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I see patients who have done IVF cycles in other clinics all the time. How they responded in the earlier IVF treatment cycle provides me with valuable information, based on which I can tailor a better treatment protocol for them.

One of the basic questions I ask them is - Please tell me more details about your earlier IVF cycles . What were the meds which were used for superovulation ? What was the dose used ? How many follicles did you grow ? How many eggs were collected ? What was the E2 ( estradiol) level in the blood ? How many embryos were transferred ? What was the embryo quality ? DO YOU HAVE PHOTOS OF YOUR EMBRYOS ? What was the endometrial thickness ?
Can you please show me the printed treatment summary from your IVF clinic ?

Many of them look at me blankly. ( I am sure some of them wonder why I expect them to know all this - after all, they are just patients, and not doctors ! )

Others get defensive and say -
" The doctor did not tell us anything. "
" The clinic does not provide medical records. "
" They keep a copy of the medical treatment and do not give the patient anything at all."

Now I think that any clinic which does not routinely give the patient a treatment summary of their IVF cycle at the end of the treatment is a bad clinic . However, while the absence of the medical treatment summary reflects badly on the doctor who provided the treatment, it is also a reflection of the fact that the patient has been a bad patient as well !

" The doctor did not give me a copy of the records " is not a good answer. Getting a copy of your medical treatment details is not only your right, it's your responsibility as well ! And if you do not assert your responsibility, then you are as much to blame as the doctor is !

It takes two to tango - and while you cannot change someone esle's behaviour, you can change your own ! Start off from the first visit by observing what happens in the clinic. Does the doctor give you a copy of your consultation sheet ? your lab tests ? Do other patients have their records with them ? Ask at the first visit itself what the clinic policy is about medical documentation.

If your doctor refuses to give you your records after your treatment is over ( because he does not want you to go to another doctor), then you need to become assertive ! Ask for a copy of your medical records - and make this request in writing, with a copy to the Administrator of the Hospital. If you do not get a reply, then ask your lawyer to write the letter for you - I can guarantee this will produce results !

Patient Centered Health Internet: "Eventually, the IHE-based Health Internet will support patients as equals on the Health Internet. Eventually, the routing between different IHE nodes will be more direct, and then the benefits of IHE might begin to outweigh the benefits of the simple Direct Exchange.But for now, the Direct model empowers the patient in ways the IHE model could never hope to."

New models will allow patients to share their medical records with other doctors - and with other expert patients as well - many of whom can give excellent advice, since they've "been there , done that " !

Why do Indian doctors continue practising in exactly the same way their seniors did 40 years ago ?

A major lacuna is the poor quality of medical records which most doctors keep. The medical record is the heart of clinical care - and yet it's extremely poorly maintained in Indian clinics today. The majority of doctors do not even bother to store and keep their patient's medical records - they just write down their opinion on their letterhead and hand it over to the patient. Usually, this is just a laundry list of tests the patients needs to do and a hand written illegible scrawled prescription - without even a mention made of the clinical findings or what the diagnostic impression is ! While it's good that the patient owns his own records, what happens if the patient forgets to get his records for the next visit ? This creates a lot of frustration for the doctor, who berates the patient for his carelessness - but the damage is done ! Wouldn't it make much more sense to keep a copy - and give one to the patient if he wants it ? Is this a lot of hard work ? Not anymore ! In the old days, one would have to make carbon paper copies or provide xeroxes, but using electronic medical records, this is now very easy to do !

Clinical care protocols are very similar in the US and in India. This is hardly surprising - after all, patients are the same the world over , and most will need the same kind of treatment. However, while most Indian doctors will provide exactly the same standard of medical care a doctor in the US does, why is there such a big difference in the way they keep medical records ?

In the US, every medical encounter is carefully documented ! Perhaps this was originally done for protecting against lawsuits for medical negligence; but today, the US government is making it compulsory for all US doctors to use EMRs - not just to improve the quality of care, but also to reduce costs ! Why don't Indian doctors use exactly the same approach to documenting their clinical care ? Are they too busy to do so ? too lazy ? or do they feel it's not important enough ?

Why do most doctors in India not bother to document their clinical encounters well ? Why is medical record keeping still shoddy and badly done in most practises ?

If Indian doctors understand the clinical importance of keeping good quality medical records, then why are they so reluctant to use EMRs ( electronic medical records ) ? In the past, it was true that PCs were very expensive; and that few doctors would afford them. Also, many older doctors were not very computer -literate; and the software programs which were available for medical record keeping were very doctor-unfriendly ! A combination of computer-unfriendly doctors and doctor-unfriendly software meant that most doctors were quite disillusioned with EMRs and were not willing to use them.

The good news is that things have changed dramatically ! Technology has improved; computers have improved; and Indian medical software companies such as Plus91 ( in which I am an angel investor) are realising the importance of mapping the doctor's clinical processes and respecting his work-flow so they are now making EMRs which are doctor-friendly and which enhance his productivity !

So why aren't Indian doctors rushing out to buy these , given the fact that they are inexpensive and can help them to improve the care they provide to their patients ?

Partly, this is because of the unhappy experiences doctors have had with Indian medical software in the past. It was the computer-savvy early adopters who were the first to lump on the IT bandwagon 10 years ago, to try to use computers to improve clinical care. Unfortunately, they burnt their fingers, which is why they are reluctant to try again.

As a consequence, most doctors do not know any one else who is using EMRs; and because they have little exposure to practise management skills during their training, they still do not understand the value an EMR can provide to their life.

Another major problem is that Indian doctors are not willing to pay for this. This is because they have been completely spoilt by the pharma companies . Because they are so used to getting everything free from pharmas, they are not willing to pay for anything at all ! This means EMR companies find it hard to sell their products - but if they do not generate revenue, how will they be able to produce good software ?

Please remember that your patients form the heart of your practise - and your patient's medical records are worth their weight in gold. If you keep them carefully; update them religiously; and share them with him, you can show your patient that you have all his medical details on your fingertips. This will help to inspire confidence in your clinical skills . Patients will rave about how well-organised you are - and this word of mouth marketing will help you get more patients, as it differentiates you from other doctors.

Also, by keeping your patient's records, you are creating a lot of patient loyalty and "stickiness" . If your patient is confident you know all about him because you have all his medical details, he is going to be very reluctant to switch doctors - after all, who wants all the hassle of explaining his medical history all over again to a new doctor ?

However , if you do not keep your patient's records; and the patient has to start explaining everything which has happened to him every time he sees you, be is likely to lose confidence in you very quickly ! ( That doctor does not even remember my name - forget about my medical problems !)

Hospitals in India have started documenting medical care electronically; and boutique medical clinics and chains have also started doing so. This is very heartening progress - and doctors who do not start doing so soon are going to find they will start losing their patients to computer-savvy doctors ! You need to move with the times - or you will get left behind !

We treat patients from all over the world and many of them want to do a phone consultation with me before coming to our clinic for an IVF treatment.

I can understand why they want to do so - after all, going half way across the world to get treated by a doctor you've never seen or met is a major leap of faith - and talking to the doctor can help to reduce some of this anxiety !

While it's true that the human touch is very important in providing good medical care, the truth is that it's not humanly possible for me to do so. This is true for many reasons.

For one, because of time zone differences, it's quite difficult to find a time slot which suits both the patient and me. We often end up playing phone tag - causing even more frustration ! Also, phone connections in certain countries ( such as Africa) are not of good quality, so that it's hard to hear each other. Also, sometimes patients forget some of their questions ( not all of them are well organised enough to prepare a list of their questions) , which means they often need to call twice or thrice ! Also, sometimes they do not understand what I am saying , because I may use a medical term they are not familiar with and it can be hard to explain everything in detail on a phone call . Another problem is that the husband calls me ; and after I finish answering his queries , his wife calls in another 5 minutes for additional clarifications, because he could not explain to her what I told him ! And when I am busy seeing patients in the clinic , it's hard for me to spend time on the phone . This means that my phone conversations are often short , which gives patients the wrong idea that I am curt or rude !

However, my major argument against a phone consultation is that it is not a very efficient means of communication ! There is no documentation , and too much scope for confusion and errors. This is why I prefer email, where everything is written down. I can answer as many questions as the patient has - and the patient can share this information with friends or family members who are doctors or nurses , to make sure I am providing sensible advise. They can also cc their spouse, to make sure everyone is on the same page. Because we can store and refer later on to this email conversation trail, there is no scope for ambiguity; and no confusion about medications or their dosages .

It's also much easier for me to answer more complex questions in case more clarity is needed, because the patient can ask for more details in his reply, in case he does not understand something I have said. Moreover, the advise I can provide by email is far more sophisticated and reliable as compared to a phone call, because I can think carefully before sending the email ! Email also allows the patient to send me all their medical records, so I have all the medical details I need to provide intelligent answers , customised to the patient's medical history !

A major benefit with email is that I can provide links to the relevant pages on our website, so they can get even more detailed information about their specific problem. While some patients email is much more impersonal than a phone call, I believe email is much more efficient, when used intelligently !

This is why I request patients who want to talk to me to send me their medical details by filling in the free second opinion form instead, so I can guide them properly. Some get upset with me because I refuse to talk to them on the phone - while others understand that I am doing so in

This is a guest post from Mr Aditya Patkar, Marketing Director, Plus91.

Patient Safety is a vital aspect of healthcare. Medical errors can lead to deaths and medical tragedies which are preventable , leading to heartburn and losses for all doctors and patients . In any industry, software is used to improve efficiency and accuracy. I am going to highlight some basic examples as to how medical software ( electronic medical records, EMR and practice management software, PMS) can be used to improve patient safety.

1. Prescriptions and Medications: The commonest errors occur when doctors write prescriptions on paper and the patient or the chemist misreads the prescription. This is a common occurrence and a printed prescription generated from software with prepopulated Drug Data is the safest bet against such a mishap. Other errors which can be prevented include: mistakes made by doctors in writing the dosage or strength( which intelligent software can automatically prevent) ; and the inadvertent prescription of a combination of drugs which can cause harmful drug interactions. These features are already present in the Plus91 clinic package , Clinkare. This ensures standardized prescriptions, reducing the possibility of error and confusion !
Another neat feature is sending reminders to the patient to take their medication at the correct time via SMS. This ensures high patient compliance , because missed dosages could lead to major problems in treatment. This feature is available in ClinION , the hospital management solution from Plus91 Technologies.

2. Patient History: If doctors are in a hurry, and if a patient comes without his old case papers , the doctor may end up prescribing the wrong treatment ! Not having easy access to the past medical records is a major pain point for all doctors ! EMRs allow storage and instant retrieval of the patient’s medical records, allowing doctors to make better medical decisions , thus ensuring patient safety. This feature ensures that the doctor no longer needs to rely on his error-prone human memory ! Intelligent EMRs also have built-in Clinical Decision Support systems , to help the doctor practice evidence-based medicine.


3. Patient Data Entry: As we know, GIGO holds true – garbage in, garbage out ! Accurate entry of patient data in the system can be ensured by various validation measures and checks in the software. A simple example is the use of validated fields , which accept only values within a pre-defined range. Thus, if the value for hemoglobin is entered as 100, this will be automatically rejected !

4. Check for Informed Consent: A patient must know what procedure they are undergoing – what the risks are; and the important dos and don’ts, to help ensure a good outcome . A software program can ensure that the consent forms are filled in using a reminder / validation system , to ensure that all the patients queries have been answered. It’s also possible to use a video/presentation format , with a consent thumbprint or electronic signature taken at the end. This is helpful for risk management, because it documents that informed consent was obtained. It also ensures that the patient follows all the key preoperative instructions ( such as coming on an empty stomach before surgery . )

5. Check lists: A checklist ( as described in Dr. Gawande’s new book “The Checklist Manifesto”) is the doctor’s most trusted friend. Clinic software programs come with check lists which need to be marked as complete before the next set of tasks ( on the next screen) can be accessed. This ensures that all important steps are carried out in order.


6. Alerts and reminders. SMS or Email alerts can be automatically sent by the software, when there is a problem. For example, if a key lab value falls out of a particular range , the doctor can be automatically alerted, so he can take the needed corrective action !

We see a number of patients who have failed IVF cycles elsewhere, so we have a fairly good idea of what makes some clinics bad.

Here's a short list of features which can help you identify a poor quality IVF clinic

1. Clinics which depend upon outside embryologists to do their procedures for them. IVF is a demanding process and your embryos need the full-time loving care and devotion of an experienced embryologist. A full-time embryologist spends a lot of time honing his skills and optimising the conditions in his IVF lab to ensure high pregnancy rates. This is not something a "visiting embryologist" can do. Thus, these clinics will very rarely freeze spare embryos , and your supernumerary embryos are usually discarded - or donated ( without your content or permission) to another patient.

2. Clinics run by over-busy doctors who travel a lot and are not available in one location. This is a problem for many reasons. These doctors are so busy shuttling from clinic to clinic, that they simply cannot provide the needed care and attention to their patients. While this may not be an issue for many young patients ( who are good ovarian responders), this can be a major problem for patients with poor ovarian reserve or those who develop OHSS. Another problem is that these clinics will often treat patients in batches. This means they will group all their patients together, and do about 10-15 egg collections in one day ! While this works fine for young women this not a good option for difficult patients ! After all, when you have 25 women cycling at one time, how can you possibly ensure that all 25 women will grow eggs at exactly the same time so that they are allready for an egg pickup on the same day ? When there are too many patients , care gets regimented and fragmented, and there is more scope for errors.

3. Clinics with too many assistants. Because there aren't too many good IVF clinics, the good clinics are all very busy. To maximise their patient through-put and revenue, the senior doctor employs assistants. This means that often the history is taken by a junior - and patients rarely get a chance to bare their soul or establish a rapport with the senior doctor. As the treatment progresses, most of the instructions are relayed to the patient by a nurse or an assistant. Once you've paid your fees and signed up for the IVF treatment, you rarely get a chance to see the senior doctor again !

4. Clinics which do not provide medical documentation or records. This is a major problem because IVF clinics want to "hang on" to their patients. They are worried that their patients may desert them or go to another doctor, which is why they treat the patient's medical records as their personal property - and refuse to give even a copy to the patient. A good clinic should routinely give you a treatment summary as well as photos of your embryos - and if they do not, then you should be very concerned !

This is a guest post from Mr Aditya Patkar, Sales Director, Plus91, in which I am an angel investor.

As we improve our software products and work with more doctors, we are learning a lot about what doctors in India want from information technology . How do Indian Doctors view IT as an enabler ?

In theory, one would expect doctors to want to use IT for the following applications.
1. Computer Based Medical Records (EMR)
2. Clinical Information Sharing Networks
3. Clinical Decision Support
4. Administrative Functions – Accounts and Patient Profile Management
5. Computer Generated Prescriptions
6. Better Patient Communication and Care

However, what the practicing doctor wants in real life is quite different !

So what does the typical doctor’s list look like?

1. Accounts and (Mis)-Management

Indian Doctors give a lot of importance to accounting in their Clinic Software; they expect the package to bill as per their requirement. Unfortunately, because many of them do not always want to declare all their income , they want the software to provide “deductions” . We have to educate them that a good package will help them to improve their cash flow and collections by allowing them to track their patient inflow so that they know what business they are generating on a regular basis. Intelligent software will help to prevent embezzlement and will discourage the office staff from pocketing the doctor’s hard earned money ( which is easy to do , since this is still a predominantly a cash business today)

2. Referrals Management

Referring patients to specialists and other clinicians is a common practice the world over, but in India it has an additional financial angle. Doctors want to know how many patients they were referred and by whom, so that they can make the necessary payments back to the referring doctors.

3. Medical History

Doctors want easy access to their patient’s information to help them make better medical decisions. While they are happy about the fact that the software gives them instant access to the patient’s medical records, they are still reluctant to use clinical decision support tools, as they would rather depend upon their clinical ability, than use a computer .

4. MIS ( Management Information System( Reports and Patient Registers)

MIS reports and registers are a commonly requested feature . Sadly the uninitiated ones forget that data first needs to be entered properly , so that it can be intelligently extracted. The reasons for the MIS reports are both noble (research purposes) and mundane (for filing income tax returns) .The biggest challenge here is designing forms and data capture mechanisms which give useful reports. Often , there is a big disconnect, when doctors design incomplete templates , and still expect to be able to generate relevant data ! . Garbage In = Garbage Out !

5. Custom Designed Templates

Plus91’s software has designed so that doctors can customize their own templates , to suit their personal preferences.. Doctors love this feature, as each one wants to design something as per their own workflow.

What of the future ? We hope that as the Indian doctor matures and becomes more comfortable with using IT, he will want the following features as well.
a. Clinical Decision Support
b. Computerized Prescriptions
c. SMS/Email alerts and reminders
d. Online EMRs
e. Insurance Claims Management

Plus91 software is already built to provide these enhancements, which will give a definite boost to the quality and efficiency of their practice , and also help them to improve their profitability.

I saw a 30 year old woman today who wanted a second opinion. She had failed multiple IVF cycles in other clinics and had been advised surrogacy. When I reviewed her medical records, I found out that her ovarian reserve had never been properly tested. I checked her AMH levels, and found to my dismay that they were very low. She had very poor ovarian reserve and would need donor eggs if she wanted a baby. I was afraid she would be upset when I broke this news to her, and did so as gently as I could .

I answered all her queries :

Why didn't the other doctors do this test for me ?
How come I am still growing eggs if my AMH is so low ?
Can't we treat the AMH level ?

and then asked her - Are you angry with me for giving you this bad news ?

She looked at my crestfallen face , and then gave me an answer which proved she was wise beyond her years ! She reassured me - Please don't worry doc, actually, this is good news. At least we know now what our problem is, and rather than continuing to grope in the dark, we can explore options which will maximise our chances of success !

Truly I am blessed that I have the opportunity to learn so much wisdom from my patients daily !