There is no Market for EMR in India

India is a very price sensitive market. The Maruti/Suzuki advertisement - 'kitna deti hai?' is an epitome of the reality. The big success of the mobile/telecom in India is because of it gave an instant gratification to the users. The Sabjiwala vendor keeps a mobile because of free incoming, such that he can be called by the customers for home delivery and he gets an instant boost to business - instant gratification.  

Likewise in the Healthcare the hospitals have a 2-5% budget for IT and give a step motherly treatment to IT. All because IT is considered as a support function and not a direct business benefit. Most of this budget is spent in areas that give tangible business benefits and/or instant gratification - e.g. HIS and in that for Billing, Material Management, Procurement, Lab and Pharmacy. The EMR is an after thought and that too almost never for clinical reasons; rather EMR is used as a point-of-use application for material management. 

The current Healthcare Financing model is to blame for this. Every cost gets passed on to the patient. >80% is pay-out-of-pocket. Therefore the hospital must ask the question at every stage - After all how much can the hospital load the patient's bill? Almost 2% of the Indian population falls below the poverty line every year because of medical expenses; for which they have to sell their land and assets.

Bottomline - Indian Healthcare-IT market is very small and almost negligible for EMR, until new models of Healthcare financing emerge - e.g. Govt's Universal Healthcare, 49% FDI in Health Insurance, Micro Finance etc.    

IT Planning in Hospital Planning!

-------------------------
Read TG Hospital Planning Framework on slideshare: https://www.slideshare.net/PankajGupta9/tgi-hospital-planning 
-------------------------

Yesterday I had a meeting with a hospital planner who is planning the expansion of a super specialty Govt hospital in Delhi.

He wanted to get a consultant to plan the cables/routers/switches/LAN/WAN for the hospital. I lost the battle of convincing him that - the cable/router/switch/LAN/WAN design depends on the hardware infrastructure requirements, that in turn depends on the medical devices and software application portfolio. In other words Hospital IT portfolio is extremely inter-dependent and it is self-defeating to plan the Hospital's cables/routers/switches/LAN/WAN components in isolation.

He couldnt understand that the Lab, Radiology, Cath lab, Oncology, Laproscopic OT etc will need redundancy and additional capacity in terms of cables/routers/switches. We need to calculate the average and peak load for each Dept. and then design the cables/routers/switches/LAN/WAN as per that. Whereas typical cable vendors dont know how to calculate transaction loads in Hospitals. For example bulk uploading of Lab results needs a network capacity that is far beyond the regular. LAN/WAN design will also depend on weather you want any wi-fi in wards and selected patient areas or whole hospital. 

Someone needs to decide if all the servers will will be located locally or in a remote data centre. Considering the performance issues, it is better to have the imaging servers located locally. Need to plan for a local server room and network cabinets on every floor because Smart hubs/switches/routers need a server room environment. Further someone needs to have a back-up and disaster recovery plan. The cables/routers/switches/LAN/WAN design is dependent on many such considerations. It is never a cake walk as he assumed it to be!

The industry doesnt have any single vendor that has all the consultants in one team. The only way is to have a Healthcare-IT 'Principle Consultant' that can assemble a team of functional, software, hardware infrastructure and cabling consultants for planning the entire IT Roadmap for the Hospital.

I have seen some hospitals in GCC region [without taking names] that have very high adoption of IT systems by the end-users coupled with JCI Accreditation with minimal non-compliance. These are an indication of IT integrated into Hospital process and design. 

India needs Health Information Exchange for Universal Healthcare

Universal Healthcare by nature of the word Universal cant be done without public and private sector healthcare providers and payers coming together on the same platform. Essentially this platform has to be an IT platform because no paper model or human brain can process so much data and still keep it accurate across the board. India needs an health information exchange [HIE] to enable Universal Healthcare dream. The HIE must have Registries for Identity management of patients, doctors, facilities and payers. Somehow the public and private sector decision makers fails to understand this simple fact. Or shall I say that people born before 1960 have a severe disability and prejudice towards anything to do with technology. Unfortunately it is this generation that is in the decision making positions today. I guess we have to wait another 10-15 years before new blood can replace these old hags and make some better decisions for Universal healthcare. Until then the Health of Indian citizens will continue to suffer. God save us if an epidemic or pandemic was to strike in the meantime. Worse - India will be sitting duck, caught napping if a CBRN disaster happens.

mHealth Buzzword has become Lopsided

This is my post from 2010 in my googlegroup, where I had said that B2C mHealth model will fail. Just reposting it here for a wider audience as the topic is getting relevant again due to failures of B2C mHealth ventures:

mHealth has become a latest buzzword for many telecom companies presumably because they offer consumer oriented services over mobile, and want to enter another sunrise vertical - Healthcare.

In my opinion - mHealth means connecting all the Healthcare stakeholders using a mobile platform and enabling the health
information exchange. Whereas currently mHealth is being promoted just as 'Call a Doctor' service.

In the Healthcare context it is incorrect to assume the patient as a consumer; rather the Patient-Doctor relationship is at the centre of
healthcare.

Unlike mEntertainment, mCommerce or mBanking, you cant pay and download healthcare over a mobile! A doctor needs to make a diagnosis based on inspection, physical examination and various other factors that are missing in a simple mobile telephonic interaction.

Having said that, mobile services render themselves very favorably for chronic disease management where the doctor is already familiar with the patient and can pull up the patient file to provide an advice to the patient over the mobile. However even this should be treated as an interim consult until the the patient can get to the hospital/clinic.

Health Information Exchange will be the next big healthcare application over mobile services together with broadband internet.
Perhaps the industry has to get there after experimentation/failures.

Global HIS/EMR vendor nightmare outside US

No credible large health IT company present in this sector today.
Unique confluence of events resulting in ALL major global health IT companies undergoing major transformations or facing business challenges or not focused on this geography today.
Service companies not stepping up to fill the vacuum, including global IT service vendors.
Private sector CEO’s/CIO’s, in this sector, grappling with - ‘which system / vendor do I select now’?
Public sector and Governments losing faith after spectacular global failures.
Market is, competitively, extraordinarily open to all. No single vendor today has significant credibility, or has the business focus or currently has the scale / resources required to be the leader in this market.

• Google withdraws Google Health Platform
• Microsoft shuts down Amalga outside US
• Microsoft downsizes Health Vault globally
• Cerner shies away from expanding Internationally
• Cerner and iSoft penalized in NHS projects
• iSoft acquired by CSC – Cultural conflict between product and service cultures imminent.
• TrakHealth acquired by Intersystems – product portfolio conflict within Intersystems
• Epic, McKesson, Eclipsys/Allscripts, GE – almost exclusively US focused. Looking outside the US only on special request and on an exception basis.
• Similar scenario in established Indian Health IT product companies eg Napier Healthcare struggling to scale up.
• IBM, Accenture – shutting down generic HIS/EMR/LIS/RIS service practices.
• Infosys, Wipro, TCS – downsizing , struggling or moving away from healthcare IT services.. Struggling with Productization strategy even in Indian health IT sector alone.
• FCG and Covansys acquired by CSC – no further progress on their deep healthcare research capabilities.
• ACS acquired by Xerox; Perot acquired by Dell - Cultural conflict between hardware and service cultures imminent.

On a short-term to medium-term, Quarter-by-Quarter cycle basis, Healthcare IT always looses out on financial ROI as compared to any other industry vertical. Whereas on a long-term 7-10 year horizon, Healthcare IT gives sustained returns because it is a recession proof industry. However this doesn't fit in with the typical 3-5 year investment cycles.

** Disclaimer: All this information is based on a combination of our collective consulting experiences, knowledge of the healthcare industry, published news articles and our own analysis. We are posting it here just as a consultant's opinion without any prejudices. -- Dr Pankaj Gupta, Dr R Balaji.

Size of Healthcare-IT Market in India

There are a lot of numbers floating around on the web about size and scope of Healthcare IT market in India. Therefore I decided to add to the confusion. Here is my take on it--

Size of the Healthcare-IT Market in India:

- beds to population ratio 9:10000 or 0.9:1000 which is less than 1/3 of WHO recommendation. [Kaiser Family Foundation - http://www.globalhealthfacts.org/data/topic/map.aspx?ind=78]

- Considering 1.2 billion population of India = i.e. 1.2 * 10^9 / 1000 = 1.2 * 10^6 beds = 12 Lac beds

Cost of building 1 bed = INR 40 Lac. Usually 15% of that is the cost of hospital operations per year. 

Usually the hospitals allocate 2-5% [Average 3.5%] of budget for IT.  

The Healthcare IT market is about USD 504M per year. ((1200000 * 4000000) * 15%) *3.5% = INR 2520Cr = USD 504M

- India needs 80K to 1 Lac beds every year for 30 years. [Deccan Herald - http://www.deccanherald.com/content/94485/india-needs-add-1-lakh.html,

http://www.reuters.com/article/2008/06/04/idUS117882+04-Jun-2008+BW20080604]

Commensurate to the expected growth of hospital beds, the Healthcare IT market is expected to grow @ about USD 160M per year. ((80000 * 4000000/2) * 5%) = INR 800Cr = USD 160M

- Whereas [in real] India has been able to add only 10k-15k beds every year for past 5 years. [http://www.rediff.com/money/2009/jul/27india-inc-finds-wealth-in-health.htm]

The Healthcare IT market is currently growing @ about USD 30M per year. ((15000 * 4000000/2) * 5%) = INR 150 Cr = USD 30M

Therefore Total Healthcare-IT market size = 504 + 30 = $ 534M. Currently growing every year @ 5-6%. If the new hospital infrastructure picks up speed, then we can expect the market to grow @ 31% every year.

---------------------------------------

Spectrum of Healthcare-IT deals:

Only the top end hospitals have implemented EMR. Rest all the hospitals and healthcare organisations have clinical work mostly on paper. They have implemented some stand alone IT systems such as billing, material management, Lab, Pharmacy or all of this in a single HIS. However the HIS is for administrative and auxiliary medical functions only and it lacks any clinical automation.

Top 5 Hospital chains are entering into multi year contracts for total IT outsourcing.

Example1 - Max Healthcare has a ITO with Perot Systems worth USD 20M over 10 years. Includes infrastructure upgrade, EMR implementation, application support and clinical transformation. It is a private cloud hosted on the Dell data center. [http://www.expresshealthcare.in/200910/market32.shtml]

Example2 - Fortis Healthcare has a ITO with HCL worth USD 15M over 5 years. Includes infrastructure upgrade, new application implementation and support. this includes support for EMR. They have TrakHealth EMR from Australia. Now TrakHealth is owned by Intersystems USA. It is on a private cloud hosted in HCL data center. [http://www.financialexpress.com/news/fortis-signs-outsourcing-deal-with-hcl/525300/]

Example3 - Manipal Hospitals has signed a deal with Wipro for implementation of Wipro HIS product over 10 years. Manipal Hospitals also has a similar deal with TrakHealth EMR from Australia.  The size of the deal is not known.  [http://www.thehindubusinessline.com/industry-and-economy/info-tech/article3480169.ece]

Example4 - Narayana Hrudayalaya has signed a 10 year deal with HCL for putting their applications on the private cloud infrastructure. NH is implementing the ICT HIS/EMR, which is a break away group from earstwhile SRIT. The size of the deal is not known. [http://www.medicalbuyer.co.in/index.php?option=com_content&task=view&id=3988&Itemid=92]

Lower end of the spectrum is 20-50 bed nursing homes. There are HIS products being sold for INR 5-10 Lac for licenses including support for 5 years.

Chains of Labs and Pharmacies are the new entrants into the Healthcare-IT. It is a good trend to watch but the largest chains have only a few hundred centers which is a minuscule as compared to the mom-and-pop shops and fly-by-night Lab and Pharmacy operators in this market.  

GP clinics have little or no automation in their clinics. They dont have the motivation for any IT implementation. Also they cant afford a capex model in IT because they work on a extremely low-cost opex model.

The market is extremely price sensitive, it is looking for solutions on the public cloud with an opex model. Almost all healthcare organisations dont want to own any capex. However they are most concerned about the data security because India lacks any data security act.

The funny thing is that most hospitals budget for IT as a support function and not as a core business enabler. Therefore it gets a very low priority. Also they invest in IT because its the in-thing not because they need to solve a business problem. No one can call any IT implementation a success because the success criteria were never established. The large hospital chains have now started investing into large deals way beyond their budget because they have burnt their fingers with fly-by-night operators; but it is still not clear to them as to what do they want out of it!

spoke @ the World IT Forum 2012

Folks, I spoke @ the World IT Forum 2012 in New Delhi.


Theme: Institutionalizing the use of ICT for better healthcare.


Just wanted to share it with you all.
WITFOR 2012 Presentation

Innovation

I was recently appointed to the Health sector innovation council. The question that stared at me was - why India lacks innovation. India's track record is poor in building products and brands. Why is it so?

Traditionally Indians have used their ingenuity to find the ‘Jugaad’ that works around the paucity of resources and funds. Somehow we have lost it along the journey towards modernization and this Jugaad paradigm didn’t permeate into our modern education system and work ethic. In many ways our current paradigms don’t promote innovation.

In our modern life, Innovation is killed in a very organised manner starting from tender age. We got scolded by parents and were asked to 'shut up' when we asked too many questions. We were beaten with a ruler by the class teacher for being purely inquisitive. Our schools are still designed to produce clerks for empire. Professor threw us out of the class for challenging his/her hypothesis. The boss grossly lowered the annual appraisal rating because we had too much independent thinking!

The British tasked Thomas Babington Macaulay to create our so called "back-breaking" education system way back in 1835. The fossilized education system to which we still cling on to today is 180 years old! Obviously we could not do anything while the Brits were ruling us. But what about the 65 years after that? They called it quits in 1947. We sat back comfortably in our kursis, chewed paan and continued blaming the British for our woes. Still. 65 years after they quit having to do anything with India!

 

And now as a country we are wondering why we lack innovation! Our innovative spirit died long ago. Our parents, teachers and bosses are proud of rooting innovation out and making us worthy of modern society and rise up the ladder. Our education system, parenting philosophy and work ethics kill innovation rather than promote it.

We must change the paradigm today to expect some innovation emerging from our next generation in 20 years.

Also Read my blog: Higher Education System Suffers - http://healthcareitstrategy.blogspot.in/2014/10/shortage-of-teachers-higher-education.html

References:
https://en.wikipedia.org/wiki/House_of_Commons_of_the_United_Kingdom
http://timesofindia.indiatimes.com/interviews/Our-schools-are-still-designed-to-produce-clerks-for-empire-Sugata-Mitra/articleshow/19113224.cms
https://en.wikipedia.org/wiki/English_Education_Act_1835
http://vadakkus.com/2013/02/12/macaulayism-origin/