MAXimising Benefits

Max Healthcare IT Transformation Cover Story in Ehealth Magazine Eletsonline. Perot systems corporation Total ITO. Largest VistA EHR implementation outside the Veterans Health Administration (VHA) - U.S. Department of Veterans Affairs and outside the USA. The institutional memory of the grand success was lost in the merger of Perotsystems with Dell Services further merged with NTT Data. Though the success achieved in Max is unprecedented and still largely unmatched. Lot of firsts here. First Indian Hospital chain to go on a private cloud. All Hospitals working from the same HIS/EHR/LIS with common IDs for Patients, Doctors, Facilities. Records having Diagnosis, Procedure, Lab Standard Code Sets.

Published in eHealth Magazine : 01 October, 2010, Read the details

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.

Original publication for Reference: http://ehealth.eletsonline.com/2010/10/11436/

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. HIS and all other software applications of 7 Max hospitals are now running from the Dell data centre
4. HIS re-engineered and stabilized to take the load of new environment
5. Physical, Network and Data level security established
6. Operations management as per SLAs
7. Governance process for decision making
8. Integration with Medical Devices - ICU, ECG, EEG, LIMS, Lab Analysers, CT, MRI, Modalities, RIS, PACS, Surgery, Scopes etc.
9. Bar Code, Medication Administration and Nursing Devices
10. Computer on Wheels, Mobile CPOE Orders Devices
11. Retail Pharmacy, CRM, Physician Mobile, Remote Monitoring Devices

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 institutional memory of the grand success was lost in the merger of Perotsystems with Dell Services further merged with NTT Data. Though the success achieved in Max is unprecedented and still largely unmatched.

Read the details

Healthcare IoT - Welcome to The Future

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Listen to Dr Pankaj Gupta speaking @ IoT Grand Slam 2015:
https://www.youtube.com/watch?v=bFSm4Xhr4E0 
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The global IoT healthcare market is expected to grow from $30 billion in 2015 to $150 billion+ by 2020 and IoT-enabled connectivity within hospital labs will increase total global laboratory test throughput by more than 3 billion diagnostic tests over the next 5 years. 

The Internet of Things (IoT) is the network of physical objects or “things” embedded with electronics, software, sensors, and network connectivity, which enables these objects to collect and exchange data. This has huge applications and implications on Healthcare. Are we prepared for the next big game changer? 

Every aspect of healthcare has devices from direct care to supporting care and rehab to community care. With the advent of smart mobile phone that space started getting connected and shrinking into the smart phone. Now the smart phones are eating away into the medical devices space. The networks are getting smarter such that the line between IT infrastructure, Networking and Applications is blurring as we move to the cloud. The Digital Hospital has all of these. Whereas Disease management takes this beyond the enterprise into the homes and lives of the person. Insurance and Pharma are analysing the lifestyle data which is not necessarily disease data. Our lives are rapidly getting digitized! 

On the flip side: Imagine what happens if someone changes the calibration of Lab analyser, Radiology modality, Cath Lab, Dialysis devices, ICU or bedside monitors. Or switches off a pacemaker. Or changes the rate of infusion or gas in the OR. All of this and more can be potentially done remotely in an IoT connected world. Scared already? Welcome to the future.

Look for the latest IoT Slam event @ https://iotslam.com/

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.

https://www.linkedin.com/pulse/new-healthcare-aggregators-smac-iot-dr-pankaj-gupta

CAUSE Methodology for Healthcare Organization Change Management

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See Dr Pankaj Gupta @ Healthscape IDE 2017 Panel Discussion Video1: Clinician Adoption challenges are the biggest hurdles to hospitals adopting technology. What are these Adoption challenges? Dr Gupta trying to defend that Change Management is important but in-vain :-) !
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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.

Most of the large transformation projects fail because the contract did not make time and budget for the Change Management and the organisation did not recognise Change Management as a specialised expertise.

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.

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.

New Healthcare Aggregators: SMAC and IoT

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See Dr Pankaj Gupta @ Healthscape IDE 2017 Panel Discussion Video 2: https://youtu.be/7RgY-5lp1qQ. Why are hospitals not moving to cloud computing?

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The old paradigm of business as a linear value chain is now facing extinction. Businesses are now ecologies and not merely producers and sellers ! That requires a change in thinking. Customer Relationship Management (CRM) needs to be a mission at every step of the process. This is hard to overemphasize! The internet is clearly the medium that allows such integration across time and space. It is time to take a more accepting look at Cloud and Social Media technologies. This offers the only universal layer of engagement across stakeholders. The investment in IT hardware as we knew it in the past has been greatly optimized by mobile. It has brought a tactile feel to life and work for all of us. Mobile mirrors the nature of Healthcare in terms of immediacy and continuity so well. Healthcare needs to embrace it wholeheartedly. Healthcare can only profit from it.

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 e.g. TrakHealth, iSoft. Also many traditional HIS/EHR are losing market share as the market is moving from client-server to cloud and from Capex to Opex models e.g. Wipro HIS, TCS Med Mantra, HealthFore. Many of these players like Wipro, TCS, CSC are suffering in their primary market [USA] due to shifts in US Govt policy and Automation and hence lack the Executive confidence to invest in product upgrades for the Indian market. On the other hand many incumbent players are not able to shift out to cloud because of their long term negotiated contracts in client-server model e.g Napier, Akhil, Srishti. New cloud based players like Dwise, UBQ, SRIT, ICT, Attune are small in size and yet to reach size and scale. Whereas Practo is trying to solve a problem that doesn't exist! Someone was stupid to assume that Appointments and Scheduling will sell whereas we Doctors want to see long waiting line of patients outside our clinics. Also the patients like to see waiting queues - in Doc sahib ki chalti hai.

Effect of Demonetization -- many hospitals are going to be sold off to PE that can invest in FDI e.g. Fortis is on the chopping block. The new management is going to hit on the bottom-line, optimize processes, re-skill staff and invest in growing the topline. All this is obviously a compelling case for Digital! So the time is now when full conversion of Client-Server Enterprise class to Digital [SMAC, IoT, CRM, AI] will happen. Now Healthcare CIOs have a choice to make - keep eyes closed and risk losing their jobs or tighten the belt and ride the Digital wave. Welcome to the Future!

The Government push towards MDDS/EHR Standards is not helping the old horses. PM Modi has put the focus of his Digital India on Healthcare, Education and Jobs [see http://economictimes.indiatimes.com/topic/Digital-India]. Whereas Healthcare is a State Subject and District Health Officers are wondering how do we benefit from Digital! Hard for many to imagine SMAC is a unifying force across enterprises and IoT breaks the silos. PM Modi's Digital India can be quite a game changer!

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.

The movie Avatar has beautifully depicted the concept of Small data ^ = Big Data where small knowledge base of each living being [App] is contributing towards the collective consciousness [Big Data] of Eywa. Now the question is will the future of SMAC/IoT be driven by technology or biotechnology?

Anyways for now - The time has come when you don't need big monolithic HIS software to run hospitals. Now you can do everything with small mobile based Apps for every function. Though I am already seeing many of these Apps in the market but what is lacking is a unified platform on which the Apps should be built such that the data can be seamlessly collated. Also it gives the provider the flexibility to select from a bouquet of Apps.

IoT integration platforms are emerging that will integrate at the App level, Data level and Semantic level. Anyone in the ecosystem can slice, dice, run reports on the collated data.

Successful Cloud models have dug the grave for the Enterprise Hardware. Capex has got converted to Opex. Now you can pay for the software on the cloud like you pay your monthly electricity bill.

SMAC coupled with IoT has a potential to bring the Aggregator Business model to Healthcare. Soon the unorganised and fragmented primary care, secondary care and supporting care market will begin to get Aggregated. I see these Aggregators becoming larger than established capital intensive Enterprise market similar to what happened in the Automobile market. It will be in the interest of Insurance, Pharma and Govt to go all out and support this emerging SMAC/IoT driven Healthcare Market Aggregation.

What happened in the FinTech space will now happen to HealthTech too. Just as the FinTech became a game changer to the Financial sector, a Digital Healthcare Ecosystem is taking shape. So many times bosses mocked new technology and got it wrong! Healthcare Businesses that are still in a denial mode will have huge re-skill challenges and risk shut shop.

References:

Why Healthcare must Re-imagine itself - and how

https://www.linkedin.com/pulse/why-healthcare-must-re-imagine-itself-how-arun-kumbhat

Why All Indian Hospitals IT is in Bad Shape

http://healthcareitstrategy.blogspot.in/2014/04/why-all-indian-hospitals-it-is-in-bad.html

Global HIS/EMR vendor nightmare outside US

http://healthcareitstrategy.blogspot.in/2012/08/global-hisemr-vendor-nightmare-outside.html

Thick client vs Thin client

http://healthcareitstrategy.blogspot.in/2008/08/thick-client-vs-thin-client.html

There is no Market for EMR in India

http://healthcareitstrategy.blogspot.in/2012/10/there-is-no-market-for-emr-in-india.html

Size of Healthcare-IT Market in India

http://healthcareitstrategy.blogspot.in/2012/06/size-of-healthcare-it-market-in-india.html

Indian Pharma companies on US FDA lens

Why are so many Indian Pharma companies failing on Data and Quality standards and getting warnings that can lead to 483? Currently, 40+ Indian manufacturing sites are listed on FDA’s import alert list..

Global Supply-Demand issues: Indian Pharma is a major supplier of Generics to the world. If shun atleast 2/3 of the world runs a risk of demand-supply gap in Generics. Hence it is in the interest of UN, WHO and Developed Economies to help Indian Pharma climb the FDA compliance.

Cultural Issues: Traditionally Indian Pharma industries lack respect for Data and Quality paradigm. IT and Quality are the least paid and lowest in Hierarchy. Compare it to the Global Pharma MNCs where the IT and Quality hold Director or C-level positions.

Regulatory Issues: Highlighting weak regulation and monitoring of the domestic drug industry, three recently-introduced medicines are being prescribed and sold though there is a lack of rigorous trials on crucial safety and efficacy parameters. The pharmaceutical industry in India should face the same stringent regulations as elsewhere in the world, rather than continuing to allow patient safety to be put at risk by unproven drug treatments, says an article published in TOI. The Quality issues arise because Pharma Industry is under Ministry of Chemicals not under Ministry of Health @MoHFW_INDIA. This is a huge accountability gap in India. It will be in the interest of Public Health agencies like WHO and Global Fund and Global Pharma MNCs to demand the Dept of Pharmaceuticals to be located under the Ministry of Health with proper accountability established.

Data Reliability: Majority of the FDA observations are for relatively commonplace documentation or procedural issues...so many of the observations are for egregious errors like altering official documents in front of an inspector, or documenting important manufacturing or electrical data on scrap paper in pencil. Manipulated clinical trials data. “Generic” user accounts had been created in the Laboratory Information Management software system.

QA/QC Issues: Manager has admin rights on the software to edit or overwrite the data. Fudging of attendance records such as same employee working in 2 different sites at the same time. Even unauthorized QA document control stamps are reported. 

Other issues: Partially completed and/or unofficial training records. No response to consumer complaints. Incident reporting cover ups. 

References:

• FDA Form 483s From India: A Deep Dive Into the Problems: http://www.raps.org/Regulatory-Focus/News/2015/11/09/23562/FDA-Form-483s-From-India-A-Deep-Dive-Into-the-Problems/#sthash.bMMKjjGv.dpuf
• The Rs1 trillion FDA impact on Indian pharma: http://www.livemint.com/Companies/zcSsHW6iNvlulIW5K1qk9N/The-Rs1-trillion-FDA-impact-on-Indian-pharma.html
• Cadila Healthcare shares slump 15% on warning letter from USFDA http://www.financialexpress.com/article/markets/indian-markets/cadila-healthcare-shares-slump-over-15-on-warning-letter-from-usfda-december-31-2015/185907/
• Indians face risk from unproven drugs: Lancet http://timesofindia.indiatimes.com/india/Indians-face-risk-from-unproven-drugs-Lancet/articleshow/49029617.cms