We interview Prof K. Ganapathy, President of Apollo Telemedicine Networking Foundation, Director at Apollo Tele Health Services and previous President of Telemedicine Society of India. Apollo Telemedicine Networking Foundation (ATNF) was established by Apollo Hospitals – Asia’s largest healthcare group in 2000. The Foundation specialises in giving remote consultations and second opinions to both patients and doctors, helping them overcome large distances and spiraling healthcare costs to access quality care.
How does use of technology in healthcare in India, and in particular telehealth, compare with other countries?
A major deterrent to the adoption and growth of telehealth in India is the difficulty in optimizing a business model which will cater to all stake holder in the eco-system. Most telemedicine projects in India, similar to other countries in the world, are not self-sustaining as revenue generation is a major issue. Philanthropy at best can start a project but will not sustain it without a business model. Individuals who need remote healthcare the most, are those who can afford to pay the least. The present public-private partnership (PPP) model where the government bears the capital and operating expenses, while the private organization manages the entire programme on a turnkey model appears to be attractive.
As for telehealth, with India being a heterogeneous country, a single telehealth model will not fit all states. The 36 different Indian states have different levels of growth and development, availability of technology, awareness of telehealth. Diversified languages, levels of literacy and of course, a major shortage of healthcare personnel make the implementation of telehealth in India a challenge. Models will have to be customized and tailor-made to suit, specific requirements.
Big data analytics provided from wearable technology that is in fashion now in the West, are also buzz words among the so-called elite in urban India. However, in my opinion these are unlikely to enter the main frame of healthcare in the foreseeable future. Most doctors in India still believe in TLC (tender loving care), personal interaction, and empathising with a patient rather than depending completely on big data analytics – the latter unfortunately often inadvertently ignores the former.
Telehealth has been around for some time, how has the use of it evolved in the past 5 years?
In the last two to four years, there has been dramatic change. Until 2014, we had a very difficult time trying to promote telemedicine since Apollo Telemedicine started South Asia’s first department of Telemedicine in 2000. A few years ago, the Government of India started taking telemedicine seriously and the state governments have followed. Today, most state governments in India have just started on telemedicine and telehealth. The government has realised and accepted the fact that building enough brick and mortar hospitals to deliver healthcare is just not possible. Generally speaking, 80% of India’s specialists cater to only 20% of India’s population.
In India, it is impossible to have a single model of telehealth, so we have many models. One way of executing telehealth is through special tele-camps e.g. for tele-orthopaedics, tele-neurology, tele-rheumatology, etc. Eight to ten patients wanting a neurological consultation are assembled in a small town, and a specialist sees these patients remotely one after the other.
The other way is for patients to fix a virtual medical consultation themselves. Many patients – those in middle-income and higher-income groups have internet connection at home with good broadband connectivity. Ask Apollo is a 100% virtual service launched in 2015. A patient anywhere in the world can fix an appointment virtually with a specialist or a superspecialist, and pay for the consultation with a credit card. Now let’s say a woman has breast cancer, three different specialists who are all looking after one particular organ of the body – a medical oncologist, a surgical oncologist and a radiation oncologist will be present at the same time to interact with the patient virtually at the same time and will jointly advise the patient on what is to be done. To my knowledge, not many organisations provide “virtual tumour boards”. We have also just started on another model where we provide remote health care to existing internet-enabled villages through Common Service Centers (CSCs). Our dream is that, within the next few years, we would have connected 60,000 villages.
Today, people have recognised that information and communication technology can be used for healthcare. So, the answer to your question is yes, there has been a tremendous growth of telehealth in the past two years. I am confident that in the next three to five years, telehealth will become, an integral part of the healthcare delivery system in India.
It sounds like telehealth is adopted rather evenly across multiple specialties in India?
Unfortunately, the level of telehealth adoption across specialties depends entirely on the individual doctor. For example, there may be thousands of cardiology patients requiring telecardiology services, but cardiologists are not very enthusiastic about telemedicine. On the other hand, we have rheumatologists who like me is passionate about telemedicine, and does about 1,100 tele-rheumatology consultations a year from my department alone. So adoption of telehealth in a speciality depends not on patient requirement, not on the specialty, but entirely on an individual doctor’s adoption of the technology.
Are there any initiatives to help more reluctant doctors adopt telehealth?
Apollo Telehealth services is just embarking on the mega-project of developing 194 e- Primary Health Centres (ePHC). In India, we have the Primary Health Centre (PHC) at the bottom of the healthcare delivery pyramid where every 5-7 villages share a PHC. There are about 620,000 villages in India. Very recently, some state governments have started outsourcing the operation of PHCs. In this project, Apollo Telehealth Services will be fully responsible for providing virtual specialists and super specialists for a population of almost 10 million people. These specialists – private doctors in Apollo’s employment, will be connected from their homes or their offices to give consultations to some of the poorest in India who come to the government primary health centers.
Another significant development in the last two years has been government hospitals outsourcing reading of images to private organisations. Tele-radiology in the public-private partnership (PPP) mode is also now been adopted. Every month a state government floats a new tender. Tele-dialysis is also commencing.
Both physicians and providers are important drivers in the use of telehealth technology across healthcare systems. But how are patients coming to embrace telehealth?
In healthcare, people are slowly understanding that they would be saving thousands of rupees with technology. They can avoid a trip, particularly if it’s a sick person that needs to be accompanied by a few other people. Slowly it is changing, and I think patient resistance will eventually not be something important. Unfortunately doctors are still not enthusiastic about telehealth. One of the main reasons is compensation. We still do not have an effective business model. The fees that a doctor gets for a teleconsultation is less than a face-to- face consultation. He also gets it much later, and after tax deduction. Therefore, doctors are not always enthusiastic about teleconsultations.
I really think for telemedicine to take off, we have to incentivise the doctors. Unless the doctor is incentivised, we may have a small incremental growth, but not a radical transformation which is what we want.
So the same technology is used in different ways, and it is used by different people. It also is being used in increasingly different settings right now – i.e. care is moving out of healthcare facilities and into the homes of people?
It depends on the necessity. In the Himalayas, we have 2 telemedicine units at 14,000 feet height. Depending on circumstances, healthcare equipment is used by different people under our direct real time remote supervision and guidance through a video conferencing camera. Tele-mentoring has saved several lives. We have even tele mentored cardio version and thrombolysis for acute myocardial infarction.
How can telehealth be made to work better for patients?
The only way to make telehealth work better for patients is to provide “ patient delight “ and a customer experience which will make them come back again. For this, all players in the act need to be trained, and re-trained. More importantly, they may have to unlearn what is currently been deployed in a face-to- face encounters with patients. We have not yet reached the stage where the stakeholders are passionate about telehealth. The presence of a passionate leader who believes in telehealth makes the difference between successful and failed telehealth projects.
How do you envision telehealth use in the next decade? What future possibilities are there?
Telehealth in the next decade should not be viewed as a distinct specialty or a new discipline as it is now. Telehealth is only a means to achieve an end and not an end by itself. It is an enabler and therefore should be incorporated and integrated into the entire healthcare delivery system. The phenomenal explosion in the field of mobile internet, mobile hardware and software is making distance meaningless and geography history! We are in a stage of transition. All transitions offer great opportunities, however during the period of transition there will be scores of issues which needs to be identified recognized and solved. I am confident that in the next decade Telehealth will be embraced universally for the simple reason that there is no other solution worldwide to provide equitable health care.
One of the important things that is going to happen is, the doctor as we know him today, will disappear in a another ten years from now. A lot of things that were originally done by a doctor or a nurse, will be done by the community directly – by the patient. When I qualified as a doctor 42 years ago, I used to take the blood pressure. Later, nurses took the blood pressure of patients. Today, many in India take their own blood pressure, blood sugar, pulse rate, oxygen saturation and so on. Apollo has a major project in the Himalayas, where we have a prescribed point of care diagnostics, where 22 different blood tests — liver function test, renal function test, cardiac enzymes, cholesterol, lipid profile, are done in a few minutes with a afew drops drop of blood. These are all FDA-approved. Biochemistry laboratories as we know them today may become redundant ia few years. People will be able to do different blood tests themselves. They will even be able to do their own electrocardiograms (ECGs). In that way, the world is going to change completely.
For more on telehealth and other digital technologies shaping healthcare, download the Economist Intelligence Unit’s report on Digital Health: Total Convergence.