Telemedicine | Health Care Transformation

By David Ellis and Ramana Yashaswi	November 20, 2012
Telehealth is emerging as the only viable way to bring modern medicine to most citizens of developing countries. It may become the only viable way to provide access to many in the United States, too.

"A little over a decade ago," according to a recent CNN report, "there were about 100,000 phone lines in Nigeria, mostly landlines run by the state-owned telecoms behemoth, NITEL. Today NITEL is dead, and Nigeria has close to 100 million mobile phone lines."

One of us (Ellis) read this report while on a business trip to India in October to help inaugurate a biologic medicine research and development lab that will develop advanced genetic therapies. The mission of the lab is to make available biologic drugs that typically cost upward of $20,000 a year in the United States to people in India who earn $100 a month. (That is not a bad salary, by the way, in a country where the World Bank says about a third of the population lives on $1.25 per day and about 69 percent live on less than $2 per day.)

Health Care Access in India

Cost is a major hindrance to medical and dental care for people everywhere except those in Canada, France, the United Kingdom and other countries that provide government-run universal care for their citizens far more cost-effectively than the United States' market-based model. Even in India, most working people can afford to visit a doctor, who typically charges about $4 for an office visit and, for minor ailments at least, often does not accept payment until the patient recovers (think of it as fee for outcome vs. fee for service or vs. capitation schemes).

If the very poor can make it to a government-run or private hospital, they receive treatment for free. A 1,000-bed government hospital we visited left a lot to be desired in appearance and cleanliness, but had caring and capable doctors and nurses, and spacious operating rooms (at least 800 square feet, we estimated) many U.S. surgeons would die for. The hospital is poorly equipped compared with the large U.S. academic hospital for which one of us once worked, but its doctors successfully perform sophisticated procedures nevertheless. Private hospitals, especially one we visited that was established by Indian doctors based in the United States, can be much cleaner, much better equipped and much more reassuring to the patient than government hospitals. But they do not necessarily produce much better outcomes for patients.

Indigent patients, like anyone below the poverty line, can obtain a state-provided health card, which effectively is free health insurance. Usually and sadly, however, the truly indigent often lack the basic capacity or familial support needed to apply for a health card, and the hospitals lack social workers who might help them. The difference in the quality of care for patients who have a government health card vs. those who do not can be significant. For example, a card-carrying patient with a fractured bone may receive complex orthopedic surgery to implant rods and pins and a lengthy hospital stay; whereas, a patient without a health card will receive only a plaster cast and pain killers during a much shorter stay.

It would be nice to think that a stroke of the policy pen could rectify that anomaly, but this is a country whose government spends less than 1 percent of its gross domestic product on health care. Compare that with the United States, which is at nearly 18 percent! In any case, fixing the anomaly would not do much to help the hundreds of millions of rural Indians living not just below the poverty line but also, more importantly, living out of reach of a hospital or even a doctor. Hospitals and doctors in India's vast hinterland are few and far between.

Telehealth to the Rescue?

Telehealth now has reached a point of technological and procedural sophistication, at ever-reducing cost, that it is rapidly filling in the vast blanks in India, Africa and other fast-developing areas. This is not to say that nothing has happened in the United States, or that there are no successful telehealth networks up and running here. But most telehealth projects in the United States to date have been grant-dependent (therefore, short-lived), of limited scale and difficult to sync with the system in place ? with physicians' schedules and practices, with reimbursement models, and so on.

Vijay Govindarajan, a professor of international business at Dartmouth College, thinks that India could teach the United States a thing or two about telehealth. In a Wharton School article, he suggests that Indian telehealth is being driven by extreme need resulting from several factors, such as:

• "a severe shortage of doctors, especially in rural areas";
• "very high patient volumes";
• "widespread availability of mobile networks";
• "rapid growth in the availability of low-power, hand-held medical monitoring devices"; and
• the development and adoption of standard, nonproprietary telehealth communication protocols.

However, he believes the innovations of Indian telehealth also will be adopted in the United States, because these factors are starting to matter here as well.

The Wharton School article provides an overview of the state of telehealth in India. It describes several of the major initiatives in some detail, including:

• A network established by the nonprofit World Health Partners in 2008. Some 1,200 nonprofessionals diagnose and treat minor ailments using low-cost mHealth (mobile health ? health care delivered via cell phone or smart phone) technologies, initiate teleconsultations for more complex cases, and refer the most difficult cases to one of 120 entrepreneur-run health centers equipped with more sophisticated but still affordable mHealth technologies to measure vital signs (pulse, blood pressure, heart rate, electrical activity of the heart) and transmit them to doctors at WHP's central medical facility in New Delhi. Consultation charges vary from 20 cents for patients below the poverty line to $1. Since inception, the network has provided about 35,000 consultations.

• The Narayana Hrudayalaya network, which connects about 100 telemedicine centers in India (and 55 in Africa). Since its 2002 launch, it has conducted around 53,000 teleconsultations in cardiology, neurology, urology and cancer, and conducts from 200 to 300 electrocardiographs daily via digitally connected ECG machines that transmit ECGs from remote doctor offices to specialists. The specialist opinions are passed back to the remote local doctors. Network doctors also used a telemedicine connection with anesthetists at Children's Hospital of Philadelphia to learn cardiac anesthesia for pediatric liver transplants.

• Wireless service provider Airtel works with Healthfore and Fortis Healthcare to provide Mediphone, which offers "basic medical guidance on nonemergency health problems" via cell phone, with service to customers for less than $1 per consultation. Similar systems dispatch paramedics with laptops and medical diagnostic equipment to make house calls and conduct consultations via videoconferencing.

• Microfinance firm Equitas launched telehealth centers in association with HealthNet Global to provide physician video consultation service to Equitas members for $1 per consult.

Inexpensive and easy-to-operate medical devices being deployed in these networks include a low-cost ECG machine that takes digital images and emails them to cardiologists in the United States, and a device for early detection of eye disease that also collects and transmits data.

Lessons Learned

Despite its rapid growth in India, telehealth has not yet reached critical mass there. With a population of nearly 1.25 billion, India now has close to a billion phone connections ? so the problem does not lie with technological infrastructure.

The main reason it hasn't caught on, according to an executive at one of the telehealth networks, is that it remains a challenge to get doctors to provide telehealth service and to persuade patients that they can trust the advice they receive. Another executive says that for telehealth to reach critical mass, both doctors and patients must want it. A third hints at what is probably the key issue: For care providers, broadband service providers and patients to fully embrace telehealth, they need incentives.

What form the incentives might take is for another discussion, but one can easily envision nonmonetary forms. The important thing is to acknowledge that incentives for providers and patients are a key issue that should be addressed in any telehealth project. Perhaps that is the biggest lesson the United States can learn from India's experience with telehealth.

Finally, there is one more critical lesson to be relearned (it is hardly new) from the Indian experience with health care in general: Access to doctors and hospitals is of little use, regardless of whether it is face-to-face or via telehealth, if the patient cannot afford the medicines they prescribe. The government hospitals in India try to deal with problem by distributing only generic drugs, but that has obvious limitations. The government is striving to get a handle on this problem through a policy that encourages the development of generics and biosimilars (generic forms of biologic drugs) in India.

David Ellis is a futurist, author, consultant and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. He also is a regular contributor to H&HN Daily and a member of Speakers Express.

Ramana (S.S.V.) Yashaswi, M.S., is a consultant at the 100-bed Yashaswi Hospital in Guntur, India. He is an orthopedic surgeon specializing in trauma and joint replacement and is also a professor of orthopedics at Guntur Medical College and director of the Walk Foundation, which provides prosthetic limbs to the poor, free of charge.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

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