|Year : 2022 | Volume
| Issue : 2 | Page : 103-109
The business of telehealth
Apollo Telemedicine Networking Foundation, Chennai, Tamil Nadu, India
|Date of Submission||01-Mar-2022|
|Date of Decision||03-Mar-2022|
|Date of Acceptance||04-Mar-2022|
|Date of Web Publication||18-Apr-2022|
Apollo Telemedicine Networking Foundation, C/O, Apollo Main Hospital, No. 21, Greams Lane, Off Greams Road, Chennai - 600 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The author has been actively involved in the successful management of a number of small and mega telehealth projects. This communication summarizes the importance of management science in addressing operational, technical, and clinical challenges in virtually reaching the unreached. These are seldom discussed. Publications dealing with organizational, regulatory, and cultural issues vis a vis its deployment in initiating, sustaining, and making viable telehealth activities have been reviewed. The WHO framework for the implementation of telemedicine services gives some guidelines. This article reflects personal experience, from discussions with the author's street-smart team. The latter's approach fitted in with the dicta of management gurus. A detailed need assessment study was the first step. Risks in program implementation, challenges in providing teleconsultants, and the necessity for training, retraining, learning, relearning, and unlearning are emphasized. Identifying champions in the community and team and making the project self-sustaining is critical. Future-ready access to cost-effective, need-based, appropriate technology including a robust telecommunication network is vital. Patient perspectives of telemedicine quality must be considered. Measurable, reproducible, objective parameters to quantify success need to be defined. Barriers need to be foreseen and addressed. Legal, regulatory, and security issues have to be complied with. Cultural transformation is necessary for the acceptance of technology-enabled remote virtual health care. Urban teleconsultants need to be sensitized for community interaction while deploying cutting-edge technology. Identifying opportunities to initiate telehealth activities, implementation challenges, and adoption of pandemic-associated specific strategies are discussed.
Keywords: Business of telehealth, management science and telehealth, telehealth in India, telemedicine in India
|How to cite this article:|
Ganapathy K. The business of telehealth. Apollo Med 2022;19:103-9
“Once a new technology rolls over you, if you are not part of the steamroller, you are part of the road”
| Introduction|| |
Providing equitable, quality, accessible, affordable health care, in a milieu of infrastructure and personnel shortage, to 1.3 billion Indians is a challenge. The coronavirus disease-19 (COVID-19) pandemic has resulted in telehealth being accepted. Conventionally, components of telemedicine discussed are purely clinical and technical [Figure 1]. Publications seldom highlight the importance of management science. WHO defined telemedicine as “Delivery of health care services, where distance is a critical factor, by all health care professionals using Information and Communication Technologies------.” Telemedicine plays a significant role in bridging urban–rural health-care divide.
Clinical telemedicine formally started in India on March 24, 2000, when Bill Clinton commissioned the world's first VSAT enabled village hospital at Aragonda, commencement of public–private partnership (PPP) projects in 2015 resulted in increase in teleconsultations. With COVID-19 being notified as a pandemic, worldwide ”contactless medicine” was advocated. This resulted in new strategies being developed., Clinical protocols and operating procedures were introduced in specialties. Notification of Telemedicine Practice Guidelines on March 25, 2020, clarified many uncertainties.
| Planning a Telehealth Project – Initial Steps|| |
A detailed need assessment study was carried out before every project. The team interacted with all stakeholders including administrators, doctors, district health officials, patients, and the community. Clinical problems were identified. Beneficiaries, at the ”bottom of the pyramid,” had to interact with urban superspecialists. Challenges included (a) convincing the community that an urban health-care provider could appear on a screen, make a diagnosis, and advise treatment empathizing with them, (b) convincing doctors at the remote center that the new service would not undermine their importance, (c) convincing government that a radical exponential cultural transformation could be implemented and the program would be cost-effective using appropriate need-based technology, and (d) program managers would be transparent, accountable, responsible, and open to external third party audit. The team included young ”street smart,” dependable workaholics with common sense and a determination to achieve success. Managerial decisions were reviewed in real time and corrective measures were instituted.
Acceptable, clear, unambiguous, reproducible, measurable parameters to decide on what constituted success were defined. Quality of service was measured through feedback. Key performance indicators were defined. Channels of communication and grievance redressal mechanisms were instituted. Escalation and evaluation matrices were customized. Internalization of processes and protocols enabling smooth functioning was ensured with constant training. Training, capacity building, CME programs, weekly and monthly project reporting [Figure 2], efficient community engagement, and optimized capacity utilization were implemented. Monitoring and evaluation included impact assessment study of measurable milestones and monthly reports. Program management included budgeting and defining service-level agreements (SLAs) for all activities. This included data bandwidth SLA for service providers and penalties for service commitment outage. In a previous publication, the author had pointed out the lopsided distribution of superspecialists and the necessity for telemedicine.
|Figure 2: Illustration of reports submitted and real-time online dashboard|
Click here to view
| Training|| |
Training was carried out for staff and government employees in (a) clinical areas, (b) information technology (IT), (c) attitudinal change, (d) community linkage, and (e) creating beneficiary delight. Change management and workflow process re-engineering were new areas. A new workflow process was integrated into the existing government health-care system. An intensive 3-month training was given [Figure 3], for telehealth coordinators/facilitators. The training covered the basics of telemedicine, telemedicine equipment, IT for tele-emergencies, trouble shooting, petty cash accounting, management information systems and reporting, and community linkage programs. Staff were taught presenting clinical problems in emergencies. Special programs were held for radiographers [Figure 4]. X-ray films developed at remote entries were scanned and transmitted. A well-integrated teleconsultation unit with remote diagnostic devices (digital 12 lead electrocardiogram, spirometer, stethoscope, and point-of-care diagnostics) and seamless Internet connectivity enabled implementation.
|Figure 4: Teleradiology centers – Training of teleradiology facilitators|
Click here to view
| Telehealth Services Commencement|| |
One hundred thirteen items with redundancy constituted the tele-emergency services considering patient and doctor requirements, inclement weather, and isolation. Community contact was initiated with resource persons distributing simple, illustrated information booklets in the local language [Figure 5]. Change management issues were faced with local staff, who initially perceived telehealth as a threat. Technology provided virtual specialists on a screen, but providing drugs and tests was difficult. ”Just enough” bandwidth always available was better than unreliable ideal bandwidth. Redundancy was provided with an additional backup. Telehealth services were also provided through mobile ”Hospital on Wheels” and in a real-time camp mode while screening noncommunicable diseases.,
| Risks in Implementing Programs|| |
Technology acceptance was a concern. A resource in each center was dedicated to community outreach. A detailed standard operating procedure was made. Constant skilling and upskilling ensured the use of hardware and software. English-speaking translators were made available. Dedicated generators, with adequate diesel, ensured constant power. Subsequently, solar panels were introduced. Specialists in quaternary care hospitals had to provide teleconsults for a token compensation. Younger consultants were more enthusiastic.
| Cost-Effectiveness|| |
Doctors were reluctant to work in isolated areas. Helicopter evacuations were expensive. Cost of the project during the first 15 months, with its major societal impact, was INR 23 million. In addition to saving effort, time, physical discomfort, and emotional stress, INR 9.7 million would have been spent on travel alone. Environmental benefits included reducing carbon print, as 100 ambulance trips of 150 km each and probably five helicopter evacuations were avoided.
Evidence of cost-effectiveness is necessary for widespread telemedicine adoption. Ensuring funding and sustainability is necessary. Donors, governments, cross-subsidy, for-profit companies, and rarely venture capitalists have been sources of funding. Mars and Scott analyzing 77 reports calculated that the number of consultations per site per week (C/S/W) was low, 1.8 ± 3.5 (median 0.7) C/S/W, with 61% of services reporting <1 C/S/W and 71% reporting 2 or fewer C/S/W. Use was calculated as C/S/W using data from 49 papers and 36 abstracts, covering programs of 1–10 years' duration, from 19 countries, with 7 international services. The low numbers indicated the actual utilisation of Telemedicine services. Many authors conclude that there are insufficient data to determine true economic impact. Successful telehealth applications are generally run by local telemedicine champions with ad hoc funding. Few have succeeded in reaching large-scale, enterprise-wide adoption. Personal user advantage and incentivization are as important as advocating general societal advantages.
| Public–Private Partnerships|| |
The tender awardee is responsible for providing technology solutions (connectivity, software, and hardware) and teleconsultants and creating community awareness. In spite of major operational challenges, quality telehealth care has been provided in mountainous isolated, inaccessible, and sparsely populated regions. A study of 14 PHCs and CHCs in North India in 2013 demonstrated that INR 8.8 million was the annual cost for 7 PHCs with a per capita annual cost of ₹170.8 for preventive, curative, and promotive services. Human resources accounted for more than 50% of total costs. In a 4-year study on eUPHC executed in a PPP mode reported by the author, operational cost included salaries, human resources, consumables, travel, administrative charges, and printing. 728.20 million INR would have been spent by the underprivileged community on laboratory tests alone at a mean cost of ₹3807 instead of ₹584.84 million actually incurred at UPHC's at a mean cost of ₹946. In comparison to the eUPHC, only 31% of tests were available in other PHCs. This robust review proves that enabling digital health results in considerable savings. Capital expenditure is one time and per capita costs progressively decrease. Costs for laboratory tests was 28.84% of that in private laboratories. Cost per specialist teleconsultation was ₹165.
| Measuring Performance of a Telemedicine Network|| |
A telemedicine network is a subsystem within an organization. Telemedicine systems should compute setup and running costs to ensure sustainability measuring performance is essential, selecting characteristics to be measured, choosing a method to measure, analyzing collected data, and implementing decisions based on these results. ”Performance” criteria would differ for each stakeholder, for example, patient, telehealth coordinator, teleconsultant, and financial officer. Societal perspectives could be different. Measuring impact should be contextual with appropriate indicators and metrics. Indicators ”indicate” impact but do not quantify, whereas metrics are ”numerical indicators” quantifying impact. Combination of indicators and metrics is needed. Indicators could include (a) utilization (How busy is the network? (b) quality (how good are responses? (c) usability (how easy is the system to use? troubleshooting technical problems?), and (d) patient outcomes.
| Social Factors Influencing Growth and Development of Telehealth|| |
Local champions promote participation, exploiting technological and financial options. Sustainability depends on existing structures and processes in the local health-care delivery system, policy frameworks, communication and technology costs, and physician and patient acceptance. Telehealth service is sustainable when part of the health-care delivery system. Rajendra Singh in a public health case study discusses two champions forming a lasting relationship to improve public health care. In this study, the author provided vision and leadership and staff provided key operational support resulting in successful implementation. Collaboration within the institution, developing community alliances, external partnerships, shared vision exploiting funding opportunities and technological options, identifying critical services, engaging external specialists, and improving administrative processes are important. Telehealth implementation requires rethinking and redesigning of functions, structure, and culture to achieve improvements in cost, quality, service, and speed. The main objectives are developing new business processes supporting and improving service delivery, continually evaluating enterprises' structure and operations to achieve more responsive systems. Interpersonal trust, faith in reliable appropriate technology, and teleconsultation process are necessary. Use or nonuse is determined by the social context in which technology is implemented. Collaboration between entrepreneurs, managers, bureaucrats, health-care professionals, and patients is critical. Analysis of beliefs, perceptions, and attitudes about telemedicine is important. Solutions should be technologically appropriate and culturally sensitive., Appropriate technology is the simplest solution achieving the desired purpose in existing social, cultural, economic, and environmental conditions and promoting self-sufficiency. Such a technology with fewer resources is sustainable. Change management is addressing the human factor, defined as ”resistance to change.” Change is the process of switching from ”old” to a ”new” situation. Individuals are aware of reasons for change, changes that are necessary, details of new technologies, its implementation, and new skills required. Most telehealth evaluation studies are technology centered and focused on utilization rates. Patient opinions shape the marketplace and need to be studied. Health care is a competitive industry. Low utilization rates could be due to poor telemedicine encounter experience.
| Quality Measurements Influencing Growth and Development of Telehealth|| |
Telehealth is a major innovation at the technological, social, and cultural levels. Telehealth projects are complex, innovative, and continually evolving. Some effects cannot be anticipated. Telehealth has a poor record of implementation and adoption. Incentives to health professionals have been suggested to increase telemedicine adoption. Self-sustaining telemedicine applications improve access to health care and savings. The rate of adoption is the speed with which a technology is adopted. The importance of introducing evaluation and monitoring needs to be recognized. Quality assurance (reviewing reports, monitoring cases/users, and checking data) in telemedicine programs has been stressed. A Continuous Quality Improvement program is essential in providing clear, unambiguous specifications and understanding how the system works. Enforcing standards and accreditation is crucial to maintain standard operating procedures and protocols. The Quality and Accreditation Institute has announced the setting up of a Telehealth Accreditation Program.
| Barriers to Adoption of Telemedicine|| |
These include technology integration, interoperability, standardization, security, time constraints, and financing. Technology can be provided, but health professionals need to use it. Their perceptions, legal issues, technical difficulties, time, convenience, and cost are critical. Hurdles relate to reimbursement, policies governing telecommunication and information technologies, development, and licensure. Difficulties in introducing telemedicine and eHealth have been pointed out.,, Internal resistance to changes in work processes and organizational transformations are barriers. Studies from the United States list economic factors.
| Success of Telemedicine|| |
Acceptance by clinicians and beneficiaries, demonstrable savings, improved access to health care and reduced effort and travel time, and adoption into everyday practice are reasons for successful telemedicine applications. Fringe benefits of telehealth deployment include facilitating, recruiting, and retaining health professionals in remote areas, by reducing isolation through virtual networking opportunities.
| Discussion and Literature Review|| |
Management scientists use analytical tools, including quantitative prediction and optimization techniques to qualitative problems, structuring, and solution search approaches. Active deployment of management science in disruptive innovations like telehealth is limited. Adoption of telemedicine, patient satisfaction, and doctor-patient interactions depend considerably on the utilization of human management principles. The latter is intuitive the diffusion of innovation theory is useful in assessing perceptions about a new technology, for example, telemedicine. Telehealth adoption is a complex behavior determined by a large set of psychosocial factors. If patients perceive that telemedicine will save time/money and increase comfort, they may adopt telemedicine. Pre-experience perceptions shape decision to (a) sample telemedicine services and (b) use services regularly. Greater the perceived advantage and perceived compatibility, greater the intent. User advantage determines the speed of adoption. The rate of adoption is the speed with which technology is adopted. Increased access results in increased utilization. To ensure effective operation, skillful planning and implementation are as essential as system design, software functionality, and technical prowess. Optimization of work processes is important. Operations need to be re-invented to use newly available information. Identifying significant pain points results in new innovative solutions. Innovative uses of telemedicine have been reported.
| The Changing Health-Care Scenario|| |
The new normal will be predominantly remote health care. Physical visits will be for procedures in single-specialty hospitals. Personal health records will be updated in real time and stored in the cloud. Individuals will manage their own health with assistance from a nurse practitioner. Smart robots with artificial intelligence will help conduct or interpret laboratory tests and other tasks performed at home with networked diagnostic devices. Internet, mobile computing, and inexpensive sensors will offer the opportunity to democratize health care, making the system resilient. Technology-enabled care will increase productivity and savings, improving health outcomes. Continuum of health care will provide individualized care maximizing resources.
| A Peep into the Future|| |
Instead of patients moving from remote areas to hospitals, information will move from a centralized area to the patient. Digital efficiency should not be at the cost of tender loving care. Telemedicine should be a tool to achieve an end, requiring skills in medicine, digital tools, information and communication technology, and administration. Telehealth will make health-care accessible, accountable, equitable, and affordable maintaining patient trust. Humankind is witnessing an unprecedented growth in health-care IT. Machines will be interacting directly through the World Wide Web (Machine to Machine – or the Internet of Medical Things). Present human-to-machine interaction will reduce. With three billion using social networks, distance will become meaningless and Geography History! Remote health care is here to stay. The work from home culture will be adopted by the health-care provider and the beneficiary. The Government of India's free software for teleconsultation eSanjeevani has already been used 17.2 million times. The future of health care lies in building hundreds of stand-alone, small, satellite clinicians' offices and diagnostic centers. The existing hospital-centric focus will shift to patient-centric focus.
Scores of individuals have managed various telehealth projects. Dr Prathap C. Reddy Founder Chairman Apollo Hospital Group had realized in 1998 that telehealth would be the future. Preetha Reddy Vice Chairperson and Sangita Reddy Joint Managing Director gave carte blanche to the operational team. Vikram Thaploo CEO is managing an outstanding team of dedicated professionals. S Premanand Chief Business Officer ATHS, Dr Ayesha Nazneen Chief Medical Officer, V Krishnamurthy Deputy General Manager, Tamilmaran Sr. Manager, and dozens of section managers and their assistants are all part of this extraordinary team. Secretarial assistance was rendered by Lakshmi, Executive Secretary.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Camillus J, Shobha R, Ganapathy K. Strategy in the time of pandemics, climate change, and the Kurzweil singularity. J Strategy Manag 2021;14:300-14.
Ramanadhan S, Ganapathy K, Nukala L, Rajagopalan S, Camillus JC. A model for sustainable, partnership-based telehealth services in rural India: An early process evaluation from Tuver village, Gujarat. PLoS One 2022;17:e0261907.
Ganapathy K. Telemedicine and neurological practice in the COVID-19 era. Neurol India 2020;68:555-9.
] [Full text]
Ganapathy K. Distribution of neurologists and neurosurgeons in India and its relevance to the adoption of telemedicine. Neurol India 2015;63:142-54.
] [Full text]
Xixi L, Rai A, Ganapathy K. Designing cost-effective telemedicine camps for underprivileged individuals in less developed countries: A decomposed affordance-effectivity framework. J Assoc Inf Syst 2020;21:1279-312.
Ganapathy K, Nukala L, Premanand S, Tamilmaran P, Aggarwal P, Saksena S, et al
. Telemedicine in camp mode while screening for noncommunicable diseases: A preliminary report from India. Telemed J E Health 2020;26:42-50.
Mars M, Scott R. Telemedicine service use: A new metric. J Med Internet Res 2012;14:e178.
Zurn P, Vujicic M, Lemière C, Juquois M, Stormont L, Campbell J, et al
. A technical framework for costing health workforce retention schemes in remote and rural areas. Hum Resour Health 2011;9:8.
Whitten P, Holtz B, Laplante C. Telemedicine: What have we learned? Appl Clin Inform 2010;1:132-41.
Ganapathy K, Reddy S. Technology enabled remote healthcare in public private partnership mode: A story from India. In: Latifi R, Doarn CR, Merrell RC, editors. Telemedicine, Telehealth and Telepresence. Cham: Springer; 2021. p. 197-233. Available from: https://doi.org/10.1007/978-3-030-56917-4_14
. [Last accessed on 2022 Feb 28].
Ganapathy K, Chawdhry V, Premanand S, Sarma A, Chandralekha J, Kumar KY, et al
. Telemedicine in the Himalayas: Operational challenges – A preliminary report. Telemed J E Health 2016;22:821-35.
Prinja S, Gupta A, Verma R, Bahuguna P, Kumar D, Kaur M, et al
. Cost of delivering health care services in public sector primary and community health centres in North India. PLoS One 2016;11:e0160986.
Ganapathy K, Das S, Reddy S, Thaploo V, Nazneen A, Kosuru A, et al
. Digital health care in public private partnership mode. Telemed J E Health 2021;27:1363-71.
Singh R, Mathiassen L, Stachura ME, Astapova EV. Sustainable rural telehealth innovation: A public health case study. Health Serv Res 2010;45:985-1004.
Paul DL, McDaniel RR Jr. Facilitating telemedicine project sustainability in medically underserved areas: A healthcare provider participant perspective. BMC Health Serv Res 2016;16:148.
Obstfelder A, Engeseth KH, Wynn R. Characteristics of successfully implemented telemedical applications. Implement Sci 2007;2:25.
Berger JT. Culture and ethnicity in clinical care. Arch Intern Med 1998;158:2085-90.
Hernández-Torre M, Montiel-Amoroso G, Pérez-Jiménez M, Dávila-Montemayor M, Voisinee C. Health projects in Mexico: The contribution of tecnologico de Monterrey. In: Ho K, Jarvis-Selinger S, Novak Lauscher H, Cordeiro J, Scott RE, editors. Technology Enabled Knowledge Translation for eHealth: Principles and Practice (Healthcare Delivery in the Information Age). London: Springer; 2012.
Piette JD, Mendoza-Avelares MO, Milton EC, Lange I, Fajardo R. Access to mobile communication technology and willingness to participate in automated telemedicine calls among chronically ill patients in Honduras. Telemed J E Health 2010;16:1030-41.
Scott RE, Mars M. Principles and framework for eHealth strategy development. J Med Internet Res 2013;15:e155.
LeRouge CM, Garfield MJ, Hevner AR. Patient perspectives of telemedicine quality. Patient Prefer Adherence 2015;9:25-40.
Wootton R, Vladzymyrskyy A, Zolfo M, Bonnardot L. Experience with low-cost telemedicine in three different settings. Recommendations based on a proposed framework for network performance evaluation. Glob Health Action. 2011;4. doi: 10.3402/gha.v4i0.7214. Epub 2011 Dec 6. PMID: 22162965; PMCID: PMC3234078.
Wootton R, Liu J, Bonnardot L, Venugopal R, Oakley A. Experience with quality assurance in two store-and-forward telemedicine networks. Front Public Health 2015;3:261.
Kangarloo H, Dionisio JD, Sinha U, Johnson D, Taira RK. Process models for telehealth: an industrial approach to quality management of distant medical practice. Proc AMIA Symp. 1999:545-9. PMID: 10566418; PMCID: PMC2232705.
Information Brochure for Accreditation of Telehealth Facility. Centre for Accreditation of Health & Social Care, Quality and Accreditation Institute 1001; 2021. Available from: http://qai.org.in/Document.asp?id=143
. [Last accessed on 2022 Feb 28].
Royston G. Meeting global health challenges through operational research and management science. Bull World Health Organ 2011;89:683-8.
Rosen JM, Kun L, Mosher RE, Grigg E, Merrell RC, Macedonia C, et al
. Cybercare 2.0: Meeting the challenge of the global burden of disease in 2030. Health Technol (Berl) 2016;6:35-51.
Swan M. Health 2050: The realization of personalized medicine through crowdsourcing, the quantified self, and the participatory Biocitizen. J Pers Med 2012;2:93-118.
Zanaboni P, Wootton R. Adoption of telemedicine: From pilot stage to routine delivery. BMC Med Inform Decis Mak 2012;12:1.
Bagayoko CO, Gagnon MP, Traoré D, Anne A, Traoré AK, Geissbuhler A. E-Health, another mechanism to recruit and retain healthcare professionals in remote areas: Lessons learned from EQUI-ResHuS project in Mali. BMC Med Inform Decis Mak 2014;14:120.
Gagnon MP, Duplantie J, Fortin JP, Landry R. Implementing telehealth to support medical practice in rural/remote regions: What are the conditions for success? Implement Sci 2006;1:18.
Payne TH, Bates DW, Berner ES, Bernstam EV, Covvey HD, Frisse ME, et al
. Healthcare information technology and economics. J Am Med Inform Assoc 2013;20:212-7.
Haranath SP, Ganapathy K, Kesavarapu SR, Kuragayala SD. eNeuroIntensive care in India: The need of the hour. Neurol India 2021;69:245-51.
] [Full text]
National Teleconsultation Service. Ministry of Health & Family Welfare; 2021. Available from: https://esanjeevaniopd.in/
. [Last accessed on 2022 Feb 28].
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]