Saturday, January 14, 2017

Effect of Demonetization on Healthcare

Demonetization is a master stroke by PM Modi. It has done to Healthcare what all Transformation consultants put together couldn't achieve in 75 years.
These are few of my observations. Maybe isolated incidents and may not represent a wider trend; But this is what I saw...'pratyaksh athwa pramanit'.
  1. Cash payments in Hospitals have gone Digital! Patients come and say 'cash nahin hai saab ji'. Hence acting as a filter between need and want. Will pay Digitally for only what is required and not what can be postponed. What was under the table has come overboard. Only 5% of the GDP is spent on health and 80% of this is in the form of out of pocket expenditure. Almost all of this out of pocket was cash; out of which I think 70% will get converted to Digital that will show in the books and attract relevant tax. Over 80% bed utilization is usually considered profitable. However I have seen bed utilization falling by 30% in the demonetization period. I think this could be a short term shock effect, hope not a long term trend!
  2. The biggest impact is on Doctors in private practice for primary and secondary Healthcare. They can no longer hide some of the cash payments. Their cut practice will stop or be washed overboard. Labs, Pharmacy, Specialists, Hospitals have stopped paying cash [cuts] back to the practitioner. 'aap ko pata hai, cash to ab hai hi nahin Doc saab'. As per some estimates cut practice forms 80% of their income but hidden from income tax. About 60% of total health expenditure in India was paid by the common man from his own pocket. Almost all of this out of pocket was cash, out of which I think 70% will get converted to Digital that will show in the books and attract relevant tax. 
  3. Sales of OPD prescriptions and OTC has become Digital! Pharmacies were already geared for Digital payments but now the % of Cash payments has gone down to minimal. This is a good thing because now the traceability of the sale has gone up. Each transaction has a unique number and can be traced by batch number. Out of all health expenditure, 72% in rural and 68% in urban areas is for buying medicines for non-hospitalised treatment. Almost all of this was cash, out of which I think 70% will get converted to Digital that will show in the books and attract relevant tax. 
  4. IPD Medicines are fully Digital now. Whatever came through the HIS was Digital anyways. Now the medicines being bought directly by the patient are also Digital. Soon Pharma companies will have access to reliable Digital data for forecasting, which was a struggle thus far. Organised retail Pharmacy stores can handsomely monetize this Digital data.
  5. Hospital consumables and materials are about 30% of the operations cost; where the procurement has gone Digital! Where is the cash to pay for all the material supplies? Hence forced to do direct funds transfer to the bank.
  6. Medical consumables and material supplies to primary care and secondary care sector were all cash transactions. Now becoming cashless online payment. Small material suppliers risk getting wiped out as their business margin [< 8%] is lesser than the total tax liability!
  7. Although P&C/Gen Insurance saw heavy FDI inflow after the amended law last year; but same didn't happen to Health Insurance thus far. This is because the Actuaries can't calculate the risk when the Indian Healthcare relies on hidden cash transactions and under the table deals. It's happening now because of demonetization. Insurance feels more comfortable dealing with claims that have a Digital footprint. i.e. Insurance is more comfortable reimbursing a Digital expense because it reduces the chances of fraud and abuse. From a Actuarial perspective the risk comes down. Full traceability. Hence I saw a large Healthcare group offering OPD Insurance cover. Now that is a commendable change! Thus far private Health Insurance coverage is between 3-5% and total Health Insurance coverage is between 14-18% of India's population; this is expected to grow exponentially because insurance becomes attractive in a clean business environment.
  8. MNC Medical device OEM want to sell directly in India now. Not through dealers because the payments have become Digital and 100% FDI is allowed and overboard. As per FICCI the Medical Devices and Equipment industry, valued at US$ 2.5 billion contributes only 6% of India’s US$ 40 billion healthcare sector. It was growing at a annual rate of 15%. The need for Digital records, Digital payments and with IoT coming in, I expect it to grow @ over 20% annually.
  9. Labs were already Digital ahead of other Healthcare stakeholders. Now thinking of leapfrogging to SMAC, IoT, Automation and AI in a big way. LOINC standards approved and notified for India! International Lab chains eyeing India as a viable market.
  10. Radiology business is falling. Unnecessary imaging is going down. Traceability and transparency is reducing repeat tests. Obviously Patient benefit and Insurance wins.
  11. Drug counterfeit market that was expected to be 50% of the market in India has been hit badly as it was all cash market. Pretty much struggling to survive. Obviously plugging such a leak is a huge benefit for all. Recognised Pharma companies should be celebrating. The total yearly drug spend of US$ 36.7 billion currently should see a huge jump this year as the market spend shifts from counterfeit to genuine drugs. It will be interesting to watch if this shift will benefit generic or patented drugs!
  12. All the ad-hoc or lower level staff were daily wagers and are on daily or weekly cash payments. No one really knew if these daily wagers were real or existed only on paper. Salary payments under 30K per month did not attract TDS and hence were mostly used as a buffer or to siphon the black money. Now the ordinance of all Salary to be paid Digital brings all this out in the open! Going forward 'Ram lal 1, Ram lal 2, Babu Ram x, Babu Ram y' will no longer exist.
  13. National Health Protection Scheme - Health Insurance cover of up to INR 1 Lakh per family for the poor and BPL has been hanging fire for a year now; But PM Modi announcing INR 6K direct benefit transfer [DBT] for every pregnant woman in the country is the last straw on the corrupt public healthcare systems back. The Govt will need to establish unique Digital Identifiers and registries for Services, Patient, Provider and Facility; hence EHR v2 and MDDS Standards notified. Where the DBT will be done by Jandhan, AADHAAR and mBanking [JAM]. This is start of the Public Health Transformation!
  14. Real estate use for Healthcare is suddenly in demand! The dealers and builders are calling me and offering spaces at 75% discounted rentals, the same were unwilling to talk because they could get higher prices elsewhere. Now I tell them I dont have the cash to rent/buy.
  15. Didn't you wonder - !! - when the balance sheets of large hospital/healthcare chains were showing losses year-on-year? Obviously this was a siphon going on. Demonetization wiped out the [black?] cash stores of HNI and traditional Indian business houses. Hence Demonetization has given a major blow to the investment confidence in green field and brown field hospitals and other capital intensive Healthcare businesses. Soon these siphon businesses will start getting sold out or wiped out of the game. Hence democratisation of funds creates a level playing field for new age digital healthcare business to compete with the old boys club. Let's bet on the winning horse now!
  16. 80% of healthcare infrastructure is in public sector whereas 80% of healthcare spend is in the private sector. Majority of the spend in private sector was in cash. These cash based revenue sources for private Hospitals have taken a big hit. Value of volumes from Govt Insurance programs like CGHS, ECHS etc. have gone up. With demonetization and Digital payments the corruption is expected to come down significantly. Hence the public sector hospital functioning is expected to improve and give private sector hospitals a run for their money. Nalayak beta bhi ab layak ho gaya ;-)
  17. India sovereign is now ready to become probably one of the largest Reinsurers in the world. Banking system is flush with unprecedented funds. Insurance companies will be fools to not notice! Health Insurance is no exception. Hence sets the stage for rolling out one of the world's largest Universal Health Coverage [UHC]. The number of Indians falling below the poverty line [BPL] every year due to health spending is anything between 2 to 7% of the nation’s population, and this total is on the rise. Hopefully UHC will stem this.
India's demographics playing in favor of shift to Digital payments. About 70% of India now is below the age of 40. Over 900 Million mobile phones in India. Over 60% are smart phones. AADHAAR has crossed over 1 Billion mark; its coverage is now at 93 percent among adults, 67 in children in the 5-18 age group and 20 percent of those aged zero to 5. Massive spread of Jan Dhan accounts, RuPay Cards in rural India, BHIM payment platform, Tax incentives for Digital payments, India's own GPS [NAVIC] are all preparations for the Digital onslaught on traditional lala and cash ka dhanda.
This year all balance sheets will show huge jump in revenue, assets and tax! win win for all. India will be soon ready for Universal Health Coverage! All the Healthcare MNC big boys are already eyeing India as it emerges from the shadows.

MAXimising Benefits

MAXimising Benefits

Published in eHealth Magazine : 01 October, 2010
The IT outsourcing deal puts Max Healthcare on the roadmap for becoming the best IT-enabled hospital chain in the country The Indian healthcare system has recently realised the potential of information and communication technologies in completely transforming care delivery at hospitals. The industry witnessed its first complete IT infrastructure technology outsourcing deal in September 2009, when Max Healthcare and Dell Services (formerly Perot Systems) partnered for developing IT operations at all Max Hospitals. The cost of the deal, Rs 90 crore (excluding infrastructure cost), is an indicator of the increased priority that is now being given by Indian hospitals to IT, which is an extremely positive sign. As per the agreement, the deal will last for ten years, out of which one year has already passed, and a lot of positive transformation has already been noticed. The unique partnership is not only expected to provide a lot of value to Max Healthcare in terms of enhancing the quality of services and reducing treatment costs, but it will also be a great learning experience for Dell, which marked its entry into the Indian healthcare market with this deal.Status update Post its inception in September 2009, the ITO deal will last for 10 years and which, according to Dell, will comprise of three major phases – transition, improving productivity and optimisation.
As one year has passed, the transition phase is almost over. During this phase Dell installed the entire IT infrastructure for Max, by migrating the already existing IT infrastructure to a modern infrastructure. The entire data centre of Max, which was housed in their Okhla office, was migrated to the Dell facility in Noida. To reduce hassles, the shifting work was done during off hours on weekends, so that the work at the hospitals does not get affected. The entire process lasted for a couple of months and currently all Max Hospitals are running from the data centre housed in the Dell facility in Noida. The servers and network devices have been installed with monitoring devices that generate alerts in case a problem arises. There is also a situation management process in place to ensure that even the problems of highest criticality get resolved within a definite period of time.
Summary of outcomes beyond the published article: Max Healthcare was the largest ever full ITO and Clinical Transformation Account of Perotsystems International. $20M deal across multiple years. Total Business Transformation done including technology, process, people and business. This includes Enterprise Architecture, Operations and Projects:
Phase I: Infrastructure Upgrade completed
  1. - Centralized Service Desk for L1 support and triage to L2 and L3 teams
  2. - Converted the P2P network to a MPLS private cloud
  3. - Servers from all 7 Max hospitals migrated to a remote data centre at Dell
  4. - HIS and all SW applications of 7 Max hospitals are now running from the Dell data center
  5. - Homegrown HIS re-engineered for stability, scalability and HL7 integration with VistA EHR
  6. - Physical, Network and Data level security established
  7. - Operations management as per SLAs
  8. - Governance process for decision making 
Phase II: 
  1. - Customization of Opensource VistA Electronic Health Record System. Max Healthcare is the largest VistA implementation outside the VA and anywhere outside the USA. 
  2. - Implementation of CPOE, CDSS, BCMA, ePrescription
  3. - Developed standard master data e.g. Service master, Lab master, Drug master, etc.
  4. - Order sets, Notes Templates
  5. - HL7 based Enterprise Application Integration using Mirth.
  6. - Clinical transformation as per ADOPTS methodology
Business Benefits realized by Max Healthcare:
  1. - Private Cloud IT Infrastructure: plug-n-play environment for new facilities
  2. - Business downtime due to infrastructure and HIS outages is history
  3. - Process Re-Engineering -- 1000 beds in 7 Hospitals; expanded to 1500 beds in 11 Hospitals. 
  4. - Standardized operations without disruptions reduced the waste and improved the topline. 
  5. - Near paper-less, > 95% Adoption in Clinical.
  6. - Achieved full NABH and HIMSS Stage 6 accreditations later. 
  7. - Hospital was able to attract FDI investments.
The grand success was lost somewhere in the merger of Perotsystems with Dell Services [now merged with NTT Data]. Though the success achieved in Max is unprecedented and still largely unmatched. Time to get the credit back to the team where it is due.

India has its own National eHealth Standards Now

MDDS is an initiative taken by Department of Electronics and Information Technology (DeitY) to promote the growth of e-Governance within country by establishing interoperability across e-Governance applications. This will help in semantic standardization and when aligned with the integration solutions will ensure interoperability among disparate systems.

In this regard MoHFW had prepared MDDS standards for Health in 2013, under the leadership of the Committee on MDDS for Health Domain with active participation of NIC, NHSRC, CDAC, Taurus Glocal Consulting, United Health Group and a number of technical partners and officials of MoHFW.

On 12th Dec 2013, The MOHFW organized a draft standards roll-out workshop. The purpose of this workshop was to appraise all stakeholders on the developments so far and deliberate on strategies for roll-out of the standards. Inputs received in this workshop will help in improving these standards. It will also help in bringing consensus for the nationwide implementation of these standards.

On 30th Dec 2016 MDDS has been notified as part of the EHR v2 2016.

a) Ministry of Health & Family Welfare Website
EHR v2 2016: 

MDDS for Health:

b) National Health Systems Resource Centre Website (

Proposed National eHealth Authority [NeHA]

Good to see national ehealth authority [NeHA], health information exchange [HIE] and national health information network [NHIN] reaching some real relevance. The concept note has been put into the public domain. You can read it here:
I had coined the term national ehealth authority [NeHA] in 2011 while doing the public health IT study report together with national health systems resource center [NHSRC]. You can see it here under Studies and Evaluations:
I then spoke about NeHA, HIE and NHIN at the WITFOR 2012. You can read it here:
I again spoke about NeHA, HIE and NHIN @ the eHealth conference Hyderabad 2012.
You can watch it here:
I then wrote about it in the meta data and data [MDDS] standards for health domain again in 2013. You can see it here
On 30th Dec 2016 MDDS has been notified as part of the EHR v2 2016. I am honored to see MDDS as part of EHR v2 standards now incorporated into the Digital India program.
Ministry of Health & Family Welfare Website-
EHR v2 2016: 
MDDS for Health:

Wednesday, June 8, 2016

Key Note Address @ Science and Technology Week JWTC GE Bangalore

I got a rare honor: I was invited by GE to deliver a Key Note Address @ the Science and Technology Week in JWTC GE Bangalore on 16th May 2016. I spoke about the New Healthcare Aggregators: SMAC and IoT.

The era of hierarchical command and control is over. Now is the time for horizontal networking across Communities of Practice [CoP]. Whatever gets the maximum likes becomes the In Thing. Whatever is the In Thing gets used the maximum. Students are learning more from the online networking than from the formal classroom and professors. Research will reach the point of use as soon as it gets published. Primary care Providers in semi-urban and rural areas will have access to latest therapeutic recommendations. The old Adage that 'Knowledge is the only form of power that is not expendable but grows when shared' has become true.

There is a huge Vacuum in Indian Healthcare-IT space. Large Healthcare-IT vendors have exited the market. Either they lost interest and exited or got bought out. Also the market is moving from client-server to cloud and from Capex to Opex models. New cloud based players are small in size and yet to reach enterprise class. Existing players are not able to shift out to cloud because of their long term negotiated contracts in client-server model. The time is now when full conversion of Enterprise class to SMAC will happen anyways. Healthcare CIOs can keep eyes closed or tighten the belt and ride the Digital wave.

Tuesday, May 24, 2016

CAUSE Methodology for Healthcare Organization Change Management

For Boot-Strapping Healthcare Organisation Change Management, I follow my proprietary CAUSE Methodology for managing change in people, process and technology. This has emerged out of our collective experience of managing change in healthcare organisations.
  • Consciousness of need to change: The people must be informed by the Head of the organization again and again until they are very clear in their mind about why the change in needed. There is no over communication for this. Treat the organization like an anxious child about to undergo a surgery and will need a lot of reassurance.
  • Aspiration to support change: The organization must Aspire to support the changes. Since the organization is going through a transition this is an opportunity for the organization to redefine itself across the organization. The Aspiration must come from within not without.
  • Understanding how to change: Once the organisation is conscious of the need to change and they aspire for the change from within then they are ready to be trained. Before this stage any trainings will be futile. Now train the team on new processes and technology extensively, again and again till it becomes second nature to them. Keep Checking for gaps in knowledge between expected and achieved.
  • Strength to over come hurdles and implement change: It is important to realize that processes will break and problems will happen when such a major implementation is done. Trick is to recognize the problem areas before it is too late to avoid big failures. Top management should be ready to cope up with the hurdle and internal resistance and not buckle down under pressure.
  • Ecosystem to support, sustain and adopt change: Lot of support is required in terms of hand holding and training till the change gets adopted by the users and is irreversibly embedded into the ecosystem. Unless you support the change till it becomes an ecosystem the change will not last. It will swing back to zero as an elastic and throw the organization into chaos.

My experience spans Organization change management, Business transformation, Clinical transformation, Knowledge management, Transition management, eHealth Consulting, mHealth Consulting, Chronic Disease Management, Solution design, Implementations. Due to my background and experience I am interested in Healthcare Operations, Pharma, R&D Labs, Medical Devices, IoT, SMAC, next generation technology platforms for Digital Hospitals.
CAUSE Methodology is an outcome of having done organization change management over and over again. I have applied this framework to many healthcare organisations in terms of IT, Process, Quality and Management changes. 

Friday, February 19, 2016

Top Health IT Trends to Expect in 2016

Technology has transformed healthcare around the world at a faster rate in the last few years than at any other time in history. There are many exciting innovations poised to help improve patient outcomes and the landscape of healthcare as a whole over the next few years. For 2016, we can expect to see the following IT driven changes in India:

Expanding Telemedicine Services

The telemedicine market in India is expected to reach a valuation of about $18.7 million by 2017, according to Deloitte. Since telemedicine makes it possible to provide needed medical services from a distance, this may be particularly helpful for individuals in rural communities that do not have access to the larger hospitals and centralized facilities. Medical professionals can provide advice to patients and can even consult with patients about specific issues using video chat options.

Greater Integration of SMAC

SMAC, standing for Social, Mobile, Analytics, and Cloud technologies have transformed every business in India and around the world and healthcare is no exception. As medical facilities get on board with using social options, patients will be able to interact with their doctors and obtain information about their health and well being in new and convenient ways. Analytics in healthcare will allow information to be analyzed and cross referenced, assisting with research and outcome improvement.

Mobile integration puts health information at the patient’s fingertips in a way that was not possible in the past. This may help improve outcomes and communications between medical providers and patients in countless ways as the shift to mobile is embraced. The movement from client server to cloud is shifting the industry IT vendor landscape, with many smaller and newer vendors beginning to replace large vendors that have traditionally assisted with IT needs.

Increased Use of Medical Wearable Devices

The use of health and fitness wearables has increased substantially over the past few years and is expected to continue to increase at an ever-faster rate until about 2020. Start-up companies are experimenting with creating wearables featuring health IT features. We may see prototypes emerge this year that allow patients to instantly send remote information about biometric data that is obtained using sensors in various medical wearables. This could allow physicians to spot medical issues much faster.

Improved Mobile Access to Health Insurance

Private health insurance covers about three percent of India’s population. The government health plan covers about eight to nine percent of India’s population, while the rest is paid out of pocket. In 2015 the Parliament passed the Insurance Bill where the FDI in Insurance was raised to 49 percent and health insurance has been declared as a separate business. Also 100 percent FDI was allowed in medical devices. These two policy changes will bring a boom to the mHealth and health insurance market in 2016-2017.We predict Insurance support for mHealth solutions including outpatient visits and chronic disease management or non-communicable diseases [NCD] as it is called in India.

Many companies now also allow individuals to apply for health insurance using mobile apps. In 2016, we can expect to see even greater competition in the industry with more mobile access and improvements in automating the claims process.

More Complete Patient Histories with EHRs

EHR and MDDS for health domain standards were notified in September 2013 and approved in December 2013, respectively. As medical facilities adjust to using systems to keep electronic records, we can expect to see more complete patient histories begin to affect outcomes and standards of care. This is especially true across borders, as many developed nations are now employing the same standards for coding and keeping EHRs. We may see 2016 bring forth improved software that simplifies electronic record keeping, transitions of care, coding, and billing.

Widespread Adoption of Surgical Robots

India has been behind the ball in adopting surgical robots for some time now, but we may see many more robots flood the hospitals this year. Intuitive Surgical, the creator of the U.S. based da Vinci surgical systems, considers India an important market. The Vattikuti Foundation plans to increase the number of surgeons trained to perform robotic surgeries from about 147 currently to 300 by 2020.

IoT Revolutionizing Patient Care

The Internet of Things is an extremely beneficial addition to the medical industry. We expect IoT platforms to emerge that will enable integration of all healthcare applications, devices, and things. Health monitoring devices can track vital patient information such as blood pressure, heart rate, and blood sugar levels every single day and communicate this information to medical professionals. Pacemakers and other medical devices can also be connected so that information is transmitted daily and not just during doctor visits. Medical professionals can directly communicate when information is worrisome and can save time from running unnecessary tests when health signs are good.

CRM Improving Patient Relations

Customer relationship management has always been important, but is now easier than ever because of SMAC technologies and EHRs. Doctors can communicate more freely with patients and can track all interactions for future review. These options will help make doctor/patient relations more personalized. A personalized approach will improve patient satisfaction and may also help to improve outcomes.

Guest Author: Amanda Flowers is a graduate in Psychology, with minor in English Literature and Public Health. She draws on her knowledge of these subjects to create online content that addresses human needs in a simple way. Flowers is currently a freelance health blogger and working for Blue Cross Blue Shield of NC .

Co-Author: Dr Pankaj Gupta, Healthcare Business Executive, @pankajguptadr,