Is the paranoia around H1N1 in Pune / India justified? – A look at some factoids & information resources

Honestly, I don’t have the exact answer. Only time will tell whether we, the citizens of Pune (and India) over-reacted, or should have done a lot more. All we have right now are statistics, data-points, examples from other regions of the world, and expert advisories to look at and  learn from. 

In this article, I am listing out the various relevant factoids, observations and information resources that I have stumbled upon over the past few days. I will let the readers draw their own conclusions.

What is painfully clear though is that we don’t have enough data, and we often don’t rely on credible sources of information. In absence of data and facts, the common population is always swayed by ‘headlines’ and ‘sound bites’ – Sadly, this is true even in the 21^st century. Thanks to the latest technology, data can be accessed easily; yet this same technology can also help in spreading rumors a lot faster as well.

Here are some factoids and observations:

1. According to WHO and other estimates, there are nearly 1 Billion cases of normal flu (influenza) each year.  Around 3-5 Million of these are severe and 300,000 – 500,000 of these result in deaths.

Statistically speaking (based on a simple extrapolation that India’s population is apprx 1/5 of World Population) that translates to 200 M cases, 600,000 – 1 M severe cases, and 60,000 – 100,000 deaths.

For a city of Pune, that translates to 500 deaths/year or 10 deaths/week.

All these are huge numbers. And yet, until a few weeks back, we hardly even thought about ‘influenza’ as something serious! 

2. On a related topic – Pollution levels in Pune and in all major Indian cities are at very dangerous levels. Yet very few perceived the need to wear masks over all these years. Do we know the statistics of upper respiratory problems in major Indian cities?

3. According to WHO (World Health Organization), the recommended mask to protect against H1N1 infections is the one that meets the N95 standard. Yet, these constitute a miniscule amount of the ones being worn around in Pune. The others don’t really offer any significant help. For a complete list of Do’s and Don’ts regarding masks – please refer to the next section.

4. Commonsense tells us that it is better to wear masks in crowded places; but they are not very critical when walking or driving on uncrowded, open roads. Yet, what we are seeing around in Pune is quite the opposite. It is also amazing to see so many people wearing masks that are covering their mouths, but not their noses?!

5. Last year, over 200 riders lost their lives in 2-Wheeler Accidents in Pune – many of these deaths could have been prevented had the riders been wearing helmets. Yet I see so many people on Pune roads today wearing masks but not helmets!

6. According to what I have read thus far, the H1N1 strain is not significantly more virulent than the traditional influenza virus. The prescribed treatments are also very similar to normal flu.

7. Most individuals who get infected with H1N1 will get back to normal in a few days (similar to the normal flu). This is not a virus like HIV that an individual will carry with him / her for the rest of their lives!

8. Apparently, a vast percentage (by some accounts, up to 90%) of the Indian population tests +ve on the skin test for TB (Tuberculosis). Majority of these tests yield a –ve result on a follow-up (and more reliable) X-Ray test. Disease causing germs (viruses and bacteria) are present everywhere – in most of the cases, the immune system should be able to take care of them! It is only when the immune system becomes weak (in case of old age, young children, patients suffering from certain chronic ailments, etc.) do these germs present any significant danger.

 

Here are some useful information sources:

1. Flu related statistics (from Roche Laboratories – makers of Tamiflu)  http://www.flufacts.com/impact/statistics.aspx

2. Comprehensive Flue Related Information from US Dept of Health & Human Services and CDC (Center for Disease Control)  www.flu.gov  http://www.cdc.gov/h1n1flu/

3. Comprehensive Flue Related Information from WHO (World Health Organization) http://www.who.int/csr/disease/swineflu/en/

4. A map based depiction of Flu cases across the globe http://www.healthmap.org/en

5. WHO – FAQ about H1N1 http://www.who.int/csr/disease/swineflu/frequently_asked_questions/what/en/index.html

6. WHO – Document regarding use of masks http://www.who.int/csr/resources/publications/swineflu/masks_community/en/index.html

7. WHO – Document regarding cleaning hands as a key preventive measure http://www.who.int/csr/resources/publications/swineflu/AH1N1_clean_hands/en/index.html

Issues With America’s HealthCare System – A Patient’s Perspective

I had the misfortune of suffering from an extended illness in America and experienced firsthand the many problems and issues with the American HealthCare system. In this brief article, I will try to list some of the major ones that I can recollect from my personal experience (See list below – points are in no particular order).

 

Please note that I still believe that the American HealthCare system is amongst the best in the world; especially when it comes to treating really tough medical conditions, and performing complicated surgical procedures and emergency medical services. It still retains some of the best doctors and other medical talent in the world.

 

My issues are more systemic and process related. In the end, one would expect a little more from world’s most advanced and expensive healthcare industry! Note these are my personal observations – whether some of these points can be generalized further needs more data points from other patients and consumers of this healthcare system.

 

1. Cost of HealthCare Insurance – The cost of healthcare has undergone a major increase over the last decade. The increasing insurance premiums have forced many private sector companies (that offer health insurance to their employees) to increasingly pass on a bigger chunk of these costs to the employee. This increase has been significantly more than the rate of inflation, and has resulted in no perceptible change in the service quality.

 

2. High costs for the un-insured, and the under-insured – This issue is extremely critical and has already been discussed ad nauseum in every media outlet, by numerous experts.

 

3. Insurance Claims Processing – Even for patients that have some of the best insurance coverage, the process of settling claims is far from perfect. Discrepancies and errors are common. In certain cases, interpretation of ‘what’s covered vs. what’s not’ is not clear. The 3-way communication across, Doctor’s Office – Insurance Company – Patient, further adds to the process complexity and mismatches. I personally had to deal with many of these claims related issues. To resolve these, often times you end up spending hours on the phone with the insurance company.

 

4. Impact of ‘medico-legal issues related complications’ on behavior? – I am not a legal expert and cannot pass explicit judgments here, but sometimes one gets a feeling that the entire medical staff’s (not just the Doctors, but also the Nurses and other support personnel) interactions with a patient are biased by a ’medico-legal’ angle. Most answers are very generic, vague and filled with ‘disclaimers’. I understand that this is a big issue, but it is a bad trend if it affects the medical staff and patient communication. This communication channel needs to be one of those most ‘open’ ones!

 

5. Accessibility of a doctor – Most doctors work during the regular office hours and are not available on evenings and weekends. Hence seeing a doctor often times results in a forced half-day vacation during weekdays for many patients. Evenings and weekends are out of bounds and if you are in urgent need to see a doctor, in most cases an Emergency Room is your only option.

 

6. Difficulty in getting to a specialist – Often times it’s very difficult to schedule an appointment with a specialist. Many are booked out weeks into the future. And if you can’t see them right away, and are in some serious trouble, the standard answer that you might get is ‘Go to an Emergency Room!’

 

7. Difficulty in asking any simple follow-up questions to a doctor – If you have the most mundane follow-up question, it is still very difficult to directly ask your doctor. Even if you call during office hours, your call is routed to a nurse who often has no background about your particular case (except for some case-papers). Typically, the nurse is very busy and answers a simple – ‘I will get back to you’. If you call outside office hours, then your best bet is an answering service! I agree that many times it is not feasible for a busy doctor to directly talk to the patient. But some intermediate solution needs to be worked out. After all, I think that the most expensive healthcare system in the world should have at least some ‘personal touch’.

 

8. Information Technology in Healthcare – I get the impression that the Healthcare industry hasn’t leveraged IT to the fullest extent as compared to many other industry sectors. This can be seen in hospitals as well as in doctor clinics. From basic things like Electronic Medical Records (also referred to as Electronic Health Records), to a better integrated hospital management system (across billing, insurance, clinics and service providers) a lot of improvement is needed. Even today, there’s hardly any electronic data interchange of a patients reports, health records and doctor’s notes across practices and hospitals.

 

I have had to fill in volumes of paperwork every time I went to see a new doctor. Why can’t there be some automation of a patient’s insurance records and medical history? Why does a new patient have to arrive at a new doctor ‘15 min early’ to fill out reams of paperwork, many times when he is not in a mental/physical condition to be dealing with this? A patient has to maintain an increasingly heavier load of files, and paper documents, and make it accessible to any new doctor that he might be seeing.

 

9. Difficulty in Scheduling Simple Procedures – Even simple diagnostic procedures (e.g. Ultra-Sound, Endscopy, etc.) can sometimes take days or even weeks to schedule. I don’t really know why this happens. Is this merely a scheduling problem or a supply scarcity of resources?

 

10. Newer patented drugs are regularly being introduced and are prescribed in many cases. Not sure if the incremental benefit that some of these provide over the existing older (and still under patent) or off patent/generic drugs can be weighed against their exorbitant costs. I am not an expert and cannot make this judgment, but do think that this is something that needs to be researched further. Again – since the US consumer is supposedly the ‘richest in the world’ he has to pay the highest (in most cases) for the patented drugs compared to other developed countries. This is another issue that has been a big point of contention, with lot of discussions in the media.

 

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Electronic Medical Records (EMR): A Practical Solution

Messaging, Social Networking, Photo Albums, Filing Taxes, Stock Market Investments, Banking, Paying Bills and many other activities are moving online and are being converted to an ‘electronic form’. The internet user base in India (especially in the Metros and Tier-1 cities) is growing at a very fast rate.

 

Yet, something that is very critical, something that is very personal – Medical Health Record, is still stuck with that ‘nearly 2000 year old ancient Chinese invention – Paper’! Why aren’t medical records being stored in an easy to use electronic format? As in any big change, there are multiple reasons ranging from the availability of appropriate technology, stakeholder education, standards, and process changes.

 

Today, core technology is not a bottleneck. Having appropriate technology systems for the Indian environment is important. Stakeholder education and requisite process changes at hospitals and clinics are more critical. Let us try and explore the advantages of Electronic Medical Records, and their adoption. Let us begin with the definition of Electronic Medical Records (also referred to as ‘EMRs’) – Wikipedia defines Electronic Medical Records as medical records in a digital format.

 

In the past, detailed medical records were often only generated during surgical/other critical procedures or during treatment of a serious illness. Advances in medical sciences have meant that today, we undergo a lot more preventive tests and procedures. There is a great deal of focus on improved diagnostics and preventive care. This has resulted in a dramatic increase in the number of medical records an individual would typically maintain.

 

Rapid and easy accessibility of these medical records can help save time and effort, and can potentially be a life-saving aid in case of an emergency. Paper records by their very nature are difficult to manage, copy, carry, and forward to others.

 

Benefits of Electronic Medical Records

 

Electronic Medical Records can deliver multiple benefits to the various stakeholders in the healthcare process. For patients, they simplify management of their medical history – across multiple doctors, hospitals and other facilities. They also enable quick access and retrieval in case of an emergency. Risk of loss of valuable data is greatly reduced.  For hospitals and other healthcare providers – EMRs simplify the overall records management process. For doctors, EMRs enable quick review of past history of a patient and aid in rapid diagnosis. They also enable a doctor to quickly forward and discuss a patient’s condition with a colleague or a specialist.

 

Further benefits of Electronic Medical Records can be achieved if they are made available over the internet. This enables ‘pervasive’ accessibility of an individual’s complete health picture at anytime, anywhere in the world. Adequate processes need to be taken to provide a secure login and password to maintain privacy and confidentiality of the data. A comprehensive and user-friendly categorization, storage, search and retrieval workflow needs to be enabled.

 

Similarly, intelligent offline availability of these EMRs is also critical (especially in India) where internet adoption (especially amongst senior citizens) is not that high, and where internet availability is not reliable. Offline availability can be enabled through storage devices such as CDs, USB drives, etc. It is important that the offline usage scenario has the same user-friendly search and retrieval capability of the EMRs.

 

 

Stages of Electronic Medical Records Evolution

 

EMRs are evolving through the following 4 stages (as described in Wikipedia):

 

1. Non-Electronic Data (Paper Documents)

2. Machine Transportable Data (Email, Fax, Scanned Documents)

3. Machine Organizable Data (Scanned Documents with metadata descriptors)

4. Machine Interpretable Data (Fully digitized documents with metadata descriptors)

 

[Note – ‘Metadata’ is defined in the subsequent paragraph].

 

Presently a majority of the hospitals and clinics in India are still stuck at Stage-1.

 

Stage-2 can be easily implemented but has limited value when it comes to cataloging, organization and searching of records. Stage-3 has tremendous value and relatively low cost of implementation (we will discuss this further). Note, ‘metadata’ means the ‘description of data’ and can include various organization information around a medical record such as ‘Type of document’, ‘Doctor’, ‘Date’, ‘Category of document’, ‘Importance’, etc. Stage-4 can deliver the ultimate value, but is quite expensive and complicated to implement.

 

Adoption of Electronic Medical Records – A Roadmap

 

Clearly, Stage-4 signifies the ‘utopia’ of EMRs adoption. However, what is the cost-benefit scenario? Let us explore this further.

 

Stage-4 needs the complete data (i.e. each and every row, column and field in a document) to be stored as a computer interpretable entity. Essentially, this entails a computer model (or dictionary) of each and every conceivable field (health condition (e.g. ‘Blood Pressure’, diagnostic parameter (e.g. Systolic/Diastolic), their values (e.g. 120/80), acceptable ranges (High: 100-140, Low 60-100), etc.) in any type of medical record needs to be created and stored. This is easier said than done! Such a data dictionary could run into tens of thousands of items. Free form text, such as doctor notes are even more difficult for a computer to interpret. For many hospitals and other data sources, where data is not generated electronically at source – this entails an additional manual process for keying in the data into the data dictionary format. Even if data is available electronically, lack of standards implies that different doctors and hospitals maintain different formats (in other words, each hospital has its own data model/dictionary!) – And a big mapping and data conversion exercise is essential. This predicament is a big reality in US today where every major hospital chain has implemented their own versions of such data dictionaries. As a result, they are not interoperable. In the real world, a patient visits multiple doctors/hospitals across cities and hence electronic data in one hospital’s format is meaningless during his next visit!

 

Lack of standards is one of the biggest reasons why Stage-4 EMRs haven’t been successfully deployed in US and in many other developed countries.

 

In India, we are long way off from such a common standard.  Stage-3 simplifies all the implementation issues in Stage-4 by directly storing a scanned the paper document, the diagnostic image, or an electronic document in its native format (e.g. ‘.pdf’, ‘.doc’). There is no conversion into a ‘standard format’. The only limitation here is that such records cannot be machine readable. However, that is a small price to pay to achieve comprehensive cataloging and archiving of medical information. As described earlier, these documents carry a complete digital description (metadata) and can be stored, cataloged, searched and retrieved electronically with ease.

 

As can be seen from above, a good medium balanced approach is Step-3; especially for a developing country like India. Quick benefits can be derived through a lower relative investment, and the time for implementation is also very fast.

 

‘Practical’ Solution for Electronic Medical Records

 

 

 

 

A practical solution for Electronic Medical Records in the Indian context can be based on ‘Stage-3’ described above. In future, this can be migrated to Stage-4. The basic building blocks of such a solution are described below. Pune based ‘ArogyaDarpan.Com’ offers such a practical approach to Electronic Medical Health Records.

 

1. Online Web-Service to Upload, Describe (add metadata), Save and Search/Retrieve Documents in different formats.

 

2. Offline software capability to search and retrieve previously saved EMRs

 

3. Offline service capability to collect, scan and process documents, obtain other electronic documents directly from legacy systems. This can be further extended to automatically source and integrate medical documents from various legacy systems at different doctors/hospitals.

Healthcare in US – Interesting New York Times Article about ‘Disruptive Innovation’

The US Economic Crisis has pushed two very critical issues off the front pages for now. These include: Healthcare System Re-haul and Alternative Green Energy. In the coming weeks, I am hoping to blog more about these topics.

 

Recently, I came across a terrific article on ‘Disruptive Innovation, Applied to Healthcare’ in the New York Times. The article written by Janet Rae-Dupree takes an interesting view of the present state of the health-care system in US, and the changes necessary to fix it. Here is a brief extract:

 

“THE health care system in America is on life support. It costs too much and saps economic vitality, achieves far too little return on investment and isn’t distributed equitably. As the Obama administration tries to diagnose and treat what ails the system, however, reformers shouldn’t be worried only about how to pay for it……” To access the complete article, please click here.

 

I have personally experienced the limitations, the bureaucracy, and the idiosyncrasies of the American health-care system first hand, during the course of a long illness. I cannot understand how the world’s richest country can have such a fundamental, basic human necessity; in such a bad shape.

 

The new Obama administration has committed to focusing on the health-care system. During the election campaign primaries, there was a lot of discussion around how Sen. Hillary Clinton could approach this whole issue, given her previous attempts at it in the 1990s. Unfortunately now, with the economy in front and center, it will be a while before fundamental changes are made to this system.

 

 

 

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Do You Understand Your Doctor’s Prescription?

I have always been interested in learning more about the ingredients in the various common medicines. During school days, chemistry was one of my favorite subjects and may be it is this reason; or it could simply be my general interest in any ‘trivia’! To add to this, I have had the misfortune of having a variety of minor (and a few major) illnesses, resulting in me being at the receiving end of various pills. Over the years, I have made an attempt to understand some of these common medicines, their ingredients, actions, and other properties. In this series of articles, I will make an attempt to provide some basic information of the categorization of common prescription drugs, as well as provide some information about their ingredients and their effects. I will start off with my discussion on why many people today don’t have a basic understanding of this area, and why I feel this is very important. Based on the feedback, I will publish follow-up detailed articles on individual medicine categories.

 

At the outset, I would like to put out a few clear disclaimers and ground-rules. 1) I am neither a doctor, nor a pharmacist. Hence please consider this article as ‘general information’ only. Please do not use this information to decide on any self-medication/self-treatment strategy. Always consult your doctor prior to taking any medications or undergoing any treatment. 2) While I have researched the various terms and medicines in this article, there might be some inadvertent mistakes or omissions. Please provide me feedback and corrections (especially, if you are a Doctor!). Like some of my previous blog articles, this one too is targeted towards readers in both India and USA; hence I will make some distinctions where necessary. At some places, I will try to provide mappings between American OTC (over-the-counter) medicines and basic medicines in India. This is of particular interest to people like me, who have moved back to India after spending many years in the US.

 

 

How many people make an attempt to review, understand, and re-check their tax returns, prepared by their tax-accountants? How many pay attention to their financial planning and investing, in spite of having a good financial advisor? How many get involved in the detailed designing of their homes, after hiring top architects & designers? According to my knowledge, a good percentage of people do spend time on these activities. Yet when it comes to medications, these same highly-educated and well-to-do people can be completely ignorant. A common excuse one would hear is, ‘I trust my Doctor! Why do I need to know this?’ Another one, ‘This is not my area – I am too busy to spend time on this.’ Or one more, ‘If I start thinking about this, I will have too many questions, worries and concerns – potentially driving me towards a hypochondriac behavior! It’s best I stay away from it!’ There are quite a few other similar questions…let me make an attempt to put forth my views on these.

 

An interesting saying goes this way, “In God I trust; everyone else bring me data!’ Or the famous Ronald Reagan quote, “Trust but Verify”. Clearly, people think it is important to understand and verify the outputs of their financial and tax experts. Same holds true when they work with other specialists. Yet, when it comes to their own personal health, why this sudden blind trust? I have nothing against the doctors; they are doing their noble jobs in the most professional way. The onus is on the patients to have some understanding of what is being prescribed to them; and what course of treatment they are on. Simply saying I don’t understand this, is not the right answer. A top-notch design engineer will go out of his way to understand the minute details around tax codes on his returns, and still be completely clueless about basics of common cold medications. An experienced computer professional will learn the subtle nuances of home building/architecture when building his new house, while not knowing anything about the prescription antacid medicines he has been taking for months. These successful professionals, one would presume, are ‘too busy’ to learn anything about their medications. I guess these are not as important to them as their financial or residential priorities.

 

In today’s world of constant stress, many people don’t want the added worry about their health & medicines all the time. They would rather have their Doctor worry about it. This third concern about ‘potential hypochondria’ is partially valid. Yet, there is a thin line between complete ignorance on one side, verses full blown hypochondria on the other. Some of my Doctor friends suggest that patients with partial knowledge (especially those that have ‘learnt’ things on the internet) cause more harm to themselves than patients who don’t know anything, and completely trust the Doctors. This may be partially true to some extent. Partial knowledge is always a bad thing. Not only could it cause hypochondria in some patients, it also leads them to often ask irrelevant questions to the Doctors (who, especially in India are highly pressed for time). However the solution for this cannot be to stop learning about the basics. ‘Partial Knowledge’ in any discipline is a bad thing – yet the solution to this cannot be to stop learning! There is this phenomenon in India to blame many things on the ‘internet’ (this is especially prevalent amongst the people of older generations who haven’t been fully exposed to it…). Blaming the ‘internet’ for partial knowledge is like blaming newspapers, or books! What’s the point in blaming the medium? We, the human race haven’t progressed by stopping the learning process. I do agree that the medium needs to be utilized properly.

 

I think it is imperative that patients understand some basics about the common medications. Moreover, in my view they also need to understand some fundamentals that they should have learnt in their high-school biology class. As medical sciences advance year-over-year, isn’t it the responsibility of the common man to at least be aware of some basics, when interacting with the Doctor? If nothing else, it can speed up the efficiency of the whole diagnosis process.

 

In this series of articles, I will discuss some of the common medications that most people end up taking at some point or the other. For simplicity sake, I will divide these common medicines into the following categories (this is my no means an exhaustive and complete list. Feedback/additions most welcome).

 

• Basic Pain-killers (Opiates based pain-killers not covered here…)
• Anti-Inflammatory – NSAIDs ( and COX2 Inhibitors)
• Antibiotics (1^st gen – 4^th gen)
• Common Cold & Cough Medications
• Anti-Allergy
• Antacids & Other Digestive System Related Medicines
• Vitamins & Supplements
• Skin Medications
• Other External-Use Medications
• Others (This is a place-holder for other important common meds that are not categorized in the above categories) 

In subsequent articles, I will discuss each of these categories in more details. For now, simply classifying common medicines into these categories can be the first step towards their understanding. Note that many of these basic medications are available in the US as ‘OTC’ drugs (Over the Counter – available without any Doctor prescription). In India, while rules are in place to ensure what drugs are sold through prescription only, often times this ends up being implemented at the discretion of the pharmacist.

 

I understand it can be overwhelming to deal with the myriads of medicine names that are available in pharmacies and drug stores. One problem here is the competition in the drug industry. Most common medicines are out of patent and can be produced virtually by any drug company. Hence multiple versions (brand names) of the exact same medicine are often created. This brand proliferation leads to more confusion. Here’s a simple US example. ‘Motrin’ and ‘Advil’ have the exact same active ingredient – ‘Ibuprofen’. Yet I have seen people who stick with one of these brands, like a true brand loyalist! By the same token, in India – many cold medicines, marketed under variety of different brand names have often times the same list of active ingredients. Same is true regarding various prescription antibiotics. In US, all prescription medications come with a fairly detailed information sheet, from the pharmacist. However, in India no such additional information is available, making the understanding that much more difficult.

 

How do we start this learning? As I said earlier, the first step is to just understand the categorization. Simple classification is often times the first step in structured learning in most disciplines of knowledge. Secondly, be observant! Next time you look at a medicine bottle; don’t spend time looking at the brand-name. These change all the time. Instead, please look at the ‘active ingredients’. Active ingredients are key chemical compounds in the medicine. These provide the necessary therapeutic properties of the medicine. The ‘inactive ingredients’ serve other purposes such as providing bulk, etc. This will be a good step towards understanding these medicines. Initially don’t worry if you don’t understand these complex chemical names! For now, just try to find the common names across different medicines that you might be taking. Soon you will start noticing the commonalities. You might realize that most cold medicines have an active ingredient of ‘Paracetamol’. This active ingredient is also referred by its other name ‘Acetaminophen’. This is probably one of the most common ingredients found in a variety of common cold medications, fever medications, and pain-killers.

 

Well, this is already turning out to be a long introduction article…I think I should stop here, and continue further discussions on these categories in the next article! Once again, comments, feedback and suggestions are most welcome.

 

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