Telemedicine

An exclusive interview with Krishnan Ganapathy

1. You are on the Board of ATNF & ATHS. How did you come to be involved with them?

It started on September 16 1996, I had just finished delivering an institute lecture at the Indian Institute of Technology Kanpur, a globally recognised institution. Just after the Q & A ended at 09:00PM, Prof. Srivathsan, HOD of Electrical Engineering Department insisted I have dinner with him. He introduced me to the word “Telemedicine”. We jointly prepared a project report from 11:00PM – 04:00AM. Then commenced a love affair, which over the next 26 years has taken its toll. My legally wedded wife is often relegated to No. 3. Initially, I was wedded to Neurosurgery and now it is Telehealth. Having started the first Stereotactic Radiosurgery unit in South Asia and as Secretary of the then 2200 strong Neurological Society of India, conventional wisdom dictated that I should continue to focus my skills and energy completely, on what I was trained for, namely neurosurgery. However, deep down was a nagging feeling: “Was there not something else, which I could do, which could help more than a few thousand neurosurgical patients.” And then the story began. I took the road less travelled by and the rest, as they say, is History! In fact, I embarked on making Geography History, and distance meaningless!

KRISHNAN GANAPATHY is a Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery. Hon. Distinguished Professor, The TamilNadu Dr. MGR Medical University, Emeritus Professor National Academy of Medical Sciences Member Roster of Experts Digital Health WHO. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services, India. URL: www.kganapathy.in E Mail: drganapathy@apollohospitals.com

Dr Prathap C Reddy Founder Chairman Apollo Hospital Group visionary Nostradamus that he is, gave me all the support and encouragement. On March 24th 2000, Bill Clinton formally commissioned the world’s first Very Small Aperture Terminal (VSAT) enabled village hospital at Aragonda in Andhra Pradesh (birth place of Dr. Reddy). In 2001, Apollo Telemedicine Networking Foundation was formally established as a not for profit Section 25 company. Taking modern healthcare to remote areas using technology was the mission of ATNF. In between my neurosurgical commitments, I spent time and effort to help a skeleton staff of four full-time employees to achieve what in 2001 appeared preposterous: remote consultation. Every opportunity to put a then hardly existent Indian Telemedicine on the world map was utilised. In 2007 the commercial arm Apollo Telehealth Services was started. Today the Apollo Telehealth division alone has about 1275 employees. Almost 25,000 e-Health transactions are done every day. With a dynamic CEO and an outstanding support staff the initial passion displayed by the founders has become infectious and contagious. The organisation is on auto pilot mode. This would not have been possible but for the freedom and encouragement given by Dr Sangita Reddy Joint Managing director of the Apollo Hospitals Group who oversees the Telehealth Division.

2. Who benefits the most from integration of Telemedicine into Health Systems?

There is no one set of patients benefitting more from using Telemedicine. Incidentally I prefer the term Telehealth to Telemedicine The former is an all encompassing term covering every aspect of health including promoting wellness, while the latter implies only a one to one diagnosis and treatment. Providing dependable Knowledge on a smart phone will lead to people empowerment and a reduction of preventable diseases. Promoting health literacy the e Way is critical. Under Ayushman Bharath, the world’s largest Universal Health Coverage for 500 million Indians, 150,000 Telehealth enabled Wellness Centers will be functional throughout India. Theoretically, every single individual, healthy or sick, rich or poor, urban or rural, educated or not, can benefit in different ways through “contactless” medicine. Distancing is a term that should not exist for those deploying Virtual Healthcare - we are always there 24/7 on a small or large screen.

3. What are the challenges facing Telehealth today?

In one way the challenges facing Telemedicine today are far less and can be addressed. When I first embarked on Telemedicine 24 years ago, the very word was unfamiliar to most. It took a decade of intensive persistent evangelisation to create the semblance of an awareness. The second decade was spent in achieving a behavioural modification and technology acceptance among all stakeholders in the ecosystem. During the last four years, thanks primarily to Public Private Partnerships, revenue generating business models have started to become available. The single most important challenge facing Telemedicine is addressing the question WiiiFM (What is in it For Me). WiiiFM is different for each stakeholder. COVID 19 pandemic has made the entire globe realise that today distance is meaningless. Physical distancing could be the norm. Convincing the beneficiary that Telemedicine has advantages over in-person visits, will no longer be a major challenge, particularly with proactive steps taken by the government. The challenge is to customise and make available a cost-effective, need-based, userfriendly, efficient, secure Telehealth system compliant and adherent to newly formed regulations. Telemedicine systems must be future-ready and culture-sensitive. Insurance companies in India have already started recognising Telemedicine for reimbursement. Revenue generation is critical for ensuring self sustenance.

4. You are reputed as having helped pioneer introduction of Telemedicine in India. What advice do you have for someone wanting to establish a Telemedicine programme?

Be future-ready. Learn from the mistakes of your predecessors. Remember that no Telehealth programme can be sustained unless it is revenue generating. Technology is a means to achieve an end not an end by itself. With more access to technology do not forget that you are a doctor first and last. TLC (tender, loving care) can be bestowed virtually. Empathise, sympathise with your patient on the screen (small or big). Wipe their tears. Listen to them Find out what they want. Answer all queries. Technology is the least important. Context is critical. Stop a teleconsult if your gut feeling suggests necessity for a face to face interaction. Adhere and comply with all changing regulations. We are in a stage of transition. All transitions offer great opportunities. Telemedicine, like medicine itself, is not black or white. It is still various shades of grey. Look back to March 10, 1876 when Alexander Graham Bell made the world’s first telephone call, a request for medical help, “Watson come here I want you”, after having spilt battery acid on himself. We now have a diamond spoon in our mouth. COVID-19 is providing us with tens of thousands of virtual non-Covid patients! You cannot ask for a more opportune time to initiate Telehealth. A strand of RNA 120 nms has become the most efficient CTO (Chief Transformation Officer)

5. What impact has the COVID19 pandemic had in integrating Telemedicine in day-to-day clinical practice?

Following notification of COVID-19 as a pandemic, on March 25, 2020 the Ministry of Health, Govt of India notified Telemedicine Practice Guidelines for the country. This had been pending. Due to uncertainty of legality in deploying Telemedicine, many doctors were not using this. Today, thousands of doctors have attended orientation programmes conducted by the Telemedicine Society of India and other organisations. I have personally given 52 webinars in the last 22 months on various aspects of Telehealth. Over 35,000 doctors have attended. One webinar during the first wave was attended by 11,775 doctors. Another webinar was for 8 countries and 808 attended. The interest then was unbelievable. Hundreds of hospitals in the public and private sector started offering free teleconsultations for screening of COVID 19 patients. Contactless medicine is now being accepted. It appears that the work from home (WFH) culture will include doctors as well!! In every crisis there is an opportunity. Delivery of healthcare services is being re-looked at. Even when the pandemic becomes an epidemic, Telehealth is here to stay. It will take centre stage after being in the periphery for 24 years.

6. There is debate over the robustness of cybersecurity measures for patient data in Telemedicine. What is your opinion on this?

We concede that privacy and security of patient data is important. 200 million healthcare records have been reported to have been compromised in the USA alone. The later entry of India in using electronic medical record (EMR), has ensured that we don’t piggy back, we don't even leap frog (after all how far can a frog leap) we pole vault. Ethical, legal, social issues guidelines regarding Data Ownership of EMR have been notified. Protected Health Information, data ownership, data access and confidentiality, EMR preservation and patient identifying information have all been addressed in great detail under existing Indian laws including IT Act 2000 and their amendments. The stakeholders understand the importance of cybersecurity. However, sometimes I feel that we are getting paranoid about cybersecurity in healthcare. Yes it is important, but if we wait for a totally fool proof secure system, EMR’s and HIS would never see the light of day and the cost would be astronomical. Even the White House can be hacked!! It depends on how badly the hacker wants the information. I have always felt that there is a cultural difference between India and the west so far as hacking health records is concerned!!! We are not primarily a society which will litigate at the drop of a pin. Trust still is part of our vocabulary.

7. What is the importance of Global Certification in Telehealth?

Quality is never an accident. It is always the result of intense sincere effort, intelligent direction and skilful execution. The International Standards Organization (ISO) has developed a Technical Specification, ISO/TS 13131 Telehealth Services. This standard, supports healthcare planning, service and workforce planning, organisation responsibilities and financial and IT management. ISO develops standards recognised and respected globally. It brings experts together to improve quality and provide world-class healthcare services. To maintain global recognition, maintaining quality needs to become a habit, a unique opportunity to transform one’s DNA if necessary !! Success is the sum of small efforts, repeated day-in and day-out. Standardising systems, processes, documentation and re documentation alone will ensure providing quality remote healthcare for anyone, anytime anywhere. On December 10th 2021 the ISO 13131 -2021, certification for Telehealth Services was obtained for the first time, anywhere, by Apollo Telehealth Services. This was a remarkable display of considerable team work led by passionate managers.

8. At 71 what do you now intend to do?

I am reasonably satisfied with my erstwhile professional career both as a neurosurgeon (helped start Stereotactic Radiosurgery in 1995 and Robotic Radiosurgery in 2008) and my contribution to the growth and development of Telehealth from 1998 onwards. I am delighted that the Next Generation is doing far better. I am optimistic that in my life time, I will see digital health and technology-enabled remote healthcare being universally incorporated into the healthcare delivery system. Twenty two years ago Dr. Prathap Reddy in his infinite wisdom told me “Ganapathy, your job is to make the pie bigger, your share of the pie will automatically become bigger”. I now wish to concentrate on knowledge transfer, sharing what I have learnt over the last half a century, by giving more talks and writing more. My recent appointment as a National Emeritus Professor by the National Academy of Medical Sciences India offers an opportunity to spend some time in different medical institutions interacting with students and staff.