India is one of the early adopters of telemedicine so why do you think that it has not taken off in a big way in India?
| Aravind Sitaraman |
Telemedicine has existed in the healthcare landscape for over a decade and its benefits are only now being recognised. However, there are many factors contributing to the very modest adoption of telemedicine in India.
The major issue that we need to overcome in this country is a mind-set that we need to use only those technologies that we have created. During the Cold War era, this mindset was valid but that era died about 15 years ago and the world has moved on.
Secondly, we need to adopt technologies that will not infuse complexity in the edge because that would make maintenance and scaling a major challenge.
Thirdly, there is the basic infrastructure issue—power, networking availability, ecosystem players etc.
Fourthly, we need to normalise the telecommunication rates that resonate with the rest of the world. This is especially true for humanitarian applications.
Fifth, we need to create an incentive system for the government and private doctors to participate in telemedicine since they view it as a direct challenge to their livelihood.
These challenges present a country like India with an excellent opportunity to innovate and choose the latest technology to advance its healthcare needs, in turn creating a large number of jobs in rural areas. This will not only address the healthcare needs of the country but also inject money into rural areas in a responsible and scalable manner.
Tell us about Cisco’s role in shaping the telemedicine industry in India?
On an average, India has one doctor for 1700 citizens while the optimal average should be one doctor for 600 citizens. In some cases, the ratio is up to 25,000 citizens to a doctor. The US has one doctor for 350 citizens. If India aspires to be a superpower, we need to increase the number of doctors by six times. This is impossible as no country can organically grow their medical population six times and meet quality. Even if we do drastically increase this number, there are very less chances that these educated doctors will want to live in a remote area that is without basic infrastructure, education, healthcare, and a marketplace.
That’s where our telemedicine technology comes into the picture. Our solution virtually delivers a doctor, specialist, or a super-specialist to a patient in a remote area through networking technology. The interaction between them is through a video using a vernacular language. The doctor can read and see all vital tests that are done on a patient. The patient can interact with the doctor as if he is present in the same room. Finally, the doctor can dispense a prescription or recommend a course of treatment that can be taken by the patient just as he would in a real-life situation. This fundamentally balances out the doctor-citizen imbalance which we see in India as well as the urban-rural divide in terms of resource availability.
Our solution is significantly different from other offerings in this space. For one, we provide a very scalable video-based architecture delivered securely from a cloud using our latest collaboration technologies.
For another, we offer an end-to-end project management, reporting, and technology support for our customers. We do not believe in selling our equipment and disappearing.
Can you tell us about Cisco’s HealthPresence telemedicine platform, hardware, installation and bandwidth requirements?
The Cisco healthcare solution leverages the network as a platform, and combines advanced audio, video, and third party medical devices to create a high quality clinical consultation environment enabling doctor-patient consultation remotely. Primary healthcare centres (PHC) or community healthcare centres in rural areas are connected to the district hospital or a super-speciality hospital that hosts the healthcare solution. The key process that is followed is as below:
- Patients visit the paramedic at the village primary health care centre, which has the patient Point of Diagnosis (PoD) installed.
- The paramedic initiates a call to the remote doctor at the district hospital that has the Doctor PoD. The remote doctor instructs the paramedic at the PHC to record patient’s vitals and other clinical data using the third-party medical tools connected to the PoD. Once recorded, data is then transmitted over the network to the remote doctor, on a real time basis.
- The doctor conducts the consultation remotely, makes a diagnosis and prescribes appropriate treatment.
While the platform can perform well from about 256kbps, to get the optimal user experience we insist that the installation should have about 1mbps. The whole interaction is managed out of a cloud with some specialised software at the edge.
What are the implementation issues in telemedicine?
Cisco’s approach to solving the healthcare problem that countries like India face is a radical departure from conventional thought. Governments have tried to increase the number of doctors, offer incentives or coerce them to go rural areas, and also use alternative or traditional medicine. All these have failed since it is virtually impossible to get a doctor who has spent an enormous amount of money to acquire a degree to live in rural conditions where there is little education, speciality healthcare, marketplace, or public services. Traditional medicine works very well as a preventive solution but cannot handle the modern issues created by industrialisation.
With our solution, we are not getting the country to catch-up with the developed nations. We are providing a platform for the nation to leapfrog into the future and dramatically improve the human development indicators. However, we do face many issues:
- Firstly, we have to first convince many to accept that conventional methods do not work and we need to embrace technology as means to deliver doctors virtually.
- Secondly, the lack of infrastructure in rural areas is also a major challenge. In many areas, there is little or no stable power. Lack of Internet connectivity is an issue but the government is working to resolve this. We do not have adequate trained personnel to manage the systems that are deployed; however, we see this as an opportunity to create rural employment for such an ecosystem. We need to normalise the telecommunication rates that resonate with the rest of the world. This is especially true for humanitarian applications.
- Thirdly, we need to offer incentives to the doctors in the rural areas to participate in this solution lest they view this offering as a threat to their livelihood.
- Fourthly, patients are also used to having the doctor touch them and talk to them. While doctors do not even need to see the patient for a large number of cases, this psychological dependency is a hurdle.
Tell us about telemedicine deployment in India. How many projects have moved beyond the pilot stage?
Over the past decade, the country had inaugurated over 60 pilot projects and none of them survive today. This is primarily because we chose to adopt satellite-based delivery of these services when the whole world was moving towards fibre-based delivery of network. India has to contend with teledensity and other fundamental issues of telecommunications before it embarks on fibre. In India, we have over a million route-kilometre of fibre. With such an infrastructure, going back to satellite-based delivery of telemedicine would be going back in the past; akin to using records to play music in the age of iPods.
We have piloted the medical solution in two states and seven districts. The Cisco healthcare solution has currently been implemented in Raichur, Shimoga, Chitradurga, Gwalior, Sehore, Datia and Chindwara in partnership with the governments of Karnataka and Madhya Pradesh. As of December 10 2012, we have conducted 21,500 speciality and super-speciality consultations. We have contributed to the reduction in maternal mortality and infant mortality rates. Women and children form over half of the patients who use the system. We have used the same infrastructure to educate pregnant women on what to expect during pregnancy. We have also conducted special workshops to identify children requiring special attention and educating their parents on how to handle such children.
It is said that telemedicine would make healthcare affordable. Can you share with us how affordable is a teleconsultation as compared to physical doctor consultation?
Through our solution, we provide a very scalable video-based architecture delivered securely from a cloud using our latest collaboration technologies at the cost of $1 per consultation for technology. We typically orchestrate, create, manage, and incentivise the ecosystem that includes government, service providers, content providers, system integrators, and equipment maintenance partners. We offer an end-to-end project management, reporting, and technology support to our customers.
Without this facility, the rural poor would have to spend huge amounts of money to go to the district hospital or urban centres. By using this facility, they can get a better handle on what their issues are. This will help them then prioritise on where they should go to get treatment or understand which government mechanism to tap for funding to aid their treatment. This saving for the rural poor has not yet been computed and we need to look at it as if this amount is added back to the GDP since the money is available at the hands of the citizen to spend. When we factor in this saving, the cost of telemedicine comes free.
Telemedicine market in India is said to grow at a CAGR of 20 per cent. What are the factors for this growth?
As mentioned earlier, the growth in the past decade has been modest, most pilot projects are non-existent today.
We do have a high proportion of population that suffers from diseases like diabetes and asthma. Also, rural areas lack good medical facilities and hence the concept of telemedicine is very well accepted in the developing areas. The advent and continuous investment of high speed internet and telecommunication has made telemedicine possible and this is a factor for the continued growth of the market in these regions. The cost associated with telemedicine is often lower as compared to conventional healthcare and hence is a positive factor for the development of the market. Add to this the indirect saving we infuse into the hands of the rural citizens to spend on other essentials and we will see the benefits of telemedicine multiply manifold.
Unfortunately, though the cost of telemedicine is often lower, the infrastructure cost to provide telemedicine facility is often high. This high cost acts as a hindrance to the development of the market along with the lack of interest from patients and doctors restraints the growth of the market. It’s a bit of an uphill climb, but we are much more excited about the prospect now and see immense potential in this industry.
India has no option but to embrace telemedicine to provide medical care services to its citizens.
Telemedicine has been trumpeted as the great healthcare hope for rural India, has it been able to achieve this yet? Your comments
Telemedicine is an area that will essentially bridge the urban-rural medical divide. It virtualises the doctors in the city and delivers quality medical care to citizens in rural areas. Adopting the latest technology will propel this adoption further and will result in better human development indicators as well as jumps in the gross domestic product through indirect savings for the citizen. This will also result in better cash flow in rural areas and rural employment.
If the country wants to safeguard the health of its citizens and bring them into the economic mainstream as productivity constituents, we have to embrace telemedicine. If we do it right, I see that telemedicine centres will be ubiquitously present in India in the next five years.