LEARN INSURANCE

The Indian healthcare system has become sick. Doctors are illness experts – and not healthcare experts. Healthcare needs to learn from the revolution which has occurred in microfinancing. When given money and the freedom to use it as they see fit , even very poor people have come up with remarkably innovative ideas which could never have been planned, designed or anticipated by the traditional experts - bankers!

Information Therapy - the right information at the right time for the right person - can be powerful medicine ! Ideally, every clinic , hospital, pharmacy and diagnostic center should have a patient education resource center, where people can find information on their health problem .

This new model is called Participatory Medicine - and HELP is proud to be an Innovator Organisation in the Society for Participatory Medicine !

I am now seeing a new class of patients - the e-patients. ( Many of these come from Pune and Bangalore, the Silicon Valley of India !)

Initially, e-patients stood for patients who used email and the web. Today, the epatient has become much more powerful !

Epatients are engaged - with their doctor; with their health; and with their healthcare system. They do not just read content - they create it as well . "User generated content" is very powerful and moving , because it provides a first hand view straight from the horse's mouth !
They have blogs and post on forums and some of them can be very prolific !

They are empowered ; knowledgeable - and articulate. They have an opinion and are happy to express it !

They are experts . They realise that they are the experts on their own illness - and are happy to share their expertise with others.

They are equipped- they understand how to use the internet to help themselves and to help others as well. They will often lead and participate in online support groups; and are able to discuss technical medical matters intelligently with their doctors. They do not underestimate their competence and intelligence and understand that they have the most at stake when it comes to matters relating to their health !

They are enabled. They have access to technology and are happy to use this intelligently.

These e-patients are Exceptional patients - and these are the kind of patients who can heal a sick healthcare system ! They are the icons of a new kind of medicine, called Participatory Medicine !

Good doctors appreciate and treasure these e-patients - and form partnerships with them, because they realise that they can learn a lot from each other !

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 !

Indian doctors have an excellent reputation for their clinical skills and patients all over the world look upto them . Because of their exposure to a large number of patients during their training in medical college, they have a lot of clinical experience; excellent diagnostic acumen; and are technically proficient. They are quite conscientious and are willing to work long hours for the sake of their patients.

However, most doctors in India still do not use technology intelligently. The majority do not bother to store and keep their patient's medical records ; or if they do, it's done in an extremely disorganised fashion. Most prescriptions are hand written illegible scrawls - and most doctors still manage their clinics very poorly . The doctor is often rushing from clinic to clinic , while his patients are made to wait for ever and ever. Phone calls are poorly handled, because doctors do not realise the importance of running their practise as a small business.

The major problem is that while doctors in India are taught to be good clinicians during their training, they are never taught how to run their practise. They have poor practise management skills, and are so focussed on the clinical care they provide , that they lose sight of the overall big picture as regards the services they provide to their patients.

Remember that when a patient comes to your clinic, the amount of time he spends with you is only a few minutes. Most of it is spent waiting; filling up forms; paying money; or talking to your staff. While many doctors feel that all these activities are administrative paraphernalia which are below their dignity, the fact remains that all these do contribute significantly to the experience your patient has in your clinic ! However, if you do not spend time and energy in training your clinic staff; or if you treat your front office staff badly, they are likely to treat your patients badly as well - causing a lot of unhappiness and grief for everyone !

Unfortunately, because doctors ignore and neglect these aspects of their practise, they do a bad job with delivering services to their patients. Many do not learn to use assistants efficiently to leverage their time; while others would rather do everything themselves, because they have never learnt to delegate well.

Even worse, though that have a lot of clinical experience and expertise, they do not share this efficiently, because they do not publish medical papers or articles. The only reason US doctors are more prolific in their writing skills is because they use the time and expertise of secretaries and editors to hone their publishing skills. India has so much untapped non-clinical talent which doctors can easily use to provide better services to their patients - and a higher profile for themselves !

Sadly, most doctors are not entrepreneurial enough and have poor practise management skills because they do not learn how to handle staff; and to delegate non-core non-clinical activities to others. Unless Indian doctors learn to maximise their productivity and efficiency using technology and other people's time, they will never be able to grow to their maximum potential !

The good news is that there are now many clever young entrepreneurs ( who are not doctors) , who are entering the Indian market. They realise that the way doctors provide medical care leaves a lot to be desired - and have come up with clever new solutions to address patients' pain points. They understand that healthcare is a service business - and while the doctor has an important role to play, there are lots of ancillary services which need to be provided around the doctor, both to improve his productivity; and to make the patient experience more pleasant.

As these businesses grow and flourish, hopefully all doctors will realise the importance of paying attention to how critically important it is to focus on the complete patient experience in their clinic - not just on the clinical care they provide ! The good news is that it's easy to fix these problems - we just need to pay attention to them !

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 Chap 1 from Dr Nadkarni's book, Healing the Sick Healthcare System.

The Health–care-system is very complex . It is a
system in which any person with any perceived illness seeks
medical assistance to get rid of his illness, even if the perceived
illness is false, in the sense that it may not be a true organic
illness. The primary needs of the individual are food, clothing and
shelter. Health and education come next in order. Food, clothing
and shelter are considered most essential for the survival of an
individual. Yet every need under these heads cannot be
considered as essential. While rice, chapatti and dal maybe
considered most essential, the same cannot be said about
‘pickles’, ‘papad’ and ‘pista’, ‘badam’ and such dry fruits could
legitimately be considered as luxuries. Kashmiri chicken in five
star hotel certainly cannot be called a necessity. Same is true
about clothing. While shirt and pant or ‘saree’ can be considered
as most essential, designer shirt or silk saree would come under
items of luxuries. Most people do not realize that all the health-
care needs are not necessarily essential or vital for the survival
of an individual. There are some essential services but there are
other services which can be called desirable but not absolutely
essential and yet other services accepted by the society could
easily come under the term of luxuries. Most of the cosmetic
surgeries belong to this last category. Even many of the so called
preventive measures for long life such as use of a particular oil
in food could also be considered as not essential, if not luxuries.
Therefore, one has to realize that in health–care–system, there
are essential services, there are desirable services and there are
medical services which can be termed as luxuries.
In actual clinical practice the health professional is not just
a man of science. There is an admixture of art and science and
commerce in the actual clinical practice. Also there are three tiers
in the services provided under health-care system. Primary
health care service which is offered in the dispensaries and
primary health centres usually by a single doctor. These doctors
treat the patients who come to the dispensary for their
elementary diseases. The patients are not admitted in these
primary health-care centres. These doctors also treat the people
to prevent diseases. Preventive medicine has become a very
important aspect of the management at the primary health level.
Immunization, Vaccination, Counselling during the pregnancy,
Advice on diet and Hygiene for the family are all essential parts
of the primary health care of the society. Thus, primary health
care is one of the most essential health care services needed by
the society. Yet this is the most elementary aspect of the health
care and needs very simple equipments, investigations and
simple medicines. The doctors in these primary centres need to
have patience, a lot of sympathy and a great ability to discern
between simple and major illness. Thus, there is a lot of art and
some science at this level. ‘Medicine is an art’ applies particularly
to this primary health-care system.
At the other end of the spectrum are extremely serious
patients who are at a risk of losing their lives or at the risk of
being crippled. The medical science has progressed a lot and
many of such illnesses can be treated effectively now-a-days.
Some patients can be cured and life of many others can be
prolonged or made comfortable. But all this cannot be done
without profound knowledge of the science of medicine and many
high-tech equipments and sometimes use of newer drugs which
could be quite costly. In short, the management of serious
organic disease requires use of modern equipments and
medicines and the profound scientific knowledge of the body–
systems involved in the disease. Science plays a very major role
and the art of medicine is often sacrificed by the specialists who
offer these services. These medical services are offered only at
tertiary medical centres. They cost a lot and can be managed
only by expert consultants / specialists and super specialists.
All the intermediate groups of diseases i.e. those which
cannot be treated in dispensary or at home and yet are not so
serious as mentioned above are all treated at the secondary level
of the health-care-system. Nursing homes, private hospitals or
Taluka and District level hospitals in the public sector offer these
services. Standard equipments and standard drugs are mostly
sufficient and the medical professionals are specialists of basic
level or general specialists. A good admixture of art and science
is needed at these centres to satisfy the patients.
Apart from these, there are plenty of ailments for which the
patients seek the medical advice. Due to the modern pace in life
there is an immense increase in the psycho-somatic disorders.
The real ailment is 'tension or stress' but this emotional
imbalance is manifested in bodily illness. Some of these psycho-
somatic illnesses turn into organic diseases but many of them
remain non-organic in nature. Headache, backache, inability to
work, flatulence (gases) and many such vague symptoms are
instances of psycho-somatic diseases without any organic
changes in the body. Diabetes, hyper tension, heart disease etc.
are also phycho-somatic diseases but they cause organic
changes in the body and, therefore, become organic diseases
requiring major treatment. The first type i.e. non organic type of
psycho-somatic illness needs more of psychological treatment
while even in the second type, psychological treatment could
help a lot. In addition there are many ‘imagined’ illnesses. All
these except the organic diseases mentioned above could be
called as ‘non essential’ health care needs. Lot of art is required
in treating these diseases. But a lot of commerce also enters into
this field and even the patients are willing to spend exorbitantly
for getting rid of their ‘non-essential’ diseases.
Medical professionals are not saints and they have entered
the profession specifically to earn. They belong to a relatively
more intelligent strata of society and are highly educated.
Therefore, their expectation of earning is also legitimately high.
This legitimate demand of the medical professionals cannot be
termed as commercialization and the society must learn to
accept it as due compensation for the service rendered.
Therefore, commerce enters into the field of medicine at all
levels. Commerce enters in the medical field from the primary
level to the tertiary level and is most conspicuous in the
management of the psychosomatic illnesses mentioned above.
For the clinical practitioners, at any level, a fine balance has to
be achieved between art, science and commerce so that the
health professionals are not denied their legitimate dues while at
the same time, they are not allowed to commercially exploit the
patients who are too anxious to get well. There is no doubt,illegitimate demands are raised by some doctors and such
demands must be termed as ‘over commercialization’. This over-
commercialization needs to be curbed.
There are many systems of medicine practiced
simultaneously in every part of our country. Ayurvedic system of
medicine is the most ancient system in the country and is
respected by the masses even today. Hence, it is recognized by
state as well as central government and plenty of Ayurvedic
medical colleges churn out a lot of Ayurvedic practitioners. Even
in this system there are general practioners and specialists.
Same is true about Unani system. Started nearly 1500 years ago
in the middle east, it is more popular among Muslims and is
recognized by the governments. Homeopathy came in much
later. First founded in Germany, Homeopathy became rapidly
popular all over the world, as also in India and is now recognized
as a system of medicine like the other two faculties. Each of them
is governed by their own medical council and each separately
register their practitioners. Knowing the importance of Allopathy
as a more scientific system or, at any rate, the presently most
practiced system, all the above faculties have incorporated some
elements of allopathy in their training course. Even if it happens
to be very inadequate, it offers their practitioners a legal right to
practice allopathy simultaneously though they are not registered
nor governed by allopathy State or Indian Medical Council.
Indian Medical Council was established at the centre in
order to establish a standard of education in the allopathic
system. The council is expected not only to prescribe and
maintain the standard of medical education but is also expected
to oversee and regulate the functioning of the practitioners of
allopathy in India. In order to do so, the council had to first
prescribe the standard of education and prepare the curriculum
for various courses for graduation and post-graduation. The
council then had to define the exact role, the health-care
professionals are expected to play. Every practitioner, therefore,
must register under the Indain Medical Council.
But the council has the most insufficient infrastructure
amounting to almost nil to actually supervise the conduct of their
health-care-workers. Broadly the council depends on complaints
by their associates or by the public at large individually or through
government channels and then decides whether the person
actually is maintaining the standard or not. Even if the council
finds the behavior of the doctor sub-standard, it has very limited
powers. It can either warn the doctor or de-register him. Once a
person is de-registered, he or she cannot practice in the
allopathic system of medicine. But the legal system of the country
is so peculiar that once de-registered that person no longer is a
qualified doctor coming under the ambit of the medical council.
Therefore, for any malpractice, if he continues to do so, the
council cannot deal with him as he is no longer a member of its
body! Only the department of law and the police under them can
deal with such culprits and take necessary action against them.
The council is helpless. With meager knowledge of the
regulations under which the doctor is supposed to practice and
with such over-burden of duties to maintain the law and order in
the society, it is no wonder that the police also take no action and
various doctors who are de-registered by the council or spurious
(unqualified) doctors are practicing in the country in abundance.
The results for the society are obviously disastrous.
Thus, it will be realized that the structure of the health-care
system in India is haphazard. There is no clear-cut pattern in the
health care system in the country. Different categories of doctors
practicing their own systems of medicines-allopathy,
homeopathy, ayurvedic, unani and what not-all practice in their
own way without the control of the government and without any
co-ordination among them. The government has formed bodies
to control the practice of the doctors in each of their special
systems separately, Thus, just as the Medical Council of India
was formed to regulate and control the behavior and standard of
allopathic doctors. similar bodies were formed for homeopathy,
ayurvedic, unani etc., But there is no central body to have an
overall control over the health-care professionals in the whole
country. Each of there bodies supposedly try to maintain the
standard in their own system of medicine. The role of respective
councils of other systems of medicine was to regulate the
professional conduct of the health-care doctors in their respective
systems. But what is true of Indian Medical Council, is
substantially true for every other council like Ayurvedic,
Homeopathic, Unani ect. The role of the council is thus limited to
prescribing the curriculum for the courses of their respective
systems and to prescribing rules and regulations for the college
management to see that good standard is maintained in the
medical education. Here again the maximum the council can do
is to de-recognize a particular college or university. Political and
money pressure. coupled with incompetence of the inspecting
teams of the council, sufficiently dilute even this power of de-
recognition and sub-standard colleges continue to produce sub-
standard doctors.
But health is a concurrent subject and the state
government has a bigger role to play in the health-care than the
central government. Therefore, the state governments have
formed their own Medical Councils like say Maharashtra Medical
Council for the state of Maharashtra. Strangely these state
councils are not subordinate to the Indian Medical Council but
are completely independent bodies formed and regulated by the
state governments. Therefore, even if the medical course or
medical college is not recognized by Indian Medical Council
because it is not maintaining the standard expected by it, the
state medical council has its own right to recognize such a
different course or such a college and the graduates coming out
from such institutions are eligible to practice in that particular
state. They can not practice outside their own state, if not
recognized by Indian Medical Council nor can they go abroad
because other countries recognise only Indian Medical Council.
In a way it is not an altogether undesirable situation for a vast
country like India with a population of more than hundred crores.
It is not justifiable to have only one standard of health care
system for the whole country as social and economic conditions
in various parts of the country or in different states can be
extremely dfferent. A particular standard which can be
maintained by very wealthy states may be an impossibility for
another state which is comparatively very poor. It may be noted
that western Europe with a population of about thirty five crores
is divided into several independent sovereign countries and each
country has its own standard of medical education and its own
rules. Similarly in U.S.A. with the population of about thirty five
crores there are 48 states and under their constitution each state
not only has its own medical council to define the system in its
own state but such a medical council is also entitled not to
recognize the qualifications of the medical professionals from
other states. Such ‘outsiders’ are made to appear for their own
test before they can practice in that particular state. Therefore, it
is absurd to think of one universal system for a country of
hundred crores of people whose social and economic conditions
differ as widely as between different countries in Europe or
different states in U.S.A.. I, therefore, said that the independence
of such medical councils of each state is not so undesirable.
However, it may be noted that there is no regulatory or co-
ordinating mechanism between Indian Medical Council and State
Medical Councils, which is the matter for worry.
Even besides the medical professionals working in these
recognized systems of medicines, there are any number of
faculties of medicines which are practiced by the so called
doctors of these unrecognized faculties. They are bone healers,
acupuncturists, electro Magnetic Medical system and what not.
Unfortunately the political leadership in various regions
encourages these systems and the present government virtually
takes no action against these 'doctors'. The people at large do
not clearly know whether they are recognized professionals or
not.
Even within the allopathic system the role of each
professional ought to be properly defined and regulated. There
are M.B.B.S. doctors who are supposed to be ‘basic’ doctors.
They were the backbone of the society in the form of general
physicians or family physicians. They treated the patients
primarily irrespective of which part of the body was affected and
irrespective of the age/sex of the patients and refered the
patients to a particular specialist only when the disease appeared
to be more serious. Now there are not only specialists (M.D. &
M.S.) but there is a plethora of super specialists. (D.M. & M.Ch.)
Specialist is defined as a person who knows more and more
about less and less. The recent advances in medical technology
have undoubtedly contributed to the development of the super
specialists. For example, in an organ as small as an ‘eye’ where
an ophthalmologist is a specialist of eye disease, there are now
super specialists who look at ‘retina and posterior segment’ of the
eye, super specialists to look at the ‘cornea’ only and super
specialists who deal with the tumors of the eye only. While the
role of super specialist is becoming clearer and clearer, the
respective roles of a basic doctor and a specialist are becoming
hazier and hazier. Even the distinction between the various
systems of medicine is getting obliterated. Eighty percent of the
general practitioners now hold non-allopathic degrees like
Ayurvedic or Homeopathic or Unani. But all of them, without
hesitation, prescribe allopathic medicines and treat their patients
allopathically. Similarly many allopathic pharmaceutical
companies are manufacturing Ayurvedic drugs and their
representatives are freely canvassing these drugs to the
allopathic doctors. In short, their practice goes far beyond what
was officially taught in their respective courses. In a way,
therefore, 80 percent of the patients are being treated by 80
percent of non-qualified doctors. I emphasize that even qualified
doctors become ‘non-qualified’ when they transgress the limits of
the systems they were taught.

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

A few Sundays ago , I was privileged to be invited by Dr. Nikhil Datar, a pre-eminent gynecologist and medico-legal expert to witness his premier talk on Patient Safety. It was hosted by IMA Dombivali and over 40 doctors turned up to hear Dr. Datar’s talk. Dr. Datar had recently returned from UK where he attended a program organized by WHO on Patient Safety. I was there because Plus91 Technologies believes in making patient centric software solutions which don’t just automate the clinic or hospital , but also improve quality and service.

The doctors quickly realized that they need to reflect and close loopholes in their own practice, so that they could ensure patient safety. Sometimes we are so focused on the trees, that we lose sight of the forest ! The Q and A session was very interactive , and all doctors left the seminar with a lot of food for thought.
As a software company involved in producing intelligent Healthcare software solutions , patient safety becomes a vital cog in what we are doing .

1. Plus91 creates solutions which ensure and promote safety
2. The unique patient safety features we offer allow us to explain to doctors why are products are better than the others in the market
3. Using Plus91 products helps doctors to get patients more involved in their own medical care - allowing patients to feel safer and better informed.

So what does patient safety entail? It covers a lot of ground , right from something as basic as washing your hands before doing a physical examination ; to something as complicated as giving instructions to your assistants during bypass surgery. They key learning was the need for everyone to be aware of the fact that medical care is a highly complex enterprise and that things can go wrong ; and we need to improve communications and processes to prevent minor errors from becoming major issues.

Simple techniques like reading the names of the medicine aloud; using color coding on various instruments, and storing patient records in a neat and systematic manner can help provide better quality care to the patient. Being aware of the possibility of errors can help you prevent them very effectively, as you take corrective action. Of all the cases which result in a complication, in only about 1% is this a result of negligence. Most are a result of preventable errors – and the majority are not individual failures , but system failures.

A lot of good work is now being done in India in this field by numerous players. The ones which Plus91 Technologies is directly involved with include Dr. Nikhil Datar, PIET (Patient Information and Education Trust), PEAS (Patient Education and Awareness Series), HELP (Healthcare Education Library for People) and Dr. Malpani who is organizing a conference in October in Mumbai called Putting Patients First. As technology pervades healthcare, I can already envision many places where Plus91 can actively help improve patient safety standards. The possibilities are exciting , not only in their scope and challenge, but because this is one place where we can actually claim that we saved a human life – and working towards this goal inspires us with enthusiasm and energy !

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 !

This is a guest post from Mr Parag Vora, CEO of Infoseek in which I am an angel investor.

In the past, most doctors used to feel that marketing was below their dignity. Medicine was considered to be a noble profession, while marketing was seen to be a sleazy way of soliciting for patients. In today’s competitive market however, , a doctor can no longer continue to retain these outdated beliefs. Every doctor needs to wake up and realise that marketing has become a necessity for survival. Look around you - the corporate hospitals have already started eating into your market share and now take away a large chunk of patients who used to come to you in the past ! Is it because they are better than you? More experienced ? Or that they provide better patient care ? I don't think so ! In fact, the care in many of these hospitals is impersonal – and very expensive ! Why do patients go there ? The answer lies in the simple fact that they are able to 'MARKET'; 'BRAND' and 'POSITION' themselves much better than you can !

Marketing is not the same as advertising ! It basically means you use techniques which influence your patient's choice in selecting his doctor, by demonstrating the true value of your expertise and services. Marketing is something doctors has always done. It’s just that in the past, it was basically simple “word of mouth marketing. In today’s age, you need to adopt the marketing methods being followed by other industries.

To understand how marketing can help your medical practice, you first need to understand how a patient chooses a doctor. The quality of medical care and the expertise of the doctor is a major factor , but the truth is that it is extremely difficult for a patient to assess this , because he simply does not have the technical sophistication to be able to differentiate between a good doctor and a bad doctor ! Hence , patients look at proxy measures , such asreferences from family and friends; the doctor’s “reputation”; whom the local chemist recommends; and often by doing a google search !

In my opinion, a kick-start to your marketing efforts should be focused on your current patient population. Provide them with excellent care and service and they will be the best marketeers for your practice. If you treat them well and provide them cost effective medical care, they are certainly going to recommend you to their family and friends.

Your image is another very important marketing tool for you – and your clinic’s ambience plays a key role ! This could be a plus– or could be a black mark against you ! For instance - acramped waiting room with paint peeling off the walls ; a dirty consulting and examining room; ill-behaved support staff; and no information about the services that you offer. Do you think this will inspire confidence in your patient while he is waiting to see you ? Whenever I check-in to a hotel room, the first thing I see is how well maintained the washroom is. It tells me a lot about the hotel and its service , and builds up their image. Isn’t the first impression often the last?

You must have some marketing “collaterals” ( marketing also uses jargon, just like doctors do !) The list of such collaterals should include :
1. Brochure(about your practice and services)
2. A professional website
3. A patient resource center within your clinic with patient education books and DVD’s.
4. A short AV film about your clinic; your expertise; infrastructure; with patient testimonials.

Marketing yourself does not have to cost a lot of time and money . Marketing is simply letting your patients know that you are genuinely willing and able to take care of them !

This is a guest post from my friend, Dr. Shalini Ratan, MD, Founder , Nirvan Life Sciences Pvt. Ltd. at http://nirvanlifesciences.blogspot.com/.

Health care today is unlike health care yesterday.

The healthcare market is growing by leaps and bounds. According to reliable sources, the market size for the private sector in healthcare has shot up from Rs 85,500 crore in 2006 to Rs 1, 48,050 crore now. This accounts for 80 per cent of the total market—the highest share in the world. About 15 hospital projects are slated to open this year. The number of doctors and nurses enrolled in medical colleges and nursing schools will have to triple over the next 10 years. An additional 520,000 students physicians will be required by 2012.

In this scenario there is enormous scope for clever medical professionals. However, with this demand come new challenges! Doctors need to learn new skills in order to keep their patients satisfied, because the modern breed of patients are evolving as consumers and demand much more attention from their doctor. At the same time one has to overcome the hurdles to achieve higher goals in practice. Doctors in private practice will need to develop themselves to compete with the corporate hospitals which have a marketing team for their service promotion, huge marketing budgets and well groomed medical practitioners. So at the end of the day, to provide complete healthcare experience to the patients the doctor has to play the role of a medical expert as well as a medical entrepreneur.

The role of a medical practitioner today is not only of a clinician and an academician, but also a manager and implementer for providing excellent medical services. And this requires a “Mindset Shift” of the medical professionals.

A doctor invests almost a decade in becoming a trained professional through technical education and internship. However the formal medical education fails to train the doctors in some key skill areas. A doctor to be highly effective need to learn art of communication with their patients, build a compassionate doctor – patient relationship and be highly efficient in operational skills. As doctors are not groomed in a corporate environment they need to polish their skills to become Medical Entrepreneurs.

Enhancing Doctor - Patient Relationship is an area of importance today. There is a need to empower and engage patients in today’s technology driven era. Knowledge and understanding of the needs of patients and their families now is more crucial than ever in providing exceptional patient service. Today a doctor’s reputation is driven by the combination of patient experience and perception of services provided to them.

The medical professionals would need to re-think about enhancing doctor-patient relationship, should be able to understand the basic principles of medical practice management, develop familiarity with the language of healthcare marketing and acquire various soft skills like communication, handling team and understanding the online digital world. This would help them handle medical practice effectively.

A doctor would need to combine multiple talents - technical expertise in their specialty; understanding the importance of hospitality in the hospital ; and above all, developing a compassionate and empathetic approach in order to create loyal patients.

So the need for a doctor today is to have a patient centric approach, practice medicine effectively as a professional, not a trade and earn profit smartly.

Image by thinkpanama via Flickr

This is a guest post from Mr Parag Vora, CEO, Infoseek, in which I am an angel investor. Infoseek makes patient educational videos in India.

Getting Informed consent from the patient remains a very tricky area in medical practice today . Failure to obtain valid consent is one the commonest reasons patients go to court when they are unhappy with their doctor.Unfortunately, no standardised guidelines have ever been published by the Medical Council of India, Indian Medical Association, or any other ‘reputed’ medical body. This is a huge lacuna, and the importance of taking consent has never been taught to most doctors properly, even though there has been a huge rise in medico-legal and malpractice claims in the past decade or so.

All over India there is a lot of diversity in the way consent is taken and interpreted. There have been instances where consents have been highly inadequate; and in some cases, the doctor has completely forgotten to take a consent altogether ! What makes a consent an ideal consent is still a grey area in India. The ambiguity in the consent document leads to variable interpretations that have resulted in damages to medical fraternity in the form of malpractice claims and litigations.

The Supreme Court of India has laid down certain guidelines in its various judgments for what makes a consent valid; and how it should be taken. Consent and its adequacy has been the most common issue that crops up in medico-legal situation. This is especially true in certain specialties such as obstetrics.

Initially, the concept of Informed consent was developed in order to protect the health of participants in clinical trials and healthcare research. However, in view of the importance of patient autonomy, and the need to protect doctors against medical lawsuits, it is now considered to be an important component of all aspects of health care. Though a very commonly used term, , the fact remains that it is very difficult to prove that the patient did in fact provide true “Informed consent” in a court of law in a medico-legal case.

There are many reasons for this. The limited amount of time available to counsel patients in a busy practice may make this impractical. Also, “How much to reveal” and “How to inform the patient about the risk of complications without scaring the patient away ” is another practical issue , thus making it difficult for doctors to fulfill the legal criterion of informed consent. The inadequate level of education and the language barrier poses another important and genuine problem in our country.

We all know that mere signing on the consent form is not considered to be enough in a court of in law. Similarly , doctors feel very vulnerable when a patient, inspite of being genuinely adequately informed about the risks of the procedure, conveniently claims that no explanation was given to him by the doctor, when he is on the witness stand !

All good doctors want to have a truthful, genuine, transparent doctor- patient relationship where the interests of both the parties are recognised and respected. There is adequate data to prove that giving proper information to patients has improved patient satisfaction and decreased litigation in medical practices.

As a step in streamlining the consent taking process and helping it to make it truly informed consent, to protect both doctors and patients , we are launching P.E.A.S™ Patient Consent software, which has been developed with the help of one of India’s leading medicolegal experts, Dr Nikhil Datar. This software helps manage medicolegal risk with innovative tools which enhance doctor-patient communication at the same time ! The software provides a multilingual, audio visual patient information - cum - consent taking solution for the first time in India . This allows doctors to achieve detailed, provable documentation of the consent process , without wasting his precious time .

Transforming Healthcare: Epocrates CEO Kirk Loevner | Sramana Mitra on Strategy " Why is the healthcare market so backward?"

KL: One of the main points I have addressed is that the incentives are misaligned. There is another inhibitor. You cannot require the healthcare providers to change their workflow. You have to be a tool or service that fits into their existing workflow. Too many of the products require them to change the way they interact with patients. It is too invasive. That is why we have experienced great adoption. Our tools are convenient and easy. We are not invasive. As we move into new areas, we have to be careful that we do not fall into the same trap of requiring clients to change to match us.

While most doctors have a lot of medical expertise, they are usually poor at practise management because they are often not well organised. There's a lot doctors can learn from clever software engineers and IT professionals as to how to streamline and improve their workflow !

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.

Medical Flying squads were created in order to handle medical emergencies . They were first developed by obstetricians, and a team of medical personnel was rushed to help women with complicated labours and childbirths. They were very useful and were responsible for saving many lives .

While flying squads are no longer very common, the Ahmedabad Medical Association has created a new concept of medical flying squads to help doctors who are faced with unexpected complications or emergencies.

One of the nightmares for any doctor in practise is an intraoperative emergency or complication. Unfortunately, no matter how careful and competent the doctor, it is a sad fact of life that complications will occur. For example, a patient may have a cardiac arrest during a minor surgical procedure; or a patient may die because of uncontrolled bleeding during a caesarean section.

When this happens, angry relatives and friends ( often goaded by goons ) will take matters in their own hands. There are now many instances where doctors have been beaten up and hospitals have been damaged, when these kinds of incidents occur. Doctors feel vulnerable and defenceless - and this has led to a rift between doctors and patients. Doctors will often turn away emergency cases because they do not want to take a risk in case the patient does not do well.

Unfortunately, the police are of little help in such emergencies. They will often fail to turn up - or even when they do, they often refuse to intervene or protect the doctor.

Even more significant than the physical damage these incidents cause, it is the irreparable harm they do to the doctor's psyche and his reputation which are especially worrisome. The doctor's broken bones will heal - but a good reputation created over a lifetime of providing good medical care goes down the drain in a few minutes. The media is quite happy to add fuel to fire, by reporting on the " doctor's gross medical negligence", without ever bothering to find the facts.

These incidents have an impact on other doctors as well, who then develop an patient-unfriendly attitude. Rather than treat each patient encounter as an opportunity to serve and heal, each patient is seen to be a potential adversary !

On a recent visit to Ahmedabad, I was very impressed to learn about a very clever initiative which the Ahmedabad Medical Association, an organisation which is now over 108 years old, has developed. Rather than depend upon the police to help them in their time of need, doctors have banded together to help each other.

The Association is remarkable for the sense of unity and camaraderie which exists amongst its members ! Practically all doctors in Ahmedabad are members - both family physicians and specialists. They have set up a medical flying squad, which consists of a group of senior doctors, who will rush to the aid of any doctor, no matter what time it is, whenever they receive a distress call.

An intraoperative emergency or complication is every doctor's nightmare - especially when this occurs in a small private nursing home. With this kind of backup service available, doctors in private practise can rest assured that help is just a phone call away !

Not only does the squad provide valuable medical assistance and a useful second opinion in handling the emergency, they provide a cool head to assist the doctor, who is often scared witless when the patient has a complication. This group of doctors provides reassurance to the relatives, that their patient is getting the best possible medical care from the leading specialists. They help to maintain peace and order - and can also organise police support if needed, as they are respected citizens who are held in high regard.

I think this is a great service and this is a model all Medical Associations all over the country can learn from. Senior doctors - including those who have retired, can offer to serve on these Flying Squads. Not only will this help them to keep gainfully occupied, it will also help them to earn a lot of respect and goodwill. After all, if doctors do not help each other, then who will ?