This article reviews the necessity for digital health to be incorporated into the healthcare delivery system to achieve the necessary radical transformation. The challenges in executing this and the necessity to address 'WiiiFM' (What is in it For Me) is discussed in the setting of the inevitable evolution of Homo Digiticus.
Eighty per cent of India’s specialist doctors live in urban India. 700 million Indians living in rural India have to travel 50 to 100km for secondary care. While we have outstanding medical centres of excellence, the great majority of Indians cannot access them. With an increasing population, rise in life expectancy, higher purchasing power due to rising income and increasing literacy levels, expectations of the healthcare 'consumer' are reaching an all-time high. Life style and non-communicable diseases are now becoming a public health hazard. Living in an information age, knowledge empowerment is also becoming a reality. It should therefore be no surprise that the recession-proof healthcare industry is expected to touch US$27 billion in 2016-17. The annual average revenue growth during the last five years has been 20-25 per cent. With 78 per cent healthcare expenditure in India being out of pocket, there is a large market for health insurance. Growth in the healthcare industry has to be exponential not incremental, if the urban rural health divide is to be bridged and if we are to reach even the minimum prescribed WHO standards. Realising this, the Government of India has committed to double its contribution from 1 per cent of the GDP, to 2 per cent in the 12th five year plan. Over the next five years, India will require investments of INR6 lakh crores to attain the global median of 24 beds per 10,000 persons from the present.
The ICT Scenario
The growth in Information and Communication Technology has been exponential. Though the use of personal computers and broadband penetration is still predominant in urban India, rural tele-density in India is approaching almost 65 per cent. The Govt. of India in its National Telecom Policy envisages even a ‘Right to Broadband’ scenario by 2020. The United Nations has already declared access to the Internet a human right. A government funded fibre optic network to connect 250,000 Panchayats in India was launched in October 2011, under the Universal Service Obligation Fund (USOF), to increase broadband penetration in rural and remote areas. This will improve delivery of public services and empower village residents, who constitute 70 per cent of India's population. It will change eGovernance, education, and agriculture. Delivery of healthcare could truly be transformed. These Panchayats will have a cell tower and other related infrastructure. Public and private operators will share facilities for providing last mile wireless services to rural customers. Broadband wireless access will consist of a mix of 3G / 4G cellular, mesh WiFi, and WiMAX. With a projected cost of INR30,000 crores, this is scheduled to be operational by 2014.
Given the Health and ICT scenario outlined above, it follows that the growing health divide between the advanced countries and emerging economies, could be quickly bridged by adopting eHealth. The World Health Organization broadly defines eHealth as the transfer of health resources and healthcare by electronic means”. eHealth is all about ensuring the delivery of the right health information about the right individual, to the right person at the right place and the right time, in a seamless, cost-effective manner, using appropriate need-based Information and Communication Technology with a view to enhance health outcomes and improve system efficiency. eHealth is about modernising health system methods and technologies to increase the quality, safety, timeliness, and efficiency of health service. eHealth is a long term project requiring clarity, ownership of direction, strong collaboration and accountability among all key stakeholders, with attention to specific achievable deliverables. To promote digital health, strong leadership is required to solve conflicts between and within organisations. Skill development and adoption of new practices would be a challenge. ICT portals could improve patient-provider communication, contain cost, provide reliable health information, reduce medical errors and enhance efficiency by enabling access, utilisation and collaboration. Introduction of ICT curriculum in all health training institutions and retraining of already qualified medical practitioners should become mandatory. Allotment of budget for ICT is critical to ensure sustainability. Unlearning and Relearning by all users is more critical than choice of technology. An information intensive sector, improvements in healthcare can occur only if e-health technologies are applied as enabling tools for re-organisation, supported by the necessary skills. The biggest advantage for emerging economies is that we need not follow the West or even piggy back, we can directly leap frog. In so far as eHealth is concerned the digital divide is not insurmountable.
Can the digital revolution lead to better healthcare? There is only one answer to this question and that is an emphatic Yes. As every sixth human and every fifth mobile phone are in India this discussion will be India centric—after all, if it is doable in India it should be doable anywhere. Digital Health Care (DHC) is the use of Information and Communication Technology to encompass all aspects of healthcare—preventive and curative. DHC is particularly useful in promoting wellness, not merely curing illness. One has to accept the fact that worldwide, particularly in the developing countries, there is and will always be a major shortage of basic infrastructure to provide healthcare. 20th century solutions cannot be used for 21st century issues. DHC can considerably extend the reach of the healthcare provider and also assist the individual to get expert opinion thousands of miles away.
Advanced Computer Assisted Systems, Virtual Reality (VR), and imaging systems could eventually minimise the usage and dependence on expensive and complicated invasive diagnostics as well as surgical procedures. Also, amalgamation of medical VR and CAS holds the potential to improve medical outcomes in a cost-effective manner by increasing the accuracy in diagnosis and surgery. Several procedures will eventually be shifted from the operating room to radiology centers and outpatient surgery rooms. Increased use of mobile digital X-ray systems will make it easier to transmit images across the internet. The physical absence of radiologists in suburban India can be replaced by their virtual presence. Sophisticated computer programmes will serve as knowledge-based systems, attempting to replicate the performance of a human expert on some specialised reasoning tasks. These expert systems can be used for disease diagnosis. Knowledge can be stored and manipulated to help the user to solve a problem or make a decision.
The author has overseen 75,000 teleconsultations in 25 different specialities from 95 telemedicine centres mostly located in suburban and rural India. Home telecare and electronic house visits have been initiated. Skype is being used for teleconsultation from patients homes. In Karnataka hundreds of family physicians, small clinics and hospitals have been connected to tertiary cardiology centres where ECGs are interpreted and opinion given with a turnaround time of 30 to 45 minutes. eICUs are being planned where smaller ICUs will be connected to highly trained experienced intensivists. High risk newborns in rural India have their retinas evaluated by super specialists hundreds of miles away. 60 VSAT enabled Hospitals on Wheels provide specialist consultations in different villages.
EMR is slowly being introduced not only in tertiary corporate hospital groups but also in selected remote government run primary health centres. At the 3rd international conference on Transforming healthcare with ICT held in Hyderabad from Aug 31st to Sep 1st 2012 more than 400 stakeholders in Digital Health spontaneously affixed their signatures to the Cyberabad Declaration, requesting the government to take regulatory steps and provide the necessary infrastructure and support to make eHealth a reality in India. Obviously the time has come. This augurs well for the future.
More than 500 grand rounds have been carried out between the various tertiary Apollo hospitals using multi point video conferencing. The Ministry of Health, Govt. of India has a programme of eLectures linking hundreds of post graduate medical training centres, using VSATs supplied by the Dept. of Space. Using the National Knowledge Network Simulation Skills Laboratories using 1 Gigabyte per sec bandwidth will become available- this is the new vibrant India giving birth to digital healthcare. The Dept. of Telemedicine, Apollo Hospitals Chennai is one of the 10 super speciality hospitals in India connected to 39 countries in Africa under the Government of India Pan African e-Network project. About 2500 lectures have been delivered for doctors in Africa thro this network.
Challenges in introducing digital health
These challenges include evaluating the appropriateness of existing Healthcare ICT applications, based on impact and effectiveness of the delivery of health services, standardisation, interoperability, reliability and robustness. Human resource development and skills in information systems design and implementation is critical to successful application of ICT in healthcare. These skills need to be staged and nurtured preferably locally. Building competencies finding and retaining skilledpersonnel, enhances access to information and resources resulting in empowerment of patients to make informed healthcare decisions, and improves quality, value and patient satisfaction. Users want credible reliable information, convenience, accessibility, and the assurance of privacy. All these can be provided digitally. Issues to be considered in deploying ICT in healthcare would include the availability of data-related standards, regulatory and legal frameworks, electronic content that is relevant, applicable and culturally appropriate and options to ensure continuity and sustainability of ICT projects. The technology should be simple, relevant and local, built on what is already available and in use. Users need to be involved in the design by demonstrating benefits that would accrue to them. Experience shows that there is no single solution that will work in all settings. The complexity of choices of technologies and the complexity of needs and demands of health systems suggest that the gradual introduction, testing and refining of new technologies, would be the way forward.
Anyone, anytime, anywhere at affordable cost, making geography, history and distance meaningless will be the new mantra. This is what digital health is all about. In India, mHealth could be the specific answer to improve the quality of care, without significantly increasing costs. The most important enabler to make these breakthroughs come true, is not further advances in technology, but meticulous attention to WiiiFM for every single stakeholder in the entire ecosystem. The question 'what is in it for me' has to be satisfactorily answered if digital health is to be incorporated into the healthcare delivery system. A solution is not a solution unless it is universally accepted. Digital health should produce not just customer satisfaction but customer delight. Creating awareness aggressively with success stories is a prerequisite. Lars Leksell the inventor of the Gamma Knife, had remarked half a century ago - I quote “a fool with a tool, is still a fool”. He also observed that when one has a hammer everything around you looks like a nail, particularly when the hammer is expensive. Technology should not go in search of an application. We should develop a technology for a pre-conceived application. Digital technology should be viewed as an enabler to achieve an end, not an end by itself. As one belonging to the BC (Before Computers and Before Christ are one and the same) era, I strongly feel we should not become slaves to technology. TLC should continue to be Tender Loving Care not only telephone or TV linked care.
K Ganapathy is a Senior Consultant Neurosurgeon at Apollo Hospitals and President of Apollo Telemedicine Networking Foundation. A Past President of the Telemedicine Society of India, he was a Member of the National Task Force on Telemedicine; He was a former Secretary and Past President of the Neurological Society of India, Former Secretary General of the Asian Australasian Society of Neurological Surgery and Former Honorary Consultant and Advisor in Neurosurgery Armed Forces Medical Services. He is also President of Indian Society for Stereotactic & Functional Neurosurgery.