In the great olden days the physicians were in “solo practice and at liberty to take their own calls 24 hours a day “when they treat patients on emergency. The physicians kept the hand written record for them and enter in to patients’ record the next time when ever free time exists. Patients or the Insurance companies used to pay the Bills without asking any questions. No one knew or really cared to know the cost of the elective surgical procedure / Treatment and the cost used to vary 100% - 300 % from one physician to other or Geographical Location to other. The Paradigm shift is hardly a strong enough word for the changes that have occurred in health care world. As recently as 3 decades ago the stake holders to take health decision were physicians and patients. The treatment mode was fee for service and clinicians were rarely questioned about clinical decisions.

In contrast now a day’s Physicians are held accountable for following Medical council’s guidelines and formularies and subjected to external evaluation processes. Records have been captured in digitalised from through computerisation. Physicians started accessing the medical records through World Wide Web. The stake holders in health care now include employers to handle e-health records, Private corporate, Government statutory bodies for analysing the treatment protocol s , disease management ,and Demand management . This started affecting the way the health care is delivered to patient and the

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The game rules started changing rapidly in Health care delivery the focus got shifted to reducing the Health care costs and increasing the efficiency. E-technology is used to access, store and analyze large amounts of information related to patients they deal with. Electronic communication provides the end users rapid feedback and improves over quality and efficiency. Health care cost containment and corporate restructuring helped the corporations to cut budget and instituted cost reduction strategies such as out sourcing, the health care industry negotiated discounted payments to physician and hospitals. Non health care organisations could reduce costs by downsizing man power. This lead to massive consolidation and mergers of hospitals, health care facilities, physician practices and even health management organisations. This process improvement and quality initiatives helped to develop an integrated delivery system to most effectively and efficiently manage specific deceases related to various communities. Health care industry changes were stimulated by a push to control increases in health care cost. The initial cost containment effects were started by big corporate and insurers. This intern led to monitoring patient illness and use of resources such and right diagnostics and treatment options. This approach to control the health services have evolved in sophisticated effects on controlling the consumer demand for health care services. This evolution of managed care has made it possible by surge of computer based e-technology with large amount of data storage and fast retrieval. Service utilisation review was introduced for examining the necessity, efficiency and appropriateness of the use of available resources in all segments of health care delivery system. It is focused on cutting down the costs for excessive and unnecessary use of health services associated with acute hospitalisation. Using historical data the reviewer informed to the physicians the treatment orders that appear fall outside the norm and question the need for appropriateness of those adopted treatment options. Initial attempts to restrict and control services were interpreted as highly intrusive and insulting to physicians. The process was perceived as one that drove a wedge between the physicians and the patients. While the end result may been beneficial for the patient, the primary intent was to cut the cost for health care. Service Utilisation review required access to data related to particulars of illness condition and diagnosis including average length of stay and diagnosis and frequency of variant diagnostics. Patient care management was later introduced as second generation Service utilisation review process appropriateness of care for individual patient involved and this was known as second generation patient manager. The Patient care manager role was to ensure that if a different and cheaper course of care was appropriate for a given patient then transfer of services to be made as efficiently as possible. In a sense the patient care managers acted as travel agent helping the patient through the health care system and getting appropriate system along the way. Demand management was one of the first attempts on the part of insurers and corporate to address the demand side of the health care equation. It is based on the principle that given right information and support to patients then they are best managers of their health. So the demand management strategies focused on providing education and support services that improved the people to manage minor health problem and make appropriate use of medical care. These lead to the 24/7 services offered by Information councillors based at call centres using computer based triage (triage is the process of determining the priority of patients treatments based on the severity of their condition) protocols. They provided information and empowerment to consumers when and where they needed. In essence these approaches lacked an emphasis on integration or continuity along the full spectrum of health care. Disease management programs became popular and some Corporate’s like Mohan diabetics research centre, LV Prasad Eye Institute, etc. have begun focusing management with specific disease. These approaches took case management to another level by focusing their effects not on all hospitalised patients but on groups of patients with same diagnosis or health problem. As disease management program are highly data driven, computer data bases and emerging e-technology have been a major factor in their successes. The disease management program still focused on disease rather than the patient. The customisation fall the shot of individualisation and care that is fully integrated around the holistic needs of patient. Disease management programs are most effective for the elderly people as they have functional disabilities associated with chronic illness. In the beginning of new millennium health care delivery system have taken dramatic different look than the past and faced continual increase in costs and competition and complex benefit design. Hospital’s started experiencing reimbursement crises. The new health care face has emerged. The new face of customer focused health management and e- health care, using web technology to increase efficiency and customisation addresses the needs of consumers as well as providers and payers. In the e - environment, educational materials, articles, and

health care professional via 24/7 real time call centres, specially oriented discussion on web, or Tele medicine etc. . It’s no secret the consumer are taking more active role in their own health management decisions demanding more information and greater convenience. They have got more familiarity and flexibility on internet. The use of web accesses has given them an advantage compare to traditional health care centre www.medicinenet.com www.aarogya.com, www.nhp.gov.in www.healthcareindia.com An increase in information accesses on web is a great benefit to insurers and providers. The e- consumers who surfs the web for the medical information before coming to physician place can make more informed decision about aggressive or experimental therapy for life threatening diseases. They also obtain the latest and best evidence up on which to base practice decisions for the individual providers. As all of these components of the health care delivery system come together through web-enabled technology, the potential for further customizing and delivery of e-health care is enormous. The classic example of customised e-care is interactive telemonitoring technology places the provider in patients home to asses symptoms adjust medication and treatments, meet immediate needs for adjust medication and treatments meeting the immediate need for information and help to the patient and avoids hospitalisation. One small scale telemonitoring pilot project conducted by Mercy health partners helped in reducing 40 re admissions in 5 months period in a group of a patient with congestive heart failure . These telemonitoring project helped 40% of the patient to improve one severity level on the new York heart association classification of heart failure and 12% improved 2 severity level. Patient who did have re admissions had shorter length of stay and more improved functional states compared to previous statement. A hall mark of good health management and patient support is the full circle approach to health care .The majority of exciting disease management resources is concentrated on preventing the acquired exacerbation and hospitalisation in the first place. Patients are encouraged to take an active role in the management of their disease. They are given in depth education about their disease and treatment and are taught how Good health management program cannot happen without adaptation of information technology. Many highly successful programs in health care like health records risk assessment tools are conducted exclusively through e-technology. Customer focused health management allows the patient to decide when and how to accesses the health care centre. They will also decide whether to comply with the diet, excess, medication’s, screening and follow up appointments with the service providers. The most successful health management is personalised in a way that attends to the issues from patients prospective. Latest good health management program’s take e - Technology as a key to accesses good data for adequate base lining of information, good tracking mechanism and real time feedback results in good outcomes. Web technology improves access to data and ability to analyse, share and apply. Advances in communication technology proved new channels for interaction between patients and service providers. Web technology has improved the ability to communicate with e-patient and it allows patients to participate actively in the learning process through interactive web applications. Utilimatly e-health management program will commonly include video component enabling patient and health care provider to interact visually even though they might be geographically separated. The use of technology will benefit the patients in making cost effective health care decisions. For the country like India where the number of people with e-skills are increasing .e-health care need to be made more popular and the corporate and government bodies should play active role and exercise adequate control that correct data is shared with people .

An overview of managed care in the managed health care hand book third addition [aspen publisher’s inc. 1996]. Disease management news no19 1998. Health risk and behaviour ,The impact on medical cause [Milliman and Robert son 1987] E-healthcare D E Goldstin [aspen publisher 2000] RK Harvey - Hospital & health services, 1991 - europepmc.org

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Prevalence and risk factors of Diabetic nephropathy in an urban south Indian population ,The Chennai urban rural epidemiology study (CURES 45) M Deepa, CS Shanthirani, R Deepa, V Mohan – Diabetes, 2007 R Samandari, S Kleefield, J Hammel, M Mehta… - International Journal for quality health care ,OXFORD university press 2001 – ISQHC Privately funded quality health care in India: a sustainable and equitable model –LVPEI.