“8th National Biennial Conference on Medical Informatics 2012”

Information Risk Management Strategy
for Healthcare Industry

Bhaskar Sahay
Pre-Sales Consultant

Symantec Company Overview 1

Symantec At a Glance

Founded in 1982 $6.2 billion revenue in FY 2011;
IPO in 1989 approximately 50% outside of the U.S.

Approximately 19,500 employees More than 1200 global patents

Operations in more Symantec footprint on more than
than 50 countries one billion systems

Included on Fortune’s Most
#382 on the 2011 Fortune 500
Admired Companies list

100 percent of Fortune 500 Invests 13% of
companies are customers annual revenue in R&D*

2
* R&D investment is Non-GAAP
Symantec Company Overview

Symantec Is –
Symantec is a global leader in
providing security, storage and
systems management solutions
to help consumers and
organizations
secure and manage
their information
and identities.


Industry Recognition
Security Leadership

• Consumer Endpoint Security
(#1 market position1)

• Endpoint Security
(#1 market position2, Positioned in Leader’s Quadrant in Gartner Magic
Quadrant3)

• Messaging Security
(#1 market position4, Positioned in Leader’s Quadrant in Gartner Magic
Quadrant leader5)
Storage and Availability Management • Data Loss Prevention
Leadership (#1 market position6, Positioned in Leader’s Quadrant in Gartner Magic
Quadrant7 )

• Email Archiving • SSL Certificates
(Positioned in Leader’s Quadrant in Gartner Magic Quadrant14) (#1 market position9)

• Core Storage Management Software • Security Management
(#1 market position15) (Positioned in Leader’s Quadrant in Gartner Magic Quadrant10)

• File System Software • Security Information & Event Management (SIEM)
(#1 market position16) (Positioned in Leader’s Quadrant in Gartner Magic Quadrant 11)

• Backup and Recovery • Mobile Data Protection
(#1 market position17) (Positioned in Leader’s Quadrant in Gartner Magic Quadrant 12 )


Global Intelligence Network
Identifies more threats + takes action faster + prevents impact

Worldwide Coverage Global Scope and Scale 24x7 Event Logging

Rapid Detection

Threat Activity Malcode Intelligence Vulnerabilities Spam/Phishing
•240,000+ sensors •133M client, server, •35,000+ vulnerabilities •5M decoy accounts
•200+ countries gateways •11,000 vendors •8B+ email messages/daily
•Global coverage •80,000+ technologies •1B+ web requests/daily

Preemptive Security Alerts Information Protection Threat Triggered Actions


1 Protect the
Infrastructure

Symantec™
Protection
Suite
Enterprise IT Security Briefing 6

Symantec Protection Suite

Backup & Recovery
Easy Management Automated Control
Messaging & Web Security

Endpoint Security

Complete Protection

Threats

Symantec Protection Suite

Backup & Recovery
• Backup live desktops & laptops
• Restore to any hardware
• Take threat-driven backups

Messaging & Web Security
• Antivirus, antispam,
antiphishing, botnet protection

Backup & Recovery • Reputation-based spam filtering
• Data loss prevention
Easy Management Automated Control
Messaging & Web Security • Exchange, Domino, Gateway

Endpoint Security Endpoint Security
• Antivirus, antispyware
Complete Protection
• Desktop firewall
• Intrusion prevention
Threats • Device and application control
• Network access control

Develop and Enforce
2 IT Policies

Symantec™ • Define risk and develop IT policies
Control • Assess infrastructure and processes
• Report, monitor and demonstrate due
Compliance care
• Remediate problems
Suite

Expanding from Compliance to Risk – Considerations

Risk
Centric

Compliance
Centric

• Driven by external mandates • Internal needs & external context
• Focus on pass / fail checkbox • Focus on continuous improvement
• Large volume of audit findings • Risk-prioritized issues drive action
leads to inaction • More holistic solution needed for
• Can get by with tactical point pragmatic view of business risk
solutions

SR B24 - The Future of IT GRC 10

Symantec Approach to IT GRC

Stakeholders
Audit Operations Business

PLAN REPORT
• Demonstrate compliance to multiple
• Define business risk objectives
stakeholders
• Create policies for multiple mandates
• Correlate risk across business assets
• Map to controls and de-duplicate
• High level dashboards with drill down
EVIDENCE

ASSETS CONTROLS

ASSESS
REMEDIATE
• Identify deviations from technical
• Risk-based prioritization
standards
• Closed loop tracking of deficiencies
• Discover critical vulnerabilities
• Integration with ticketing systems
• Evaluate procedural controls
• Lifecycle Exception Management
• Combine data from 3rd party sources

Environment
SR B24 - The Future of IT GRC 11

Critical System Protection

Operational:
Unauthorized file
 Virtual, physical and multi- changes
OS platform coverage
 Centrally monitors files, Disruptive application
Changes to OS
directories, applications and behaviors
registry keys
other system resources in
real-time
 Detects known and Inappropriate access Inappropriate access
unknown threats rights changes and device use

Business:
 Quick time to value with out- Suspicious multiple Configuration
of-the-box policy templates failed login attempts changes

 Centralized information across
dissimilar platforms Unauthorized network
connections
 Reduced business systems
impact via behavior based
operation

Critical System Protection 12

Security Information Manager

Central Visibility to Reduced Number of
Prioritization
Critical Threats Alerts
Prioritized
Reports
Incidents
Remediation

Data Normalized
into Common
Formats Aggregation and Correlation

Network Access Intrusion
Firewall
Control Prevention
Multiple Data Millions of Unprioritized
Sources Device and Application
Events
Control
Antivirus …Other log data

13
Symantec Security Information Manager

Incident and Event Log Correlation

OS
Antivirus
 Firewall breaches Database
Corporate
 Infected systems
Additional Intelligence on: Network
 Virus outbreaks
 Malicious IPs Mail and
Groupware
 Privileged user activities Firewalls
 Botnet IPs
 Worm IPs  Other internal events…
Syslogs

IDS/IPS
Other
sources…

Comprehensive Vulnerability
Scanners

Visibility

Symantec Security Information Manager
14

3 Protect the
Information

Symantec™
Data Loss
Prevention

3 Protect the
Information

Symantec™ • Discover where sensitive information
Data Loss resides
• Monitor how data is being used
Prevention • Protect sensitive information from loss


How It Works

DISCOVER MONITOR PROTECT

2 3 4

• Identify scan targets • Inspect data being sent • Block, remove or encrypt
• Run scan to find sensitive • Monitor network & • Quarantine or copy files
data on network & endpoint events • Notify employee &
endpoint manager

MANAGE

• Enable or MANAGE • Remediate and
1 customize policy
5 report on risk
templates reduction

Symantec Data Loss Prevention 17

Symantec’s Complete Encryption Platform
Full Disk Encryption (FDE)
• PGP® Whole Disk Encryption
• Symantec Endpoint Encryption (EE) FDE

Device and Media Encryption
• PGP Portable
• SEE Removable Storage Edition (RSE)
• SEE Device Control

FTP/Batch and Backups
• PGP® Command Line

File/Folder/Shared Server Encryption
Management • PGP® NetShare

Central Management of Gateway Email Encryption
Encryption Applications • PGP® Gateway Email
PGP® Universal ™ Server End-End Email and IM Encryption
• PGP® Desktop Email
Key Management
Smartphone Solutions
PGP® Key Management • PGP ® Viewer for iOS
Server (KMS) • PGP® Mobile
• PGP® Support Package for BlackBerry®
Symantec Encryption 18

4 Manage Systems

Altiris™ IT
Management
Suite
from Symantec

4 Manage Systems

Altiris™ IT • Implement secure operating

Management environments
• Distribute and enforce patch levels
• Automate processes to streamline
Suite efficiency
• Monitor and report on system status
from Symantec

Altiris IT Management Suite

Client IT Asset
Service Desk
Management
Server
Management

Altiris IT Management Suite – Sales Enablement 21

Symantec Security Recognized as A Leader in
Gartner Magic Quadrants*
Network Access Control1 Endpoint Protection Platforms2 Security Info & Event Mgmt3

Content-Aware DLP4 PC Lifecycle Config Mgmt5 E-Mail Security Boundaries6

Enterprise IT Security Briefing
22
*MQ source and disclaimer information at the end of the presentation

Protect Your Data

BACK UP RECOVER
Tier availability by application Reduce downtime risks

STORE MANAGE
Do more with your existing Realize the promise of
storage investments virtualization

23
Data Protection Solution ©2009 Symantec. All Rights Reserved.

Complete Protection for Your Information
Driven Enterprise

Dedupe Everywhere, Closer to the Source
Drive down infrastructure costs – improve performance

Simple and Complete Virtual Machine Protection
Remove virtualization roadblocks – lower costs

Better Disaster Recovery with Global Data Protection
Lower complexity and improve business continuity

Centralized Global Management and Reporting
Reduce operational overhead and gain control

Protects Distributed and Heterogeneous Environments
Completely

REMOTE DATA DISASTER
OFFICE CENTER RECOVERY

PLATFORM
SUPPORT

APPLICATION
SUPPORT

STORAGE
SUPPORT

Symantec Has Defined and Lead Today’s Backup &
Archive Market for Over a Decade…
Leading Customer Validation…

1.5 Million savvy
99% of the Fortune 90% of the Global
small / medium
500 2000
businesses

#1 Backup #1 Archiving 10 of 10 leading 10 of 10 leading 10 of 10 leading
telecommunication healthcare financial services
Market Share Market Share companies companies companies

Leading Analyst Recognition…

Leading Leading
Backup Archiving
Vision Vision

26

Email Security
Email Anti Spam
Email Anti Virus
Email Image Control
Email Content Control
Email Management
Boundary Encryption
Symantec.Cloud Policy Based Encryption
Email Archiving
Email Continuity

Pre-integrated Web & IM Security
Web Anti Virus & Anti Spyware
applications Web URL Filtering
Web Roaming User
Secure Enterprise IM
IM Security
Endpoint Security
Endpoint Protection

27

Thank you!
Bhaskar_Sahay@Symantec.com
+919910056465

Copyright © 2010 Symantec Corporation. All rights reserved. Symantec and the Symantec Logo are trademarks or registered trademarks of Symantec Corporation or its affiliates in
the U.S. and other countries. Other names may be trademarks of their respective owners.

This document is provided for informational purposes only and is not intended as advertising. All warranties relating to the information in this document, either express or implied,
are disclaimed to the maximum extent allowed by law. The information in this document is subject to change without notice.

Dr Pramod D. Jacob (MBBS, MS- Medical
Informatics),
Consultant,
Healthcare Information Technology .

Email: pramodjacob@hotmail.com

Topics covered
 About HIMSS GETF for EHR
 Core Comparisons of EHR across countries
 National EHR initiatives in the UK, Canada
and the US
 Comparisons in Funding , Governance and
Standards
 Key Lessons

Mission Statement for the HIMSS Global
Enterprise Task Force (GETF)‫‏‬for EHR
 The United States lags behind other
industrialized nations for implementing
Electronic Health Record ( EHR ) systems.

 Chartered in 2006

 The mission of the Task Force has been to
examine the reasons for this lag and the
opportunities available to close that gap.

GETF- Task Force Objectives
 Identify and describe significant healthcare
information solutions being pursued in
countries globally.

 Identify aspects of a solution that differs from
one nation to another and to determine, through
ROI in finance and quality, which represents
“best practices.”

 Identify the common threads in national EHR
adoptions that led to success or failure.

 Understand the funding, architecture, and
delivery systems of solutions in other countries,
including network models and central versus
local data repositories.

 Incorporate “best practices” into a road map for
the development of a successful solution in the
United States and other countries embarking on
implementing EHR at a national level

 To avoid the pitfalls that have had negative
impact in past implementations.

 Join and communicate with other nations of the
world to help promote common goals in the
global adoption of Electronic Health Records.

Immediate Observations
 Comparison objects were huge, i.e.. There were
so many data elements identified we had to
narrow the elements so we could provide an
“apples to apples” comparison.

Sample of comparison data
• EHR application's selected
– Different in several countries.

• Legal and regulatory process:
– Terms on which providers, health plans, public health
authorities and researchers participate.
– Privacy and rights of individual whose information is held
in EHR’s, Compliance with Federal laws regarding privacy
and security.
– Liability of providers participating in EHR’s.
– Technology products and services licensing agreements.
– Data use agreements.

 EHR Architecture: Standards Employed
 Centralized vs. distributed - HL7 v3 RIM (ISO
 Information model 21731)
 User authentication - SNOMED
 Security model - ISO TC 215
 Services model - ICD 9 or ICD 10
 Messaging model - LOINC
 Transport - DICOM
(communications) - Other
 Clinical data (moved)

Total cost
Modules employed
– Software cost
– Hardware cost – Clinical
– Practice management
– Implementation cost
– E-prescribing
– Training cost – Scheduling, billing
– Infrastructure cost – Other
– Operation cost

Who pays
– Clinical users
– Private funding
– System funding
– Federal/regional/state/local

Core Comparisons
 Overview of healthcare system of country

 National EHR Program
- National IT/ICT status and strategy
- National/Regional EHR Approach

 EHR Governance
- Legal/Regulatory
- Healthcare policy
- EHR Financing

Core Comparisons
 Technology

 Adoption

 Outcomes
- Benefits
- Implementation Experiences

 Next steps for each country

Expected functions of EHR/EMR
• Review of encounters, problem list, medication
list
• Clinical Documentation like progress notes
• Order entry such as for medicines, lab tests and
procedures, results of tests
• Alert systems like drug-drug inter action
• Supports clinical decision ability such as
correction of dosage in case of renal insufficiency.

HIMSS GETF white paper
 Title :
Electronic Health Records:
A Global Perspective
2nd edition- Aug, 2010
 Website link:
http://www.himss.org/asp/topics_FocusDynamic.asp?faid=197

England EHR program
 NHS has ongoing project known as National
Program for IT (NpfIT) from 2002
 The Spine is a national central database for patient
summary records (Summary Care Record (SCR)) -
Comprises a central health record repository ,
access control, messaging hub and a portal for
clinical users
 Services being implemented by four categories of
external suppliers

England EHR program
 Four categories of external suppliers :-

-National Infrastructure Service Providers (NISP)
:- delivering National Network for the NHS
(N3) and NHS mail.

- National Application Service Providers (NASP)
:- providing services such as the EHR initiative
called the NHS Care Records Service (NHS
CRS) and e-prescribing

England EHR program
 Four categories of external suppliers :-

- Local Service Providers (LSP):- responsible for
systems such as GP systems, new hospital
systems and a new diagnostic application.

- GP Systems of Choice (GPSoC):- introduced
2008 to provide a greater level of choice to the
primary care sector in selecting the products to
run within a practice and funded as part of the
NPfIT.

England EHR program
• EHR initiative is NHS Care Records
Service (NHS CSR):-
Two elements
- Detailed records (held locally)‫‏‬
- Summary Care Record (held nationally)‫‏‬
• Detailed records securely shared between
different parts of the local NHS like one GP
practice to another (GP2GP)

England EHR Program
 Summary Care Record- summary of patient's
important health information available to
authorized NHS staff anywhere in NHS in
England.
 Patient can access their summary records
through secure web portal “HealthSpace”

 Summary Care Record stored in the Spine
central database.

England EHR Program
 Status:-

-June 2011- Major Projects Authority (MPA)
substantial achievements such as the Spine, N3
Network, NHSmail, Choose and Book and
PACS. However, the National Program for IT
has not and cannot deliver its original intent.

- Recommend that dismember the program and
reconstitute it under new management and
organization arrangements.

Canada EHR Program
 Canada Federal Government established an
organization called Canada Health Infoway
Inc (Infoway) in 2001 to support and accelerate
the development and adoption of interoperable
EHR solutions across Canada.
 Infoway is a not for profit organization whose
goal is that by 2010 , each province and territory
will benefit from new health information
systems that will modernize healthcare.

Canada EHR Program
3 key factors of national Health network
led by Infoway

1. Strategic Investor- Infoway collaborates with
federal/provincial/ territorial authorities,
healthcare organizations and IT vendors to
identify investments. Once investment
decisions made, public sector partners lead
implementation with Infoway providing
strategic direction.

Canada EHR Program
3 key factors of national Health network led
by Infoway

2. Gated funding – Infoway provides 75 % funding
with provinces and territories funding balance.
Gated funding model where funding given on
attaining specific implementation milestones
3. Interoperability- Infoway promotes use of
common architecture and standards to ensure
systems can interoperate. Established Infoway
Standards Collaborative.

Canada EHR Program
 The Electronic Health Record Solution (EHRS)
Blueprint provides an overall architecture for a
national system, that guides development of the
whole and individual parts.

 The architecture is technology neutral – does not
mandate use of a particular technology, product
or vendor. It just describes how the system
should work. Any application selected by
provinces or local jurisdictions must be
complaint with the blueprint.

Canada EHR Program
 This principle along with the use of standards
based applications reduce cost and risk, which is
Infoway's business strategy

Canada EHR Program
Infoway's EHR Solution (EHRS) Blueprint

 Flexible business and technical design
framework allowing solutions , components and
business rules to be reused by multiple
applications in health IT.

 Ensures all EHR solutions can exchange patient
health information across healthcare
organizations in a seamless and secure manner.

Canada EHR Program
Infoway's EHR Solution (EHRS) Blueprint

 Addresses business, conceptual and logical
architecture, deployment models and potential
applications for healthcare IT.

Canada EHR Program
Status
Goal :
- By 2010 fifty percent of Canadians on EHR
- By 2016 hundred percent

Achieved :
- By March 2009 reached seventeen percent
- By March 2010 reached thirty eight percent

USA EHR initiative
 Feb 2009 American Recovery and
Reinvestment Act (ARRA) with the HITECH
Act being the Healthcare Information
Technology component.
 Budget of $ 20 billion ( $ 36 billion)

 Through the Medicare/Medicaid programs

USA EHR plan
 General principles :-

- Carrot and stick for physicians /providers/
hospitals to adopt EHR systems
- Setting up of Health Information Exchange
initiatives like RHIO
- Setting up national HITRC and Regional
Extension centers

USA EHR plan
Carrot and stick for providers
- Each will receive about $ 44000 over five years
if implement EHR by 2011 and 2012.
Decreasing if after; no subsidy if after 2014.
- If do not show “ Meaningful use of EHR” after
2014, will get decrease in payment from
Medicare and Medicaid and no annual increase
for services.

USA EHR plan
Health Information Exchanges initiative

- Amount of $ 300 million to establish health
information exchange (HIE) initiatives across
regions and states-(RHIO) to hook up to a
National Health Information Network (NHIN)

USA EHR plan
Health Information Exchanges initiative

- Use of standards for inter operability and
exchange of data between hospitals and clinics.
- Further funds available for the network and
increasing broadband capability.

USA EHR plan
HITRC and Regional Centers

- Setting up 70 Regional Extension centers with
a central Health Information Technology
Resource Center (HITRC)
- Regional Extension centers- assistance to
providers through education, outreach and
technical help in selecting and implementing
the EHR

USA EHR plan
HITRC and Regional Centers

- Form a collaborative network that is facilitated
by the HITRC.
- About $ 600 million for regional centers.

USA EHR plan
Status :-
- By Nov 2011:- 20,000 providers and
1,200 hospitals achieved Stage 1
meaningful use and received payment
- By end of 2012 expected to reach 100,000
providers achieving Stage 1

Asia EHR initiatives
 Hong Kong
 Singapore
 Malaysia

Comparing EHR in different
countries
Next few slides will compare
- Funding
- Governance Models
- Standards and Interoperability
between different countries

Funding
 Central Government -England, Germany,
France, Netherlands,
Sweden, South Africa,
Denmark, New Zealand.

 Private Sector -India, Israel, Japan.

 Central, Local and Private -Canada, Hong Kong, USA.

 Central and Local -Australia

Governance Models
Governance Model Countries
Centralized England, New Zealand

Private Sector United States

Distributed Germany, Denmark

Standards and Interoperability
Parochial Standards France, Sweden,
Netherlands, Denmark

International (such as England, South Africa,
HL7)‫‏‬ New Zealand, Australia

Interoperability-Driven England, United States,
New Zealand, Australia

Multiple Systems Israel

Key Lessons
 Requires a commitment from high levels of
government and private sector.
 Flexibility and configurable applications
 Data standards for Interoperability needs to be
implemented .
 Physicians/Clinicians must be involved.
 Training is a essential piece that must be funded
and subsidized.
 Change management crucial.

Thank you
Dr Pramod D. Jacob (MBBS,MS- Medical Informatics),
Consultant,
Healthcare Information Technology.
Email: pramodjacob@hotmail.com
Tel: (+91) 9370715571

EVALUATION OF COMPUTER USAGE IN
HEALTHCARE DELIVERY AMONG
PRIVATE PRACTITIONERS OF NCT DELHI

ORAL PRESENTATION

Ganeshkumar P* Arun kumar sharma O.P.Rajoura

Assistant professor, Department of Community
Medicine,
SRM University, India.

BACKGROUND AIMS METHODOLOGY RESULTS CONCLUSION SCOPE

BACKGROUND
• Indian health system - increasing cost and demand pressures
and a shortage of skilled health care workers till the root
• Poor integration of information - between the health sectors -
incapable to handle public health issues & lack of proper
evidence in public health decisions
• 70% of the population use - private sector -not integrated with
the govt. system & often not regulated.
• Ehealth strategy – proven solution ; remains incompetent in
pvt. sector – never documented or little initiatives to assess the
utilization of ICT by the private health care delivery systems in
India.

NCMI 2012 , Ganeshkumar - 26 2


AIMS AND OBJECTIVES
1.To evaluate the usage and the knowledge of computers
and Information and Communication Technology (ICT) in
health care delivery by private practitioners.

2.To understand the determinants of computer usage by
the private practitioners.

NCMI 2012 , Ganeshkumar - 26 3


METHODOLOGY
Cross-sectional study – Nov’ 07 – Dec ’08 – 3 districts of Delhi
state – 600 clinic based private practitioners .

• Inclusion criteria: only modern medicine practitioners; practicing for 1
year in same location

Software
USAGE Hardware KNOWLEDGE

Internet
NCMI 2012 , Ganeshkumar 26 4


KNOWLEDGE

SOFTWARE – 60%
MEDIAN
COMPOSITE
HARDWARE – 10% SCORE

INTERNET – 30%

15 POTENTIAL BARRIERS 60

Patient
Technical
Logistic Financial related

7 & 28 3 & 12 3 & 12 2&8

SA A N D SD



RESULTS
• 85.5% - males and the mean age of all - 45.46±5.52 years
• 77% - own computer - but only 10.5%(63) – using in clinic
• 22% - had known about EHR – but only 8.8% - using in clinic
• Male and super speciality practitioners - more knowledgeable

PRESENCE OF EHR COMPUTER
PRACTICE
IN THE CLINIC KNOWLEDGE SCORE
SPECIALTY
N(%) (MEAN ± SD)
General practice 20(5.7) 2.26±1.05
General surgery 1(3.6) 2.48±1.04
Internal medicine 11(17.2) 2.42±1.07
Super speciality 16(24.6) 3.1±0.98
Others (Paeds,O&G) 5(5.3) 2.43±1.03
Statistical test X2: 32.22 df:4 p<0.000 SSB:40.02 df:3 p<0.000
MIE 2011, Ganeshkumar 26 6


• Practitioners who attended a computer course were 13.8 times
[OR: 13.8 (7.3 - 25.8)] more likely to have installed an EHR in the
clinic
• Most (86.3%) thought - lack of time was the major barrier and
nearly 50% – disagreed that cost is not a barrier
• Data entry - a cumbersome process - reasons for not installing a
computer in their clinic

POTENTIAL DETERMINANTS ADJUSTED ODDS RATIO P VALUE

Speciality practice 1.9(1.15-3.12) 0.011
Super speciality practice 8.18(2.57-5.99) 0.000
Presence of computer
3.93(1.67-9.26) 0.002
professional in the social circle
Female practitioners 0.493(0.27-0.87) 0.016


CONCLUSIONS
• Computer in clinical practice – low usage – low understanding –
low priority
• Existing knowledge by training influences more positively in
practicing a new technology in their clinical practice
• Limitation - cross sectional study - difficult to establish temporal
assoc. between knowledge and usage
• Major perceived barriers - technical related issues
• Significant determinants of usage
– Practice speciality,
– income,
– presence of a computer professional in the family and
– gender - significant determinants of usage


SCOPE
• Educating & training the doctors and a step forward - the
students in medical school
• Encouragement by government for using computers in clinic
– policy design
• Regulations for mandatory maintenance of electronic records
• Involving professional bodies in govt. programs – Public
private partnership – ehealth
• More research into the usability – patients & doctors –
potential determinants – diffusion of technology in practice


THANK YOU FOR YOUR
ATTENTION
DR.P.GANESHKUMAR MD
SRM UNIVERSITY
ganeshkumardr@gmail.com
+91 98406-40483


POST GRADUATE TEACHING
& CADAVERIC DISSECTION WORKSHOPWORKSHOP
& CADAVERIC DISSECTION
IN HEAD & NECK SURGERY - 2010

Dept of ENT-HNS, Army Hospital (R&R)
&
Dept of Anatomy

Army College of Medical Sciences
Foundation for Head – Neck Oncology

Supported by ICMR, MCI


Tea Break

Please be back in 10 mins for the next session

& CADAVERIC DISSECTION WORKSHOP

Lunch Break

- 01 hour
- Lunch is laid out in the canteen downstairs
- Cadaver dissection starts at dissection hall,
Anatomy Dept at 1330 hrs
- Please reach Dissection Hall 10 mins before


• Group photograph will be taken during the
tea break.


• Workshop Dinner

Date: 21 Jan 12
Time: 1945 hrs
Venue: Officers Mess, AHRR
All faculty, Delegates and Observors are
requested to attend.

PRESENTATION

© 2011 Spanco Ltd, All rights reserved

COMPANY PROFILE: INTRODUCTION
• Spanco Limited is a company engaged in creating Large scale
Global Head Quarter Mumbai, India Technology Infrastructure to help drive governance efficiency across
key sectors.
Global Presence India, UK, Africa, USA & Middle East • Consistently ranked in ET500 amongst outstanding companies of India
Inc.
Rev FY10 1182 Cr. • ISO 9001:2008, ISO 27001 and SEI CMMI Level 3 certified
• Focused offerings for Government, Telecom, Power and Transport
FY 11 (UA)- 1469 Cr. Verticals
• Presence e in Four continents with large spread across major cities in
Employees 12000+ India

Business structure
Shareholding Pattern as on March ‘11
Business Verticals

Bodies E-Governance SI / Power Service Provider BPO
Retail Corporate
investor 10%
15%

Technology Infrastructure
Sector Modernization(NeGP, RAPDRP,USOF Very Large state and
Institution 3g/Wimax,AAIM) National Infra Projects
investor Promoters
35% 40%

Services
Infrastructure Government Application
Citizen Interface Outsourcing
Management Transformation Development


COMPANY PROFILE: KEY PROJECTS

Smart Card DL/RC
SWAN Projects Punjab
Disaster Mitigation
Maharashtra
Andhra Pradesh State
State Data Centre Indian Railways
Rajasthan - Odisha Passenger Reservation
System

Key Projects
Security Surveillance
Airport Authority of India
Distribution Franchisee
– Nagpur

Integrated Border
Check post - MPRDC
Telemedicine
IT Infrastructure
CSCs in Maharashtra
Anna Centenary Library APDRP

Mobile Banking
Pension


COMPANY PROFILE: AWARDS & ACCOLADES
Maharashtra State IT Award for Best IT Company in eGov space for 2010

"UDYOG RATTAN AWARD” & “EXCELLENCE AWARD” by the Institute of Economic Studies (IES)

Nominated for the NDTV Profit Business Leadership Awards 2010 – IT Category

Consistently ranked in ET500 amongst outstanding companies of India Inc.

Ranked amongst top 500 Non Finance Companies by ‘The Business World Real 500’

Ranked 5th BPO Company in the Country by Data quest 2010

Amity Leadership Award 2009.

Spanco GKS awarded as best outsourcing solution provided in middle east by Insight (Middle East) for
2010

Spanco BPO Ventures Ltd. ranked in India’s Top 20 ITES and BPO Companies
4


MIZORAM TELEOPTHAMOLOGY PROJECT

BRIEF SCOPE
• Setting up a system for delivery of Eye care through Tele
Ophthalmology
• Supply of IT systems, Medical equipment, Power back up
connectivity, furniture and physical infrastructure at
multiple sites
• Identifying Ophthalmic Assistants, Link workers
• Training
• Operations, Maintenance
• Build database of patients
• Creating awareness of the project in the rural areas


Challenges for Implementation in Mizoram

• Difficulty in delivery to State - Permit issues
• Difficult Terrain – Long travel time due to road conditions.
• Finalization of sites was time consuming because of permissions from
department at multiple levels, allocation of space
• Lack of availability of Electricity, water connectivity
• Availability of Ophthalmic assistants - difficult to get the resources and then move
them to remote locations
• Link workers - still a challenge (even after approaching several departments). We
have finally decided to approach the Church for help
• Availability of technical support - difficult to get resources and provide support in
remote locations

6


Thank You

7


electronic patient records
in sri lanka

hospital health information management system

denham pole MD
consultant in medical informatics

subjects covered

overview of health care in sri lanka
early attempts at ePR
initiatives from the private sector
problems faced by the red cross
how were they solved
overview of hhims software
denham pole MD 2 04 February 2012

health care in sri lanka

state health care for 60%
230 state hospitals with beds
out-patients ++
private curative services for 40%
45 private hospitals with beds
family practitioners ++


in south asia ePR is in its infancy
even manual record-keeping is rudimentary
WHO advocates for improved records
2003 – several MOH initiatives started
2005 – WHO uses tsunami mandate to install
ePR systems
none of these systems had long-term success


2003 MOH: polonnaruwa, kurunegala, anuradhapura
2005 WHO: karapitiya, matara, ampara, trincomalee, batticaloa

why early systems failed

databases too complex

resistance from clinical staff

infrastructural and environmental problems


private sector initiatives

austrian / swiss / norwegian red cross –
proprietary software
• currently 26 hospitals running

sri lanka government (ICTA) – open-source
software
• 5 hospitals running, 6 more in planning


recent
developments
• proprietary software
2006-9: austrian / swiss /
norwegian red cross
(27 hospitals in east)
• open-source software
ICTA: 10 hospitals in 4
provinces

• lunar technologies
4 hospitals in 3 provinces


problem faced by red cross

clinical staff refused to use ICD to code
diagnoses

health ministry insisted on ICD for statistics

free-text input not a viable alternative


ICD 10 daggers and asterisks


daggers and asterisks explained


how was it solved

concept groups allowed appropriate terms to be
selected – event, findings, disorder, procedure
synonyms user-friendly for staff whose mother-
tongue was not english
cross mapping to ICD 10 codes satisfied official
requirements


snomed – ct


royal college of physicians

individual patient care

care of populations – epidemiology

cost – effectiveness


simplicity


portable/mobile solutions

iPhone access

what can hhims do

patient registration
simple OPD/Clinic record-keeping
admission records
public health statistics
infectious disease notifications
appointment system
laboratory ordering/reporting

what are the benefits of
using hhims
clinical staff: better informed, easier to do
administrative work
hospital administrators: medical record
management, stock control, performance indicators
central ministry / WHO: better public health
information
patients: better documented record, better care,
possibilities of telemedicine

patient overview


ODP visit


admission


snomed look-up


out patient registration

new patients are first registered before seeing the doctor

paperless registration desk

registering a patient

admission desk

nurse admits the registered patient

paperless OPD – large hospital

some doctors’ tables are paperless

paperless dispensaries

some dispensaries are also paperless


paperless OPD – small hospitals

smaller hospitals benefit from improved documentation

paperless wards

some wards are also paperless


paperless wards

smaller hospitals benefit from improved documentation

admission desk

new patients are first registered before seeing the doctor

OPD

paperless

manual records

before ePR


Lunar Technologies (pvt) Ltd.
15B, Fullerton Estate II, Gamagoda 12016,
Kalutara, Sri Lanka.
www.lurartechnologies.net
info@lunartechnologies.net

thank you

denham pole MD
consultant in medical informatics
lunar technologies
sri lanka

Foto: Fröken Fokus

Telemedicine for Developing
Countries
Jeremiah Scholl, Senior Researcher, Health
Informatics Centre, Karolinska Institutet,
Stockholm Sweden

Presented by Dr.Shabbir Syed-Abdul
Taipei Medical University and National Yang Ming
University, Taipei, Taiwan.

Health Informatics Centre, Dept. of LIME and Dept. of Medicine (MedSolna), KI

Foto: Fröken Fokus

About Jeremiah
• From Denver, Colorado
• PhD in Media Technology, Luleå University of
Technology (2000-2005).
• Norwegian Centre for Integrated Care and
Telemedicine. Tromsø, Norway (2005-2010).
– WHO Collaborating Centre for Telemedicine
– Research Manager is Richard Wootton (lots of
experience with Telemedicine for Developing
Countries).
• Health Informatics Centre at Karolinska Institutet
since January 2010.

Foto: Fröken Fokus

Overview of presentation
• Clinical use for second opinions

– Overview of systems
– Challenges to widespread adoption
– Some successes in India
– Looking to the future


Foto: Fröken Fokus

Clinical use


Foto: Fröken Fokus

Obtaining second opinions
• There are quite a few different networks, some
of which have evolved into large scale.
• There is some evidence of positive impact.
– 34 articles reporting clinical experience.
– All studies except 1 reported benefits for
Telemedicine.
• Possible publication bias.
– Methodology often poor.
• Sometimes they don’t even include the total number of
patients.


Foto: Fröken Fokus

Obtaining second opinions
Some well established International
networks
1. Partners Healthcare, Boston, USA
2. Tripler Army Medical Centre, Honolulu, USA
3. iPath Association, University of Basel,
Basel, Switzerland
4. Swinfen Charitable Trust, Canterbury, UK
5. Institute of Tropical Medicine HIV/AIDS
Telemedicine network, Antwerp, Belgium

Foto: Fröken Fokus

Partners Healthcare, Boston,
USA
• Date of first operation: 2001
• Mechanism: Email
• Referring sites: Rovieng Health Centre, Cambodia;
Rattanikiri Hospital, Cambodia
• Expert sites: Sihanouk Hospital, Phnom Penh; Harvard
Medical School, Boston
• Description: Email consultations are used to support
health workers at a rural clinic in northern Cambodia.
The email advice comes from specialists at a tertiary
hospital in Phnom Penh and from the Massachusetts
General Hospital in Boston. In 2003, a second site at a
small hospital in northern Cambodia began referring
cases.


Foto: Fröken Fokus

Tripler Army Medical Center,
Honolulu, USA
• Mechanism: Web
• Referring sites: US-associated Pacific islands
• Expert sites: Tripler Army Medical Center,
Hawaii
• Description: A web-based teleconsulting
system is used by the main US Army hospital in
Hawaii to support referrers in hospitals (mainly
military hospitals) around the Pacific.


Foto: Fröken Fokus

iPath Association, University of
Basel, Basel, Switzerland
• Mechanism: Web
• Referring sites: Several (mainly telepathology), e.g. Cambodia,
Solomon Islands, Bangladesh Also more recent teleconsultation
work, e.g. Ukrainian Swiss Perinatal Health Project
• Expert sites: Mainly Swiss, European
• Description: The iPath software was originally developed for
telepathology case conferences (for which it is an excellent tool, and
several tens of thousands of case conferences have now been
conducted — technically by a number of different organizations who
all use the same software). More recently the software has begun to
be used for general teleconsulting (i.e. non-pathology work).


Foto: Fröken Fokus

Swinfen Charitable Trust,
Canterbury, UK
• Mechanism: Email and Web
• Referring sites: Global
• Expert sites: 513 consultants in 68 countries
• Description: A simple email teleconsultation system
was established at a single hospital in Bangladesh by a
UK-based charity. Specialist opinions were obtained
from a small panel of volunteer consultants. The
operation has now grown to service over 100 hospitals
around the world, with a panel of more than 500
consultants. An automatic message handling system is
employed, supplemented by a more recent web-
messaging system.


Foto: Fröken Fokus

Institute of Tropical Medicine HIV/AIDS
Telemedicine network, Antwerp, Belgium
• Mechanism: Email and Web
• Referring sites: Global (40 countries as of 2009)
• Expert sites: 20 experts (Antwerp and others)
• Description: Internet-based decision support service to
assist health-care workers in the management of difficult
HIV/AIDS cases. Available to physicians working in
resource-limited settings. Queries are handled by a
coordinator that forwards them to a network of
specialists, based at the ITM and at other institutions.


Foto: Fröken Fokus

Utilization
Operator Cases (as of 2008- Years
2009)
Partners 900 6
Healthcare
Tripler 3000 10
iPath 500 5
SCT 1500 9
ITM HIV/AIDS 950 6


Foto: Fröken Fokus

Utilization
• Despite there being…
– A number of services.
– Years of experience.
– Free!
• Overall utilization seems extremely low in comparison to
potential demand.
– Consider that:
• Developing world contains 5400 million people in 127 countries.
• Suppose 1/10 people sees a health-care professional each year.
• Suppose in 1/100 of these interactions, the health-care professional
concerned would like to seek a second opinion.
• This would imply 5 million referrals each year.


Foto: Fröken Fokus

Why is utilization so low?
• Evidence of the following challenges
– Cultural problem of asking for help.
– Referrers too busy.
– Perceived loss of control.
– Lack of communication infrastructure.


Foto: Fröken Fokus

Cultural problem of asking for help
• SCT: About half of
requests are by ex-pats.
– Malawi: 50% of doctors
registered in Malawi are
Malawian.
• This indicates it may not
be a major problem.
• One report from India
however states that
patients might loose trust
in a doctor that uses
Telemedicine.

Foto: Fröken Fokus

Referrers too busy
• Doctors would like a second opinion.
However they are too busy to ask for one.
• An experiment with medical students on
elective time in developing countries
increased usage of Telemedicine.
• Thus, there is some evidence for this.


Foto: Fröken Fokus

Perceived loss of control
• SCT. Asia-pacific region. Country making about
30 referrals a year. 2004 new health minister
with nationalistic tendencies: Referrals stop


Foto: Fröken Fokus

Lack of connectivity
• Existing connectivity options all have
limitations.


Foto: Fröken Fokus

Advantages and disadvantages of
various connection technologies.
• Satellite
– Advantages: Can go anywhere.
– Disadvantages: Expensive and requires government help.
• Internet
– Advantages: Cheap and (sometimes) fast service
– Disadvantages: Not always available in rural areas. Telecom
companies must make a profit to be there. Only as reliable as
fixed infrastructure.
• Mobile phone
– Advantages: Quite widely available. Inexpensive for low
bandwidth (sms, audio)
– Disadvantages: Not available in all rural areas (especially
Africa). Low bandwidth, and/or expensive for data. (I.E. Not
ideal for routine video conferencing usage or large data
transfers).


Foto: Fröken Fokus

Lack of connectivity
• Experiments in South India show large
increase in Telemedicine by using point-
to-point WiFi.
• Recent Study indicates interest in
connectivity with DTN to improve adoption
of Telemedicine.
• Thus, this can be overcome.


Foto: Fröken Fokus

Awareness?
• How much is awareness a problem?
– How many of you are aware that Swinfen
Charitable Trust provides free access to
specialist advice via Internet?


Foto: Fröken Fokus

Where to go from here?
How do we develop a?
• Within country networks.
• Demonstratable health outcomes.
• Shown to be cost-effective and
sustainable.
• Acts as a model for other countries to
copy.


Foto: Fröken Fokus

Within country Telemedicine
Networks
Indian Experience


Foto: Fröken Fokus

Telemedicine Networks in India
1. Apollo Telemedicine Networking
Foundation.
2. Indian Space Research Organization
(ISRO).
3. Aravind Teleophthalmology Network.


Foto: Fröken Fokus

Apollo Telemedicine Networking
Foundation
• First telemedicine centre in Aragona in
1999.
• Wide spread international network.
• Provide a wide range of Telemedicine
services.
– Tele-Radiology, Tele-Dermatology, Tele-
Pathology, Tele-Cardiology, Remote ICU
Monitoring, Ambulance Monitoring, Mobile
Telemedicine Unit, Electronic Health Record

Foto: Fröken Fokus

Apollo Telemedicine Networking
Foundation
• Details of their services not extensively
published much in medical literature.
• Thus, it is difficult to generalize their
experiences.


Foto: Fröken Fokus

Indian Space Research
Organization (ISRO)
• Providing Telemedicine services since
2001.
• Uses satellite link.
• 60 remote hospitals connected to 20
super-specialty hospitals.


Foto: Fröken Fokus

Dealing with Connectivity
Problems.
• Aravind Teleophthalmology Network.
• Built on customized point-to-point Wifi.


Foto: Fröken Fokus

Aravind Eye Care System


Foto: Fröken Fokus

Aravind
• Largest eye-care provider in the world by
volume
• 5 hospitals:
– Madurai, Theni, Tirunelveli, Coimbatore, and
Pondicherry
• 2006-2007
– 2.3 million patients
– 270,000 surgeries
– most for cataracts 4


Foto: Fröken Fokus

New Model: Vision
centres – Doctor stays at urban
hospital
– Interacts with patients via
Telemedicine.
– Technician operates the
ophthalmic equipment and
PC
– Counselor follows up with
patients based on the
diagnosis provided by
tele-doctor

Foto: Fröken Fokus

Some key challenges to sustainable Telemedicine
system in developing countries

1. Financial self-sufficiency
2. Operational self-sufficiency
• Challenging in areas without good communication
infrastructure.
• Do not want to rely on outside donors to pay for bandwidth
forever etc.
• New techniques allow custom point-to-point WiFi connectivity to
be set up.
• Audio, Video, Email, Web etc.


Foto: Fröken Fokus

Financial self-sufficiency
• Sustainable deployment must be cash-
flow positive.
• Positive monthly cash flow is easier to
achieve than profitability (including
recovery of capital investments).
• Limits aid to start-up $, but not ongoing
operations.


Foto: Fröken Fokus

Capital expenditures
• Some can be framed as a monthly cost.
• PC that costs $600 and lasts five years.
– $10 per month without interest .
– $14.70 per month with interest (8%).
– $11.76 per month with salvage value of 20%.


Foto: Fröken Fokus

Operational self sufficency
• Ongoing system maintenance and support.
– power, hardware, software, expansion and new
installations.
• Local groups do not start out with the ability
to handle this.

Thus the system has:
– component robustness
– easy-to-use management tools for local staff
– tools for remote management by experts

Foto: Fröken Fokus

Incremental approach


Foto: Fröken Fokus

Incremental approach
1) Moved 4 vision centeres to their high
speed wireless
2) Added 5 more vision centres.
• May 2007 -December 2007
– Average of 3,632 patients per month.
– 75% new patients, 25% follow-up
– 9,835 patients diagnosed with severe cataract
or refractive errors
– 90 percent (8,814) got their sight back

Foto: Fröken Fokus

Results
• 50,000 telemedicine examinations so far
• 3600 per month
• Expanding to 50 centers in next 3 years
– 500.000 examinations expected per year.


Foto: Fröken Fokus

Limitations
• Apollo:
– For Apollo network.
– Seems good but its unclear how others in India can benefit from
their success.
• ISRO:
– Expensive satellite system.
– For use by a few public clinics.
• Aravind
– Very specific for use with their clinics.
– Provides good model of developing custom connectivity and
service!
– But not all questions others need to deal with are answered.


Foto: Fröken Fokus

Limitations
• The vast majority of clinics in India are
private clinics that are not part of the
Apollo network or Aravind network.
• Many are small with only a few patient
beds.
• It is unclear how to apply these
experiences to these clinics.


Foto: Fröken Fokus

Challenges with further development of
Telemedicine in India
• Lack of economic incentives for private clinics.
– Local clinics are often run as businesses by the medical practitioners.
– Common source of revenue at these clinics is % of the fees collected
from patients they refer to hospitals.
• If they use telemedicine instead of send the patient, they would miss out on
this revenue.
• Potential negative impact on the doctor-patient relationship.
– Patient perspective: Physician treats them immediately, or refers them
to a hospital for additional care.
• Why does this doctor need to ask an outside network for help? Maybe (s)he
is not so good?
• Lack of awareness of potential.
– How many people are aware that SCT can provide free specialist advice
to physicians?
• Lack of adequate infrastructure in some rural areas.
– Aravind model could help.


Foto: Fröken Fokus

Conclusions


Foto: Fröken Fokus

Conclusions
• Telemedicine holds a lot of promise to improve healthcare systems
in developing countries.
– Improved access to care, help to overcome lack of resources.
• There are many international Telemedicine networks that offer
support.
– There are some challenges with their use: Patients may be skeptical;
Referrers may be too busy; Loss of control; Lack of infrastructure
– They seem underutilized.
• Awareness also may be a problem.
• There is some success with within country Telemedicine networks
– Ukraine: Success with teleconsultation for trauma and orthopedics.
– India:
1. Apollo
2. Space
3. Arvind eye care system
• It is possible to overcome lack of infrastructure.


Foto: Fröken Fokus

Conclusions
• Challenges for Telemedicine in India
– How to create economic/organizational alignment between clinics and
specialists?
• Comprehensive insurance programs?
– Apollo and Aravind show that connecting clinics and hospitals financially enables
Telemedicine.
• Government run Telemedicine centres and increased awareness among
patients about benefits to them from Telemedicine?
– What if Telemedicine becomes a known service provided by government
hospitals? Perhaps patients will accept and trust this.
– How to make patients comfortable with Telemedicine usage by doctors?
• If patients understand that doctors ask Telemedicine centres to save the
patient expensive trips to hospitals, then maybe they will trust their doctor
more?
– Improve awareness for those that would like to use international
networks.
• Why not use SCT?


Foto: Fröken Fokus

References
• “Telemedicine support for the developing world”, R. Wootton -
Journal of Telemedicine and Telecare, 2008
• “Deploying a rural wireless telemedicine system: Experiences in
sustainability”, S. Surana, R. Patra, S. Nedevschi… - IEEE
Computer, 2008
• “In what circumstances is telemedicine appropriate in the developing
world?”, R. Wootton and L. Bonnardot - JRSM short reports, 2010
• “Experience with low-cost telemedicine in three different settings.
Recommendations based on a proposed framework for network
performance evaluation”, R. Wootton, A. Vladzymyrskyy, M. Zolfo, L.
Bonnardot- Glob Health Action, 2011
• “Study on the potential for delay tolerant networks by health workers
in low resource settings”, S. Syed-Abdul, J. Scholl, P. Lee, W.S.
Jian, D.M. Liou – Computer Methods and Programs in Biomedicine,
2012


Foto: Fröken Fokus

Thanks!
jeremiah.scholl@ki.se


“8th National Biennial Conference on Medical Informatics 2012”

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (19)

Destaque

Destaque (16)

Semelhante a “8th National Biennial Conference on Medical Informatics 2012”

Semelhante a “8th National Biennial Conference on Medical Informatics 2012” (20)

Último

Último (20)

“8th National Biennial Conference on Medical Informatics 2012”