The e-Doctor

Corporate Hospitals are using telemedicine, GIS and Wi-Fi to penetrate rural healthcare market. Nancy Singh tells you how

When Dr A Ramadoss, Union Minister, Health and Family Welfare, declared his intention to link all the Primary Healthcare Centres (PHCs) in India electronically, so that he could access it at a click of a button, the task does appear to be a daunting one, considering that India has 23,236 PHCs, 1,46,026 sub-centres and 3,346 Community Health Centres. The Union Health Ministry, under a seven-year Integrated Disease Surveillance (IDS) Project and an out lay of Rs 400 crore plans a complete IT-linked network.

When corporate bigwigs started vouching for telemedicine, it was not far for the health minister and Government to take cue. “Telemedicine, though early for us, is going to be our future," says Dr Ramadoss. RR Shah, Member-Secretary, Planning Commission, Government of India, gives an insight. "The 21st Century would be all about data management. Large amount of data storage and management, which was not possible earlier, is achievable today because of IT. Conceptually, I don't foresee any problem to use Medical Information System (MIS) to link all PHCs," says Shah.

"Our ultimate aim is to tap the population of 1.3 billion," says Christopher Thomas, Chief Strategist, Intel Corporation.

Courtesy: Yes Bank

What's e-health?

A VSAT-enabled mobile telemedicine van

Although it is a known concept now, e-health was barely used before 1999, but now has come to characterise as not only 'Internet medicine', but also virtually everything related to computers and medicine. The World Health Organisation (WHO) defines e-health as: "The cost-effective and secure use of information and communications technologies in support of health and health-related fields, including services, surveillance, literature and education, knowledge and research."

"It is often misinterpreted to be only Hospital Information Management System (HIMS) and to maintain an electronic medical record (EMR). However, e-health also ushers in the concept of 'personal health record', which thus translates to enabled healthcare," believes Dr Anil M, Senior Functional Consultant, Integrated Healthcare Group, Shobha Renaissance, Bangalore. Apparently, industry leaders and marketing gurus, rather than academicians, coined the term. They created and used this term in line with e-commerce, e-business, and e-solutions in an attempt to convey the promises or principles around e-commerce to the health arena, and to give an account of the new possibilities that the Internet is opening up in healthcare.

"After the Green Revolution, the White Revolution, the next would be telehealth" - Dr K Ganapathy Neurosurgeon and Head Telemedicine Apollo Hospital, Chennai

In the confines of clinical applications, e-health implies telemedicine, which involves EMR to obtain records, data transfer to obtain distant specialist opinions and interactive video-conferencing for group consultations. It also includes clinical decision-making software that gives doctors access to varied information about diseases and its cure, prescription via the Internet or tele-homecare, e-prescription and tele-monitoring.

Telemedicine has huge bonus points for a hospital edging to add market value to its brand. Be it any group, big or small, all of them have invested in telemedicine centres across the country. The model followed is the hub and spoke—with the hub being the main hospital and the districts and talukas being the spoke (see illustration on page 39). The results are encouraging. "Telemedicine makes geography, history and distance meaningless," avers Dr K Ganapathy, Head, Apollo Telemedicine Networking Foundation. Thus, a doctor sitting in Ludhiana can examine, investigate, monitor and treat a patient say sitting in Goa. "Expertise, and not the patient, is transferred using IT, thus eliminating unnecessary travelling," adds Dr Ganapathy.

Aravind Eye Hospital, Madurai and Sankara Nethralaya, Chennai are using tele-opthalmology to penetrate the market. "Using Wi-fi, we created 'vision-centres' to generate awareness about eye camps, and VSAT-mobile vans to go into the interiors of the villages about 8-10 times a month," informs RD Thulasiraj, Director IT and Systems, Aravind Eye Hospital, Madurai. The Hospital was one of the early starters to integrate ICT in its healthcare services by using IT as early as in 1983. Another example of successfully using ICT is Baramati, near Pune. Baramati has telemedicine centres linked to Chennai's Madras Medical Mission. "So, we can stay in touch with cardiac experts, who are available 24 hours," says Dr Amol Goje, Director, Vidya Prathishtan's Institute of Information Technology, Baramati. Intel Corporation supports the project.

Why Go Rural?

"Governments have a well-structured healthcare network, still primary healthcare continues to find demand" - Sandeep Sinha Programme Manager, Healthcare Practice, Frost & Sullivan, South Asia & Middle East

Almost 70 per cent of the Indian population or over 700 million people reside there. Here is a market opportunity that corporates can tap. "Primary healthcare market has huge potential in India. The growth is more in tier I, tier II cities and developed tier III towns. Though the Central and State Governments have a well-structured healthcare delivery network to the village level, primary healthcare continues to find demand," says Sandeep Sinha, Programme Manager, Healthcare Practice, Frost & Sullivan, South Asia & Middle East.

An inadequate healthcare delivery provides an opportunity to the corporate world a chance to supply quality services. "Our experience at our hospital shows that accountability of community workers with respect to delivery of a particular health programme, say immunisation or blindness control, is not credible," says Dr SN Krishnan, COO, Mediciti, Hyderabad, which is planning a huge data network or electronic health records. "We want to connect all stakeholders in the healthcare system into a single infrastructure, which we have termed as Shared and Continuum Health Information Network (SACHIN). This strategy has worked well in Hyderabad," adds Krishnan.

The reversal of the pyramid, with the focus shifting from illness to wellness Courtesy : Yes Bank

Using Mobile Technologies

If they do not come to you, then you better go to them. Little wonder, the concept of VSAT mobile van is a huge hit. Apart from channelling the latest equipment, they even offer cosmetic surgery! The healthcare system is innovating models to double utilisation of its existing resources in a bid to reach the 'real' India. "We are moving away from the hospital-doctor set-up to the community. There has to be a 'disruptive innovation' and it can lead by innovation and technology," says Dr Vikram Chhatwal, CEO, Reliance Health.

Telemedicine, when used effectively, can double utilisation of scarce human resources,"Telemedicine makes business sense for us," agrees Sugato Basu, Vice President, Business Development, Apollo Health Street, Hyderabad. Though experts believe telemedicine itself would not be a successful model on a stand-alone basis because of infrastructure and cost-effectiveness, it must be integrated within the existing model. "Telemedicine through kiosks, tele-radiology, tele-ECG, VSAT, mobile TM vans are feasible options," says Praneet Kumar, Head-Quality Assurance, Fortis Healthcare, New Delhi. This in turn, increases occupancy rates of hospitals in the integrated TM model.

Another technology that can be useful is Geographical Information Systems (GIS). GIS is a computer system for capturing, storing, checking, integrating, manipulating, analysing and displaying data related to positions on the Earth's surface. In the context of healthcare, it helps track disease profiles, check population base, health records. Aravind Eye Hospital when faced with a common problem of low-admissions in eye-camps, used GIS to publicise the camp. "Using GIS helped us target clusters in various villages and we saw a 30 per cent jump in attendance," says Thulasiraj. Since then, it has successfully carried out over 1,500 eye camps. "GIS can be used for epidemiology, micro-planning and disease management," says Jitendra Shah, Member, Indian Association for Medical Informatics and Consultant, SciTech Park, Pune University.

Case Study

The Aragonda Story Seven years ago, what started as a pilot project and proof of concept validation has turned out to be a success story. A non-descript village in Karnataka is now discussed as a case study for the world's first VSAT-enabled village to have telemedicine. Aragonda has indeed been an eye-opener. Not only have its 1,837 patients benefitted from tele-consultations, but even doctors in village hospitals enjoyed the fruits as well. "I realised that the frequency of tele-consultation decreased dramatically over the years, because the doctors had learnt the remedies," says Dr K Ganapathy, Neurosurgeon and Head, Telemedicine, Apollo Hospital, Chennai. The journey required team efforts from all the stakeholders. There were 172 grand rounds held between Apollo Hospital, Chennai, and Apollo Hospital, Aragonda, every Tuesday morning since 2003. Today, paediatricians from Chennai review case histories, reports, CT, ultrasound, and X-ray images of children. Live echocardiograms and colour doppler are transmitted to a paediatric cardiologist. Follow ups of these cases are then discussed. Aragonda served as a catalyst to encourage ISRO to provide hundreds of VSAT for telemedicine and today the Foundation has set up 102 telemedicine centres.

The Glitches

On the face of it, the potential of telemedicine or tele-radiology may seem vast, but there are many hurdles to cross to make it highly successful. "In India, everything is stable except change," observes Kirit Randheria, IT Manager, Sahayadri Hospital, Pune. He believes that implementation is not by the system alone, but also from the user's end. "From a process perspective, Government has good processes in place, but they need to translate these to latest technology," says Gopi Nath, Director, Public Sector, Hewlett-Packard.

In addition, such equipment operates on electricity. Although, most have a back-up system, it is not for more than three to four hours. Agrees Christopher, "Electricity and connectivity is still not there. So infrastructure needs to be in place."

Another issue is availing labour, as per a study conducted by FICCI and Ernst & Young: "The biggest challenge for the healthcare industry today is an acute shortage of trained personnel, ranging from doctors, nurses, technicians and even healthcare administrators. We foresee a shortfall of over 4,50,000 doctors by 2012." Such challenges present an opportunity for both domestic and foreign players to assume the role of 'training and education'. Foreign players, seeking to enter the Indian market, have a two-fold advantage. They get a piece of the booming education sector and can source some of the talent for their own countries as human resources, as shortage in healthcare will be a global phenomenon.

The amount of investment for basic tele-medicine infrastructure is high and charging users would be unfair. One of the reason why corporates are tying up with insurance companies and introducing schemes to make the treatment affordable. The Rs 20-scheme of Yeshaswani Scheme and the Re 1 Rajiv Gandhi Yojana initiated by Narayana Hrudayalaya are cases in point.

"The complex nature of healthcare delivery and diversities, data creation and management is indeed a daunting task in India. Remember, we are talking about creating Electronic Health Records (EHR) and EMR, and mostly dealing with people with few records to their name. The basic challenge is encouraging them to form their database," says Ashwin Naik, Founder, Vatsalya Healthcare Solution Pvt Ltd, Karnataka. Apart from this, all technologies and data transfer requires a high bandwidth and such infrastructure is yet to be put in place.

"One concern is that, as 90 per cent of specialist doctors are mainly urban-based, so getting them to settle in rural India means luring them by paying them as much or more," says Dr Vijay Singh, IT Head and Medical Officer, Healthcare Relations and Telemedicine, Narayana Hrudayalaya.

Since healing has a psychological impact, one cannot undervalue the physical presence of a doctor. "Nobody wants a computer to mete out treatment. It is the 'healing touch' people require," says Randheria.

Courtesy:BioAnalytical Technologies

Miles to go

The fabric of Indian healthcare delivery has the character of its domain country, diverse yet simple, networked yet chaotic. As Dr Ganapathy concludes, "After the Green Revolution, the White Revolution, the next would be telehealth." The corporates are happy they get to expand their referral base and users are happy to avail of the best treatment at their doorstep. It is a win-win situation, though not without shades of grey.

nancy.singh@expressindia.com