Hospi

IT in HospitalsINRODUCTION -1- IT in Hospitals What is Information Technology? It is the branch of engineering that deals with the use of computers and telecommunications to retrieve and store and transmit information Embedded System : An embedded system is a special-purpose system in which the computer is completely encapsulated by the device it controls. Unlike a general-purpose computer, such as a personal computer, an embedded system performs pre-defined tasks, usually with very specific requirements. Since the system is dedicated to a specific task, design engineers can optimize it, reducing the size and cost of the product. Embedded systems are often mass-produced, so the cost savings may be multiplied by millions of items. Handheld computers or PDAs are generally considered embedded devices because of the nature of their hardware design, even though they are more expandable in software terms. This line of definition continues to blur as devices expand. Examples of embedded systems • • • • • • • • • • • Automatic teller machines (ATMs) Avionics, such as inertial guidance systems, flight control hardware/software and other integrated systems in aircraft and missiles Cellular telephones and telephone switches Engine controllers and antilock brake controllers for automobiles Home automation products, such as thermostats, air conditioners, sprinklers, and security monitoring systems Handheld calculators Household appliances, including microwave ovens, washing machines, television sets, DVD players/recorders Medical equipment Handheld computers Videogame consoles Even computer peripherals themselves such as routers and printers have embedded processors IT Enabled Applications in Government Hospitals in India: Governments all over the world are getting increasingly concerned about their ability to meet their social obligations in the health sector. The situation has become critical in light of rapidly increasing costs for medical care, aging population, lack of government funds, and so on, all of which threaten the quality of services delivered. The hospital managers are very concerned about the lack of hospital infrastructure and resources to provide a satisfactory level of service. Equally concerned are the government administrators who have limited financial resources to offer healthcare services at subsidized rates. In this paper, we first describe a set of critical problems faced by government hospitals in India based on a study of government hospitals in several states. We then discuss three successful IT enabled applications (telemedicine, egovernance, and BPR) to satisfactorily address some of these problems in government hospitals in India. Introduction -2- IT in Hospitals The Government of India is very conscious about its social obligations in the healthcare sector. It offers primary, secondary and tertiary healthcare services to its citizens at highly subsidized rates. Primary healthcare services focus on problems related to childbirth, malnutrition, and water borne and air borne diseases etc. Secondary healthcare services offered through municipal dispensaries and maternity homes offer basic outpatient services and limited inpatient services. Tertiary healthcare is offered through general hospitals (hereafter referred to as government hospitals). These hospitals offer a wide range of outpatient and inpatient services, including a few super specialty services. Many government hospitals also serve as teaching hospitals for undergraduate and postgraduate studies in medicine and nursing. A hospital superintendent heads each government hospital. Hospital superintendents have the dual responsibility to manage their hospital resources in providing healthcare services to the patients, and to extensively interact with the bureaucrats in the municipality, district, or the state governments in the administration of their hospitals. Problems facing Government Hospitals In this section, we outline some of our observations on the working of government hospitals and the problems faced by them in the delivery of healthcare services. Inadequate resources The number of patients seeking medical attention in tertiary care hospitals has increased 25-35 percent in the last five years. One of the main reasons is the declining levels of healthcare services at the Primary and Secondary units, and therefore the increasing expectations of a better level of service from tertiary care government hospitals. However, there has been no augmentation of infrastructure and other resources in government hospitals to handle the increased number of patients satisfactorily. Hospital superintendents are stretching their resources beyond limits to offer their services. Increased demand and inadequate resources result in poor quality of service. Very High Fixed Expenses Fixed expenses in Government hospitals (salary, wages, and overheads) have gone up from 70 percent in the last decade to almost 80 percent of the total revenue expenses at present. This is mainly due to the increases in the salary of government employees arising out of implementing the recommendations of the 5th Pay Commission Report of the Government of India. Insufficient funds for Variable Expenses Allocation of government funds to the hospitals has not increased in proportion to the increase in fixed costs. This is mainly because the government does not have adequate financial resources to satisfactorily meet all its social obligations in education, transport, health, and so on. Poor allocation of funds from the government to the health sector, and the high fixed expenses in providing healthcare services have led to insufficient funds to meet the variable expenses for patient care. Laboratories and the operating theatres account for almost sixty percent of variable expenses. Examples of variable expenses include expenses towards purchase of surgical materials, lab chemicals and kits, medicines, drugs, and the spare parts for repairs and maintenance of medical equipment and instruments. As a result, many patients are forced to buy medicines and drugs from private chemists by paying high prices, and depend on private clinics for laboratory and radiology investigations. Low User Charges While the expenses for medical care has increased significantly over the years, there has been no substantial increase in the revenue income from patient care. This is mainly because user charges have not been revised for the last 20-25 years. User charges are abysmally low. For example, patients are charged only Rs. 350, i.e. approximately USD 7 for any major surgery, and Rs 250, i.e. USD 5 for minor surgeries in government hospitals. User charges in private hospitals and clinics are at least ten times the charges in government -3- IT in Hospitals hospitals. While the user charges are kept low to provide subsidy, expectations from the public for quality healthcare services are very high. Irregular Allocation for Capital Expenses Allocation for capital expenditure in medical and information technology has been insufficient and irregular. As a result, it has not been possible to replace aged equipment and instruments in the operating theatres and investigation departments, adding to the concerns in the delivery of hospital services. Non availability of equipment in imaging and laboratory departments is a common complaint in many hospitals. Non-availability of medical equipment and instruments forces the poor patients to seek medical help from private clinics, by paying very high service charges. Archaic Purchase Policies Government policies for procurement of materials are the same for all government departments, such as healthcare units, educational institutions, transport department, and so on. Special requirements of hospital supplies such as expiry dates of drugs and medicines are therefore overlooked. Rate contracts are religiously followed, at the expense of quality, reliability and procurement lead-time considerations. Too many vendors, legacy systems and procedures, frequent delays in making payments to the vendors, and lack of proper record keeping lead to stock out of medicines and drugs in government hospitals. Under-utilization of Resources Operating Theatres and Investigation departments together account for almost 70-80 percent of the total capital investments. However, these facilities are fully utilized only in the morning shift from 8. 00 AM to 2.00 PM. At other times, these facilities are lying idle to handle only emergency cases. Lack of Administrative support The government organizational structure and the administrative support to the government hospitals are not sensitive and responsive enough to the needs of the hospitals. There is no post of a manager or an administrator, many sanctioned posts are lying vacant and the administration keeps recruiting temporary staff to fill these positions. Frequent transfer of administrative staff between government departments (hospitals, schools, transport departments etc) adversely affects the working of the hospitals, as the hospital requirements are different from other government departments. Hospital superintendents are finding it more and more difficult to satisfactorily play their dual roles of interacting with the government and the public in providing healthcare needs. Poor interface with the citizens Government interface with the public is very poor, leading to unrealistic expectations from the public on healthcare services. Public is not aware of the nature and magnitude of the costs incurred by the government, revenues from patient care, the subsidy on healthcare, and their impact on cost effective quality healthcare. As a result, there are several complaints and newspaper articles about the poor quality of healthcare services from government hospitals. IT Applications in Health Large investments have gone into developing IT applications in healthcare management worldwide, with a view to improve the delivery of healthcare services. However, rigorous assessments of the costs and benefits of such investments are not very well reported [1]. The ambitious project to install a Hospital Information System in the Limpopo province of South Africa, initiated in response to a national strategy to restructure healthcare, consumed about $ 30 million, but failed at the implementation stage -4- IT in Hospitals [2]. The story is not unique to developing countries. In UK, NHS spends about 200 million pounds every year for IT in acute hospitals, but published evidence on the value of IT to NHS hospitals is scarce and far from conclusive [3]. Reports from the Audit Commission in UK have even criticized the use of computer systems in NHS hospitals [4]. There is a healthy debate going on in many countries (both developed and developing) regarding the amount of money for investment in information technology when there is a shortage of funds for investments in medical technology (eg, diagnostic equipment) as well as towards purchase of drugs and medicines. Choice of appropriate IT applications in health sector is therefore extremely critical. We believe that it is necessary to demonstrate moderate benefits from moderate IT investments, before committing large sums of money for large IT projects. Our approach to the choice of IT applications in Government hospitals in India has been to choose those areas where immediate benefits can be demonstrated, and an assessment of costs also can be made. Accordingly, we have chosen three areas for IT investments in government hospitals Below, we discuss through case studies, three successful implementations of IT applications in India, based on telemedicine, e-Governance, and BPR approaches. Each one of these IT applications addresses a specific issue facing the delivery of healthcare services in Indian government hospitals. The telemedicine project involving public-private partnership addressees the critical issue regarding shortage of funds for capital expenditure in district hospitals. Our e-governance application modeled around the concepts of Activity Based Costing of surgical services address the critical issue regarding user charges in government hospitals. Our IT-enabled BPR application address another critical issue regarding shortage of funds for variable expenses towards purchase of drugs and medicines. We describe each of these successful IT applications in some detail below. We have selected different hospitals for each IT application, so as to clearly understand the problems in implementation. A Telemedicine project We illustrate below the experience of a successful public-private partnership in a telemedicine project at a district hospital in the southern state of Andhra Pradesh, India. This district hospital is one among the ten district hospitals in the state of Andhra Pradesh which enjoy a certain degree of autonomy under the World Bank Assisted Program on Health Sector reforms. Like in many district hospitals, the diagnostic facilities in the selected district hospital are also very poor. As a result, many poor patients in this district depend on private diagnostic centres for radiological investigations, by paying very high service charges. The autonomy enjoyed by this district hospital facilitated the state health authorities to enter into a public-private partnership to provide telemedicine facilities at the district hospital. The telemedicine infrastructure consists of a Telemedicine Specialist Centre (TSC) at the private hospital and a Telemedicine Consulting Centre (TCC) at the district hospital. The TCC houses an ultrasound, a 500m A x-ray unit, and a CT Scan interfaced with the telemedicine software. Patients now present themselves for radiological investigations at the TCC in the district hospital. The TCC has a high-end scanner for scanning images and transmitting to the TSC, a web camera for net meetings, and videoconferencing equipment to videoconference with the specialists at TSC. The specialists at TSC interact with the patient and the medical staff at TCC, view the lab reports, carry out live radiological investigations by viewing the transmitted images, and recommend an appropriate line of treatment. Telemedicine is also used by the general practitioners at the district hospital to get second/special opinion -5- IT in Hospitals from super-specialists at the TSC to confirm diagnosis, plan treatment, provide acute interventional plan in case of medical emergency etc. Since 65-75 percent of treatments do not require surgical interventions, telemedicine offers immense possibilities to offer quality healthcare services to patients in far away cities and remote areas. Besides long-distance clinical healthcare, the district hospital is also using its telemedicine center for patient and professional health related education, public health and administration. The telemedicine project is providing training to the general practitioners in remote areas to prevent and respond to typical disease patterns in their areas. Design of interactive modules between the general practitioners at TCC and the specialists at TSC for understanding the nature of ailments has also created a Healthcare Knowledge base. During the last monsoon, a possible outbreak of an epidemic was brought under control by the district authorities by relying on the telemedicine infrastructure for consultation with experts and for expediting the dispatch of emergency drugs and medicines. Future plans include using the telemedicine infrastructure as a channel for communication, assist “community-reach” programs in getting the message across (potable water, village sanitation, etc), facilitate successful implementation of population control programs, create a channel for AIDS awareness, and so on. The experience of the patients, healthcare professionals at the private and district hospitals, and the government healthcare officials are very satisfying. The entire cost of the telemedicine project including staffing the TCC at the district hospital was borne by the private hospital. In return, the private hospital would receive a share of the user charges collected by the district hospital. This arrangement of sharing the user fee was possible since the district hospital enjoyed a certain degree of autonomy. The revised user charges at this district hospital, though higher than other district hospitals in the state, was still 50 percent lower than the charges at the private diagnostic centres, and therefore there was no protest by the public either. Encouraged by the success of this initiative, the private hospital is now setting up telemedicine centers at a few more district hospitals. An e-Governance Application In this section, we present our successful implementation of an e-Governance application to revise the user charges in government hospitals, which is a very sensitive issue. It is necessary to understand the costing of hospital services in order to establish appropriate prices for hospital services. Costing of hospital services is a very complex activity as every service is a combination of several activities, each activity consuming a variety of resources. Traditional methods of costing hospital services do not recognize the variable levels of consumption of hospital resources for each service. Distortions thus arise in the costing of hospital services that lead to distortions in the pricing of services. Activity Based Costing overcomes these limitations, as it allocates costs based on the amount of each resource consumed for each service. Below we discuss these concerns briefly for costing and pricing of surgical services Surgical services in government hospitals are grouped under General surgeries, Orthopedic surgeries, and so on. Each group of surgeries has its own Operating Theatre (OT). Each OT works as an independent unit with its own OT resources. OTs are major cost centres as they consume vast amount of hospital resources and account for large overhead expenses. In return, OTs are expected to generate a substantial amount of revenues to the hospitals. Government hospitals classify all the surgical procedures into two categories: Minor and Major procedures. Minor procedures priced at Rs. 250 (i.e. approximately USD 5) include dressings, suturing, biopsies, circumcision, excisions etc, and account for 50 percent of the total number of surgeries. All other procedures ranging from appendectomy to radical procedures such as pancreatechtomy are classified as major surgeries. All major surgeries are priced at Rs. 350 (approximately USD 7). Implicit in this pricing -6- IT in Hospitals policy is the assumption that all major surgeries consume the hospital resources more or less uniformly. This assumption has led to a serious imbalance between costing and pricing of surgical services. We selected LG Municipal hospital under the Ahmedabad Municipal Corporation (AMC) Ahmedabad, in Gujarat State, in order to understand the activity costs for surgical services. OT activities consist of preparing the OT complex, pre-operative procedures on patients, anesthesia procedures, surgical procedures, post operative patient care, and post-operative OT work. We collected data on the resources utilized for all general surgeries in the above hospital over a period of three months. The ABC methodology classified 336 out of 626 procedures (54 percent) as Minor procedures, which more or less agrees with the existing classification. However, ABC methodology classified the remaining 290 procedures into four categories, the average cost of each category being Rs 2400 (USD 50), Rs 3600 (USD 70), Rs. 4800 (USD 95), and Rs. 7000 (USD140) respectively. ABC costing thus revealed major distortions in the existing system which classifies all these 290 procedures under a single category (Major). We then developed an e-governance application to share our finding with the government authorities, elected representatives and the citizens groups. We posted an OT chart everyday in the LG hospital displaying the surgeries performed, ABC costs for each surgery, current user charges, and recommended user charges under various levels of subsidy. Our objective was to “educate” all the stakeholders about the actual cost of surgical services and thereby argue for revising the user charges for a desired level of subsidy. After long and protracted discussions with all the stakeholders, AMC finally implemented our recommendations to classify all the surgical procedures into five categories (as against the existing two categories) and revise the user charges for surgical procedures for an 80 percent level of subsidy. Based on our success in revising the user charges for surgical services, we argued for revisions in user charges for laboratory investigations as well (Operating Theatres and laboratories are the major cost centres in any hospital). All the three AMC hospitals in Ahmedabad have since revised their user charges for surgical and laboratory services. AMC also succeeded in convincing the citizens the need for periodical reviews of user charges and revise them as and when necessary. The costs for designing, developing, and implementing the e-Governance applications were borne by AMC, and the Indian Institute of Management, Ahmedabad where the author is working. AMC recovered the costs over a period of one year through increased user charges for surgical and laboratory services. The benefits from this e-Governance application are far reaching. Our e-governance application contributed significantly to educate all the stakeholders about the concerns on user charges, government subsidy, and the quality of hospital services and thereby evolve a rational policy for user charges in line with the stated policy on subsidies. An IT-enabled BPR application As mentioned earlier, fixed expenses in government hospitals account for almost 80 percent of the total revenue expenses, leaving very little money towards variable expenses for patient care. An analysis of variable expenses in hospitals shows that hospital supplies (consumables and disposable items for medical, surgical and laboratory needs) account for 90 percent of variable expenses. Our analysis therefore focuses on the existing system of managing the hospital supplies and recommending a reengineered system for purchase and inventory management of hospital supplies at a large government hospital. GCR Hospital (GCRH), situated in a large city in Western India specializes in the treatment of Cancer. The purchase committee at GCRH is entrusted with the task of preparing and processing tenders for all the 2000 items, and the selection of vendors on rate contracts for each item. Once the rate contracts are approved, the purchase officer is free to place orders with the approved vendors. GCRH maintains a list of 400 suppliers for an annual purchase of approximately Rs. 50 million (approximately USD 1 million). About 1200 purchase orders are placed every year. -7- IT in Hospitals We reengineered the purchase system as follows. We first classified all the 2000 items into a few Minor Groups under each Major Group. For each minor group, we then identified the number of suppliers, value of purchases, and the number of purchase orders placed (see Exhibit 1 for a sample year). Our reengineered purchase policy calls for tenders for each minor group of items, and not for each individual item as in the past. Each vendor was asked to submit rate contracts for 25 %, 50 %, 75%, and 100% of the annual requirements for each minor group of items. We also cut down the credit period for payment from three months to one month. Vendors were selected on rate contracts for each minor group of items to satisfy the annual requirements of the hospital. Our efforts in streamlining the purchase procedures at GCRH has led to cutting down the number of vendors from 400 (small, medium and large vendors) to 75 medium-to-large vendors. By relying on a fewer number of large vendors to meet the annual requirements, and by reducing the payment period to one month, GCRH has saved 15-20 percent in the value of hospital supplies purchased. We then focussed our attention on the inventory management system. The existing system for inventory management at GCRH woks as follows. The stores department maintains a set of registers/ledgers to record each type of transaction – receipt of goods, issue to departments, orders placed, orders pending etc. These records are maintained mostly for audit purposes, and not for managing the inventory. As such, these ledgers are all prepared independently, with no integration of information across ledgers. Each department places its monthly indent to the stores by the first week of every month. Items are issued to the departments based on the availability of stocks. There is no well defined re-order policy for any item, orders are placed with the approved vendors based on the subjective assessment of the stores clerk regarding his estimates for quantity required, quantity in stock, and the lead time for various vendors. Many items are out of stock frequently due to various reasons, such as delayed delivery, and limited budget for hospital supplies. GCRH followed a three-month credit period for payment to vendors. We reengineered the existing system of inventory accounting by integrating it with working of the purchase, stores, finance and the user departments by creating a Materials Management Group. This group consists of an officer from the purchase, stores, and finance departments and a representative for all the user departments. This group is responsible for all decisions (policy, planning, and monitoring) pertaining to purchase, receipt, issues and payment for all the hospital supplies. The combined effort of reengineering the purchase and the inventory management practices and implementing a computer based materials management process at GCRH led to a saving of 25-30 percent on the value of purchases. The design and development of the reengineered IT system were done by the IT staff at GCRH. The total cost for carrying out this study including the design, development and implementation of the IT system was less than the savings achieved. This application satisfactorily addressed the concerns on the shortfall of funds for variable expenses towards the purchase of medicines and drugs at GCRH. Conclusion The public-private partnership in the telemedicine project demonstrated improvements in delivery of healthcare services to people in a remote district. The e-Governance application brought the municipal authorities, healthcare professionals and the citizens on a common platform to better understand the costs, subsidies and the quality of healthcare services, and thereby arrive at rational user charges. The IT led BPR application cut down the purchase value of hospital supplies and thereby provided some relief to the hospital authorities in managing the variable costs for patient care and thereby improve the delivery of healthcare services. The three case studies described in this paper demonstrate successful IT applications in addressing three specific issues facing the government hospitals in India. The success of our IT applications in government hospitals can be attributed to two major factors. One of these factors is our emphasis on an assessment of the costs and benefits. The other factor is our ability to demonstrate the benefits to all the -8- IT in Hospitals stakeholders in the delivery of healthcare services, namely the providers (government), professionals (hospitals) and the beneficiaries (citizens). Emergence of Corporate Hospitals The emergence of corporate hospitals on a larger scale is animportant development, although not for reasons most often associated with it. While corporate entry into healthcare is important for the bed-supply deficit to be bridged, it is even more important for the professionalisation of hospital management. Till recently, modern management systems had not penetrated most healthcare institutions, with some notable exceptions. Most hospitals would organize their resources and manpower within structures that had evolved rather than been designed. The processes would be structured to ensure multiple points of control rather than patient convenience. Information capture would be rudimentary and information rarely integrated beyond that required for reporting purposes, because of which any data-based quality control would not be possible. With corporate entities entering the healthcare sector, they are introducing managerial practices and tools, which they had been using for long, in the hospitals that they are promoting. Moreover, these entities are showing a marked preference for professionals, even for non-clinical and clinical support functions. This, in turn, is leading to the expansion of the hospital management education industry. The benefits of professionalism are obvious. In most cases, ICRA has noticed significant differences between professionally managed hospitals and those managed otherwise. Usually, professionally managed hospitals have better systems and control procedures, which provide for better support to the delivery of quality care. However, ICRA has also come across corporate hospitals where a lack of appreciation of healthcare as a service has been evident from the non-availability of life saving equipment and support infrastructure; presumably, these were sacrificed to lower project cost or save on operating expenses. The entry of corporate entities into the healthcare sector is also having another, but not so obvious, impact on certain institutions: the not-for-profit hospitals. These hospitals, which subsidise the delivery of care for the poor by charging those who can afford to pay on a cost-plus basis (usually referred to as private patients), are finding it increasingly difficult to attract private patients. A continuous decline in occupancy levels in the private wards of such hospitals has been observed -a trend that these institutions are trying to arrest by offering comfort levels (in private wards) matching those available in corporate hospitals. Contribution of corporate hospitals in health care In the corporate sector Asian Heart Institute and Wockhardt Hospital have contributed significantly to tertiary care in the city. As more people get insured more tertiary care hospitals will be required. Besides companies like Wockhardt, Ranbaxy is also starting a chain of private hospitals. Foreign direct investment is also in the pipeline to establish hospitals in the country and the city of Mumbai. Increasing Popularity of Day Care Services The popularity of day care services (discharging the patient the same day a surgical or other procedure is conduced) is on the rise. However, not many hospitals have systems to support the tight planning, skill and backups required to execute day care. Contributions of private charitable organizations in Mumbai in health care Today with all the drawbacks, Mumbai city gives the best medical care to its citizens. There are 42,000 hospital beds in the city of Mumbai. The Municipal and Government hospitals maintain about 12,000 beds and the Charitable hospitals also maintain approximately 1200 beds in the city of Mumbai. The remaining 18,000 beds are provided by Nursing Homes and small hospitals. Both Municipal and Government hospitals do not provide even 25% of the medical care that the city requires. The budget of the Municipal -9- IT in Hospitals corporation for medical care for this year is 830 crores and I am sure that approximately 150 crores may be spent by the Government for their hospitals in the city of Mumbai making a total of about 1000 crore of rupees for health care which is provided by the tax payers money. I must admit that the Municipality has the responsibility of spending money for preventive medicine as well. The remaining 75% of medical care especially secondary and tertiary care is provided by the charitable hospitals of Mumbai. These have been established by Philanthropists and are held on very high esteem in the whole country. When the full time system was implemented in the medical colleges in Mumbai a large number of prominent teachers who were holding honorary positions had to leave and they moved to private hospitals for practice. This certainly had an effect on teaching in the medical colleges, which is now reflected in the quality of medical graduates from Mumbai who do not enjoy the same prestige as compared to the graduates passing from some of the premier institutions of our country. The students coming out of All India Institute of Medical Sciences, Vellore and many other Universities are holding significantly higher academic positions as compared to Mumbai today, which is a sad state of affairs. There are several instances where people who are trained in institutions especially in the South are migrating to Mumbai for practice and making a dent against the locally trained doctors, which is amply evident. This clearly sends a signal that the training in medical colleges has deteriorated and something needs to be done by the Government and the Municipality to improve the medical colleges of Mumbai city. The Government and the Municipality should increase the grants to the four medical colleges in Mumbai city, as these are premier institutions of this state for training of doctors. The large private hospitals in Mumbai like Bombay Hospital, Jaslok Hospital, PD Hinduja National Hospital, Lilavati Hospital, SL Raheja Hospital, Nanavati Hospital and Breach Candy Hospital have contributed a lot to the health care of the city. Now there are many medium size hospitals like Cumballa Hill Hospital and Heart Institute, Saifee Hospital, Prince Aly Khan Hospital, Guru Nanak Hospital and many others which have also contributed a great deal. These hospitals have brought about a drastic change in the practice of medicine in the city of Mumbai. When highly trained professionals joined these private hospitals, they attained a significant name in professional services in the country. During the last several years, patients from all over India have been coming to these private institutions for best professional services. The Association of Hospitals has a membership of 40 charitable hospitals but there are many other charitable hospitals who are not included in the list. It may be a while before you get the prescription to correct your heartbeat on your mobile phone, but Indian hospitals are initiating steps on this journey by implementing Hospital Information Systems (HIS). HIS are evolving from integrated order entry systems, administrative systems, and departmental subsystems within a hospital, by extending and integrating into ERP. Hospitals in India are in various stages of implementing HIS. "We are a multi-location hospital and nearly 70 to 80 percent of the hospital's activities are covered by the HIS. It is difficult to say that we have arrived with a implementation such as this," says Sunil Kapoor, Corporate IT Head, Fortis Hospital. Some of the modules that are present in HIS are registration, emergency, OPD, wards, laboratory, billing, help desk, purchase and pharmacy. "Our HIS encompasses most of the functions and work flows of a hospital such as billing, material, administrative, clinical back office and MIS integrated as one system," affirms Suresh Shenoy, VP IT, Wockhardt Hospital. The trend is catching on rapidly, and most hospitals have already started this process in the last decade. Impact on the cost of healthcare Hospitals are of the opinion that deploying HIS will not make healthcare more expensive. Currently corporate hospitals are deploying HIS as they are in a position to sustain the huge investment. Healthcare in India is just beginning to realise the importance of integrated, configurable, systems. "The driver is ROI, and in the long run, benefits are realised from the bottom line and quality of care delivered to patients. It - 10 - IT in Hospitals will take a couple of years to reach a level of maturity. With stress on international quality standards and best practices, an attempt has been made-probably for the first time in India-to imbibe the same in IT systems," adds Shenoy. Medical tourism is not a major factor for technology implementation in Indian hospitals. The greater chunk of such tourism comes from India and its neighbouring countries. Having said that, if systems are in place, it might just boost tourism. "Patients whether national or international are the same; however, the expectations of foreign patients are usually a little higher," comments Mahesh Shinde, CIO of Hinduja Hospital. The Central Ministry of IT has created a sourcebook, 'A Proposed Framework for IT Infrastructure for Healthcare in India.' The document speaks of being an initiative towards standardising and seamlessly integrating the various sectors of healthcare on common platforms to bridge the gaps and bring in economies of scale. Its implementation is, however, yet to see daylight. The healthcare industry in India is also trying to bridge the gap between technology and medical needs. Medical Computer Society of India (MCSI) is one such institution which believes that medical institutions in the west have already spent millions of dollars only to later realise that some systems do not suit their purposes. They fear that a similar scenario of haphazard development of medical application of computers is going to follow in our country as well. To avoid such a situation, the institute co-ordinates the expertise of specialised doctors who have an interest in bringing technology to healthcare. A team effort Hospitals which have deployed HIS have solutions from different vendors with the in-house IT department building a lot of the modules. A case in point is Fortis. "We had tried to deploy an European system, but that did not work out. The Indian medical system is largely private as opposed to the European system. Hence we were left with no choice but to develop our own," says Kapoor. Others such as Wockhardt have worked with vendors. Wipro developed a core ERP called HIS Version 2.0 with inputs from Wockhardt and Harvard Medical International, USA. The local IT team developed some tools and MIS around an ERP. Much of the automated lab equipment and EPABX systems interact with the HIS, ensuring the data flow, and avoiding duplication and error. These medical equipment and related software are sourced from different vendors, says Shenoy. This system is being deployed in Mumbai and Nagpur, and is based on Microsoft Windows Server with modules that cater to all functions-from administration and marketing to billing and health check-ups. An integrated system Having an integrated system obviously helps ensure smooth functioning. Hospitals have a critical environment, and improving efficiency can mean saving lives. According to Kapoor, by having the HIS connected to front-office systems, patients will be informed of the requirements for radiology. HIS supports complicated packages to be defined, administered and billed. Confusion in package billing is a major source of revenue loss the world over, believe experts. Inventory control gets better as every item is tracked-from purchase to consumption. Departmental stock is also tracked. Any number of stock points can be created in HIS, material flow by indent followed by acknowledgement of receipts. Reduction of time in various patient-care processes such as registration, lab results and billing can be achieved. Integration of various system components (all modules of stock/billing/ registration/clinical/ward/ pharmacy) helps in the natural workflow and in maintaining consistent information. Shenoy says that OPD appointments can be scheduled on phone based on a doctor's availability; actual patients registered in waiting can be seen by the consulting doctor from his room, which allows him to - 11 - IT in Hospitals manage patients in a better way. The dose advised can be issued to pharmacy directly and the pharmacy in turn can respond to it. So, how much are hospitals investing in IT? IT investment may be generally 3 to 7 percent of the overall hospital infrastructure budgets, say CIOs. "Over a period of two years and above, the realisation on investments boosts the bottom line. Also one has to remember the value addition in the quality of care delivered to patients," says Shenoy. Hinduja Hospital has spent about 2.5 crore in phases over a decade to deploy HIS. One of the challenges is to get doctors to use the system. Kapoor says that doctors are now excited about the integration and often stimulate the IT team to expand the deployment to address more areas. Future in PACS The next system that most Indian hospitals are looking to deploy is Picture Archiving and Communication Systems (PACS)-a system that is used to capture, store, distribute and display medical images. Electronic images and reports are transmitted digitally via PACS, eliminating the need to manually file, retrieve or transport film jackets. A PACS system comprises four principal components-imaging such as CT and MRI, a network for the transmission of patient information, workstations for interpreting and reviewing images, and long- and short-term archives for retrieving images and reports. Combined with the emerging Web technology, PACS has the ability to deliver timely access to images, interpretations and related data. PACS breaks down the physical and time barriers associated with traditional film-based image retrieval, distribution and display. "In the next phase, there is a plan to integrate PDAs, tablet PCs and cell phones," says Shenoy. Internet holds much potential in healthcare. Tele-communication between a central hospital and a satellite clinic or hospital can be enabled especially when a physician consults with domain experts in other hospitals concerning a patient's case. HIS combined with Internet can enhance personal private communications among healthcare staff using email, transfer clinical information about patients among two hospitals or clinics for consultation or decision support, retrieve up-to-date medical information from the Web, and initiate discussion among healthcare providers & researchers by using e-mail lists, real-time video chat system and various electronic textbooks. While this is being realised abroad, it may take some time for such automation to come in India. However, the process has begun and the efforts of the Indian healthcare industry are currently to integrate their systems and work efficiently before thinking of bringing other technology benefits directly to patients. Wipro HealthCare IT Healthcare worldwide is constantly undergoing changes due to new research findings, new medical technologies and new business models. These challenges are further compounded by the fact that healthcare is an information intensive field. Data must be timely, accurate and reliable - it could make the difference between life and death. The benefits of Information Technology can effectively address the challenges faced by healthcare providers. Information Technology solutions in healthcare help provide enhanced care to patients while conforming to present and emerging standards and regulations and ensuring seamless integration within the various departments of the hospital. It also has critical social relevance in providing accurate monitoring and compliance with best procedures and practices. Wipro HealthCare IT Ltd. (Wipro HCIT) is a dedicated Health Informatics Company and is part of Wipro Technologies (www.wipro.com). Wipro’s revenue from combined IT and IT Enabled Services businesses is US $ 1.2 billion (FY 2003-04). - 12 - IT in Hospitals Wipro HCIT has a talent pool of over one hundred professionals with healthcare domain, Information Technology and management expertise. We have 45+ satisfied global healthcare customers with successful implementations in private and government hospitals, clinics, pharmacies and diagnostic centres. Our in-depth knowledge of the healthcare industry enables us to analyse your business needs, assist you in re-engineering business processes and synergise your operations with IT solutions, to positively impact your Key Result Areas. Wipro HCIT’ s credentials include: Over 650 person years of experience in Healthcare IT In-depth understanding of the challenges faced by healthcare providers Experience in implementing at over 45+ global running hospitals and new hospital sites Process sophistication and well proven project management skills Improving clinical, operational and financial outcomes of healthcare providers Benefits of our proposition include: Improved clinical, operational and financial outcomes of healthcare providers User satisfaction through friendly and intuitive graphical user interface Reliable application to support 24*7 operations of hospitals Products Wipro HCIT offers a suite of products for healthcare providers, including: Wipro HIRePS-HIS: Comprehensive Hospital Information System for medium and large hospitals Wipro HIRePS-Mini: A Hospital Information System for small hospitals and clinics Wipro HIRePS-LIS: Laboratory Information System for diagnostic centers and laboratories Wipro HIRePS-MMS: Materials Management System Services Wipro HCIT’s Managed IT Services offering provides day-to-day management and operation of IT assets and processes. -- Managed IT Services include: Infrastructure maintenance for hardware (desktops, servers, networks) Software (application and packaged software) Systems Integration services -- Consulting Services Products Wipro HCIT’s suite of products addresses different segments of providers from large hospitals to clinics to diagnostic centres. Each offering addresses the business requirements based on scale of operations and complexity. Wipro HIRePS-HIS is modular and seamlessly integrated enterprise wide resource planning system, whereas Wipro HIRePS LIS and MMS are stand-alone solutions. All our products are based on open - 13 - IT in Hospitals healthcare standards deployed on the latest technology platforms. They can easily be interfaced with third party software systems and medical equipment for increased productivity. Wipro HIRePS-HIS: Comprehensive Hospital Information System for medium and large hospitals Wipro HIRePS-Mini HIS: Hospital Information System for small hospitals and clinics Wipro HIRePS-LIS: Laboratory Information System for diagnostic centres Wipro HIRePS-MMS: Materials Management System for pharmacies Wipro HIRePS – Hospital Information System Wipro HIRePS is a state of the art HIS which is a comprehensive enterprise wide software that covers all aspects of management and operations of medium and large hospitals. It enables healthcare providers to improve operational effectiveness, reduce costs, reduce medical errors and enhance delivery of quality of care. The solution is modular and gives healthcare organisations the convenience of a flexible rollout strategy. Hospitals can choose to prioritise the deployment of those modules considered critical from the organisations patient care delivery goals. Benefits Implementation of WIPRO HIRePS-HIS consistently delivers the following benefits to healthcare providers. Increase in revenues through online charge capturing and tracking of all billable services Reduced operational costs through reduction in staff required for back office tasks Better inventory management through accurate estimation of demand, timely procurement and distribution of medical and non-medical items Increased productivity and elimination of human error through seamless integration with medical equipment Improved patient satisfaction through reduced turnaround time at points of care Improved decision making through online availability of information across departments - 14 - IT in Hospitals “Wipro’s HIS helps run the Wockhardt Hospitals in an efficient and cost-effective manner. The HIS system puts clinical and financial information at our fingertips, helping doctors and administrators in critical decision making.” Dr. Lloyd Nazareth, General Manager-Wockhardt Hospitals, Mumbai TCS Healthcare Information technology provides the Healthcare industry with the business and technical architectures needed to optimize services and offer patients better care. TCS' Healthcare offerings provide the support needed for Healthcare practices to adapt and evolve to meet industry-related changes. TCS' state-of-the-art Healthcare tools and services contribute to improving the quality of service and quality of life to patients around the world. TCS has over twenty years of business and technology expertise in the Healthcare industry and provides state-of-the-art solutions. Our Healthcare industry experts come from backgrounds in medical sciences, biomedical engineering and information technology. Our end-to-end Healthcare solutions cover the spectrum of the industry's needs. For example, our Hospital Management System addresses the needs of all of a hospital's functional areas. Decision Support Systems improve diagnosis and treatment. Telemedicine technologies transfer medical images and health information through networks and contribute in providing quality service to patients. What TCS offer TCS executes turnkey projects for hospitals and healthcare institutes the world over. We provide fully integrated and scalable end-to-end Healthcare consultancy – from hardware, software and networking to Internet solutions. Through our data warehousing and data mining expertise, we build decision support systems for clinical and critical pathways. We provide consultancy services for developing health portals, medical transcription operations and setting up telemedicine facilities, which enable access to healthcare information and quality patient care from anywhere in the world. • Hospital Management System (HMS) HMS, developed by TCS, provides streamlined operations, enhanced administration and control, quicker response to patient care, along with cost control and improved profitability. This product covers all of a hospital's functional requirements, for example, reception, billing, pharmacy, investigation areas, wards, operation theater, stores, purchase, housekeeping, dietary, medical records, bio-medical, maintenance, marketing, personnel, master health checkup, consultation rooms and others. HMS is modular, userfriendly, and easy to customize and incorporates the latest in technology. • SmartClinic SmartClinic is a comprehensive computer-based patient records system that was originally developed by Berdy Medical Systems and then customized by TCS. Created by practicing physicians, SmartClinic allows a doctor's office to capture medical data and access it whenever needed inorder to make accurate decisions, thus providing quality care and reduction in paperwork. This product covers medical history, medications, tests, progress notes, correspondence, reporting and documentation. - 15 - IT in Hospitals • AcuBase AcuBase is specialized intensive care unit software which analyzes patient data, treatment costs, quality of care and provides illness severity scores like Apache II, Injury Severity Scores, Risk of Death, Prognosis Calculations and more. AcuBase was developed by Mela Solutions, United Kingdom, and is used in over 140 sites worldwide. TCS works closely with Mela Solutions and assists them with marketing and supporting AcuBase throughout India. • WebHealthCentre.com WebHealthCentre.com, a Website launched by TCS, is dedicated to making quality healthcare accessible free of charge to people around the world. WebHealthCentre.com has India's first multi-institutional participation that provides free online medical advice. Through this facility, doctors and patients can access some of the leading medical institutions in India for medical advice. In addition, this Web site offers services like online clinic, online drug store, online bookstore, online diet advice and a facility to store health records. It has other features such as a drug index, health directories and a host of health related information. WebHealthCentre.com has been envisaged to be an important nodal point for the dissemination of health-related information in India, for the benefit of the medical community and general public alike. It has been ranked as the 7 best health portal on the Internet. Hand in hand Our strong alliances with various technology partners help us provide best of breed solutions. Among others, we market SmartClinic in India in association with Berdy Medical Systems, USA and AcuBase in association with MelaSolutions, UK. A State-of-the-art Cardiac Care Center in India The client was a new, state-of-the-art specialty cardiac care center aspiring to have a comprehensive management and information system. Being able to provide accurate, relevant and timely information for patient diagnosis and treatment is vital to a cardiac care center and often may make the difference between life and death. TCS Healthcare consultants studied and analyzed the different requirements of the hospital and identified critical areas where their expertise could make an immediate impact on patient care. Customizing and implementing a modular Hospital Management System, TCS' consultants integrated the reception, wards, pharmacy, laboratory, stores, blood bank and other functions of the hospital into an electronic patient record system. The patient tracking facility in the system enhanced the quality of post-operative patient care, as doctors, nutritionists, therapists and paramedical staff were now all able to equally access relevant patient history and records. Subsequently, other modules including administration, housekeeping and equipment interfacing were implemented. In addition to providing a unified information system for management, the system helped the center to optimize resource allocation and revenue management. "TCS has successfully implemented modules of HMS Software. It is being used in a full-fledged manner and the system is running smoothly." S. Padmanabhan, EDP Manager, Kovai Medical Center and Hospital (KMCH) Enabling Eye Care in Rural India Research at Intel • • • Overview The Challenge Reaching Rural Residents - 16 - IT in Hospitals • • • Establishing the Vision Centers Results to Date Potential Impact At an eye care clinic in Bodinayakannur, a rural village in South India, a 64-year-old man and a computer technician sit in front of a PC screen, consulting with a doctor in a hospital in Theni, 9 miles away. “Everyone said to get a checkup here,” says the man. “They said I could talk straight to a doctor through the TV.” After asking the man a few questions, the technician describes his history and symptoms to the doctor, who instructs her to give him two prescription medications and have him visit the hospital for an exam. Then the technician gives the man a microphone so he can speak directly to the doctor. “For the last week, my eyes have been itching,” he says. “There has been swelling and watering.” The doctor responds: “The redness in your eyes is because of infection. You need to apply drops for five days, six times. After three days, come to Theni. Since you have diabetes, we want to examine you. Okay?” He agrees. The consultation only took minutes, but it saved the patient a day’s time, and the wages he would forfeit if he’d had to walk the 9 miles to the hospital. “If I had to go to Theni, I would have put it off,” he says. “Because the clinic was here, I came right away.” Overview The scenario above was enabled by a collaboration involving researchers from Intel and UC Berkeley, with support from the National Science Foundation. Together they are helping the Aravind Eye Care System, a network of five hospitals in South India, in its quest to deliver affordable, quality eye care services to the rural poor. Their contribution: a custom long distance, high-bandwidth, point to point Wi-Fi network that connects rural vision centers to Aravind hospitals. This experimental network will enable rural residents to have video consultations with doctors, eliminating the need for patients to travel to the hospital for routine eye care. Long-distance (LD) Wi-Fi is a fixed point to point wireless technology, like microwave links, that enable organizations such as the Aravind Eye Hospital to develop their own wireless network in remote rural areas. These sparsely populated areas are low priority for wireless service providers and may not receive wireless coverage for many years. If wireless coverage eventually reaches these rural areas with bandwidth to support video conferencing, the long distance Wi-Fi fixed point to point networks can be migrated to wireless service provider networks with their added benefit of broader point-to-multipoint coverage. - 17 - IT in Hospitals This patient at a rural vision center in the town of Periakulum is teleconferencing with an eye specialist at a hospital 10 miles away.In developing their custom networking technology, a key challenge for the researchers is that Wi-Fi is designed for short-distance communication. To make it work over the long distances between rural vision centers and Aravind hospitals, they modified the software—specifically, the Wi-Fi Media Access Control (MAC) protocol. The result: a unique wireless network that can handle highspeed communications over distances as great as 40 miles. The Challenge Globally, India shoulders the largest burden of blindness, estimated at 15 million people. Cataracts are the leading cause of blindness in India, but glaucoma and diabetic retinopathy also are prevalent. The Aravind Eye Care System addresses this problem by offering affordable eye care to low-income patients. Nearly 70% of its patients live in rural South India, where there is an acute shortage of ophthalmologists. Two-thirds of Aravind’s services are provided free of charge. Aravind always knew that it would have to expand beyond its five hospitals to reach the rural poor. Until recently, villagers had to walk as much as 12 miles and forego a day’s wages to visit an Aravind hospital. As a result, many people who needed treatment didn’t receive it. Aravind experimented with a few models of eye care delivery including mobile vans, to determine which would best serve the many rural residents who needed access to eye care. First Aravind launched mobile clinics, sending vans to rural areas. But the clinics were cumbersome to plan, requiring Aravind to find local sponsors to host them. In addition, the vans could only visit a given area infrequently, and without a permanent presence, it was hard to promote eye-care education, which is one key to the prevention of cataracts. Aravind also experimented with two permanent clinics in Theni, installing technology to enable remote consultations with doctors in Aravind hospitals. But the technology had limited bandwidth and thus poor video quality. It also was expensive, and involved recurring costs to maintain the network. And even if the clinic concept were viable, it would be difficult to scale. Before Aravind could establish clinics in other areas of rural South India, it had to wait for third-party network carriers to provide coverage to those areas. Rural areas of Southern India were sparsely populated and low priority for network carriers and service providers. It could take years before they provided adequate coverage. Reaching Rural Residents To address these challenges, Aravind developed the concept of rural vision centers—primary eye clinics in rural areas, where patients can be remotely diagnosed by doctors via high-speed wireless - 18 - IT in Hospitals videoconferencing; get prescription glasses, eye drops and blood tests; be referred to an Aravind hospital if surgery is needed; and receive post-operative care. Intel and UC Berkeley researchers are collaborating to build an experimental research proof of concept long distance, high-bandwidth, point to point Wi-Fi network to connect the vision centers to Aravind hospitals. That will enable rural residents to have video consultations with doctors, eliminating the need for patients to travel to the hospital for routine eye care. The collaboration is part of the UC Berkeley TIER (Technology and Infrastructure for Emerging Regions) project, which is tackling the challenge of bringing the information technology revolution to the developing regions of the world. TIER is led by Eric Brewer, the Director of the Intel Research Berkeley lab. Sonesh Surana, a Ph.D. student and intern at the lab, is managing the field effort for the Aravind collaboration, focusing on the design of the system and most of the deployment, training, and sustainability aspects of the project. UC Berkeley is funding the initial deployments of vision centers, through a grant from the National Science Foundation. Intel is contributing equipment and funding for the researchers, as well as project management by Brewer and Surana Establishing the Vision Centers To connect the vision centers to Aravind hospitals, Intel and UC Berkeley researchers designed a point-topoint long-distance wireless infrastructure that combines a variation on IEEE 802.11 (Wi-Fi) technology with off-the-shelf videoconferencing software and tools that hospitals can use to maintain the network. A key technical challenge the researchers faced was how to make Wi-Fi work over the roughly 10 miles between each vision center and the nearest hospital. The 802.11 networking standard, more commonly known as “Wi-Fi”, is defined by a set of international standards that limit its range to about 200 feet. Customizing the networking hardware (mainly inexpensive Wi-Fi cards) to achieve longer distances would be costly. So the researchers redesigned the software, modifying the Wi-Fi Media Access Control (MAC) protocol, which is designed for short-range communication. Specifically, they disabled some MAC features that weren’t needed and implemented others that were, by creating a thin layer on top of the MAC. By combining their modified Wi-Fi software with directional antennas and routers to send, receive and relay signals, the research team so far has been able to obtain network speeds of up to six megabytes per second (Mbps) at distances up to 40 miles (validated at another project in Ghana). These speeds are about 10 times faster than dial-up speeds and carry 100 times as far as standard Wi-Fi technology. - 19 - IT in Hospitals In this satellite map graphic of the Aravind network, green lines indicate links from the central hospital to rural vision centers in five rural towns. All distances are in kilometers. (Graphic by Sonesh Surana) Results to Date The prototype networking infrastructure was tested and validated at the first three vision centers deployed, at Bodinayakannur, Ambasamudram, and Chinnamanoor. At Bodinayakannur and Ambasamudram, the researchers replaced existing low bandwidth (33Kbps) wireless links with the new high-speed links. “We improved the quality of video-conferencing by roughly eight times,” says Surana. “And even with that improvement, the network is underutilized; there’s more bandwidth available.” At Chinnamanoor, the new high-speed link enabled videoconferencing capability where it didn’t exist before. “Previously we had no other option for network connectivity in Chinnamanoor, and so we were not able to start a vision center there, despite high demand for eye care services,” says Dr. S. Aravind, Administrator of Aravind Eye Hospitals. Intel and UC Berkeley researchers installed the links at two of the clinics, but the Chinamanoor link was largely installed by local technologists. “The TIER team has trained our local providers as well as our hospital network administrators in order to ensure continuity,” says Aravind. Based on our training, we were able to install the Chinnamanoor network ourselves, with very little help from the TIER group.” In May 2006, local technologists installed two new links, at Periakulum and Aundipatti, with no help from the TIER researchers. The goal is to have all future installations done locally. “So many times people have come in to an area to do a project and then, when they leave, everything falls apart," Surana said. "It's been a very important part of our research to make this a project that people can build on and manage all on their own." Early results are encouraging. The first three vision centers established—at Bodinayakannur, Ambasamudram, and Chinnamanoor—screen about 1,500 patients each month. (Numbers are not yet available for the two other centers, which came online in May 2006.) Roughly 5-10% of patients—already nearly 100 people a month—experience significant vision improvement as a result of treatment, usually via cataract surgery. - 20 - IT in Hospitals On opening day of the Periakulum rural vision center, a nurse and a doctor from Aravind Eye Hospital examine a patient. Normally, the center is staffed by a single nurse who uses a computer network designed by researchers at UC Berkeley to teleconference with an eye specialist at a hospital 10 miles away. (Sonesh Surana photos)The Bodinayakannur and Ambasamudram deployments also validated that the vision centers can break even—a prerequisite for sustainability. Both clinics are projected to reach the breakeven point in less than three years, largely because the new networking infrastructure requires no annual subscription fees or ongoing maintenance costs. Potential Impact The pilot project has proven so successful that the research effort will be expanded over the next two years to include five hospitals that will be linked to 50 clinics. These additional vision centers will be able to service half a million patients in rural South India—most of whom have no access to eye care today. These vision centers will positively impact the health of the Indian economy. A recent study by the Aravind Eye Care System showed that 85% of the men and 58% of the women who had lost their jobs due to sight impairment were reintegrated into the workforce following treatment. “This makes the role of the vision centers even more crucial,” says Aravind. The presence of rural vision centers that provide video access to doctors will encourage people to seek early treatment for vision problems—a pattern that’s already emerging at the three initial centers. That could decrease the average time to first diagnosis and reduce the higher costs related to treating late-stage illnesses. In addition, low-cost network connectivity could enable each clinic to be monitored for key indicators, such as prevailing diseases and treatment results, which could aid in prevention efforts. The clinics’ networking infrastructure could be used to in other ways as well—for instance, to deliver other kinds of medical services, to stream training videos to the vision center staff, or even to generate income by offering movies or other services to villages at times when the center is closed. "Self-sustainability is a crucial aspect of the Aravind model, so we are greatly encouraged by all the indications that show these vision centers will break even sooner than we had anticipated. Based on our experience with the three initial centers, and the success of the cost-effective technology implemented by the TIER researchers, we are planning to penetrate new areas by scaling up to 50 vision centers in South India that will cover a population of 2.5 million. “This is an exciting venture, and we believe it has the potential to effectively address the problem of eye care access in rural India. TIER’s partnership has been invaluable in enabling this approach to get off the ground with such speed and success." Dr. S. Aravind Administrator, Aravind Eye Hospitals - 21 - IT in Hospitals For now, the focus is on India, but the experimental wireless networking infrastructure developed by Intel and UC Berkeley researchers could make it possible to deliver eye care services in other rural areas in the developing world. “Wherever there’s a demand for eye care or other medical services, you can easily and inexpensively install one of our networks,” says Brewer. “This could revolutionize the delivery of health care services and greatly improve the quality of life in the rural developing world.” Drawbacks of implementation of IT in healthcare The great technological divide ,Whereas some hospitals and medical schools are introducing telemedicine networks and computer assisted learning, health clinics elsewhere do not even have the facilities to carry out a caesarean section. An infant girl, barely 72 hours old after a premature birth and still struggling for life in a Mumbai hospital, needed Rh negative blood. The hospital had exhausted its stock, and the parents had failed to find a suitable donor. Someone suggested a blood bank in an eastern suburb of the city. There, a technician searched a database of nearly 2000 potential blood donors. In an hour, three donors had turned up at the hospital.The database of blood donors in Mumbai is a vivid illustration of how information technology—computers and communication—is transforming healthcare delivery in South Asia. Telemedicine networks have sprung up to deliver health care to remote locations, and patients now have the option of consulting some doctors online. For the medical community, the introduction of information technology has meant easier and faster access to peer reviewed journals, new avenues for continuing medical education, and, as one doctor in New Delhi put it, "better informed patients who might come up with surprising demands." But health watchdog groups say the impact of information technology on health care in the South Asian region is uneven. "Information technology initiatives are largely concentrated in the private, corporate health sector. And they are sometimes driven by the information technology industry." Industry officials say the healthcare informatics market in India is worth $60m (£33m; 50m), and is growing at 25% a year. Hospitals as well as doctors are investing in computers, networks, and software. "The impact is beginning to show now," says Dr Dilip Panikar, a neurosurgeon at the Amrita Institute of Medical Sciences in the southern state of Kerala, and coordinator of its telemedicine programme. "The young generation of doctors, particularly those who've graduated since the early 1990s, have adapted well to this technology," Dr Panikar said. Consultant endocrinologist Ambrish Mithal in New Delhi has his own website and sometimes answers medical queries from patients across India—and at least once from Bangladesh and Nepal. "Patients with chronic conditions seem to do significant reading on the net and surprise us with demands for treatment," Dr Mithal said. A three year old website designed for the public, doctorndtv.com, gets 65 to 100 questions a day, each answered by a panel of doctors, says Dr Samiran Nundy, a senior gastrointestinal surgeon in New Delhi who is the website's editor in chief. The website of endocrinologist Ambrish Mithal, who is based in New Delhi, fields questions from as far afield as Bangladesh and Nepal "It's widely accepted now that connectivity will help promote evidence based medicine," says Dr Chandrika Wijeyaratne, secretary of the Sri Lanka Medical Association. Sri Lanka has identified health as an area where information technology should be used to boost efficiency and service quality. At least three of the island nation's seven state funded medical schools have introduced computer assisted learning. In Nepal too, doctors are now accessing peer reviewed journals online. "In the old - 22 - IT in Hospitals days, we used to get print versions of just three journals on dermatology," says Dr Anil Jha, head of dermatology at the Tribhuvan University Teaching Hospital in Kathmandu, Nepal. Now, he says, doctors can get the feeling that they are keeping abreast of the latest in their fields. In India, the government and the private sector have both invested in telemedicine projects. India's space department has made available a domestic satellite for telemedicine, and India's largest corporate hospital group, Apollo, has connected its hub hospitals in Chennai, Hyderabad, and New Delhi to more than 45 telemedicine centres across India. Apollo officials estimate that several thousand patients have benefited from telemedicine over the past two years. The Amrita Institute has also set up telemedicine links with 20 clinics, some in remote locations, including the northern mountain region of Ladakh. Doctors at the Amrita Institute cite an example of some emergency surgery on a pilgrim who was trekking through a dense forest, which was conducted by doctors at a telemedicine centre located on the pilgrimage route. "The network gets used for patient consultation and treatment as well as for continuing medical education," said Dr Panikar, telemedicine coordinator at the Amrita Institute. However, one doctor involved in telemedicine projects says that, although the networks are in place, doctors as well as patients are yet to make full use of such wired clinics. Just as the internet has helped doctors in South Asia to get access to western medical journals, information technology is also helping the flow of medical expertise from South Asia to the West. Last September, Dr Ashok Seth, chief of interventional cardiology at the Escorts Heart Institute and Research Centre, New Delhi, was invited to demonstrate angioplasty procedures live via a satellite link to an annual meeting of heart surgeons in Washington, DC. "We see a relatively large number of patients in India with coronary artery disease marked by diffuse or multiple blockages, or vein graft disease, any of which can make the procedure complicated," said Dr Seth. Escorts dubbed the live demonstration an example of "the East teaching the West." After a similar transmission to a cardiology conference in Italy a few months ago, the hospital now plans to install a permanent camera and equipment in the angioplasty room for periodic telecast to surgeons or even medical students in India. "It's an investment to raise the quality of patient care," said Dr Seth. But the investments in information technology to boost healthcare services may be bypassing many patients. "We've nothing against information technology, but it can never be a substitute for basic infrastructure, equipment, or doctors," says Dr Sundararaman. In Chattisgarh, for example, he says, fewer than 10 of the 146 community health centres, each of which is intended to cater to a population of 100 000, have the facilities or the surgical staff to do a caesarean section. - 23 - IT in Hospitals APOLLO HOSPITAL - 24 - IT in Hospitals APOLLO GROUP The Apollo Hospitals Group today is not only an acknowledged leader in the world of super-speciality based quality healthcare delivery in Asia, but is also considered as the largest integrated healthcare delivery company, complete in every sense of the term. Apollo Group is India's leading healthcare services company. It is also India's largest and oldest corporate healthcare provider with 2000 owned and 2100 managed hospital beds. It is among the few completely integrated healthcare providers in the world-services range from owning and operating hospitals, clinics, pharmacies, hospital project management, healthcare education (nursing, hospital administration, physiotherapy, etc), healthcare technology initiatives and others. With competition and consumers expecting personalized services, it is imperative for healthcare providers like Apollo to evaluate consumers - focused technology carefully, remembering the need to balance high touch and high tech. One needs to adopt the principles of one-to-one relationship management into their initiatives and recognize the critical nature of patient identification and personalization. CRM for healthcare could use a combination of electronic, direct mail and call center channels including Internet technology for responding to identified needs gathered through interactive health risk assessments and other database sources. Patients and prospects may receive a personalized letter, direct mail brochure or matrix mailing program with feedback and tracking mechanisms. A CRM programme for healthcare requires a specially selected set of information that will support analysis, opportunity identification, data mining and communications management. This unique set of information is stored in a database that makes sense. The knowledge required for CRM for healthcare is very different from all other industries. It is technical and filled with complex patient, payer and provider information including procedural and diagnostic acronyms such as MDC, ICD-9, CPT-4, and DRG. Highly specialized knowledge, extensive healthcare industry background and understanding are necessary. In addition, the applications required to support the marketing functions are highly specialized. Apollolife has already developed products like I-My PatientTM (Doctor's front of the tool), I-My Doctor TM (patient's end of the tool) - components of electronic Customer Relationship Management (eCRM) tool which enables interaction between the patient, doctor and the hospital, for an extended period of time, for non-urgent but important medical needs of the patient. The tools offer online appointments service to the patients, creates a community of individuals who share a common healthcare issue for sharing information, experiences, etc and allows the relatives / friends of the patient to view the progress of the patient. This is often used in patients with chronic disease (Asthma, Diabetes, Hyper Tension) that need frequent DoctorPatient-Hospital interaction and this tool helps enrich this interaction. Acreditions and Awards Indraprastha Apollo Hospitals, New Delhi • • • • • Joint Commission International (JCI) USA accreditation the first and only Indian hospital to receive this gold-standard certification Grade A by CRISIL Rated Best Multi-speciality Hospital in Delhi by The Week magazine BS EN ISO 14001: 1996 for Environmental Management System BS EN ISO 9001: 2000 for Quality Management System Apollo Hospitals, Chennai - 25 - IT in Hospitals • First Indian hospital to be awarded ISO 9002 and ISO 14001 Certifications. Apollo Hospitals, Hyderabad • First JCI Disease- or Condition-Specific Care (DCSC) Certification awarded to the Apollo Hospital, Hyderabad Acute Stroke Program Other Achievements: • • • • • first to establish health insurance company first group to introduce preventive health care first to perform liver, multi-organ, cord blood transplants first to introduce new techniques of coronary angioplasty first to perform sterio-tactic radiotherapy and Radio-surgery (for brain tumors) in the country Part of Apollo Hospital group’s • Apollo Hospitals Enterprise Limited. • Apollo AHEL pharmacies Street Limited. • Apollo Health & Lifestyle Limited • Apollo Health Street Limited. • Medvarsity Online Limited • Apollo Telemedicine Enterprises Limited. • Apollo Hospitals Education and Research Foundation. • Family Health Plan Limited. Apollo Hospitals Enterprises Limited (AHEL) is recognized as the doyen “Architect of Health Care” in India. Its history of accomplishment with its unique abilities of resource management and compassionate deployment of technology and knowledge to the service of mankind justifies its recognition within Health Care Industry both in India and abroad Over two decades ago, our chairman Padma Bhushan Dr. Prathap C. Reddy, then practicing in the US envisioned “bringing healthcare of international standards within the reach of every individual in India.” He visualized a scenario in which healthcare delivery systems in India would be revolutionized and new standards in patient-care would be set. His vision took shape in 1983 with the launch of India’s first corporate hospital at Chennai. Apollo Hospitals, Chennai was an instant success and propelled Apollo groups to set healthcare paradigms all over the Indian sub-continent. Today AHEL has emerged as the single largest private hospital group in Asia and is the undisputed leader in the delivery of health care of International standards within the Asian Subcontinent. It commands the leadership by providing health care to several nations in the Asian Subcontinent through 26 hospitals, 3800 hospital beds beds expanding to 47 hospitals and over 7000 hospital beds by the year 2003. It has the largest and most sophisticated sleep laboratory in the World. It has pioneered orthopedic procedures like total hip replacement and Illizarove procedure. When necessary, it has performed difficult procedures to serve the customer. It has successfully performed pacemaker implantation in a 97-year-old patient and has perormed cardiac surgery in a 4-day-old baby. - 26 - IT in Hospitals In the delivery of Tertiary Care, AHEL stands in the subcontinent as a class of its own. Its specialists have performed 200,000 major surgeries including cardio-thoracic, neurological, cancer, gastro-intestinal orthopedic, renal, obstetrical, ENT, ophthalmological, dental, laser, plastic, cosmetic, minimally invasive, and microvascular procedures with success rate par with international standards. It has performed over 30,000 cardiac surgeries with a 98.5% success rate. It owns a 20 bed high efficiency 20 bed Bone Marrow transplant unit, largest of its kind in Asia. It has successfully performed over 100 bone marrow transplants with a success rate of 80%. AHEL takes pride in having done over 3000 renal transplants with 95% success rate. Its cardiac laboratories have successfully performed over 1,00,000 angiograms, 9000 angioplasties, 3500 mitral balloon vavuloplasties, and 2500 coronary stents Group activities The Apollo Group's plans for the future include a hospital at Narhenpita in Srilanka, a hospital in Ahmedabad, Muscat and Katmandu. Apollo Hospitals Group has a network of hospitals spread across the country. The group has a "project consulting team" that is often called the nucleus of Apollo hospitals and is India's only hospital management consulting firm. The project consultancy division, besides commissioning of projects also provides management solutions for the hospitals. After the first tertiary care hospital at Chennai, the group expanded its activities by setting up a superspeciality center at Hyderabad, 650-bed multi-speciality hospital at Delhi, a super speciality center at Madurai, a heart and kidney center at Vishakapatnam and a secondary care center at Aragonda in Chittoor district. The Indraprastha Apollo Hospitals at Delhi is a jewel in Apollo's crown. It is the largest corporate hospital outside the United States. The group has a Heartscan Center at Dubai. Exclusive Cancer care hospitals have been set up at Chennai and Hyderabad. The group manages hospitals at Pune, Coimbatore and Erode and has lifestyle clinics at Chennai, Hyderabad, Delhi and Mumbai. A complete health industry Today, Apollo Group of Hospitals is a complete health industry in itself with group companies such as Indian Hospitals Corporation Ltd. (Hospital consultancy and management division), Citadel Ltd. (Software Development Company), Family Health Plan (Health Insurance organisation), MedNet (IT connectivity program especially for general practitioners in the country), Global Informed (A company involved in health content creation) and Apollo Educational & Research Foundation (Health and Clinical Research), Apollolife.com (Apollo Health Street Ltd) and now medvarsity.com (Medvarsity Online Limited). Its strategy\mission Hospitals: Chennai, Hyderabad, Delhi, Ahmedabad, Chennai, Pune, Chenganur, Coimbatore, Jaipur, Madurai, Anantpur, Nellore, Kurnool, Bhopal, Ranchi, Bilaspur and Bacheli. AHEL’s strategy has always been: “To share our knowledge and expertise in managing existing and evolving health care institutions in tune with international standards." In order to accomplish the mission, Apollo has a wide network of hospitals and clinics not only across the country but also across the sub-continent. - 27 - IT in Hospitals Clinics: Mumbai, Pune, Nagpur and Chennai. Worldwide: Muscat, Dubai, India, Nepal, Sri Lanka and Dhaka. New initiatives Apollo Health Street Limited Apollo Health Street Limited (AHSL) provides technology solutions to healthcare industry. AHSL, was incorporated in 1999, and is a subsidiary of Apollo Hospitals Enterprise Limited (AHEL). Vision AHSL evolved from Dr. Prathap C. Reddy's vision of "Bringing healthcare of international standards within the reach of every individual". AHSL seeks to work towards this vision by using the power of Information Technology to integrate various stakeholders. Objective AHSL has identified the following objectives for serving the healthcare industry globally: Leverage India's world class facilities to provide low cost solutions to the global health care industry Provide end-to-end technology solutions to various stakeholders in healthcare industry in India and abroad. Cater to the information needs of multiple user groups: individuals, patients, doctors, clinics, hospitals, corporate firms, pharmaceutical companies, insurance companies, students, etc. Bring interactivity between the user groups and crate communities of care (e.g., Patients with similar conditions/interests, doctors, sharing cases/ research, etc. Network the Indian Health Care Delivery System Set Standards of Information Exchange (drive technology standards) Expertise Exceptional talent pool across domain, technology and management Backed by over two decades of healthcare domain expertise and leadership Prevailing culture of pioneering and imbibing emerging technologies such as telemedicine, medical elearning, clinical research etc. Strong consumer focused approach Strong partnerships with existing leaders to deliver the maximum value to customers In order to bring health care in India, to world-class standards Apollo Hospitals has taken many initiatives, by integrating Information Technology, Internet–based technology, and Telecommunications with Home health care and retailing. • • • Apollo Telemedicine KeiMed.com Apollo Life.com – Comprehensive Health Portal - 28 - IT in Hospitals • • • Family Health Plan – Health Insurance Provider Network Gateway & Administrator (T.P.A) Medvarsity.com Apollo Health and Lifestyle Limited. Apollo Telemedicine Apollo Telemedicine Enterprise Limited (ATEL) was incorporated in the year 1999, with the object of developing the 'Apollo Telemedicine Network.' The Apollo Telemedicine Network would provide the participant sites to collaborate with institutions in the country and abroad and provide their clientele access to second opinion consultation from the best experts. The Apollo Telemedicine Services will also deliver continuing medical education to keep the care providers in touch with advances in the field of medicine. It will bring the Apollo Group services with in the reach of population in Rural Areas and provide access to better Healthcare in areas not adequately served by the medical community. Kei Med.com The KEI Med. Com Limited was incorporated in the year 1999, with the main object of creating a Unified National Pharmaceutical Supply Chain with a wide range of medical goods/consumables/ drugs/ surgicals/healthcare and personal care products. The Company will be engaged in E-Commerce by using Information technology to enable supply chain management with complete logistic solutions to the customer. Apollo Health Street In their endeavor to reach out to more and more people and help them along from illness to wellness, using the power of today’s technology together with the experience and the expertise of the doctors that Apollo possesses, ApolloLife.com was born – created by Apollo Health Street Private Limited and launched by Dr. K. R.Narayanan, the President of India, on 14th August, 2000. Its objective is to create a healthcare portal that would meet the commerce and connectivity-needs of the entire healthcare industry. Another venture of Apollo Health Street is Medvarsity that is backed by two giants in their respective fields of medicine, Apollo Hospitals Enterprise in the Healthcare and NIIT in the field of IT. Medvarsity proposes to target medical students, who have a major constraint, they have too much to learn with too little a time. It will act as a catalyst for the knowledge seekers and would be complimentary to the existing education system in the country. It will cater to Undergraduate students of medical and alternate systems of medicine, Postgraduates, Specialists, Medical teachers, Practitioners and Paramedics. Medvarisity will strengthen the existing infrastructure in medical colleges by providing technical support to the faculty to enhance the quality of medical education delivered. It will constantly update its teaching aids and research on modalities of delivering medical education through IT. In short, it would be a platform to integrate all the medical colleges and create a healthy atmosphere for interactions between the faculty and the students. Family Health Plan The concept of Family Health Plan was developed in response to this overwhelming need for a costeffective healthcare option at all times. FHP is a company that has been in the healthcare insurance for over a decade. FHP has initiated their concept of ‘managed care’ in the country, to control spiraling medical costs, and to make facilities accessible. Unlike conventional health schemes, FHP reaches out to subscribers - 29 - IT in Hospitals and manages their healthcare needs proactively. Helping them to focus on staying healthy, rather than wait for an eventuality to rush for medical aid. Apollo Health and Lifestyle Limited AHLL, a subsidiary of Apollo Hospitals Enterprise Ltd., one of the group’s most ambitious initiatives, was incorporated on November 10th 2000, in order to deliver quality primary health care through the Apollo Clinics across India and neighboring countries. It plans to establish a nationwide chain of more than 250 primary healthcare centers on a franchisee basis. These clinics would be equipped to provide a one-step solution to the primary health care needs of the family as a whole and would provide consultation, diagnostic and pharmacy services. Unique Home Healthcare Unique Home health care provides a variety of services to enable an individual with medical and related need to continue continue living at home. These services include skilled care provided by licensed professionals such as registered nurses and therapists and supportive such as assistance with personal care and chore services. Home healthcare has been gaining increasing acceptance since it started especially in the geriatric age group. Conclusion With such rich history, intellectual property, fiscal management capabilities and unparalleled innovative expertise in the delivery of health AHEL has the largest Hospitals Projects and Consultancy Division in India. It has unmatchable expertise in designing, establishing and medical facilities from conception to operation. AHEL has commissioned over 25 hospital projects and more than 20 projects are under different stages of implementation. We dedicate ourselves to bringing health care of international standards within the reach of every individual. We design and deliver health care. We are the Architect of health care. Come and participate with us in the noble mission of better health for all. Its success lies in its constant endeavor to upgrade and set new standards in healthcare while optimizing on the available resources. Through growth and change, Apollo remains committed to its motto: medical excellence with human touch. - 30 - IT in Hospitals TELEMEDICINE - 31 - IT in Hospitals What is Telemedicine? Telemedicine can be defined as a group of activities which include investigation, monitoring and management of patient data as well as the education of patients and staff by means of systems which allow quick access to expert advice and patient information, no matter where the patient and the relevant information is located (definition by the European Union Committee). It offers several new avenues for bridging the gap between patients and advanced medical facilities. It is more important in developing countries since it allows extension of medical facilities to people residing in remote and rural areas where advanced medical facilities may not be available. On the other hand advanced countries look up to telemedicine as one approach that will radically improve the quality of healthcare decision making,reducing errors and waste. Telemedicine is the applied use of Information and Communication Technologi (ICT) in medicine, health and social care delivery.ICT has been used to improve th.e efficiency and the effectiveness of existing services. For example, pathology, radiology, education and training. ICT has also been used to initiate the delivery and development of new services such as teledermatology and teleophthalmology. For our purposes, we define our area of interest as those applications that: • use information and communication technology … • … to deliver health and/or social care in new ways … • … on a person to person basis … • … where those people are physically apart. Need for Telemedicine  “Emergency Medical Care is designed to overcome the factors most commonly implicated in preventable mortality, such as delays in seeking care, access to health facility and provision of adequate care at the facility.” Telemedicine ensures delivery of o right medical advice o at the right place o at the right time o o o non availability of facilities locally non availability of appropriate skills / technology locally less Travel Need for Telemedicine in India Following Factors indicate why TM is important in India • • Huge population (above 1 billion) with inequitable distribution of resources 70% of India’s population lives in rural areas whereas 75% of qualified consultants practice in urban centers Vast land area with difficult / inaccessible terrain • - 32 - IT in Hospitals • Seasonal isolation of some tracts of land e.g. due to floods, snow, etc AIIMS : IN-PATIENTS (2004-05) From Delhi (60%) From Outside (40%) Advantages of TM o o o o o Makes expertise available - anywhere Early institution of appropriate treatment Less need for transfers Effective utilization of transports Saves costs to patient , provider, system Applications of Telemedicine: Telemedicine is useful for all faculties of medicine. · Teleradiology – reading still and full motion radiographic images. · Telepathology – analysis of tissue histology samples. E-transmission of Surgical Pathology slides for Frozen sections. · Telementoring – guiding surgical and other clinical procedures from a remote location. · Telemedicine – actual physical examination, ECG etc. · Psychiatry – live interaction with patients - 33 - IT in Hospitals · Home Health care – elderly and debilitate patients. · Emergencies. Objectives of TM • • Enable the medical experts to take control of a remote medical emergency when required The telemedicine system and sub-system especially at the remote location should be designed for use by non-medical but trained personnel. The remote telemedicine system should be designed for easy portability The telemedicine solution should be cost effective requiring minimal training, installation and maintenance The telemedicine equipment used should use a optimum bandwidth for data communication • • • Legal aspects of Telemedicine: With the increasing use of Telemedicine legal and ethical issues have come to the Forefront. Specific ethical problems likely to come up in the practice of telemedicine include, lack of doctor patient contact leading to erroneous decisions because of inadequate data and lack of the comforting role of the physician’s presence. Confidentiality and privacy of patient data and use of data for research without informed consent is another problem. The question of ‘what if something were to happen’ needs to be addressed. If a doctor residing in India is giving opinion for patients residing in some other country, whose laws and which country’s judiciary would decide this situation? The problems of misdiagnosis, liability and malpractice are uppermost in the minds of policy makers in the field of telemedicine. Despite these issues telemedicine and telehealth have the potential to transform the world of healthcare. Telemedicine Consultation Case Study A live case handled by Dr. Alok Ranjan (Consultant Neurosurgeon, ApolloHospitals- Hyderabad): A patient named Shanker Chandra was undergoing treatment in Calcutta under Dr. Tamal Bhattacharya at the consultation center in Calcutta. In the course of the treatment a specialist’s opinion was required and Dr.Tamal Bhattacharya referred the case to Dr. Alok Ranjan at the specialty center in Hyderabad. Calcutta is a full-fledged telemedicine consultation center and is connected to Hyderabad Apollo Hospital. The patient’s records were sent in advance and the appointment was fixed according to Dr. Alok Ranjan’s schedule. Before the consultation begins both the centers have to enter each other’s IP (internet protocol)address for a web camera meeting in the absence of a polycam. The meeting took place for ten minutes in the course of which Dr. Alok advised the patient on his future treatment plan. This web consultation has saved Shanker Chandra quite a few expenses he would have incurred if he had to travel to Hyderabad to consult Dr. Alok Ranjan. Web consultation has its own problems like connectivity delay, image and voice distortion. Dr. Alok Ranjan Consultant Neurosurgeon, Apollo Hospitals- Hyderabad feels that Information Technology will radically change the working of medical science. Telemedicine has revolutionized medical - 34 - IT in Hospitals consultation by cutting down the distance between the rural patient and urban specialist. Dr. Ranjan feels that the direct benefits of telemedicine for patients are convenience, better care, cost effective care, state of art care and best possible care. Dr. Alok Ranjan feels the number of cases will increase from two per week now to close to twenty, which will make their task more challenging. Wider acceptance of the telemedicine concept will increase the number of referrals for a doctor and his compensation will commensurate accordingly. Doctors on the telemedicine panel should be tele-savvy, should be able to understand and answer the patient’s problem precisely and fast because of connectivity constraints. The Dr. believes that presently telemedicine in India is only for second opinion and is not a means of performing surgeries, due to lack of infrastructure. He feels thatApollo being one of the first corporate hospitals to use telemedicine, have large Growth prospects in terms of technologically backed quality treatment and in creating a niche segment in telemedicine care. In India confidential information cannot be transferred using the existing network as it is prone to web hacking etc. To overcome this problem, Hippa a European standard for data protection can be implemented to transfer confidential information between two different hospitals. Apollo has not adopted this standard for its current project but is considering it for its future telemedicine projects. Conclusion: Telemedicine has revolutionized the delivery of health care services throughout the world. And it is on the verge of becoming as common as the use of the telephone. It is not merely a privilege for those who selectively opt for it, but a light of hope for those who drastically need it. The vision that within the next ten years e-care will be a standard part of everyday health care practice, is a very practical vision. Are we getting geared up for it? - 35 - IT in Hospitals TECHNICAL DETAILS OF IT APPLICATIONS - 36 - IT in Hospitals : CT SCAN –Computerized tomography Before entering the CT scanner, a technologist will position you comfortably on the examination table. WHAT IS A CT SCAN? It's a special kind of x-ray that can produce pictures of a cross section of a part of the body. The word CT stands for Computerized Tomography. Tomography comes from the Greek word tomos which means slice or section, and graphia meaning recording. One analogy is, the patient is a loaf of bread and each slice is a picture. CT scans are able to detect many conditions that regular x-rays cannot. They can often replace exploratory surgery and other diagnostic procedures. This can save the patient discomfort and inconvenience. CT scans are also useful for monitoring a patient's progress during and after treatment. CT's can distinguish bone, tissue, fat, gas, fluid etc. They can determine if a growth is solid or fluid-filled, and if an organ's size and shape are normal. HOW DO THEY WORK? A x-ray tube focuses a narrow beam of x-rays across the body. The x-ray energy is absorbed differently by different body structures. Receptors detect the number of x-rays remaining after the x-rays have passed through the body. This information is relayed to a computer and stored there. The x-ray tube rotates around the body, scanning it. Thousands of readings are taken by the receptors and recorded in the computer. The computer analyzes the receptors readings at thousands of different points and this information is converted into an image on a video screen. - 37 - IT in Hospitals RISKS VS BENEFITS As with any x-ray procedure, radiation is a risk. However, CT scans are designed to obtain the most information with the least possible radiation exposure. CT scan images may give more detailed results than other diagnostic techniques. CT scans can often detect the smallest abnormalities, allowing treatment to begin early, when chances for cure are greater. PREPARING FOR THE CT SCAN You should wear comfortable, loose fitting clothing. You will want to be comfortable while you wait and during the test. Since schedules are tight, unexpected delays may happen, so bring something to do while you wait. You will be asked to remove glasses, earrings, jewelry, hairpins and any removable metal in your mouth for head and neck scans. Depending on the type of scan you are having, you may be asked to change into a gown or scrub pants for your procedure. You should not eat or drink anything for 4 hours prior to your appointment time as intravenous contrast may be used. You may be requested to have a lab test performed prior to your appointment to check to see how your kidneys are functioning especially if you are diabetic. For CT scans of the abdomen and pelvis, you will be asked to drink 1 quart of sugar free Crystal-Lite / contrast to "highlight" your intestines on your scan. The time between when you finish your drink and when you are scanned depends on your symptoms. On average, the wait time is 30 minutes before you are scanned. You may also be asked to drink more as you are being positioned on the table. Intravenous contrast "highlights" the vasculature in the area that is scanned making certain abnormalities easier to see. If you have had a previous reaction to intravenous contrast (X-ray dye), call and speak with our representative about your reaction prior to coming in. Depending on the reaction, we can call your doctor and have you "pre-medicated" 24 hours prior to your appointment with an antihistamine and steroid. Breastfeeding mothers will need to pump and discard your breast milk for 24 hours after having IV contrast, as this could be passed through your breast milk. Definition of the different scans Head/Brain Images of the brain Sinus Images of the sinuses in your head (this is acquired while lying on your stomach with your head up) Ears Eyes Neck Images of the auditory canals (this is acquired in 2 different positions) Images of the orbital area. Images of the soft tissues of your neck ( not spine) - 38 - IT in Hospitals Chest/Thorax Abdomen Pelvis Images of the chest (top of shoulders through diaphragm) Diaphragm down to top of hips (iliac crest) Top of hips (iliac crest) down through genital area (symphysis) Spine Depends on the area that your doctor wants examined. MRI of the Spine is used for disc disease as long as you do not have a Pacemaker. AFTER THE SCAN A radiologist will provide your doctor with an interpretation of the CT scan images. Your doctor can then make a diagnosis and explain the findings to you in terms of your health and treatment. Your body will excrete the IV contrast through your urine. This will not discolor your urine or cause you pain. This will be gone in 24 hours, so it is important to drink plenty of fluids to help your body get rid of the contrast. MRI : Magnetic resonance imaging (MRI scan) is a diagnostic test that uses electromagnetic radio waves (i.e., electrical current and magnetism) to produce two- or three-dimensional (2-D or 3-D) computer images of internal body structures such as organs, muscles, bones, and nerves. Magnetic resonance imaging can be performed on any part of the body and, unlike other imaging procedures (e.g., CT scan, x-ray), does not involve radiation. Compared to CT scan, MRI produces more detailed images of soft tissue and organs, differentiates between similar tissues more effectively, and produces less detailed images of bone. MRI scans can be used to accurately detect and locate tumors and to determine if a tumor has spread. MRI scan is often used to examine the following: • • • • • • Abdomen (e.g., liver, kidneys, spleen) Chest (e.g., heart, lungs, major blood vessels) Joints (e.g., shoulders, hips, knees) Nervous system (e.g., brain, spinal cord, nerves) Pelvis (e.g., reproductive organs) Spinal column - 39 - IT in Hospitals Patients who have any type of implant should notify the radiologist prior to the procedure, because certain types of metal implants (e.g., inner ear [cochlear] implants, brain aneurysm clips, some artificial heart valves, pacemakers, older vascular stents) are not compatible with MRI. Women who have a contraceptive intrauterine device (IUD) also should notify the radiologist, because some of these devices contain copper wire. Patients who work with metal (e.g., welders) should have x-rays taken before undergoing an MRI scan to make sure there are no metal fragments in the body. All metal (e.g., jewelry, watches) must be removed before the procedure. The image and resolution produced by MRI is very detailed and the test can be used to detect small structural changes in the body. In some cases, a contrast agent (e.g., the element gadolinium) is injected intravenously (i.e., through a vein) prior to MRI scan to increase the accuracy of the images. During an MRI scan, the patient must remain as still as possible. Sometimes a sedative is administered to help the patient relax during the procedure. If a sedative is used, the patient will be unable to drive home following the procedure and should have a friend or family member with him or her. MRI usually takes between 1 and 2 hours to perform. The MRI scanner consists of a cylinder surrounded by a magnet, a receiver, and a computer. During the procedure, the patient is placed on a moveable bed, which is inserted into the cylinder. The MRI scanner creates a strong magnetic field, exposing hydrogen atoms in water molecules in the body to radio waves and causing them to move into different positions. The way these hydrogen atoms move and then move back into their original position once the scanner is turned off provides information about tissue density in the area of the area of the body that has been scanned. A computer processes information about how the molecules move and creates a detailed image of internal body structures. Tissue that contains less water (i.e., hydrogen atoms), such as bone, appears darker and tissue that contains more water appears lighter. MRI scan of the head can be used to evaluate patients with headaches, seizures, muscle weakness, blurred vision, and hearing loss. The test can also be used to evaluate bleeding and swelling in the brain and to detect spinal cord injury in patients who have experienced traumatic brain injury (TBI). MRI scan of the brain can also be used to detect strokes, tumors, and aneurysms (widening of a blood vessel). MRI scan of the spine may be used to evaluate patients with back pain, herniated disks, narrowing of the spinal canal (spinal stenosis), and degeneration of the disc spaces between the vertebrae (cervical spondylosis). It can also be used to detect spinal fractures and tumors. To evaluate the heart, lungs, liver, reproductive organs, other organs (e.g., spleen, kidneys) and glands (e.g., adrenal glands), MRI scans of the chest, abdomen, and pelvis can be performed. A tear or aneurysm in a major blood vessel (e.g., aorta) can also be detected using MRI scan. MRI scan can also be used to examine soft tissue, joints, and bones for injury, infection (e.g., brain abscess, meningitis, spinal epidural abscess, osteomyelitis), and tumors. The procedure often is used to evaluate injuries to bones, cartilage, ligaments, muscles, and tendons (e.g., knee and shoulder injuries). A radiologist (physician who specializes in imaging procedures) interprets the results of an MRI scan. MRI VS CT scan MRI is a completely different animal! Unlike CT it uses magnets and radio waves to create the images. No x-rays are used in an MRI scanner. The patient lies on a couch that looks very similar the ones used for CT. They are then placed in a very long cylinder and asked to remain perfectly still. The machine will produce a lot of noise and examinations typically run about 30 minutes. - 40 - IT in Hospitals The cylinder that you are lying in is actually a very large magnet. The computer will send radio waves through your body and collect the signal that is emitted from the hydrogen atoms in your cells. This information is collected by an antenna and fed into a sophisticated computer that produces the images. These images look similar to a CAT scan but they have much higher detail in the soft tissues. Unfortunately, MRI does not do a very good job with bones. One of the great advantages of MRI is the ability to change the contrast of the images. Small changes in the radio waves and the magnetic fields can completely change the contrast of the image. Different contrast settings will highlight different types of tissue. Another advantage of MRI is the ability to change the imaging plane without moving the patient Contrast agents are also used in MRI but they are not made of iodine. There are fewer documented cases of reactions to MRI contrast and it is considered to be safer than x-ray dye. Once again, you should discuss contrast agents with your physician before you arrive for the examination. Sonography Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images from inside the human body through the use of high frequency sound waves. The sound waves' echoes are recorded and displayed as a real-time visual image. No ionizing radiation is involved in ultrasound imaging. Because ultrasound images are captured in real time they can show movement of internal tissues and organs and enable physicians to see blood flow. This can help to diagnose a variety of conditions and to assess damage caused by illness. Ultrasound is fast, accurate and painless, does not require the child to remain still for long periods, and the equipment is less intimidating than the large tunnels of a magnetic resonance imaging (MRI) or computed tomography (CT) scan. What are some common uses of the procedure? In children, an abdominal ultrasound image is a useful way of examining internal organs including the appendix, liver, gallbladder, spleen, pancreas, intestines, kidneys and bladder. Ultrasound is particularly valuable for evaluating abdominal pain in young children. After traumatic injury, appendicitis is the most common reason for emergency abdominal surgery. Appendicitis can occur at any age but is most common in young people ages 11 to 20. Ultrasound imaging is sometimes used to help make the diagnosis of appendicitis in children. Ultrasound imaging can:     Help a physician determine the source of abdominal pain, such as stones, abscesses or an inflamed appendix. Guide procedures such as needle biopsies, in which needles are used to sample cells from organs for laboratory testing. Help identify the cause for enlargement of an abdominal organ. Localize abnormal fluid in the abdomen. How should my child be prepared for the procedure? Your child should be dressed in comfortable, loose-fitting clothing for an ultrasound exam. Other preparation depends on the type of examination. For some scans, your doctor may ask you to withhold food and drink for as many as 12 hours before your child's appointment. For others, you may be asked to have your child drink up to six glasses of water two hours prior to the exam and avoid urinating so that his or her bladder is full when the scan begins. Sedation is rarely needed for ultrasound examinations. - 41 - IT in Hospitals What does the equipment look like? An ultrasound scanner consists of a console containing a computer and electronics, a video display screen and a transducer that is used to scan the body. The transducer is a small, hand-held device about the size of a bar of soap attached to the scanner by a cord. The radiologist or sonographer spreads a lubricating gel on the child's abdomen in the area being examined, and then presses the transducer firmly against the skin to obtain images. The ultrasound image is immediately visible on a nearby screen that looks much like a computer or television monitor. The radiologist or sonographer watches this screen during an examination; often the patient is able to see it as well. An example of the ultrasound equipment that may be used is shown at the top of this page. How does the procedure work? Ultrasound imaging is based on the same principles involved in the sonar used by bats, ships at sea and fish detectors. As a controlled sound bounces against objects, its echoing waves can be used to identify how far away the object is, how large it is, and how uniform it is. The ultrasound transducer functions as both a loudspeaker to create the sounds and a microphone to record them. When the transducer is pressed against the skin, it directs a stream of inaudible, high-frequency sound waves into the body. As the sound waves echo from the body's fluids and tissues, the sensitive microphone in the transducer records the strength and location of the reflected waves. With Doppler ultrasound the microphone captures and records tiny changes in the sound wave's pitch and direction. These signature waves are instantly measured and displayed by a computer, which in turn creates a real-time picture on the monitor. The live images of the examination can be recorded on videotape. In addition, still frames of the moving picture are usually frozen to capture a series of images. How is the procedure performed? Your child is positioned on an examination table, then a clear gel is applied to the abdomen to help the transducer make secure contact with the skin. The sound waves produced by the transducer cannot penetrate air, so the gel helps to eliminate air pockets between the transducer and the skin. The sonographer or radiologist presses the transducer firmly against the skin and sweeps it back and forth to image the area of interest. When the examination is complete, you and your child may be asked to wait while the ultrasound images are reviewed either on film or on a TV monitor. Often the sonographer or radiologist is able to review the ultrasound images in real time as they are acquired, and your child can be released immediately. What will my child experience during the procedure? Ultrasound imaging of the abdomen is painless, fast and easy. Your child will lie on his or her back on an examining table. The radiologist or sonographer will spread warm gel on the skin, then press and move the transducer firmly against the body to capture the desired images. There may be varying degrees of discomfort from pressure as the radiologist or sonographer guides the transducer over the abdomen, especially if the child has a full bladder. The examination usually takes less than 30 minutes. Who interprets the results and how do we get them? A radiologist, who is a physician experienced in ultrasound and other radiology examinations, will analyze the images and send a signed report with his or her interpretation to your pediatrician or primary care physician. Your physician's office will tell you how to obtain their results. New technology also allows for distribution of diagnostic reports and referral images over the Internet at some facilities. - 42 - IT in Hospitals What are the benefits vs. risks? Benefits   Ultrasound provides real-time (live) imaging, making it a good tool for quick evaluation of potentially emergent conditions such as appendicitis. Ultrasound equipment is much less intimidating to young children than the large equipment used in other types of imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans. Ultrasound scanning does not require a child to lie perfectly still in order to capture a useful image. Ultrasound imaging is a painless, low-cost and non-invasive examination. Ultrasound is widely available and easy to use. Ultrasound does not expose children to ionizing radiation. For standard diagnostic ultrasound there are no known harmful effects to humans.     Risks  What are the limitations of Abdominal Ultrasound Imaging? Ultrasound has difficulty penetrating bone and therefore can only see the outer surface of bony structures and not what lies within. For visualization of bone, other imaging procedures such as x-ray, computed tomography (CT) or magnetic resonance imaging (MRI) may be selected. Sound waves do not pass through air, and evaluation of the stomach, small intestine and large intestine may be limited by gas within these structures. Electronic Doctors: Using a joystick, a doctor can operate the rounding robot to check on patients from another building or another country, via the Internet and wireless links. The doctor's face appears on the robot's screen, and he or she interacts with the patient through the real-time video hookup. The aim of the technology isn't to replace human doctors, but to make it more convenient for doctors to check in with their patients, and for patients to get quick access to personal physicians who aren't at the hospital. - 43 - IT in Hospitals "It's a way to communicate in a time of need and inaccessibility," said Dr. Samer Salka, an interventional cardiologist at Oakwood Hospital in Dearborn, Mich. "At 2 a.m., when I need to see an EKG or talk to a patient, I should be able to do that right from home. I can make a diagnosis right away and then come in [to the hospital] if I need to." Virtual vs. real visit The Johns Hopkins experiment, conducted at the Maryland university's hospital, involved 60 patients recuperating from surgery. Thirty of the patients were randomly selected to receive visits by the robo-doc once in lieu of an actual visit by their doctor. "Generally, the robot checked up on patients, asked them how they were feeling, inspected their surgical sites to ensure proper healing, and answered questions," said Dr. Louis Kavoussi, a professor of urology at Johns Hopkins and the study's lead author. Two weeks after the patients were discharged, a questionnaire asked them about the "telerounds." Half of those queried said they would prefer a telerounding visit by their own physician to a real visit by another physician. Half said that telerounding should become a standard practice for post-operative patient management, and 57 percent said they would feel comfortable having telerounds as part of their future care. Wave of the future? Eighty percent of the patients taking part in the study thought the robo-doc would increase accessibility to their physician, while 76 percent believed having the robot available would permit physicians to provide more medical information. "Most patients were very comfortable with this new technology," Kavoussi said. Kavoussi owns InTouch Health stock and is a paid member of the company's scientific advisory board. The terms of the arrangement are being managed by the Johns Hopkins University in accordance with its conflict-of-interest policies. InTouch leases the robots for $3,000 a month, which includes computer software, training and technical support. The robots are not for sale because the software is updated about once a month, said Timothy Wright, InTouch's vice president of marketing.This report includes information from The Associated Press and Johns Hopkins University. Robotic Surgery Dr. Starnes has focused his clinical and research efforts on minimally invasive heart surgery, specifically "off-pump" coronary artery bypass grafting and mitral valve repair. He is very involved in the robotic surgery research efforts. Indeed, traditional mitral valve surgery involves a long incision, and surgeons must split the breast bone to reach the heart. Even using advanced techniques, the incision can be four inches long. But through the small punctures and tiny instruments involved in minimally invasive robotic surgery, patients experience shorter incisions. Dr. Starnes explains that the robot can accomplish what the human surgeon cannot because of its ability to mimic the human hand within a small, contained space. The EndoWristTM Instruments transform the surgeons’ wrists, hand and fingers into tiny instruments. During the procedure, while the console surgeon operates the sophisticated robot from a distance, the bedside surgeon is responsible for placement of the correct surgical ports and directing the robot into the patient. And like other heart surgery, nurses and anesthesiologists play key roles during the procedure. In the future, the USC Department of Cardiothoracic Surgery hopes to apply this technology to other types of heart surgery, including off-pump coronary artery surgery as well as treating intracardiac lesions, including atrial septal defects and ventricle septal defects. - 44 - IT in Hospitals Example of robotic surgery The da VinciTM Surgical System The da VinciTM Surgical System consists of a surgeon's console, a patient-side cart, a high performance vision system and proprietary instruments from Intuitive Surgical, Inc. Using the da VinciTM Surgical System, the surgeon operates while seated comfortably at a console viewing a 3-D image of the surgical field. The surgeon's fingers grasp the instrument controls below the display with wrists naturally positioned relative to his or her eyes. The da VinciTM Surgical System's technology seamlessly translates the surgeon's movements into precise, real-time movements of surgical instruments inside the patient. The da VinciTM Surgical System has the potential to change surgical procedures in three basic ways: Make existing MIS operations easier. Surgical procedures routinely performed today using MIS techniques will be performed more quickly and easily. Make difficult MIS operations routine. Surgical procedures that today are performed only rarely using MIS techniques are expected to be performed routinely and with confidence using the da VinciTM Surgical System. Some procedures have been adapted for port-based techniques but are extremely difficult and are currently performed by a limited number of highly skilled surgeons. Make new surgical procedures possible. A number of surgeries that cannot be performed minimally invasively at all today are expected to be performed through 1 cm ports. 3D Vision System The remarkable visualization provided by the da Vinci® Surgical System immerses the surgeon in an enhanced 3-D view of the operative field, providing direct eye-hand-instrument alignment and natural depth perception necessary for precise manipulation of delicate tissue layers. A custom dual lens endoscope coupled with two 3-chip cameras take the surgeon "inside" the patient. High-Resolution Image Processing Intuitive Surgical's vision system includes a high-resolution 3-D endoscope with two independent vision channels linked to two high-resolution, progressive scan color monitors. The system also incorporates image processing equipment comprised of high-performance video cameras, specialized edge enhancement and noise reduction equipment. The resulting high-resolution 3-D image is bright, crisp and clear, with no fatigue-inducing flicker or crossfading as with single monitor systems. - 45 - IT in Hospitals Visual Continuity Camera control, provided through the hand controls and foot pedals, provides near-seamless transition between views. Reposition the surgical camera in an instant with foot controls or zoom in, out, up, down, left and right by moving your hands in the desired direction. Repositioning your head at the console does not affect image quality as with other 3D display systems. 4th Arm The da Vinci® Surgical System's patient-side cart holds up to four electromechanical arms that manipulate the instruments inside the patient. The instruments and camera attach easily to the arms, and are easily repositioned by either the console or patient-side surgeon. The addition of a 4th Arm allows Solo Surgery™, a breakthrough in robotic-assisted MIS. The first two arms, representing the surgeon's left and right hands, hold the EndoWrist® instruments. A third arm positions the endoscope, allowing the surgeon to easily change, move, zoom and rotate his or her field of vision from the console. This mobility eliminates the need for an assistant to hold the camera steady. The optional 4th Arm extends surgical capabilities by enabling the surgeon to add a third EndoWrist instrument and perform additional tasks like applying countertraction and following running sutures. This optional feature potentially eliminates the need for a patient-side surgeon. The surgeon can simultaneously control any two of the operating arms by tapping a foot pedal underneath the surgeon's console. The 4th Arm is available as an option on new da Vinci Surgical Systems and can be added as an upgrade to existing da Vinci Systems. A streamlined surgical experience that benefits the surgeon, the OR team and the patient. Fast foolproof setup Rapid instrument exchange Multi-quadrant access Interactive video displays The da Vinci S™ will keep you at the forefront of minimally invasive surgery as it accomodates tomorrow's HD video technology, high-speed networking and image guidance systems. For Surgeons Unparalleled dexterity, precision and control. For Patients Shorter LOS, lower complication rates, less post-op pain and superior outcomes. For Hospitals Increased patient satisfaction, improved operating efficiencies and significant market share gain. The da Vinci® Surgical System The da Vinci Surgical System consists of an ergonomically designed surgeon’s console, a patient-side cart with four interactive robotic arms, the high-performance InSite® Vision System and proprietary EndoWrist® Instruments. Powered by state-of-the-art robotic technology, the surgeon’s hand movements are scaled, filtered and seamlessly translated into precise movements of the EndoWrist Instruments. The net result: an intuitive interface with breakthrough surgical capabilities. Components of the da Vinci Surgical System Surgeon Console - 46 - IT in Hospitals Using the da Vinci Surgical System, the surgeon operates while seated comfortably at a console viewing a 3-D image of the surgical field. The surgeon's fingers grasp the master controls below the display, with hands and wrists naturally positioned relative to his or her eyes. The system seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of surgical instruments inside the patient. Patient-side Cart Provides either three or four robotic arms—two or three instrument arms and one endoscope arm—that execute the surgeon's commands. The laparoscopic arms pivot at the 1-2 cm operating ports, eliminating the use of the patient's body wall for leverage and minimizing tissue damage. Supporting surgical team members assist in installing the proper instruments, prepare the 1-2 cm port in the patient and supervise the laparoscopic arms and tools being utilized. EndoWrist Instruments A full range of proprietary EndoWrist instruments is available to support the surgeon while operating. The instruments are designed with seven degrees of motion that mimic the dexterity of the human hand and wrist. Each instrument has a specific surgical mission such as clamping, suturing and tissue manipulation. Quick-release levers speed instrument changes during surgical procedures. InSite Vision System The InSite Vision System, with high-resolution 3-D endoscope and image processing equipment, provides the true-to-life 3-D images of the operative field. Operating images are enhanced, refined and optimized using image synchronizers, high-intensity illuminators and camera control units. The da Vinci Surgical System is the only commercially available technology that can provide the surgeon with the intuitive control, range of motion, fine tissue manipulation capability and 3-D visualization characteristic of open surgery, while simultaneously allowing the surgeon to work through tiny incisions typical of minimally invasive surgery. - 47 - IT in Hospitals Features and Benefits of the da Vinci® Surgical System The da Vinci Surgical System enables physicians to perform surgery in a manner never before experienced. The da Vinci System seamlessly translates the surgeon’s hand movements at the console instrument controls into corresponding micro-movements of instruments positioned inside the patient. Overall, the da Vinci System can provide the surgeon with better visualization, dexterity, precision and control than with open surgery, while enabling operation through 1-2 cm incisions. Superior Visualization Revolutionary true-to-life 3-D vision Bright, crisp, high-resolution image Immersive view of the surgical field The da Vinci System provides visualization of the target anatomy unlike that ever experienced, with natural depth-of-field, enhanced contrast and magnification for more accurate tissue identification and tissue layer differentiation. Improved visualization also enables surgeons to perform delicate tissue handling and dissection with added precision – even in confined spaces. This precision allows the surgeon to avoid trauma to surrounding structures and tissues such as the neurovascular bundle located near the prostate. Enhanced Dexterity, Precision and Control Fingertip control of EndoWrist® Instruments 4 robotic arms enable Solo Surgery™ 7 degrees of freedom – 90 degrees of articulation Motion scaling and tremor reduction The da Vinci System's tremor reduction, motion control and proprietary EndoWrist instrumentation enhance ambidexterity for precision and control beyond the capabilities of the human hand. The surgeon can now move instruments with such accuracy that the current definition of surgical precision is exceeded. Enhanced control and intuitive motion enables more widespread use of advanced technique, as well as a reduced learning curve because now complex MIS procedures feel more like open surgery. For example, two-handed intracorporeal suturing can become standard practice, as well as Solo Surgery™ during selected procedures with the addition of a fourth arm. Added instrument range-of-motion enhances access and safety while operating in the confined space of the closed chest, abdomen or pelvis. This enables surgeons to more accurately and easily perform complex surgical maneuvers through small "ports," eliminating the need for large, traumatic incisions. Superior Ergonomics Optimal alignment of visual and motor axes Comfortable seated posture The da Vinci System is the only surgical system designed to allow surgeons to operate while seated, which is not only more comfortable, but also may be clinically advantageous due to reduced surgeon fatigue. The da Vinci System's design allows natural hand-eye alignment at the surgeon's console, which provides better ergonomics than traditional laparoscopic technology. Since the da Vinci System's robotic arms hold the camera and instruments steady, there is also potentially reduced abdominal wall torque, less patient trauma; less surgeon assistance required and reduced surgeon fatigue. - 48 - IT in Hospitals Finally, with the robotic arms providing added mechanical strength, physicians can now offer a minimally invasive approach to higher-BMI patients. Q. Why is the product called the da Vinci® Surgical System? A. The product is called "da Vinci" in part because Leonardo da Vinci invented the first robot. He also used unparalleled anatomical accuracy and three-dimensional details to bring his masterpieces to life. The da Vinci Surgical System similarly provides physicians with such enhanced detail and precision that the System can simulate an open surgical environment while allowing operation through tiny incisions. Q. Is a surgeon using the da Vinci Surgical System operating in "virtual reality"? A. Although seated at a console a few feet away from the patient, the surgeon views an actual image of the surgical field while operating in real-time, through tiny incisions, using electromechanically enhanced instruments. At no time does the surgeon see a virtual image or program/command the system to perform any maneuver on its own/outside of the surgeon's direct, real-time control. Q. Is this telesurgery? Can you operate over long distances? A. The da Vinci Surgical System can theoretically be used to operate over long distances. This capability, however, is not the primary focus of the company and thus is not available with the current da Vinci Surgical System. Q. Is Intuitive Surgical developing the da Vinci System for telesurgical applications? Intuitive Surgical's goal is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. Our strategy to achieve this includes the development of products that allow any physician today to rapidly expand his/her surgical technique and capabilities. Our robotic surgical platforms currently enable surgeons to perform complex procedures using a minimally invasive approach. In the interest of expediting surgeon training and expanding training programs, we are exploring telesurgery as a way to facilitate surgeon-to-surgeon proctoring and coaching. We see telesurgery as a means to allow surgeons to get up to speed in robotic-assisted surgery under the guidance of leading specialists – with less disruption to their clinical schedules and less impact on their patients. Q: Where is the da Vinci Surgical System being used now? A: Currently, The da Vinci Surgical System is currently being used worldwide, in major centers in the United States, Austria, Belgium, Canada, Denmark, France, Germany, Italy, India, Japan, the Netherlands, Romania, Saudi Arabia, Singapore, Sweden, Switzerland, United Kingdom, Australia and Turkey. Q. Is Intuitive's technology patented? A. Intuitive has an extensive patent portfolio of internally developed technology, as well as a variety of patents acquired or exclusively licensed from leaders in computer-enhanced robotics. Q. Has the da Vinci Surgical System been cleared by the FDA? - 49 - IT in Hospitals A. The U.S. Food and Drug Administration (FDA) has cleared the da Vinci Surgical System for a wide range of procedures. Please see the FDA Clearance page for specific clearances and representative uses. Q. What is the cost of the system? A. The average base cost of a System is $1.5 million. Q. What is Minimally Invasive Surgery (MIS)? A. MIS is surgery typically performed through small incisions, or operating ports, rather than large incisions, resulting in shorter recovery times, fewer complications, reduced hospitalization costs and reduced trauma to the patient. MIS has become standard-of-care for particular surgical procedures, it has not been widely adopted for more complex or delicate procedures – for example, prostatectomy and mitral valve repair. Intuitive Surgical believes that surgeons have been slow to adopt MIS for complex procedures because they generally find that fine-tissue manipulation – such as dissecting and suturing – is more difficult and are less precise than in open surgery. Intuitive Surgical's technology, however, enables the use of MIS technique for complex procedures. Q. Will the da Vinci Surgical System make the surgeon unnecessary? A. On the contrary, the da Vinci System enables surgeons to be more precise, advancing their technique and enhancing their capability in performing complex minimally invasive surgery. The System replicates the surgeon's movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way or perform any type of surgical maneuver without the surgeon's input. Q. What are the benefits of using the da Vinci Surgical System over more traditional methods of surgery? A. Some of the major benefits experienced by surgeons using the da Vinci Surgical System over traditional approaches have been greater surgical precision, increased range of motion, improved dexterity, enhanced visualization and improved access. Benefits experienced by patients may include a shorter hospital stay, less pain, less risk of infection, less blood loss, fewer transfusions, less scarring, faster recovery and a quicker return to normal daily activities. None of these benefits can be guaranteed, as surgery can be both patientand procedure-specific. Q. Is this "robotic surgery?" A. Devices for "robotic surgery" are designed to perform entirely autonomous movements after being programmed by a surgeon. The da Vinci Surgical System is a computer-enhanced system that interposes a computer between the surgeon's hands and the tips of micro-instruments. The system replicates the surgeon's movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way or perform any type of surgical maneuver. Sometimes, however, the general term "robotic surgery" is used to refer to our technology. Q. Why can't surgeons perform complex procedures such as cardiac surgery through 1-2 cm ports today? A. Cardiac surgery requires an excellent view of the operative field and the ability to maneuver instruments within the chest cavity with precision and control. Surgeons historically have used the "open sternotomy" approach to heart surgery, which means splitting the breastbone, pulling back the ribs and typically results - 50 - IT in Hospitals in a foot-long incision. This provides visibility and allows room for the surgeon to get his hands and instruments very close to the operative site. More recently, smaller incisions have been used to perform a variety of cardiac procedures. However, many cardiac surgeons feel the reduced access may limit visualization and may impede access to the operative field. Q. While using the da Vinci Surgical System, can the surgeon feel anything inside the patient's chest or abdomen? A. The system relays some force feedback sensations from the operative field back to the surgeon throughout the procedure. This force feedback provides a substitute for tactile sensation and is augmented by the enhanced vision provided by the high-resolution 3D view. - 51 - IT in Hospitals SYSTEMS USED IN HOSPITALS - 52 - IT in Hospitals EMR An electronic medical record (EMR) is a computer-based patient medical record. An EMR facilitates • • • • • • • access of patient data by clinical staff at any given location accurate and complete claims processing by insurance companies building automated checks for drug and allergy interactions clinical notes prescriptions scheduling sending to and viewing by labs The term has become expanded to include systems which keep track of other relevant medical information. The practice management system is the medical office functions which support and surround the electronic medical record. Although an EMR system has the potential to permit invasion of medical privacy, if security policies are monitored effectively EMRs are as secure as banking records, for example. Electronic records in health fall under the purview of health informatics, a combination of computation and computer science and medical record keeping. According to the Medical Records Institute, five levels of an Electronic HealthCare Record (EHCR) can be distinguished: • • • • • The Automated Medical Record is a paper-based record with some computer-generated documents. The Computerized Medical Record (CMR) makes the documents of level 1 electronically available. The Electronic Medical Record (EMR) restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems. The Electronic Patient Record (EPR) is a patient-centered record with information from multiple institutions. The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease. • EMR issues As of 2006, adoption of EMRs and other health information technology, such as computer physician order entry (CPOE), has been minimal in the United States. Less than 10% of American hospitals have implemented health information technology, while a mere 16% of primary care physicians use EHRs. The vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s. The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%. The following issues are behind the slow rate of adoption: - 53 - IT in Hospitals Interoperability In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda. Without interoperable EMRs, practicing physicians, pharmacies and hospitals cannot share patient information, which is necessary for timely, patient-centered and portable care. There are currently multiple competing vendors of EHR systems, each selling a software suite that in many cases is not compatible with those of their competitors. Only counting the outpatient vendors, there are more than 25 major brands currently on the market. In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer, in order to address interoperability issues and to establish a National Health Information Network (NHIN). Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. Congress is currently working on legislation to increase funding to these and similar programs. Adding older records to EMR To attain the wide accessibility, efficiency, patient safety and cost savings promised by EMR, older paper medical records ideally should be incorporated into the patient's record. The digital scanning process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by different healthcare professionals over the life span of the patient, some of the content is illegible following conversion. The material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. In addition, the destruction of original healthcare records must be done in a way that ensures that they are completely and confidentially destroyed. Results of scanned records are not always useable; medical surveys found that 22-25% of physicians much less satisfied with the use of scanned document images than that of regular electronic data. Privacy A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also. Multiple access points over an open network like the internet increases possible patient data interception. In the United States, this class of information is referred to as Personal Healthcare Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws. In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care. The organizations and individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. The growth of EHR creates new issues, since electronic data may be physically much more difficult to secure, as lapses in data security are increasingly being reported. Information security practices have been established for computer networks, but technologies like wireless computer network so offer new challenges as well. Social and organizational barriers According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EMR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself. Such organizational and social issues include restructuring workflows, - 54 - IT in Hospitals dealing with physicians' resistance to change (or, alternatively, software engineers' evolving research in deep modeling of the physician's knowledge and workflow domains), and creating a collaborative environment that fosters communication between physicians and information technology project managers. Exemplifying this need are several highly publicized HIT implementation fiascos, including one at Cedars Sinai Medical Center in Los Angeles, in which physicians revolted and forced the administration to scrap a $34 million CPOE system. Preserving electronic records Under data protection legislation and the law generally responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, owns the information contained within the record and has a right to view the originals, and to obtain copies under law. Additionally, those responsible for the management of the EMR are responsible to see the hardware, software and media used to manage the information remain usable and not degraded. This requires backup of the data and protection being provided to copies. It will also require the planned periodic migration of information to address concerns of media degradation from use. Legal status of EMR Medical records, such as physician orders, exam and test reports are legal documents, which must be kept in unaltered form and authenticated by the creator. • Digital signatures Most national and international standards accept electronic signatures. According to the American Bar Association, "A signature authenticates writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer." With proper security software, electronic authentication is more difficult to falsify than the handwritten doctor's signature. However, as the recent rise in identity theft demonstrates, no security method can totally prevent fraud, so auditing information security will continue to be prudent when using EMR. Digital records such as EHR create difficulties ensuring that the content, context and structure are preserved when the records do not have a physical existence. As of 2006, national and state archives authorities are still developing open, non-proprietary technical standards for electronic records management (ERM). • Standards Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EHRs and EMRs. These include: • ASTM International Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various HER or EMR systems, allowing easy interoperability between otherwise disparate entities. ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare. • - 55 - IT in Hospitals • CEN - EN13606, the European standard for the communication of information from EHR systems, and HISA, a services standard for inter-system communication in a clinical information environment. DICOM - a heavily used standard for representing and communicating radiology images and reporting HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material. ISO - ISO TC215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures. Open EHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models. • • • • Customization Pricing for EMR systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EMR systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit a medical specialty, environment or other specified needs. There are also EMR systems available that do not use templates and therefore can be easily personalized by each individual user, for example those based on Concept Processing technology. Caveats and concerns There are issues surrounding the generation and management of electronic medical records (EMRs), sometimes known as electronic health records (EHRs). There are two primary categories of the EMR; the "born digital" record and the scanned/imaged record. The "born digital" record, which is information captured in a native electronic format originally is information that may be entered into a database, transcribed from an electronic tablet or notebook PC, or in some other manner captured from its inception electronically. The information is then transferred to a server or other host environment, where it is stored electronically. The second category is records originally produced in a paper or other hardcopy form (x-ray film, photographs, etc.) that have been scanned or imaged and converted to a digital form. These records are best described as "digital format records", as their content is not able to be modified or altered (with the exception of the use of third party software to make "overlay notations") as electronic records are. Most medical records generated preceding the year 2000 are of this category. The process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact and accurate capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by any number of healthcare professionals over the life span of the patient, there exists a high probability of some of the content being illegible following conversion. In addition, the material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. Consideration should be given to developing a procedure to sample and verify images at a high ratio to - 56 - IT in Hospitals determine the accuracy and usability of the scanned images prior to disposal of the physical records, if they are disposed of at all. Further, all electronic repositories of information are subject to the need for periodic conversion and migration to ensure the formats they were captured in remain accessible over the life of the patient, and in some cases beyond, to the expected life of their heirs. Additionally, those responsible for the management of the EMR are responsible to see the hardware, software (applications) and media used to manage the information remain viable and are not subject to obsolescence or degradation. This will require generation of backup copies of the data and protection being provided to these copies in the event of damage to the primary repository. It will also require the planned periodic migration of information to address concerns of media degradation from use. These are all costly, time consuming processes that must be planned and budgeted for when making decisions to convert physical medical records to digital formats. Another major concern is adequate protection of privacy of the individuals whose records are being managed electronically. This class of information (in the US) is referred to as Personal Healthcare Information (PHI) and its management is addressed under the Healthcare Insurance Portability and Accountability Act (HIPAA) as well as many State-specific privacy laws. The organization/individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. Public implementations As of 2005, one of the largest projects for a national EMR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic medical record by 2010. The Canadian province of Alberta's Alberta Net care project is a large-scale operational EMR system. US medical groups' adoption of EHR (2005) Adoption of electronic medical records by US doctors is increasing slowly. The latest data from the National Ambulatory Medical Care Survey (NAMCS) indicate that one-quarter of office-based physicians report using fully or partially electronic medical record systems (EMR) in 2005, a 31% increase from the 18.2 percent reported in the 2001 survey. However, the survey also states that just 9.3% of these physicians actually have a "complete EMR system", with all four basic functions deemed minimally necessary for a full EMR: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. Barriers to adopting an EMR system include training, costs and complexity, as well as the lack of a national standard for interoperability among competing software options. - 57 - IT in Hospitals Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. On July 18 2006, CCHIT released its first list of 20 certified ambulatory EMR and EHR products and then on July 31 2006, additionally announced that two further EMR and EHR products had achieved certification. In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture or (VHISTA). A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests. Other various it system being used nowadays 1. INTEGRATED HOSPITAL MANAGEMENT SYSTEM It is an on-line solution package for computerizing the administrative, financial, patient care functions in hospitals for improvement of quality of service and efficiency. The system has the flexibility to allow customization to suit individual hospital requirements. The package has been developed on the WINDOW NT Platform. Specifically, the technology has been transferred for a 300 bed management system to M/s. ACCEL Automation System, Chennai. 2. HOMOEPATHY REPERTORISATION SYSTEM (HRS) 3.0 It is a software package to assist the physician in using the Kents Repertory for repertorisation and selection of remedy. The knowledge based uses all the 66 rubrics of Reportory and arrangement of chapters and rubrics are such that the selection is easy and the results are displayed using a multiple-window screen. The technology has been transferred to 3 organizations and one individual i.e. National Institute of Homeopathy, Calcutta, Govt. Homeopathic College, Trivandrum, Nehru Homeopathic Medical College Hospital, New Delhi and Dr. Lalit Sharma, J&K. 3. INTEGRATED LINAC SYSTEM FOR TREATMENT OF CANCER PATIENTS Development of an Integrated System with 6 MV Medical LINAC in corpora ting simulation facilities and treatment planning is in progress. The specification is targeted to meet the requirements of the typical cancer centers of Indian Hospitals. 4. NEONATAL OPEN CARE SYSTEM FOR RURAL MASS Neonatal mortality is major concern in India, especially in the rural areas and there is a need for a simple, easy to operate and maintain neonatal care equipment for providing an affordable intermediary care at block and taluk levels. A low cost warming unit with in-built flexibility to work under adverse conditions, like voltage fluctuations, etc., and suited for rural environment has been developed by SAMEER, Chennai. It also provides transporting facility of the infants under warm conditions to nearby district hospitals. The system is undergoing field trial at New Born Unit of Govt. RSRM Hospital, Chennai. 5. 3D TREATMENT PLANNING AND DETECTION SYSTEM IN CANCER THERAPY Three dimensional treatment planning system has been developed by TSCS Integration, CDAC, Pune & SGPGIMS, Luck now. The system along with diagnosis provides data for optimization of drug dose, treatment plan & radiobiology models. - 58 - IT in Hospitals 6. DISINFECTION OF HOSPITAL WASTE USING MICROWAVE TECHNOLOGY The hospital waste management system has been developed by SAMEER, Mumbai. It uses microwave technology for disinfecting microbiological and infectious wastes from Hospital or Laboratories. The technology enables waste treatment without creating environmental pollution. The system has been tested with large varieties of infected samples at Haffkine Institute, Mumbai. The technology for commercial production has been transferred to M/s. Thermax Pvt. Ltd. 7. DEVELOPMENT OF TELEMEDICINE TECHNOLOGY IIT Kharagpur and Webel Electronic Communication System are developing a prototype communication network interconnecting referral hospitals, district hospitals and health centres with dial up/leased lines for distant consultation, diagnosis and monitoring of tropical diseases. The project focuses on tropical diseases like skin and blood related diseases such as leprosy etc. The development of software for reliable communication of multimedia data related to tropical diseases and patients' database have been carried out along with the medical experts of School of Tropical Medicine. The telemedicine system would be put to extensive field trial shortly for treatment of patients. The technology has been transferred to WEBEL. 8. DEVELOPMENT OF WEB BASED APPLICATION FOR TREATMENT AND FOLLOW UP ACTION OF CANCER PATIENTS The programme is for oncology information, on line medical advice and disease surveillance. The objective is to establish and oncology network as an intranet surveys for providing advice for remote regional cancer centers in cancer detection treatment, pain relief and follow up. Initially the system is to be started between Trivandrum and Cochin. 9. DRUG AND DOSE CALCULATION FOR PEDIATRIC POPULATION. This software package developed by the department of Pharmacology AIIMS to assist pediatricians in decision making with respect to dosing of drugs and to provide the pediatrician a tool, which can effectively calculated the exact doses for a patient, including renal failure. The drug listed alphabetically have also been grouped systematically according to their use i.e. CNS drugs, Cardio Vascular Drugs and Anti biotic Drugs. 10. COMPUTERISED BASED BRAILLE TRANSCRIPTION SYSTEM It converts text to Braille and electrically converted text to Braille and electrically operates Braille printer which can be operated without any previous knowledge of Braille. The computer based Braille transcription system is presently available in six Indian Languages (e,g) Hindi , Assamees, Orriya, Bengali, Manipuri & Marathi and More languages are being added. 11. NETWORK AND COMPUTERISED BRAILLE TEACHING SYSTEM National Programme for Braille Literacy with the application of information Technology has been developed. The objective is to evolve system for aiding Braille literacy in corpora ting modern computer networking and applications of Information Technology. The program envisages generation of education in regional languages which can be translated automatically to Bharti Braille system, Braille teaching and training and providing central Braille library. 12. WATER TREATMENT PLANT AUTOMATION PLCs and SCDA system installed and commissioned. Acceptance test is over and have been installed in Delhi Jal Board where it is functioning successfully. 13. TELEMEDICINE SYSTEM The Telemedicine system being developed by CEDTI, Mohali in collaboration with CDAC, Pune is aimed to develop a system for application of computer and communication technology for use in telemedicine. The system will be useful for transmitting clinical data, images and graphics over the telephone lines. The - 59 - IT in Hospitals first phase of the Telemedicine, which aims to link three premier medical institutions – AIIMS, New Delhi, PGI, Chandigarh and SGPGI, Luck now for tele-consultation and tele-education was inaugurated by Union Health Minister Sh.C.P.Thakur at the Post Graduate Institute of Medical Education and Research (PGIMER) on 13th October, 2000. 14. HEALTH MONITORING SYSTEMS System Health Monitor (SHM) is used to monitor and Display the status of different signals of Microwave Data Link System (MDLS). There will be two SHM, one at local site and other at remote site. Both SHMs are connected by a VHF link for Data and Voice transmission. Events of error are stored in the Data base. - 60 - IT in Hospitals FUTURE OF IT IN HOSPITAL - 61 - IT in Hospitals NEW TRENDS IN HOSPITALS 1) The IT trail: Exports, BPO and more Health care was made out to be a big business for the Information Technology companies a couple of years back. Though the last two years may have been slow- paced for IT companies, at least in the Indian market, things are hotting up with growth in private sector, fierce competition from the multinational IT companies and opening up of medical business process outsourcing (MBPO). According to National Association of software and service companies (Nasscom), the market for the software products for the healthcare sector in the country is estimated to be Rs 500 crore growing at 15-20 per cent annually. While an estimate of market for software exports is not available, analysts place the current MNCs exports itself at more than $ 250 million per year. And this is a result of the vertical focus that health care has assumed, say experts. Today, the top MNCs in healthcare-IT, viz, Covansys, Cognizant and Syntel, each employing 1000, 900, and 500 employees rake in nearly 25 per cent of their revenues from health care. “Vertical domain knowledge is what helps the MNC consulting companies keep their pricing high despite competition from India,” says a consultant. Though Indian companies are no where second to MNCs in terms of product, most Indian companies tend to be focused on the low end of the consulting services world, ie, generic technology services say experts. The MNCs are ramping up their presence in India, taking advantage of the low cost of labour, most of them planning to recruit at least 2000 professionals each by 2004. Never mind that they are working on their own market from India. For example, IBM is already executing a $ 250 million health care project for Empire Blue Cross Blue Shield from Bangalore say sources. Also, for the international markets, MNCs do not have to create a brand as it already exists in the markets they serve. Says Dr Saji Salam, head, HL7 India, “All they need to do is perfect the offshore delivery model, which is being done by recruiting managers from the large Indian companies.” And it is the Indian companies who are facing competition both on the domestic and international fronts. Though Indian majors derive 90 per cent of their health care revenues from global contracts, experts feel that MNCs have an edge over the former in terms of domain knowledge, including understanding of global best practices and standards in the specific domain. Explains Dr Salam, “Health care is local in focus and what works in Europe might not work in the US. My only advice is: invest in standards. China and Taiwan are far ahead of India in terms of Health Level seven and Digital imaging and communications in medicine (DICOM)-certified professionals.” HL 7 is a standards developing organization operating in the healthcare arena to design standard for the electronic exchange of healthcare-related information and DICOM provides standards for transfer of images. He says that extending products tailored for the Indian market to the US health care space does not work and hence re engineering Indian products for the US and European markets does not make sense. As for domestic markets, even as Indian IT companies are targeting their efforts towards the same, they complain that there still is no maturity in the market and it is still at a stage that banking sector was 15 years back. J Rajagopal, Director- Global Life Sciences & Healthcare Practice, TCS, says that it is only in the last six months that health care really seems to be getting anywhere. “We have seen more activity in the last six to eight months in the domestic market than the last few many years. We have sent out more proposals, had more meetings and more presentations in these months. We also had roadshows in 6 cities to educate the clinicians and administrators on our hospital management systems.” TCS estimates put the growth around 25-30 per cent in the future, which presents a big opportunity for the company. - 62 - IT in Hospitals However, the slow pace of progress in India has not been worrisome because of business from outside India. Now again, companies are preparing to venture into MBPO, considering the increasing demand for back office work from hospitals in the US. Rajagopal says that in the next 12-24 months, companies would have taken off in this area too. Apollo Health Street’s $ 3.5 million initial investment in medical business process outsourcing (MBPO) is an indication enough of the kind of money that goes into this business. But what is a greater challenge is providing the domain expertise in medical services. Apollo Health Street of course has the backing of its parent company Apollo Hospital. Apollo Healthstreet and Wipro bagged four contracts for MBPO from hospitals in the US last year. But unlike the other trends in health care like medical transcription or telemedicine which saw a lot of ambitious players, BPO is taking time. Explains Rajagopal, “BPOs require intimate knowledge of the hospital back office, understand, demonstrate and conduct a pilot project because of which they were taking time to plunge headlong.” It is still not very clear what areas would fall under BPO but in case of Wipro, hospitals send x-ray, ultrasound, computerised tomography, MRI etc. to Bangalore and diagnoses are sent back to US. Apollo covers billing, coding and adjudication for insurance purposes. Meanwhile, IT companies are gearing up to serve the US clientele because they would always go in for a company that provides both BPO service and IT rather than go for two different agents says Dr Salam 2) Practice management solution for cardiologists Mumbai-based Ketan Software Ltd has designed a specialized software solution for all cardiologists called Cardio-ket. It is a Patient Information System which acts like doctor’s assistant and secretary as well. It has built in integrated utilities like scheduler, reminder, dialer, address book, inventory control, account maintenance etc. to make life much more easier for doctors and help him plan and work. Further with its unique Artificial Intelligence, software starts thinking the way doctor diagnoses, prescribes, advices, etc. and then acts like a parallel doctor which is completely trained by the doctor himself. Further, software is made scalable so that it can be used by a single user or be converted to multi-user system to support small nursing homes and hospitals. With a Drug Information System having more than 14000 brands, the software also helps as quick look-up reference for all brands, searchable on body systems, generic name, company name and drug composition. Cardio-ket helps doctor to create standard referring letters and certificates at a click of a mouse along with a option of selecting various kinds of pre-designed letter heads. It allows doctor querying on any kind of information and also helping easy retrieval and also help in analysis and prepare summary reports. There is also an option to attach scanned images like X-rays and photographs to maintain complete patient file. Also doctor can record the patient data using microphone and can later convert the audio file into text data with the help of medical transcribers. Some of the salient features of software are: l Paperless, foolproof, systematic maintenance of records of patients and easy retrieval of records l Very efficient patient management system l Stores patients’ personal details, disease history, family history, treatment details and visit details Inventory Control System for in-house drugs and surgical equipment l Sound File Maintenance for medical transcription Angiography & Angioplasty Module allows storage of complete angiography & angioplasty doctor procedure details along with image representation. Cardio Investigation Module is an extra module for cardiological investigation of doplar, echo, stress test which have been bundled along with the kit. - 63 - IT in Hospitals 3) Knowledge-based marketing: Future of healthcare marketing In today's age, every consumer wants to be served according to his or her unique and individual needs. Oganisations have also geared up to provide customised solutions, tailoring their services/ products based on actual customer preferences, rather than on generalised assumptions. Hence all the businesses are exploiting the information systems and technology to accumulate huge amounts of customer data, as they understand that the knowledge in these huge databases is important to gain competitive advantage and support various organisational decisions. There is a great need of a well-defined, simple but integrated system to extract the knowledge of the customers from these huge databases and then to apply this knowledge for making various critical decisions, particularly marketing decisions. The healthcare market is no different, where a great deal of information is available from the transaction databases (every point of service utilisation) and from customer/corporate (health-seeker) databases. This great wealth of database gets unutilised and thus wasted due to the lack of appropriate tools and techniques required for the analysis. Hence, database marketing in healthcare sector is characterised by marketing strategies linked to knowledge-based marketing which uses appropriate tools for searching and analysing customer data in order to find implicit, but potentially useful information, thus revealing previously unknown patterns and ultimately comprehensible information. These tools are called Data Mining Tools, like statistical analysis, graphic visualisation, decision trees, etc. These tools help in profiling the consumer/customer (health seeker), profiling the variation/deviations in transaction and finally analysing the trend. Profiling the consumer/customer A hospital seeks to decide on the right strategies to market its services, on the basis of the profile of the health seeker. Hence an appropriate model of the health seeker is the first step. This entails information regarding the demographic profile along with the health seeking behavior mapping. The Data Mining Tools can be extremely helpful in this situation. Frequency of facility/service utilization Mapping the number of times service provider/hospital is visited, and revisited, the particular facility/service utilised by the health seeker; thus building on the various promotional tools and consumeroriented programme, clubbing of frequently availed relevant services, age-wise service clubbing, etc. Revisits can be utilised to promote a loyalty Programme. Service utilisation in the recent past This is to map the number of times the services have been utilised in the recent past and to understand the reason of non-utilisation of services, if any. Similarly, the mapping can be used for a group of health seekers (like corporate) to understand their pattern of facility/ service utilisation. The programme can thus be tailored as per the specific needs. Identifying and isolating consumer / health seeker groups This can be done by concept description (grouping customers based on the domain knowledge and the database) and by class description (clustering the health seekers according to attribute similarity and conceptual cohesiveness). This can be elicited by the following example. Health seekers falling in the category of 'eligible couple' can be provided packages for genetic counseling/ education regarding contraception/reproductive health education/screening for various relevant diseases/ services provided by the hospital for obstetric care and family planning. Similarly, packages can be provided for corporate group having similar demographic and occupational characteristics. Prospecting - 64 - IT in Hospitals The profiling of health seekers gives valuable indication to the service provider on prospective consumers. For instance, in the above examples, the 'eligible couple' group can be targeted for providing paediatric services/immunisation services and so on. The corporate can also be looked into in the same manner. Statistical analysis of the various promotional tools can be carried out to see the success or failure of the above promotional programme. The short term as well as long term effects of the programme can be measured by seeing the pattern of health seeking behavior. This can be the basis for evaluating the value added to the health seeker's life. Profiling the variation/deviations in transaction A deviation can be an anomaly, a change, even a fraud, and in healthcare scenario it could signal an impending disease outbreak. The knowledge of these deviations is important to the health service provider, more so is the timely knowledge and initiation of relevant actions. For example, more than normal utilisation of a particular facility/service could be seasonal variation or changing lifestyle of a particular stratum of society or could be an environmental influence resulting in the deviation. The deviation can be within the service provider's own infrastructure. For instance, comparing a group of customer care personnel and identifying those who stand apart from the average in solving the patients' problems either in a positive or a negative way. The change in the behavior of a health seeker or the provider's internal customer can provide us with the opportunity to detect and classify such deviations, and further information should be collected, if necessary. Any price change or promotional programme can also be viewed in the perspective of deviation it caused and the changes can then be queried. Analysing the trend Trends are patterns that exist over a period of time. Trends can be long-term trends like slow but sustained growth of health check facility utilisation following continuous community/corporate health education programme initiated by the service provider (hospital). Trends could be short-term, like sudden increase in the number of Gastroenterology cases during monsoon or sudden increase or decrease in the surgical cases during different periods of the year. Our Data Mining Tools, especially data visualisation, allows us to view complex patterns as visual objects in three dimension and colours. It can further be used in association with other Data Mining Tools, like concept description and deviation detection to explore the knowledge in database. Similarly, graph-based technique or other geometric projection techniques can be used to even detect hidden and subtle trends in the database. Data mining tools also provide statistical tools to precisely measure the performance of various parameters. Trends can be used to forecast future utilisation patterns. Service providers are interested in knowing the effect of various marketing programmes on the utilisation rate. These tools help in detecting the relationship between a particular programme and the profile of the health seeker (or if any change is detected in the profile). In the current scenario, all the programmes are customer focussed. Hence, all the steps targeted towards the Customer Relationship Management should be based on identifying the right customer, differentiating among them (classification), interacting with them to learn from them and finally customising the services/facility to the needs of the customers. Inadequate knowledge about customers and the lack of systematic knowledge management framework hinders the organisational efforts to manage their much-valued customers (health seekers). In the current customer-centric and customer-driven business scenario, there is a need for furthering our understanding of the use of various tools required for searching and analysing data and for a proper knowledge management. - 65 - IT in Hospitals Dr Bardhan is a consultant with Novella HMS and Dr Aanshu Sharma is a marketing executive at Lilavati Hospital. 4) Medical informatics: A promising future The hospital management and information system consists of not only information of the hospital and clinical information of a patient but also includes telemedicine, computer-assisted instructions to patient as well as doctors, and may even cover computer-assisted imaging and surgery. Surgical simulations and virtual environment are educational tools not only for doctors but also for patients. It is the era of convergence with the computer screen. Medical Informatics (MI) provides a comprehensive survey of current work performed to develop information technology for the clinical workplace. It deals with the acquisition of data from patients, processing and storage of data in computers, and the transformation from data into information data. Some topics pertain to methodological aspects of medical informatics and others are intended to be used for more advanced or specialised education. They contain the methodology for information systems and their processing. The future of MI as a profession is very promising. Medical Informatics means managing medical and health care through information science and technology. Like medicine, MI is also multidisciplinary. MI deals with the entire domain of medicine and health care, from computer-based patient records to image processing and from primary care practices to hospitals and regions of health care. Hospital management and information system Hospitals are the main providers of medical and health care. Significant progress has been made in improving their efficiency and operations. Effective computerised systems and procedures need to be implemented to ensure proper utilisation of limited resources toward cost-effective quality health care and the patient satisfaction. Before deciding to go for such system one should have some insight to the implementation of the different modules and evolving user-friendly computerised systems, which are loved and cared by all. Computer-based patient record: Physicians and health administrators can efficiently retrieve data for consequent research from the computerised medical records. Good clinical research needs accurate and detailed clinical information and they significantly improve the medical care. This detailed information can even be used for other processes in the business of medical and health care. The knowledge of advantages and disadvantages of different systems available for recording and codifying are important. Knowledge-based and expert systems: The rapid evolution of technology and clinical research makes it difficult even for the specialist to keep up. In the light of this ’information explosion’, it has been demonstrated that physicians do not always make optimal decisions. A computer-assisted diagnostic support system (CAD) generates diagnostic hypothesis from a set of patient data. It can be used simultaneously with the doctor-patient consultation. The knowledge-based system (KBS) is designed to meet the knowledge gaps of the individual physician with specific patient problems. KBS and such other expert systems (ES) can be a boon to the rural health centres because even the general medical practitioners can operate the systems. Computer-assisted medical decision making and knowledge- based systems are ideal examples of artificial intelligence. Telemedicine With the advancement in information technology, telemedicine has become an important part of medical practice. This method of distance management in medical and health care not only benefits patients but also medical practitioners. How to use the electronic transmission of medical data to enhance patient care and empower the physician is the hotly discussed topic among the health providers. - 66 - IT in Hospitals Three-dimensional imaging - Virtual endoscopy: Endoscopy, a minimally invasive procedure, limits the surgeon’s visualisation to the inner surface of the lumen. He does not see directly the immediate adjacent structures beyond the lumen wall. He mentally reconstructs the anatomic structures on the bases of information gathered from ultrasound, CT, and MR imaging. Computer generated three-dimensional virtual models can be displayed as a contiguous, three-dimensional luminal view, known as virtual endoscopy, that emulates traditional endoscopy. At present the time and cost factors are prohibitive in the widespread use of virtual endoscopy, but the future holds promise as the advances in computer and software technology may overcome these factors. Computer-assisted surgery The interest in computer-assisted surgery is motivated by the prospect of increased intra-operative patient safety. Review of current literature shows a sustained interest in developing a role for available frameless stereotactic technologies. The image guidance assists the surgeon in navigating through diseased or surgically revised complex anatomy. How this technique is evolved and enables a new level of efficiency is interesting. Surgical simulations: The advancement in imaging technology and high performance computer hardware and software have made it possible for the surgeons to intuitively explore the complex data to determine the best form of treatment in the most difficult pathologic conditions. The development of 3-D interactive anatomic road map for a particular patient’s disease and anatomy enables the surgeon to have accurate pre-operative assessment. In this interactive with real-time performance intuitive environment, students can study the lesion and practice the procedure in a nonthreatening way. Virtual environment: In the simulated world of virtual environments, the surgeon can plan and practise surgical procedures. The computer-generated surgical simulation has great potential. The virtual reality is valuable where the anatomy is complex and the surgical problem is difficult. This advanced technology can become an adjunctive training aid to the residents in training and the experienced surgeons. Telesurgery: The surgeon’s hand motions are converted into electronic signals and then sent to the tip of the surgical instrument. Endoscopic surgery, tele-presence, virtual reality, digital imaging, and networking are coming together at the physician’s work station, enabling him to work at a distance, so dissolving time and space. Physician education Computer-assisted learning is rapidly evolving and provides several advantages over traditional approaches. The biomedical knowledge base can no longer be taught in its entirety; therefore, one must depend on his learning skills. Self-directed learning and lifelong learning skills can enhance and accelerate the application of the application of an expanding knowledge base to patient care. The impact of computers on the continuing medical education (CME) programmes is immense. Patient education On the Internet, patients can quickly obtain the latest information on support groups, therapeutic modalities, late-breaking research, and individual coping strategies. If clinicians incorporate some sort of Computerassisted patient education in their practice that can empower their patients to make the right individual decisions. Internet Internet-based communications are evolving at a tremendous speed. Searching medical literature: The information technology has made searching the medical literature easier and more readily accessible. The - 67 - IT in Hospitals United States National Library of Medicine (NLM) maintains several comprehensive, cross-referenced medical literature databases 5) Need to standardise IT requirements There has been a paradigm shift in the thinking with respect to the IT needs of health care and hence the need of Information Systems for hospitals has taken a long leap for IT-enabled services and solutions. This brings in lot of difference between the conventional ways of operations to the new generation hospitals as they see this as the main nervous system of the hospital with respect to information flow, data capture, hospital management and customer satisfaction.Though the infrastructure and equipment have always been a priority with most of the hospitals in the past the new generation hospitals have taken IT as a serious investment and as a process enabler. With more and more private hospitals being commissioned in the country to bridge the gap between the need of number of beds to the present number of available beds in the country, all these hospitals have looked at IT as a differentiator to improved customer service. Today these hospitals are not hesitant to go the IT way from the day of commissioning and hence the IT investments are planned well in advance. Though this is a good way of adaptation of the western way of healthcare services that brings in information and customer satisfaction at the highest level, the needs are yet not well defined and varies from hospital to hospital. Once the needs are standardised and the processes are well defined, this would help the IT organisations to give a full proof and need based solutions to the hospitals. This is the reason that the IT organisations are having products and solutions, which are unique to them, and it becomes very difficult for the hospitals to take a decision based on the product and features. No two products are having features that are similar and follow a specific standard. Today, the needs are not only with respect to the regular hospital functionalities like registration, billing, in-patient management, out-patient management, purchase and stores, laboratory, MIS and finance & accounting, the needs are much more than these. The major areas that all these new generation hospitals are looking for range from fully automated solution for their pathological instruments to smart card interfaces. The basic functionalities however are: • • • • • • Patient information and case history Electronic Medical Records Resource scheduling and equipment Management Pathological instrument interfaces Imaging with both radiological and other instruments and associate the images with electronically Clinical specialties There are only few organisations who have all the above and are integrated with their hospital management Information solutions. With more and more IT companies trying to enter this market, unless and until there are proper steps taken to standardise the needs, it will become more and more difficult for the customers to decide and partner the right vendor.Although the trends are definitely towards standardisation of the products with standards like ICD 10 and HL 7 being incorporated in the Indian scenario. Soon there will requirements for interfacing with DICOM technologies, e-consulting and also wireless application. More and more hospitals will slowly look at three tier technologies for better management and information made available across the globe. 6) NANOMEDICINES patient’s file - 68 - IT in Hospitals The science of the very small.The term ‘nanosciences’ first appeared almost two decades ago. It describes technologies active at the nanoscopic level, i.e. involving components that are no bigger than one billionth of a metre or a nanometer, which is 80 000 times smaller than the width of a human hair. By taking atoms as the point of departure, this science of the infinitessimally small is radically changing the way in which technology exploits the atomic and molecular world. Nanotech applications include atom-scale ‘nano-robots’ that can be injected into the human body to cure diseases; electronic ‘nano-chips’ that can store and process much more information than today’s microchips; ‘nano-fibres’ for better and cleaner clothes; and ‘nano-materials’ for high performance coatings, for instance in aircraft and spacecraft. POTENTIAL APPLICATION OF NANOMEDICINE DRUG DELIVERY IMPROVED IMAGING DNA ANALYSIS NANO BARCODE TECHNIQUE IMPLANT MATERIALS ARTIFICIAL TISSUES IMPROVING BRAINS CLEANING TEETH, LUNGS & ARTERIES HUMAN TARGETS DIFFERENT USES OF NANOROBOTS 1. FOR DENTAL PURPOSE The nanorobots can be used for dental treatment. The teeth cleaning robots can collect harmful bacteriafrom the mouth. - 69 - IT in Hospitals 2. FOR CLEANING OF LUNGS Similarly the robots can be used for the cleaning of lungs. We have natural macrophagesin alveoli, but they are notable to metabolize foreign particles like fibers of asbestos and toxic effects of smoking from the lungs. But these things can be done with the help of Nan robots. 3. FOR IMPROVING BRAINS Nanostructured data storage devise measuring a volume about the size of the single human liver cell can store an amount of information equivalent to entire library. . - 70 - IT in Hospitals 4. FOR IMPROVED IMAGING Improved imaging with better contrast agents helps to diagnose disease more sensitively.The method enablesthe detection of very small tumors and other organisms that cause the disease. 5. REMOVAL OF EXTRA FATS Extra fats can be removed from the arteries with the cleaning robots Even though there are certain disadvantages in invasion of nanorobots, and even though it is in the initial stage we can say that it has certain advantages in the hospital sector. In future nanomedicines will eliminate virtually all common diseases, all medical pain and suffering. - 71 - IT in Hospitals REFERENCES - 72 - IT in Hospitals References: [1] www.apollohospitals.com [2] www.intuitivesurgical.com [3] http://www.healthcareit.wipro.com/hospital.htm [4] http://www.technologynewsdaily.com/taxonomy/term/24 [5] http://tie.telemed.org/ [6] http://www.tomorrowstrends.com/Main.asp?YearMonth=200506 Search engines: [1] www.google.com [2] www.wikipedia.com [3] www.video.google.com [4] www.en.wikipedia.org - 73 -