is the structure of the import duties; they are not only very high but the duties levied on spare parts are much higher than the equip-ment itself. For example, the duty payable for a color Doppler is 11.7 per cent but for the spare parts for the same machine, the duty is as high as 29 per cent! Why

should it be like this? In any case, the higher duties are ultimately passed on to the customer.

As regards availability of spare parts, or getting them cleared through customs, the problems have largely been solved. Most major companies have opened subsidiaries and they are able to stock the spares up to a point. Earlier when they had only distributors, there were delays and other problems.

Q. What other steps are required in terms of maintenance of these gadgets? Personnel needs, costs, etc.A. This is certainly an impor-tant factor in ensuring that the expensive equipment is kept functioning at peak level and downtime is kept to a minimum. Hospital modern hospitals are building up their biomedical engineering department and the manufacturing companies also provide a lot of help by way of updating the knowledge of the user’s representatives. This is necessary because every product has its own training require-ments.

Q What is the average period of obsoles-cence of commonly used medical gadgets? How should the arrangements for replacing outdated equipment be made? A. For most equipment, it is about six to seven years. However that is not much of a problem because the payback period for medium value equipment, particularly in north India is about two to three years. The medium value equipment that are priced between Rs 10 lakh to Rs 25 lakh include the entire range of diagnostic equipment such as auto-anal-ysers, ventilators, intra-aortic balloon pumps, etc.

Q How does one organise the funds? Are there any buy back arrangements with the supply companies? A. The funds are usually not a problem in the large and medium-sized hospitals, say 80-100 beds in size. In smaller institutions including nursing homes, there may be an issue of shortage of funds. But in most cases, they are able to overcome the hurdles on their own.

The value of portable ultrasound is quite widely undestood; it can be

a lifesaver in medical emergencies such as severe trauma


Back in the mid-1980s, when heart bypass sur-gery was being conduct-

ed in only a few leading hospitals in the country, and many of today’s common endoscopic pro-cedures were still many years in the future, it was quite common for upper middle class people to go abroad for treatment.

A bypass operation would entail expenses of Rs 4-5 lakh in the US, far beyond the reach of perhaps 90 per cent of Indian people. Likewise, world renowned heart surgeons like Michael DeBakey and Denton Cooley would visit India once a year and operate in leading hospitals of Mumbai, Chennai or Delhi, so that Indian surgeons could pick up their skills.

Medical practice then was a simpler business; students would learn how to detect enlargement of the liver by ‘palpating’ the abdo-men, and diagnose many major heart ailments by listening intently through a stethoscope. Ultrasound and echocardiography were just coming into vogue, and ‘explor-atory laparotomy’ – an operative procedure to just open the abdo-men and examine it directly, was a regular affair, particularly in cases of cancer.

Today, in the age of 3D imaging through CT scans, portable ultra-sound machines and other facili-ties, the very idea of exploratory

laparotomy seems quite absurd!It is also a fact that clinicians

tend to order many more lab tests than they used to, depend much more on machines for diagnosis than doctors of an earlier genera-tion, and this has contributed to making healthcare somewhat more expensive than it used to be. The counter argument, also true to a great extent, is that many recent medical advances have enabled people to recover from illness faster and with less pain and discom-fort,

and even lower residual abnormal-ity. The flip side of these scientific wonders is that every one cannot afford them, at least in the begin-ning, when they introduced. The costs of most medical gadgets, procedures and other aspects fall rapidly after a few years – just as

it happens in the case of mobile phones, comput-ers, laptops and so on.

Since there are no simple answers to these questions, we set out to obtain the views of the various stakeholders in the business, namely

hospital managers, hi-tech medical companies and practicing

clinicians. Each of them look at the is-

sues from a different angle, and here is

what they had to say: “It depends upon which

specialty you are talking about and how you look at expenses. In purely mon-etary terms healthcare ex-penses have definitely gone up, whether bed charges in hospitals or doctors fees,

medicines. But the benefit to the patient who is willing to

incur that cost is

tremendous,” says Dr Anil Kumar, honorary interventional cardiolo-gist in Bombay Hospital.

Dr Kumar should know what he is talking about; before joining Bombay Hospital in 1999, he was an honorary professor of cardiol-ogy at Grant Medical College, Mumbai where he would conduct balloon angioplasty for a mere Rs 55,000! A few years later, when coronary artery stents first came into the picture, the Palmer Satz product used to cost around Rs 86,000. Today the same stent is available for just Rs 20,000 while the drug eluting stents (DES) that came in later are priced at about Rs 149,000.

But he agrees that some amount of commercialisation has crept into the medical profession, but he feels the reason is the advent of private medical colleges that charge huge capitation fees to the students. “This is bound to happen,” he adds.

In hospitals belonging to the Hyderabad-based Global Hospitals group, the typical angioplasty package is about Rs 1.5 lakh, but could be higher if the stent implanted costs a lot more, while in the Seven Hills Hospitals in Mumbai and Visakhapatnam, the package is about Rs 80,000 to 90,000 plus the price of the stent.

The more important point, according to Dr Kumar, is the total transformation in the clinical course of a heart attack patient. In

Has technology made healthcare more costly?Both practicing clinicians and hospitals managers accept that healthcare has become more expensive over the years on account of advances in technology, but it has also brought huge benefits to most patients, says Sumit Ghoshal

Debate

Philips MEDICALL 2012 “prescription for Medical professionals”

“Chain Reaction” is the theme for Medicall 2012

The India economic boom has been characterized by a few sectors, which have been front-runners, and a few which have benefited from it. One such sector is Healthcare. The strik-ing feature about the Indian Health-care sector is that it has the potential to grow at a much faster rate in the foreseeable future and shall present new ‘sectors of opportunity’-Within healthcare, which shall emerge as growth drivers. Increasing participa-tion by the private sector in health-care services is stimulating change in the Indian healthcare industry.

Indian Healthcare sector has seen progressive increase in investments in healthcare infrastructure and facilities, especially hi-tech medical devices. The hospital industry is an important component of the value chain in Indian Healthcare industry rendering services and recognized as healthcare delivery segment of the healthcare industry, which is growing at an annual rate of 15%. The size of the Indian healthcare industry is

estimated to be a whopping US$ 280 billion by 2022 and slated to grow at 15 % CAGR.

When it comes to naming suc-cessful events which bear a tremen-dous influence on the industry they represent, MEDICALL gets top of the mind recall. It is India’s premier Medical Equipment Expo and the first real “supermarket” for hospital

equipment and supplies. The surprise package this year in

Medicall Chennai would be the in-novative Fashion Show on Hospital Garments. It was unveiled for the first time in India at the previous hosting of MEDICALL in Ahmed-abad and was a runaway success. This show is based on the premise that patients like children and young-

sters normally get bored of the see-ing the conventional white uniform of doctors and nurses in hospitals. Hence the organizers hit upon a novel concept of introducing a fashion show on Hospital Garments in cooperation with NID (National Institute of Design, Ahmedabad) at MEDICALL.

Another value addition at Medicall Expo Chennai would be the Hospital Property Mela to guide doctors who want to purchase or set up a hospital or nursing home. The MEDICALL Innovation in Health-care Awards would be presented to the most innovative manufacturers in the medical field. There are three categories of Awards: Product In-novation, Process Innovation and Concept Innovation. Hospitals will be invited to be a part of this awards function. Over 500 companies are estimated to exhibit at Medicall Expo 2012 Chennai which has seen an increase in exhibit space with a total of 4 halls this year.

Healthcare delivery chains in oph-thalmology, dentistry & diagnostic path labs have carved a niche for themselves and are growing at a healthy clip. It’s time to take stock of this growth, discuss about the problems therein and identify op-portunities for future. Medicall 2012 has invited eminent speakers, who have walked the talk of promoting healthcare chains. Entrepreneurs, professional experts representing engineering, design, supply chains, turnkey consultants, medical adminis-trators & top notch surgeons will not only be sharing their experiences of setting up similar chains but they will also be elucidating the value proposition. Nominate your best minds viz., the Hospital Manager, CEOs, the Medical Administrators, the Physicians and / or Surgeons

who are keen to wear a grey coat in preference to a white coat.

Medexpert, the organizers of MEDICALL, are a reputed name in events & trade shows for the health care industry. Being leading trade fair organizers in Chennai and now in Gujarat, they have proved their high degree of professional-ism by attracting the right target audiences through highly effective and focused marketing strategies. This is reflected in the level of satisfaction its participants have derived from this unmatched platform over the years. Medexpert are totally committed to making the exhibition experience of exhibitors both profitable and efficient by maximizing return on their invest-ment. Medicall Expo is testimony to this fact. www.medicall.in


the pre-angioplasty days, a serious myocardial infarct patient would be kept in the ICU for three-four days, and then in hospital for almost two weeks after which he would have to take rest at home with light activity for almost three months. Today, such a patient would perhaps undergo an im-mediate angioplasty and be back to his daily routine within seven or eight days!

Dr Pavan Kumar Pipada, a senior heart surgeon with Mum-bai’s Lilavati Hospital, puts it even more strongly. “The answer is No. Hi-tech medicine has not pushed healthcare costs upwards. In fact in cardiology and cardiac surgery, angiography and angioplasty and cardiac surgery packages have remained almost the same over last 15 years or so. They may have come down in fact due to larger no of procedures now being done at competitive costs in Metro and non-metro second level cities.” Besides, in cardiac surgery, the technique of beating heart surgery with use of Octopus heart stabilizing device, it has eliminated use of heart lung machine and corresponding consumables, thus reducing cost of cardiac surgery.

Numerous others have stood testimony to this fact – a retired engineer who recently underwent a heart bypass surgery in Mumbai’s Jaslok Hospital for just Rs 2 lakh, an elderly lady who had to pay just Rs 1.85 lakh for knee joint re-

placement (for each leg) at MIOT (Madras Institute of Orthopedics and Trauma) in August 2010.

“In a similar fashion, there are several examples where the tech-nology is bringing down the cost. This is done by either increasing the throughput, or with completely new features, which improves early diagnosis, says D Ragavan Sector Cluster Lead-South Asia, Siemens Healthcare.

Here are some examples. Ten years ago, a single slice CT was

costing Rs 1.5 crore. Now for the same price, customers can get a 16 slice CT, which on one hand increases the speed and the throughput, while on the other hand delivers lower dose to the patient. Increase in throughput,

directly leads to reduced cost in scanning, which is a big benefit to patients.

Another example is of the ad-vent of Cardiac CT scanners. This has made possible, for the first time, visualization of coronary vessels of the heart non-invasively. This has also opened up the pos-sibility to screen high risk, but asymptomatic patients possible, which was earlier not possible, as asymptomatic individuals did not want to go through a high invasive

catheter angiogram. This technol-ogy has, over the last several years, saved numerous lives. It is also now making it possible for the Hospitals to assess the patients coming to emergency wards, far too quickly, which in turn helps them to treat them within the Golden Hour.

Yet for some other routine procedures, the bills have indeed gone up. Earlier this year, a photographer in Kolkata was charged over Rs 60,000 for having a benign tumor removed from the side of his neck; a school teacher in Talegaon, Maharashtra had to pay Rs 40,000 for getting a knee liga-ment repaired through a minimally invasive procedure and another young lady was handed a bill of Rs 1.35 lakh for a laparoscopic hys-terectomy just last year. Likewise, a retired school master in Chennai who underwent a cataract surgery in both eyes was required to pay

Rs 30,000 for each eye, and a Mum-bai eye surgeon charged a senior journalist with a leading business magazine Rs 40,000 for each eye. It is also true that both the above ladies were out of hospital in about three days and returned to their normal routine in less than a week – a far cry from the days when hysterectomy involved a five inch incision, and a week in hospital (until the stitches were removed). Wound gaping and infections were common, and if the lady happened to be substantially overweight, she would be much the worse for her surgery. And both the people who had cataract surgery returned home within a few hours and made a complete recovery in less than a week.

“Hi-tech – both in diagnostics as well as therapeutics – has helped enhance the accuracy and efficacy of health delivery system. It has ushered in early and more precise diagnosis. It has brought in advanced and better modalities of treatment. It has, in many cases, re-duced the morbidity and mortality. But all this has come with a price tag that makes it unaffordable for most of the Indian population. An overwhelmingly large chunk of hi-tech is confined to the private sector health providers, while the public sector is still struggling to provide clean water, healthy environment, vaccination and family and social-welfare services,” says Dr Arshad Ghulam, a general surgeon practicing in Mumbai for more than two decades.

Luckily, eighty percent of diseases can still be managed with elementary clinical acumen and

Another aspect of added costs is the investment that hospitals need to

make to match the rising standards of patient care

“Hi-tech medicine has definitely not pushed up the cost of healthcare. The expenses incurred in cardiac bypass surgery, angiography and angioplasty have remained almost

constant over the last 15 years or so’’ Dr Pavan Kumar Pipiada,

Senior heart surgeon, Lilavati Hospital


basic medications; without taking recourse to hi-tech. The problem begins when hi-tech is imposed or rather burdened on almost every patient who comes seeking medical help, he adds

Hospital managers also accept that hospital charges have indeed gone up over the past decade or so, but they also have a legitimate reason for it. “When a hospital charges reasonable prices and provides high quality services, it pulls in a large amount of customers/patients thus, sending their profits high in the long term. The only catch here is that the payback period of the project will be slightly longer than hospitals which, Paras Healthcare charge high prices. However, this is the call that every hospital has to take on its own,” says Dr. Dharminder Nagar, Managing Director Pvt. Ltd.

Additionally, most hospitals are in expansion mode as the demand-supply gap in healthcare is huge. In such a scenario, it is tricky to manage cost of construction along with cost of new technologies. “On an average, the cost of one bed for a corporate hospital comes to around 100 lakh, and from this almost 50 per cent is cost of medi-cal technology. This is because of the high cost of technology in our country. Yet, we at Fortis, manage to get a good price as we order in bulk. Being the largest growing hospital group helps us get a good price,” says Dr. Dilpreet Brar, Re-gional Director, Fortis Healthcare.

Sandeep Sinha, Director, Health-care Practice, Frost and Sullivan, however, has a different view. He says, “The cost of technology is

continuously coming down. Earlier, cath labs used to cost Rs. 3-4 crore and now we can get a refurbished cath lab in just Rs. 30-40 lakh. Cost per bed is not rising due to technol-ogy; it is rising mainly because the cost of manpower has gone up. Additionally, the cost of hospital construction has increased. Earlier, the construction costed about Rs. 40 lakh per bed, which has now gone up to almost Rs. 90 lakh.”

“The impact of technology is not only on medical equipment but also in how the hospital’s facilities – ICUs, OTs, Patient Rooms Labs and also protocols are build. Hence, it has become imperative for modern healthcare institutions to disproportionately invest in latest technologies even when it required a high investment,” says Chandra Sekhar C, Executive Director, Marketing and Strategy, Global Hospitals Group.

This has indeed led to an increase in the costs of care, but

over a period of time, higher suc-cess rates aided by technology & expertise have also led to increase in volumes, thus stabilizing the pricing models at an acceptable level and not sky rocketing it beyond the reach of the majority, adds Sekhar.

The Global Hospitals ED also points out some instances of the costs actually coming down because of technological advance-ment. There are several examples, as technological innovations have impacted quality of healthcare ser-vices across specialties. Fundamen-tally use of advanced technologies gives better judgment capabilities of the case to the Doctors, leading to increased accuracy of diagnosis and treatment and faster recupera-tion, thus leading to a reduction of cost of treatment from a long term perspective. The costs of treatment should hence not be assessed on a per episode basis but on an overall cost of treatment basis.

Further, the use of TrueBeam STx at Global Cancer Institute for radiation therapy to cancer patients. The advantage of this world’s most advanced technology is that the number of cycles of radiation and the per-cycle time required by the patients is signifi-cantly reduced leading to lesser overall cost of the treatment.

Similarly, organ transplantation costs in India though compared with the West are significantly low, have further come down as there has been an increase in the number of transplantations being done in India which has led to equipment and drug companies offer far more attractive prices , the benefit of which is passed on to the patients.

Also, minimal invasive proce-dures, interventional procedures in the disciplines such as Car-diac sciences, Gastroenterology, Orthopedics, Neurosciences with the use of advanced technologies have greatly reduced the risk of infections and post procedure medication costs, leading to lesser cost burden with reduced length of stay of hospitalisation as opposed to the times where procedures were complex as they were unaided by technology and post-procedure challenges.

Another aspect of added costs is the investment that hospitals have to make to match the rising standards of patient care prevail-ing both in India and abroad. This is particularly significant because,

“There are several examples where the technology is bringing down the

cost. This is done by either increasing the throughput, or with

ompletely new features, which improves early diagnosis’’

D. Ragavan, Senior Cluster Leader, Siemens


apart from catering to the bur-geoning middles class within the country, India is also positioning itself as a preferred destination for “medical value travel” (or medical tourism).

A significant enhancement in the standards of ICUs, OTs, peri-odic upgradations, use of newer technologies, enhanced levels of patient care are witnessed widely. Hence on a like to like basis over the past 10-20 years, the cost of setting up of ICUs & Theatres indeed is observed to have gone up by over 100 per cent.

This is also because, with the advent of sub-specialisations in ICUs for increased and special-ized care, that is development of Cardiac ICUs, Liver ICUs, Renal ICUs, Transplant ICUs and the use of advanced ventilator systems, monitoring systems etc have also added to the investments required.

The Operation Theatres now not only command use of state-of-the art technological instruments for procedures, but also the use of advanced ventilation systems, monitors, anti-fungal materials, air-shower systems, sterile corridors. All of these significantly aid in reducing and maintaining permis-sible infection control norms.

Hospital managements always make careful calculations about how much they can invest on a particular piece of heavy equip-ment priced at, say Rs 2-3 crore. For a new hospital, this investment could form as much as 30-35 per cent of the total project cost, and existing hospitals are aware than about 10 per cent of their operat-ing costs are directly attributable to

heavy equipment. “The investments on technol-

ogy are part of the evolution & augmentation of the clinical programmes and are a factor of the quality of services the hospitals wishes to offer. They are also guided by a deep appreciation of the market requirements and the Clinical Programmes Function prepares a broad direction on the technology and investments, which are then incorporated into the busi-ness plan as part of the capex com-mitment. The plans are reviewed and decisions on investments are taken and approved by the Board,” Chandra Sekhar says.

Sometimes the decisions are also influenced by what the various

companies have to offer. On the question of whether his company is willing to assist prospective hospital clients to conduct market surveys or estimate the revenue generating potential of a par-ticular equipment, Ragavan of Siemens says, “We have the most comprehensive after sales support program. To several custom-ers, who have invested in new technology or in new geographies, we have offered our Unique First Semester Support, better known as FSS program. This comprehensive program helps the buyer to reach his breakeven point within the first six months. We have done close to 100 such programmes, all of which were hugely successful. The

program encompasses market sur-veys, clinical education of referring doctors, patients, user teams, etc.”

In addition, they also help the client organization put together the required funding for the purchase. Siemens Financial Services Pvt. Ltd. (SFSPL), a 100% subsidiary of Siemens AG., was granted a NBFC License by RBI in May 2011 to offer commercial financing solutions in sectors of Industry, Infrastructure and Healthcare. It’s been primarily set up to provide essential support to Siemens customers and other B2B vendor financing requirement.

To take care of the problem of obsolescence of the technology which happens within five to six years, Siemens has a highly evolved upgradation or replace-ment program. For example, people, who buy a 20 slice CT scanner, can get their CT upgraded to 40, 64 or 128 slices, on site, in less than two days.

The company has also launched a comprehensive Tim upgrade program to older generation MR scanners. Under this program, customers can upgrade their six or seven year old MR scanners to the current levels at half the cost of owning a new MR. This is similar in concept though not identical to the ‘gold seal’ programme that GE Healthcare has instituted a few years ago, to enable their clients to upgrade their equipment as and when significant technological advances take place.

Last but not the least, the key is judicious use of technology – a trade-off between what the patient can afford and what he or she re-ally cannot do without. As Dr Arshad says, “In conclusion, therefore, hi-tech is high value to medical practice, provided it’s used judiciously and wisely. Then, there is a well-oiled industry built around hi-tech medicine that through media publicity and tempting offers to treating physi-cians tries to capture the imagina-tion of suffering patients. It’s up to the doctor to resist these tempta-tions and take decisions based purely on medical evidence.

“The impact of technology is not only on medical equipment but also

in how the hospital’s facilities – ICUs, OTs, Patient Rooms Labs and

also protocols are built” Chamdra Sekhar C,

Executive Director, Marketing and Corporate Strategy, Global Hospitals Group


MAQUET Medical India Pvt.

Ltd.

II Floor, Mehta Trade Centre

No.1, Shivaji Colony,

Plot No. 94, Sir M V Road,

Andheri (East)

Mumbai - 400 099, India

Phone: +91 22 40692105

Fax: +91 22 40692155

[email protected]

www.maquet.com

EASIER AND SAFER OPERATIONSIN THE SHOULDER REGION WITHTRIMANO 3D SUPPORT ARM

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Improved workflow: TRIMANO acts as a “third

hand” for the surgical team, securely and safely

immobilizing the patient’s arm in any desired

position.

Ready for use immediately: no additional

connections necessary.

Flexible positioning: Using the “Click and Move”

system, TRIMANO can be moved in any direction

and securely fixed in any position. The sterile

arm rest can be locked and unlocked during the

operation to monitor the patient’s arm

movement.

MAQUET — The Gold Standard.

With the proliferation of innovative mHealth tools across the

developing world, there comes an inspiring enthusiasm for health system reform. But mHealth raises a critical question as well: how do we know mHealth tools are actually changing health outcomes for the better?

I work with the World Bank and Addis Ababa University in Ethiopia on the evaluation

of a mHealth intervention that enables rural community health workers to improve the quality and reach of their maternal and child healthcare services. We have set out to see if this tool is just a very cool device, or if it actually improves maternal health and decreases maternal and infant mortality.

You may be used to read-ing about the development and testing of mHealth tools aimed

at scaling up to farther-reaching implementation. Our work, however, is a bit different: we built a tool on which we will do no further development, and instead rigorously test the impact of this tool on health outcomes of rural mothers and children through a randomised evaluation. Basically, we are searching for hard evidence first, and leave a discussion of scale-up for once we have the data.

Since our final results will not be available until early 2013, I’ll share with you today a bit about our research design and the key question we are investigating: Does the use of a mobile phone-based tool for patient registra-tion, appointment reminders, and inventory management in the hands of community health workers result in improved ma-ternal and child health outcomes in a rural Ethiopian setting?

Impact of mHealth tools mHealth is fast becoming popular; however, do m-Health tools really work? Let us find out by testing the impact of Mobile Technology on Maternal and Child Health care, says Kate Otto

Global Practices

MAQUET Medical India Pvt.

Ltd.

II Floor, Mehta Trade Centre

No.1, Shivaji Colony,

Plot No. 94, Sir M V Road,

Andheri (East)

Mumbai - 400 099, India

Phone: +91 22 40692105

Fax: +91 22 40692155

[email protected]

www.maquet.com

EASIER AND SAFER OPERATIONSIN THE SHOULDER REGION WITHTRIMANO 3D SUPPORT ARM

WATCH THE VIDEO ON WWW.MAQUET.COM

Improved workflow: TRIMANO acts as a “third

hand” for the surgical team, securely and safely

immobilizing the patient’s arm in any desired

position.

Ready for use immediately: no additional

connections necessary.

Flexible positioning: Using the “Click and Move”

system, TRIMANO can be moved in any direction

and securely fixed in any position. The sterile

arm rest can be locked and unlocked during the

operation to monitor the patient’s arm

movement.

MAQUET — The Gold Standard.


Background In 2010, I worked for the World Bank to help develop the evi-dence base on mHealth (how do interventions influence health outcomes?) as part of its eTrans-form Africa initiative. From a World Bank perspective, it is crucial for Managers to be able to cite rigorous research when pro-viding guidance on health reform via mHealth to partner country government – does it work, and how? Or is it just a fad without impact? Since there is little such research yet available, we invested in the creation of this research, and began in Ethiopia.

What kind of health outcomes did we set out to influence? I met with colleagues at Addis Ababa University who had already been hard at work brainstorm-ing mHealth interventions, and thanks to their history of fieldwork in rural health posts, we identified maternal and child health as a key priority area for an initial intervention. Ethiopia has one of the highest maternal mortality ratios globally, at 673 per 100, 000 live births in the year 2005 which accounted for around 21 % of all deaths among women aged 15-49. The coun-try also has one of the highest under-five mortality rates at 14 of every 100 children (DHS 2005), with more than 90% of child deaths due to five preventable diseases; pneumonia, malaria, diarrhea, measles and malnutri-tion (National Strategy for Child Survival in Ethiopia, 2005).

In addition to focusing on maternal and child health, we fo-cused on Health Extension Work-ers (HEWs) as the end users of the mobile phone tool – these are the community health workers of Ethiopia, a well-developed nation-al program largely standardised across all sub-districts. Unlike the general population, whose mobile phone penetration rate is low, around 10% and literacy is low, about 90% of HEWs report using mobile phones regularly and all are literate, high school graduates. HEWs are usually not

fluent in English, but reported regularly using their phones to communicate in Amharic with Latin letters. Structurally, two HEWs are assigned to every village, or kebele, of 2,000-5,000 people, and each pair is assisted by a set of voluntary community

health workers (vCHW) who are normally assigned in pairs per 50 households.

Will mHealth for HEWs work? Putting an mHealth tool in the hands of Health Extension Work-ers for maternal and child health – but what would this tool do?

Extensive qualitative interviews with rurally-based HEWs and mothers revealed several health system bottlenecks that they felt were most urgent to address with an mHealth tool.1.While pre- and post-natal coverage rates were reported by

HEWs as very high, reports from mothers and pregnant women were conflicting. From the mom’s side, the paper card system in place to record and remind about appointments was inconsistently utilised, and if they wanted regu-lar care they needed to take the initiative to seek it. They could not rely on HEWs to remind them

or to come to their homes, and oftentimes go without care. From the HEWs were heard that their work in a single day could be unpredictable, and many different maternal health visits were not necessarily planned or priori-tised.2.Vaccinations are delivered on a monthly basis to health posts from the health centers, how-ever the health center calculates the amount delivered based on population estimates, as opposed to actual counts of new births. This meant that HEWs were sometimes faced with shortages, and other times excess that went wasted.3.Regarding referrals, HEWs reported frustration that when they sent mothers to higher care in case of obstetric emergencies, there would often be no doctor there to see the woman, and sometimes resulted in injury or death. 4.Regarding deliveries, there remains conflict between HEWs and traditional birth attendants (TBAs). While the MoH is train-ing HEWs to assist with deliver-ies, most mothers (naturally) still prefer TBAs, who are more skilled and experienced to help deliver. However, the TBAs, un-like HEWs, are not equipped with gloves, towels, misoprostol, and other supplies. HEWs keep these on hand to help ensure a clean and safe delivery, yet they are often deliberately not informed when births are expected or occurring.

A tool to respond concernsTaking this feedback into ac-count, our team designed a tool that would respond to their con-cerns. In the first Use Case, we address low levels of full ANC that deprive women of the oppor-tunity to detect health problems associated with pregnancy and avoid unsafe delivery.• HEWs will submit a form to register every mother in their kebele who could need ANC care over the next several

All HEWs and VCHW within each kebele got two kinds of cell phones

-HEW phones with multi-use software and dumb phones for

missed calls only


months (assumes that women who are pregnant know they are pregnant, and that women who know they are pregnant are forthcoming in sharing this news with the HEWs).• Submitting this form will create a longitudinal patient record for that mother, and an SMS will be automatically sent back to the HEW containing her patient’s unique numeric ID. The HEW will write this num ber down on the mother’s paper family folder.• HEWs will then submit the woman’s ID#, Name, Location, and last date of most recent menstrual cycle (or months of amenorrhea), and an Expected Date of Delivery will be auto matically calculated.• As a result of calculating this date, ANC appointments will be scheduled and reminder messages will be sent at weeks 14, 24, 30 and 36.

In the second Use Case, we ad-dress mothers who do not always come back to clinics to vaccinate their children on the date written on their child’s health folder (they may lose the card, forget the ap-pointment, or miss the appoint-ment due to other obstacles such as lack of transportation). We aim to help HEWs as well, who have no way to know the exact need in their kebele, as estimates could leave them with too many or too few vaccines on the day of the vaccination campaign.• HEWs will submit a Child Registration Form to register every child at or under the age of 11 months in their kebele.• Submitting this form will create a longitudinal record for that child, and an SMS will be automatically sent back to the HEW containing the child’s unique numeric ID. The HEW will submit a form for this child with their unique ID # and their birthdate, and as a result vaccination appoint ments are scheduled for each child at 6, 10, 14 weeks and 9 months, rounded up to the nearest month to accommodate

the ministry’s approved vac cine delivery schedule. • A week before the Woreda’s monthly vaccination cam paign, HEWs will be sent an SMS containing the names and IDs of children in their kebele who should be vacci nated in the upcoming vac cination day. One of the HEWs in each health post will submit a vaccine request form to her immediate supervisor indicat ing how many vaccines she needs for the subsequent month.

• After each vaccination day, the HEW will submit a report indicating the number of children immunised for each vaccine. A number reporting that is higher than the expected amount will indi cate that registration of children in the Woreda is incomplete or children are not showing up for vaccination on the recommended schedule, while a number much smaller than expected would indicate incomplete vaccination rates.

In the third Use Case, we ad-

dress the need to find transporta-tion for referrals to emergency care, and the need to alert Health Centers, who are oftentimes not prepared with appropriate staff and equipment in order to manage incoming emergency patients from rural Health Posts, thus causing unnecessary maternal and infant mortality.• Although ambulances are not available at Health Centers to dispatch to Health Posts, there are many local drivers of small three-wheeled vehicles (Bajaj) or other type of vehicles (mini- buses, land cruisers, etc.) who may serve the role of an ambu lance in emergencies. All HEWs will have their local Bajaj driver numbers pro grammed into their phone from the start, and would thus be immediately able to call for a vehicle (this doesn’t ensure that someone can pay for the ride or that a driver is avail able, it only ensures that in cases where someone can pay and there is a driver, that the driver is notified and takes the woman).• HEWs will call the Health Center in emergency referral situations so that Centers are prepared to receive patient.Our team randomly selected three sub-districts in the SNNP Region into one of the following groups:• Treatment 1: All HEW received mobile phones equipped to perform the three use cases• Treatment 2: All HEW and 2 VCHW within each kebele received mobile phones; HEW phones are software-equipped for the three use cases, and vCHW phones are dumb phones intended to make missed calls only.• Control: No mobile phones were distributed.

In Treatment two, as you can see, we engage the vCHWs and dumbphones, which is a very simple and low-cost and non-technical intervention – no coding required! Because we’re interested in seeing if there will be a differ-

Extensive qualitative interviews with rural HEWs and mothers revealed bottlenecks that they

felt were most urgent to address with an mHealth tool


ence in health outcomes if this option is available. The vCHWs will be expected to use their dumbphones to:• Take calls from HEWs to follow up with pregnant women if appointment times need to be changed.• Missed call HEWs when they meet or hear of mothers in households who are not yet registered.• Missed call the HEWs to request that they come register a child. • Take calls from HEWs to follow up with a child’s family to notify them of an upcoming vaccination day.• Missed call to HEW if a birth is going on and no HEW is present, so that they can at the least bring their supplies and materials for the TBA to use.• Missed call to alert HEWs of any other maternal/child health emergency.

Because the risk for spillovers

was too high if randomisation was done at the health post level (i.e. control health posts seeing what the treatment posts were up to and wanting in on it!), our design randomises one treatment per sub-district, which normally includes on health center and 5 satellite health posts. We excluded from the possible selection any sub-districts that have no mobile network coverage, any adjacent words, and any words with significantly different access to health services at the village level (as measured by population to health post ratio).

Trying to gauge changesAnd at the end of the day, what are we trying to see changes in? A few things. In terms of ANC and Delivery, we will analyse changes in antenatal care (ANC) attendance – timing and # of vis-its, in numbers of clean and safe deliveries (of births delivered in kebele) – meaning HEW is pres-

ent with her supplies, regardless of who delivers, and in number of deliveries assisted by a skilled attendant (of births delivered in kebele) – whether the TBA and/or HEW delivers. In the case of immunisations, we’ll be monitor-ing changes in immunisation coverage (TT2, Penta3, Measles). And in regards to referrals, there

is not a whole lot of change we can attribute to the phone, but will measure Instances of refer-ral to HC in which women is seen upon arrival.

As a research team, we are still in discussion over appropriate outcome measures and would be very happy to hear about others’ experiences and suggestions here. We think it is important to dis-seminate our ‘results’ – the lessons learned along the research design road – throughout the study, not just at the very end. And we invite you to be in touch with questions and suggestions!

The author works in the field of public health, experimenting at the intersection of new technologies and human behavior. She currently works with the World Bank in Ethiopia assessing the impacts of mobile phone tools on maternal health outcomes, and with Innova-tions for Poverty Action in Zambia, applying behavioral economics to find health systems solutions


As you enter a building that houses the “termi-nally ill”, one cannot but

help feeling apprehensive about what to expect. Much to our surprise, the Bangalore-based specialist oncology care centre, Healthcare Global Enterprises (HCG), is quite unlike the run of the mill hospital. The ambience is warm and inviting, providing a perfect setting for healing a dreaded disease. Dr Ajai Kumar, the CEO and Chairman of HCG, rushes into the interview, apolo-gising for a minor delay. His dis-arming smile, enviable physique and extraordinary energy come through immediately.

“Where should we begin?”, he says smiling. Although born into the family of the dean of a reput-ed Law school in Bangalore, Dr Ajai Kumar was just as confused as to what he wanted to do with his life. “This was the age when even televisions were hard to come by, a time, when engineer-ing and medicine were the only two career paths available”, he adds. Hence he pushed aside his interest in history and arts and followed his older brother into the prestigious St John’s Medical College in Bangalore.

Soon afterwards, he got interested in working with the rural program that St John’s offered to improve the primary healthcare centers, but gave into family pressure and took up the UCML exam in Malaysia. Having cleared the exam with flying col-ors, he left for the United States in 1975. He proceeded to study at

the University of Virginia, Char-lottesville, USA. During his stint at the University, Dr Ajai saw that cancer patients, in particular, were considered as the terminally ill. “I am a left leaning person”, he adds. Even though he was an ace at cardiology and topped

his class, his thoughts veered towards the cancer patients and the treatment they were meted

out, thus paving his way into oncology.

He went to his professor seek-ing advice on what he could do to pursue his interest in oncol-ogy. He was directed to doing a fellowship at the MD Anderson Tumor Hospital and Institute in

Houston, a world renowned can-cer care centre. When he applied for a fellowship at the centre,

they initially informed him that there was no position available at the centre for next three years. However, Dr Ajai , impressed them thoroughly at the interview and MD Anderson offered him a fellowship in the following year in the field of Radiation and Medical Oncology. MD Anderson provided him the opportunity to work at the melting pot of oncol-ogy, as patients from all over the world visited the centre, hoping against hope, for a cure. The ex-perience helped him develop the ability to manage a diverse range of clinical situations.

After his training at MD An-derson Hospital Tumor Institute, he got an opportunity to practice at the institute. “But I preferred to establish a cancer centre near Chicago and practiced there for over 20 years. The experience gathered there has helped me to replicate the same in India but in a bigger way,” says he.

In 1989, Dr Ajai Kumar joined a group of five oncologists in Bangalore and started the then 30-bed Bangalore Institute of Oncology (BIO), the only private cancer hospital in Bangalore at that time. This was under the flagship of Banashankari Medical and Oncology Research Center Ltd (BMORC). Today, BIO is a 120-bed hospital with over 65 consultant physicians and staff strength of nearly 300. In October 1990, he set up Bharath Hospital and Institute of Oncol-ogy at Mysore to predominantly help rural patients undergo cancer treatment.

Caring for CancerBy bringing core clinical services to one central place, Dr BS Ajai Kumar seeks to change the landscape of oncology care in the India, finds Isha Khanolkar

Portrait

“We always clamour for the end and take short cuts. In the long run it hurts the outcome. I have always

found to be the journey just as important as the end result”


In April 2000, Dr Ajai Kumar acquired a fledgling cancer centre called Curie Centre of Oncology, owned by a businessman in New York. Encouraged by the turn of events, in 2001 the same group of physicians decided to set up a holding company— HealthCare Global Enterprises Ltd (HCG) that would offer comprehensive cancer care under its unique ‘hub and spoke’ model on a pan-India basis.

As we continued probing, the Indian oncology care pioneer, we discovered several inspiring insights and views. Here are some of the questions we sought answers for.

Q What hurdles did you face while setting up HCG in India?A When I initially visited India in 1979 and visited the major cancer hospitals, there was no enthusiasm shown from any party. This was when I decided to setup my own practice in Chicago. As I returned to India, to setup the centre in Bangalore and Mysore, there was one major hurdle I faced. The local Munici-pal Corporation in Mysore was unwilling to hand over the land I had acquired to build Bharat Hospital, under the pretext of accusing me of wanting to build a hotel instead. Fortunately for me, I had met the Additional

Chief Secretary of Karnataka at the time, Mr Murthy, who came to my rescue and offered me a fresh piece of land in the KEDB Industrial estate. In this man-ner, I was able to set up Bharat Hospital which caters to the rural population in Mysore.

Q How has your father inspired the “ transparent governance” culture at HCG?A When I was in the seventh grade, I was studying in the verandah in our house, one day, when we had unexpected guests. To give you a little history, even

though my dad was Dean of a reputed law college, his pay was a measly seven hundred rupees which could not afford the slight-ly lavish lifestyle my father had in those days. We were a middle class family steeped in debt.

A professor from my father’s college had arrived with a gentle-man whose son went to the same college. The gentlemen had heard that the final exam papers were to be evaluated by my father. He offered a sum of twenty thousand

rupees to my father which would have cleared our debt completely. My father, however, refused to take the money and pulled up the professor for implying such possibilities to parents.

This moment has influenced me to build HCG in a manner that is transparent and fair. We want to ensure that the money we make, flows back into the system so we can help make the treatment affordable.We do not issue any cash to anyone and all payments are made by cheque. These values help us make the expansion possible.

Q Could you tell us the manner in which you went about building Bangalore Institute of Oncology as an Institution?A After we set up Bangalore Institute of Oncology and showed signs of growth, I moved to India in 2003. Since oncology needs a specialized and solid diagnos-tic backing, we took over this company called Tri-Star, to ensure that we had the best diagnostic care for our patients. We completed building the hospital by 2007 and added a cyclotron and a PET scan. Entirely a doctor’s initiative, our network of doctors that own a stake in the company has grown to 160 in number. Doctors bought into the concept as they saw that what we were trying to do was real.

Q Oncology Care Centers are generally expensive to build. How did you manage to obtain private equity funding?A Doctors are not used to the fact that you have to wear a hat and carry a suitcase and knock on doors for funding. But the experience of selling the idea was invigorating. We met a lot of people to pitch the concept and finally managed to draw the attention of a firm called IDF. They were aware that the venture was probably not going to be profitable but they showed immense faith in the concept and the value that we had to offer. We were given an initial funding of Rs 50 crore which was a shot in the arm for our efforts. Today we have noteworthy investors on our panel namely the Premji Foundation, Evolvence and Milestone Religare.

Q HCG works on a very unique business model. How exactly does it func-tion? A Our business model is unique as we believe in working with doctors as partners .We generally prefer not to work with business execu-tives as we are of the opinion that doctors are more appreciative of the effort, technology and type of care that is required for oncology. I believe that the quality of care should be the same, whether you visit a centre in Bangalore, Erode or Nasik. We want to be able to standardize the treatment provided to patients all over the country and have based our centers on the hub and spoke model. This model has proven immensely successful for us.

The doctors come to us because they understand and respect our transparency. For example, we had an oncology surgeon from Vijaywada who was interested in putting up a LINAC .We agreed to an SPV wherein he was given a small stake .The initiative resulted in a two hundred bedded cancer which is now planning for expan-sion. It’s a win-win situation for

“I may not believe in God but I believe in stories as they

teach you values”


both parties and the true gainer at the end is the patient.

Q HCG has always been synonymous with innova-tion and latest technology, Cyber Knife being the lat-est addition. How different is from other methods of treatments? A We believe that technology will be a great driver for the provision of good quality cancer care in the future. Cyber knife is an advanced form of therapy to treat oncology and is also known as radio surgery. Cyber knife uses a robot to focus radiation only on cancerous tumors while avoiding the normal cells. This technology enables us to provide retreat-ment if required for a patient with minimal side effects. It can treat the body entirely and even though it is slightly expensive, its results provide hope. We have provided this treatment to patients for even as little as fifty thousand to a lakh with the help of our foundation. Q Quality of care Help’s HCG stand out amongst other players in the coun-try. What are elements are essential to high quality healthcare delivery?A Oncology requires highly spe-cialized personnel to administer treatment in order to ensure desirable outcomes. At HCG, our nurses are trained in the meth-odology of treating the patients as the intricacies involved can put not only the patient in harm’s way but also the care giver. Our patients are treated by teams of doctors, physicists and nurses to ensure a holistic approach in ensuring the patients receive nothing but the best in terms of treatment.

We are the first cancer center in India, to have accreditation from National Accreditation Board for Hospitals & Healthcare Providers (NABH), College of American Pathologists (CAP), State of Illinois, and National Accreditation Board for Testing

and Calibration Laboratories (NABL), Government of India. The combined accreditation for quality from three distinguished accreditation bodies was pos-sible because of HCG’s focus on robust process for patient quality, efficient practice of diagnosis and improvements in medical outcome.

Q What role do you see the government playing in improving healthcare?A My belief is that the gov-ernment should play a role in

monitoring healthcare rather than competing with the private play-ers. Efforts like the Arogyashree program in Andhra Pradesh are welcome initiatives. The govern-ment should spend time in the improving primary and secondary care and leave the tertiary care bit to private players like us. They

should provide encouragement to private enterprises to penetrate tier II and tier III towns. We should also concentrate on weeding out the wastage in the system. It disappoints me that even though seventy percent of the healthcare in this country is private, the advisors to the government with regard to policies are from govern-ment institutions.

Q What does the future hold for HCG Group?A HCG aims to provide personal-ized care which is accessible to pa-

tients all over the country. We want patients to be able to get up in the morning and take their treatment as close to home as possible. We plan to open about ten to twelve more centers around the country .The latest addition to the HCG family is the oncology centre for Nanavati hospital in Mumbai. HCG

will help support doctors and move them to a position of power while take help from professionals. We believe that empowering doctors to build healthcare is the future to building solid institutions.

Q On a lighter note, what keeps Dr Ajai Kumar going?A I love backpacking and trek-king. I have so far run seven marathons and look forward to finishing more. “I keep active by running about twenty five miles a week,”he adds in nonchalantly. My son who is now twenty two and suffers from muscular dystro-phy is also a source of immense inspiration for me. He is more like a friend than a son and we share long conversation about life and philosophy.

Q On a lighter note, what keeps Dr Ajai Kumar going?A I love backpacking and trek-king. I have so far run seven marathons and look forward to finishing more. “I keep active by running about twenty five miles a week,”he adds in nonchalantly. My son who is now twenty two and suffers from muscular dystro-phy is also a source of immense inspiration for me. He is more like a friend than a son and we share long conversation about life and philosophy.

With inputs from Maninder Singh

• CII Emerging Entrepreneur of the Year Award, 2011 in the New Market Initiative Category.•Entrepreneur of the Year 2011, Ernst & Young Awards in the start up category.•B C Roy Award•Kannada Rajyaotsava Award•Modern Medicare Recognition for 10 Powerful People in Health Care

Awards and Recognitions

“When everyone say it can’t be done, I want to be able to say we can try.

We don’t promise outcomes”


In south Indian families, baby boys who have lovely eyes are often named as Aravind.

Hence it is no surprise that the Madurai-based Aravind Eye Care System (AECS), arguably among the largest eye care organisations in the world, also bears the same name. And in the past 36 years, since it was set up as an 11-bed eye hospital in 1976, AECS has proven true to its name, many times over.

But according to its original founder, Dr G Venkataswamy and others who have followed in his footsteps, the inspiration for the name was drawn from the world-renowned Aravind Ashram in Pondicherry, perhaps because of the Ashram’s ethos of social service and its emphasis on spirituality. Likewise, the guiding principle behind AECS, ever since its inception, has been to provide eye care of the highest quality at the lowest expense possible. In

pursuit of this laudable objective, AECS has gone far beyond the narrow confines of ophthalmic surgery and patient care. Very early in its life, it started manu-facturing and selling intraocular lenses (IOL) at a fraction of the market price, training nurses, optometrists and other technically skilled people, when it could not find them in adequate numbers.

These are the three pillars of the AECS – the eight eye hospi-tals, the LAICO (Lions Aravind Institute of Community Oph-thalmology) and Aurolab, whose IOLs, surgical blades, sutures and needles, and even medicines are much in demand in many emerg-ing countries, mostly in Asia and Africa.

Though the AECS network now comprises of eight hos-pitals located in Madurai, Theni, Tirunelveli, Coimbatore, Pondicherry, Dindigul, Tirupur and Salem, five of them were set

up in the first 30 years, while the remaining three have come up in the past five or six years. “We are extremely conservative in the way we have grown,” says Deepa Krishnan, Assistant Administra-tor, Aravind Hospital, Madurai. This is in sharp contrast with some recent organizations like the Delhi-based Centre For Sight, which went from 22 centres to 35 with a single acquisition last month, or even Narayan Hruda-laya, which is planning to set up 100 heart care centres in the next few years.

Throughout its 36 years of existence, AECS has concentrated largely on cataract, the single larg-est cause of reversible blindness all over the world, and built up a record that has amazed many eye care institutions in the developed world as well. The entire network together currently performs almost 400,000 eye surgeries per year – a total of 4 million to date,

with a complication rate lower than many hospitals in the west-ern countries.

The only other comparable institution is perhaps the Shoul-dice Hospital in Ontario, Canada, which has performed only hernia repair surgery since it was estab-lished in 1945 and has an astound-ing success rate of 99.5 per cent!

“Integration of facilities and support systems ensure that a surgeon here can perform 2,000 surgeries per year against the global average of around 500. Surgeons perform six to eight operations per hour on an as-sembly line basis with the support of internally-trained mid-level ophthalmic personnel,” says a case study published in 2010 by Amrita School of Business. Oth-ers have reported on innovations such as the technique of placing two patients on adjacent operat-ing tables at the same time with the surgeon and his operating

Crusade against blindness The Aravind Eye Care System is ample testimony to the fact that high quality care and affordable costs are not mutually exclusive, reports Sumit Ghoshal

Focus


microscope located in between. While the surgeon operates on one patient, the nurses and paramedi-cal staff start the pre-operative steps on the other patient. As soon as he finishes the actual surgery on one patient, he swings the microscope around and begins with the second patient. Though the idea appeared unusual at the start because of the emphasis on asepsis in the operation theatres, a lot of eye care institutions are now understood to be following the same technique. Besides, there is an incredible degree of standard-ization in Aravind’s way of doing things – each of the 1000-odd sur-gical procedures performed in all the network hospitals in exactly the same way. It is an excellent il-lustration of what the AECS man-agement itself describes as the “assembly line approach” which also reminds some people of a McDonald’s outlet, but nobody in AECS has any axe to grind.

The huge volumes and the rigid treatment protocols benefit the AECS in two distinct ways. First, staff productivity levels that would make any multinational company CEO go green with envy, and second, much lower rates of complications because everyone in the system moves up the learning curve at an extremely

rapid pace. Contrast this with the fact that in many public hospitals in India and abroad, an overload of patients is the commonest excuse for shoddy clinical work and poor quality of service.

The reason why they are able to adhere to carefully designed clinical protocols is that almost everyone is trained within the institution – from surgeons to nurses, optometrists and other technical people. Every surgeon who joins an AECS hospital is required to go through two to three years of training in the Aravind way of doing things, even if he or she already has a postgraduate qualification in ophthalmology. Likewise, every AECS hospital recruits young

women from the nearby locali-ties soon after they finish their schooling. The flip side, of course, is that the AECS training courses are not recognized by the Nursing Council of India or by their state counterparts, and hence these ladies cannot work as nurses in any other hospital. On the other hand, preference is usually given to women who are married and settled in that town and hence may not even want to switch jobs!

At a different level, young surgeons who showed prom-ise during the training period and the initial years are soon given additional responsibilities, administrative or otherwise. One of the earliest of these is an op-portunity for a fellowship in one

of the branches of ophthalmol-ogy at the Arvind Eye Hospital and Postgraduate Institute of Ophthalmology, which is affiliated with the MGR Medical University. Several have risen steadily over the years to join the ranks of the top management of AECS. One of the most striking examples is Dr S Aravind, who joined the organiza-tion in 1996 as a medical officer and holds the position of Director, Projects at present. Another is Dr S R Krishnadas, who came in to the Aravind family in 1987, held several senior positions, including the head of one of the hospitals, and has now become the head of HR for the entire AECS network. Yet another is Dr Venkatesh, the head of their hospital in Pondi-cherry, who joined the group in 1996.

During the intervening years too, mid-career ophthalmic surgeons get plenty of opportu-nity to do scientifically advanced research work because the Ara-vind group also runs a number of specialty clinics that offer services in retinal and vitreous disorders, neuro-ophthalmology, pediatric eye disease, oculoplasty and ocu-lar oncology, conditions affecting the uvea and cornea, and finally low vision and visual rehabilita-tion. Interestingly, though these cases (other than cataract) form about 35-40 per cent of the total case load, almost 65 per cent of the doctors are working in the specialty clinics.

In keeping with the stated mission of making healthcare af-

Even now about 20 new hospitals sign up for the LAICO programme

of mentoring and consultancy. This consists of a two year period

of active engagement, starting with a detailed analysis of its management processes and

systems, market surveys, and potential for growth.

R D Thulasiraj Executive Director, Aravind Eye Care System

“Dr Vijayalakshmi examining a patient”


fordable to the lower middle class, AECS has a system of cross-subsidization of patients – those who opt for single room or deluxe accommodation pay a higher rate for the entire treatment. This enables the organization to offer heavily subsidized or even free treatment to those from the finan-cially weaker sections of society. Further, the gargantuan volumes allow the management to split the fixed costs – salaries, housekeep-ing costs and other establishment expenses, among a much larger number of patients, and thus bring about substantial reduction in the charges that individual patients have to pay.

The AECS top management realized quite early that if they really wanted to keep their costs low over a long period, they would not be able to depend on outside manufacturers for their requirements of IOLs and other consumables. Hence they decided as far back as 1992 to start manu-facturing their own lenses, which they were then able to supply at $ 10 (about Rs 300) as opposed to the average market price of $ 70-100! The result was Aurolab, a separate organization within the

AECS fold, which was set up in 1992.

“Back then, the hospitals themselves required about 30-40 lenses per day, but there were very few manufacturers in India. They were supplying the lenses at a minimum of Rs 1000 each, which was already too much for the lower income group that we wanted to cater to,” says R D Sriram, Director, Operations, who has been associated with Aurolab for the past several years. In the beginning, Aurolab’s production was about 150 lenses per day, which they were able to supply at about Rs 300 per piece (one third of the prevailing market price). Even this was quite a complex task – the lenses were produced in three models and each model had 30 variants (depending upon the ‘power’ of the lenses required).

The demand for the Auro-lab’s products grew slowly and steadily, spreading almost entirely by word of mouth because the trust that ran AECS did not wish to advertise in the mass media. Surgeons who had been trained with Aravind but moved elsewhere later on were the most important source of this informal

publicity. A combination of high quality products being available at a fraction of the market price obviously gave them a strong advantage. Besides, a network of about 30 dealers soon came about and a majority of them have stayed with AECS in subsequent years.

Though the initial strategies helped Aurolab to create a good name for itself, by 1994 the management discovered that their system of manufacturing the lenses by hand was begin-ning to prove inadequate. A new type of single piece lens had been introduced and this also allowed the manufacturers to make the process partially automatic. “For this, we acquired three machines with an investment of $ 80,000 each – the entire amount being through internal accruals,” says Sriram.

The next leap forward came in 1997 when Aurolab decided to manufacture a range of eye drops, with technical assistance from a London-based organisation. But since a number of other compa-nies were already producing the commonly used ophthalmic drugs and marketing them in India at

affordable prices, Aurolab decided to focus on a number of orphan drugs like clotrimazole (used for treatment of fungal keratitis). In global pharmaceutical parlance, these are medicines required in relatively small quantities for people suffering from rare clinical conditions, because of which the big pharmaceutical companies, particularly multinationals, may not find these products worth their while.

This gave Aurolab, and there-fore AECS, a greater visibility in the medical fraternity and enabled the organization to avoid clashing head on against much bigger pharmaceutical companies. Besides, they decided to focus on special medicines used in retinal surgery cases, and had to be imported from western countries until then. Since Aurolab could only manufacture about 3,000 to 4,000 bottles (of medicine) per shift, these products were eminently suitable.

For marketing of these medicines, too, Aurolab turned to rather unorthodox channels such as NGOs involved in eye care, both in India and abroad. The important ones among these were:

An Aurolab production unit


CBM of Germany, the UK-based Sight Savers International and Seva of Nepal. The Wikipedia en-try on CBM (Christian Blind Mis-sion) mentions that it was founded in 1908 by German pastor Ernst Jakob Christoffel, who built homes for blind children, orphans, physi-cally disabled and deaf persons in Turkey and Iran. Likewise, the 62 year old Sight Savers Interna-tional (SSI) has spread to over 30 countries including India, where it came almost 45 years ago, and has supported the treatment of 36 million Asian patients during these years. Across the globe, SSI has helped to restore the vision, partially or totally of almost 216 million people during its six decades of existence.

Somewhere along the way, Auro-lab’s competitors also reduced their prices in an attempt to erode their support among the ophthalmic surgeons, and soon they needed a new way to retain its clientele. This came about with an increased emphasis of quality – first with the help of an ISO-9000 certification, which Aurolab was able to obtain 1997 and then in 1999, through the CE mark (which is now mandatory for all medical devices marketed in Europe). “We were probably the first medical devices company in India to get the CE mark,” says Sriram.

Side by side, the company also

diversified into surgical sutures (mounted with needles) which Johnson and Johnson were then supplying at Rs 250 per foil, and many surgeons would use the same set in more than one patient – thus exposing the patient to an obvious risk of infection. Aurolab solved the problem by making it available at a substantially lower price.

Today Aurolab has a turnover of about Rs 70 crore, makes a gross profit of Rs 12-15 crore and has an R&D budget of Rs 3-4 crore. It has a staff strength of about 550 people, of which 80 per cent are in production, and 10 per cent are technically skilled people

including engineers from various disciplines. Just about 12 per cent of its production is consumed within AECS, another 48 per cent sold to other eye hospitals inside India and about 40 per cent is ex-ported to other countries. Though Aurolab, like AECS itself, is owned by a trust, it is now thinking of seeking private equity participa-tion to finance its future growth plans. “For this we may have to set up a private limited company with the trust as a majority sharehold-

er,” explains Sriram. But this could be as much as three to four years in the future, he adds.

Interestingly a substantial number of its employees are lady chemists, who are married and settled locally, while for other categories, people hailing from Madurai (who wish to return to their native town) are preferred. These policies enable the organiza-tion to retain qualified people even though their remuneration may not always match those offered by larger companies.

While the Aravind eye hospitals have dedicated themselves to providing high quality medi-cal treatment and Aurolab has

focused on the supply side, LAICO – the third pillar, has devoted itself to training and capacity building in the field of healthcare. Its main activity, that is helping other eye care programmes to develop and grow, has spread to many countries, mostly in Africa. “Most of the time, the requests for our services come through global donor agencies,” says R D Thula-siraj, Executive Director, AECS, who has devoted a considerable amount of time and resources to

nurture the initiative.LAICO was established in

1992 in collaboration with Sight First, the $ 200 million global prorgamme run by Lions Interna-tional. Its first target was to bring about major improvements in about 36 eye hospitals operated by the Lions organization in different parts of India. Even now about 20 new hospitals sign up for the LAICO programme of mentoring and consultancy. This consists of a two year period of active en-gagement, starting with a detailed situation analysis and a thorough examination of its management processes and systems, market surveys, and potential for growth.

Following the site visit by a LAICO team, a half-day workshop is organized for key decision mak-ers in the target hospital in which they are fully acquainted with the changes they need to bring about. Then a team from the client hospi-tal visits Aravind for a week long intensive training, intended mainly to stimulate the visiting team into a new way of thinking about their own institution. When they realize that before coming into contact with LAICO, they were achieving just 10 per cent of their potential, they usually become much more receptive to the LAICO consul-tants.

The next stage is a period of hand-holding and guidance during which a new business plan with fresh targets and fresh perspec-tives on different management concerns is put together. In about 50 per cent cases, the LAICO team could make a follow up visit, but that depends upon the funding available with the client organiza-tions. But the relationship with LAICO could last for much longer than the planned period, often through telephonic queries or other means. “Some hospitals that came to us in 1994, are still con-sulting us regularly on a variety of issues,” says Thulasiraj.

So what the future hold? “We are building a bigger hospital in Chennai, which is at the moment in the drawing board stage,” says Deepa Krishnan. “A LAICO workshop underway.”

Though Aurolab, like AECS, is owned by a trust, it is now thinking of

seeking private equity participation to finance its future growth


Name of the Book: The Art of War’Author: Sun TzuTranslated by: Lionel GilesNo. of pages: 112Price: Rs. 150Published by: Harper Collins Publ. UK

There are books that stand the test of time and enthrall the readers for centuries, across

generations. The Art of War written during the 6th Century BC by Sun Tzu is one such book, which is basically a Chinese military treatise. However, this master-piece by Sun Tzu finds its relevance beyond just the war. Literally, the book is essentially to explain the complexi-ties of ancient warfare. Taken metamorphically, every word of the book finds its application in 21st Century’s world, be it business, corporate governance, sports or politics.

The Art of War comprises of 13 chapters — each dealing with dif-

ferent aspects of analysis of your own strengths and that of your opponent; like planning, strategy, leadership, resource management, intelligence, positioning and engaging the competitor. It deals with topics like importance of discipline, strengthening your cur-rent position and making tactical decisions for the future advance-ments. It also talks about the ‘first mover’ advantage.

Each chapter of the book talks about various situations that can arise in business, politics or even in life and how to handle them by efficient planning, maneuvering, teamwork and understanding of the competition. It is through such a prism of knowledge, that one can avoid wasting time, energy and resources, and can plan the right strategy. This classic has been used by military generals to plan battles, by business-men planning acquisitions and takeovers, by sportsmen planning strategy for games and everyone in between.

The chapters from the book ‘Tactical Disposition’ and ‘Ma-neuvering’ are quintessentially the most easily recognisable to modern business. .Sun Tzu also talks about ‘the art of handling large masses of men’ which can perhaps be best related to modern day concepts of Corporate Iden-tity and practices of Corporate Communications. The importance of being flexible and having back-up plans find their application in today’s time.

The Last chapter of the book ‘The Use of Spies’ talks about the importance of gathering information. Sun Tzu says “it is only the enlightened ruler and the wise general, who will use highest intelligence of the army for the purpose of spying and thereby they achieve great results. Spies are the most important element in war because on them depends an army’s ability to move.” As Bill Gates had said, “The most mean-ingful way to differentiate your company from your competitors, the best way to put distance be-

tween you and the crowd is to do an outstanding job with informa-tion. How you gather, manage and use information will determine whether you win or lose.”

The Art of War is not your run-of-the-mill management book available on every bookstand. It is an extraordinary book in the way that you can read it and float through the pages, easily missing the gist of it. However, if it strikes a chord with you, be rest assured you will be enriched with an experience that no other management guru can ever teach you. The meaning of the words runs parallel to the pages and comes alive when you deliber-ate over every period and start interpreting it based on your own personal experience. The book is a compulsory part of execu-tive training program in many Japanese organisations and even the Western business managers speak highly about the lessons and insights from the book. It has been credited with influencing Napoleon and even the planning of Operation Desert Storm. Luis Felipe Scolari, the coach of Brazil-ian football team, made the entire team study the Sun Tzu�s classic during their successful World Cup Campaign in 2002.

It would be appropriate to say that Sun Tzu’s The Art of War is like a mighty river that carries in its sweep countless tributaries. If the 21st century wars are going to be fought in boardrooms, this pocketsize dynamo is a ‘must have’ in the armour of all the corporate warriors.

Review by Maninder Singh

Management techniques from the 6th Century

BookREVIEW


NationalPeopleHosp, Bangalore Today’s Healthcare scenario is witnessing a boom and unlike other industries, health-care is probably the only industry where an error is just not acceptable. Right processes and systems hospitals need the right people to handle them, making Human Resource Management a vital part of Hospital and Healthcare Management. PeopleHosp will be a Conference series to address this topic and dwell on Strategic Human Resource Manage-ment for Hospitals.Date: July 4, 2012Venue: Hotel Ashraya International, Ban-galoreOrganiser: AMENContact: Paniel JayanthTel: + 91 9035189825E-mail: [email protected]: www.amen-peoplehosp.blogspot.in

India International Medical Equipment Expo The event aims to serve the need for high quality medical and healthcare equipment and thus will showcase a wide and varied range of medical technology. This event will be a great platform where the exhibitors can market their products and services and thus promote their brands and forge profitable business deals. The event will also serve as a forum for the interchange of ideas and experience that will in a way further the growth of the Indian medical equipment market which is among the top 20 in the world. This event will also arrange for corporate presentations and dealer programs. Date: July 20-22, 2012Venue: Chennai Trade Centre, Chennai, Tamil Nadu, IndiaOrganiser: Paramount ExhibitorsContact: Dr. Harish AroraTel: +91-172-227480102/+91-9814211848E-mail: [email protected]: http://www.medicalequipmentex-pos.com/

Famdent, New DelhiHeld annually,the Dental Event is an excel-lent blend of education with a trade expo. Afterestablishing itself as one of the premier Dental Publications, Famdent now bringsto you an event - Famdent Show. The event will also include live demonstrationsof dental surgeries and procedures.Date: July 27-29, 2012Venue: New Delhi, IndiaOrganiser: Famdent EventsTel: +91 9833992559 / +91-22-65049697E-mail: [email protected] / [email protected]: www.famdent.com

Healthex International 2012 Healthex is an international exhibition focus-ing on hospital, medical & surgical equip-ment, materials, supplies & allied services. The show presents a complete range of equip-ment, materials, services, processes, systems, components, consumables which find wide use in medical surgeries, hospitals, clinics, diagnostic centres from across the world. Date: September 7-9, 2012 Venue: Bangalore International Exhibition Centre (BIEC), Bengaluru Organiser: Bangalore International Exhibi-tion Services Pvt. Ltd., (BIES)Contact: Suresh Babu PTel: +91 99729 29976E-mail: [email protected]: www.bies.co.in

InternationalPatient Safety Indicators and DashboardsThe event will discuss topics like improving and monitoring patient safety through indica-tors, metrics and dashboards; indicators and metrics: a step by step guide; clinical quality dashboards explained; developing patient safety dashboards and indicators locally; patient safety indicators at ward level: the patient safety thermometer; medication safety indicators and dashboards; mortality as a pa-tient safety metric and dashboard indicator; developing early warning systems of patient safety issues or deteriorating performance;

and clinical quality dashboards for assuring safety and commissioning. Date: September 14, 2012Venue: Hallam Conference Centre, LondonOrganiser: Healthcare Conferences UKContact: Kerry TarrantTel: + 1932824433E-mail: [email protected] Website: www.healthcareconferencesuk.co.uk

HIMSS Asiapac 2012 The HIMSS AsiaPac team brings to you more transformational programs to the dynamic city of Singapore. The Exhibition will show-case hundreds of products and services for your healthcare IT needs. Experience live demonstrations, technology updates, new products and services in the healthcare IT industry. The IHE Interoperability Show-case forms a major part of this event. The Guest-of-Honour at the event will be Mr. Gan Kim Yong, Minister for Health, Republic of Singapore.Date: September 17-19, 2012Venue: Marina Bay Sands, SingaporeOrganiser: HIMSS Asia PacificContact: Mr. Gabriel SimTel: +65 9299 0802E-mail: [email protected]/[email protected]: www.himssasiapac.org

MedHealth & Wellness 2012 Exhibition and Conference This is an international event that highlights the continued development of the healthcare sector in Oman.. It features a wide range of health products and services, medical equip-ment, pharmaceutical products, laboratory supplies, alternative therapies, as well as sports and fitness equipment. Date: September 25-27, 2012Venue: Oman International Exhibition Centre (OIEC), MuscatOrganiser: OMANEXPOContact: Melissa DalejaTel: +968 24660122E-mail: [email protected] / [email protected] Website: www.omanexpo.com/events.php

Happenings


CEOPAGE Dr. Om Manchanda

CEODr. Lal Path Labs

My Life’s GoalsAim & Ambition: To be associated with work that tries to address problems of people.

Vision: To live life to its fullest; both work wise and family wise.

Social Goal: I come from a very small village and have experienced the dearth of opportunities faced by talented people in such locations. I want to work towards increas-ing opportunities for them. Have already started in a small way by sponsoring an all-girls school in a remote area of Haryana.

Business Goal: To build an institution that touches the lives of people, to build something that is sustainable and provides employment to a large number of population.

My Leisure ChoicesFavorite Tourist Spot: I have 2 actually; one is Milford, which is a suburb of Auckland, New Zealand’s largest city. They take you in a ship to reach this sea spot. And the second one is Alaska where I will be visiting very shortly.

Music I Like: I am a die-hard Kishore Kumar fan.

Sports I Love: Like most Indians, I love Cricket, and I do skiing whenever possible. I also wish to pursue Golf professionally.

Ask my Taste BudsFavorite Food: Japanese, absolutely gorge on Sushi and also continental, especially spaghetti and risotto. Back home, rajma-chawal and karelas.

Favorite Drink: Ice tea is an all time favourite.

In Awe of I Admire: The nature that surrounds us. In future would like to be associated with something where I can do my bit to protect this gift.

“I want to work towards increasing

opportunities

JUNE 2012

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