Technology: Telemedicine: fact, not fiction

Seamless healthcare is not a dream: it's reality. A host of tech-savvy hospitals and diagnostic centres are racing to leverage the Net's ability to stream voice, data, and multi-media content to extend their reach beyond their limited physical presence.

Call it another miracle wrought by the death of distance: the ability of doctors to diagnose and treat the ailments of patients far away. Picture this: patients walk into a small intelligent kiosk located conveniently, say, on the main street in Villupuram (a few hours drive from Chennai), or next to the local general physician's (GP) clinic in Panipat (a largish town in Haryana); network capable medical devices that can channel data across the wires-X-ray machines, scanners, and the like-transmit the results of their examination of the patients to a hospital in Chennai or New Delhi; specialists go through the data; and offer their opinions on-line. In cases where surgery isn't required, the GP can treat the patients himself; in others, the patients get themselves admitted at the nearest branch of the hospital. And all's well.

Telemedicine plans

Apollo Hospitals: plans networking with 1,000 franchisee hospitals by end-2001, serving as feeding centres for its hubs in Delhi and Chennai; expanding overseas

Diwan Chand Aggarwal Imaging Centre: digital equipment allows it to serve as a hub for remote centres; plans to offer remote consulting when its new hospital comes up in South Delhi

Escorts Heart Institute: has intranet in place and has experimented with beaming live pictures to the US for consultation; plans a tie-up with broadband networks

Telemedicine Technologies Centre: launched in January, 1999, offers telemedicine solutions and consultancy through the Net

ADS Diagnostic: plans 10 radiology centres in smaller cities within a year, followed by expansion through franchisees

This isn't science-fiction; it's reality. A slew of hospitals, and diagnostic centres are racing to leverage the ability of the Net to transmit voice, data, and multi-media content on-line and in real-time, to extend their reach well beyond their limited physical presence. Aragonda, a mid-sized village in Andhra Pradesh with a population of 15,000 boasts three isdn lines that help connect it to Chennai's Apollo Hospital. The Delhi-based ads Diagnostic is seeking to spread to 10 smaller cities like Meerut and offer remote medical advice from its nodal centre in Delhi. And the Delhi-based Escorts Heart Institute and Research Centre, which initiated its foray into this area two years ago when it beamed live pictures of a patient's heart to the US for consultation with cardiologists there, is certain that this is the future of medicine, allows patients to dial into the hospital from select MTNL outlets, and, for Rs 50, his ECG is transmitted across the telephone line and he can get advice on the ECG. If the same service were to be offered at the hospital, it would cost between Rs 200-300. Escorts is also tying up with broadband network provider Spectranet to offer services to its satellite centres in Delhi. When broadband services are available in other parts of the country, it would be a natural course of extension for the hospital. Says Naresh Trehan, 53, Executive Director, Escorts Heart Institute and Research Centre: ''Telemedicine has a multiplier effect and, sitting in one location, a specialist can treat thousands of patients all over the country or the world.''

Welcome to the world of telemedicine. Where location (of the patient or the doctor) is irrelevant. Where healthcare is cheap because the technology facilitates the sharing of the business' scarcest and most expensive resources: specialists. Where access to a doctor, however, esoteric his or her specialisation may be, is only as far away as the nearest remote-access diagnostic centre.

The philosophy behind telemedicine is straightforward: use the networked environment to help patients consult specialists located elsewhere. The essentials of telemedicine include interactivity and high-speed bi-directional data transfer. Explains Bharat Aggarwal, 30, of the Delhi-based Diwan Chand Aggarwal Imaging Research Centre, which is coming up with a modern 200-bed hospital in South Delhi: ''When the hospital is ready, we will have applications that use voice, data and video technology to help in consulting with our specialists from a remote location.'' The simplest example of it is the telephone call you make to your general practitioner to describe what ails you.

There are two levels at which telemedicine operates. Patient records take the form of images, graphical and statistical data, and details of admission, discharge and transfer (ADT in healthcare lingo). This information can be shared across the intranet of a hospital, ensuring that the patient doesn't need to turn in his records to each specialist she consults or meets, or on the Net. When these digital records are shared across a larger network between hospitals, or between remote diagnostic centres and hospitals, the concept of location-free healthcare becomes a reality. In a country as large as India, the scope offered by telemedicine is immense: no longer is it necessary to focus on setting up fully-functional hospitals across the country; small equipment-rich centres manned by the local physician, but connected to an array of specialists that only a full-service hospital can offer through a high-speed network will do.

The one flaw in this logic-and the one that is absolutely fatal-is the telemedicine business model's absolute dependence on high bandwidth. The quality and speed of transmission required for telemedicine's functioning can be met only by a high-bandwidth network. Our existing cross-bar exchanges, and copper telephone lines will not do. When transmitted across poor-quality telephone lines, scanned images could lose their resolution. The result could be an incomplete diagnosis. Or still worse, a wrong diagnosis. Apollo has realised the critical role of data transfer and is in the process of setting up an India-wide network of 1,500 VSAT terminals to link the 1,000 centres it hopes to set up over the next year. And Escorts Heart Centre is close to forging a tie-up with last-mile broadband provider Spectranet.

It isn't just the larger corporate hospitals that are heading for the Net. Even smaller ones like the Cochin-based Amrita Institute of Medical Sciences (which has begun with an intranet), and the soon-to-be-ready Delhi-based Devki Bedi Hospital (which plans to set up a remote-access centre in the Capital's Connaught Place shopping area) are. And the Hyderabad-based Cardiovascular Technology Institute, backed by A.P.J. Abdul Kalam, the Prime Minister's Advisor on Science and Technology, has successfully tested an indigenous field telemedicine unit.

That means the last-mile access node need not even take the form of a physical diagnostic centre manned by a GP; it could just be a small box carried by a local physician in a vehicle capable of uplinking the information to the nodal hospital. The objective of such experiments and applications is to reach as many people as (virtually, not physically) possible. Avers a confident-looking Prathap C. Reddy, 67, Chairman, Apollo Hospitals: ''I am targeting four billion people across the globe, not just the one billion in India.''

No one's saying anything yet, but in its initial years, telemedicine will default on one of its primary objectives: reducing the cost of healthcare. Here's why. Images from a cat scan can take up as much as 200 MB of space. And a comprehensive abdomen scan could comprise 80 images. The existing telecom networks will take a few hours to transmit data of this quantum. Add to this, the cost-component associated with the actual consultation, and telemedicine will operate at price levels that put it beyond the reach of its primary target audience.

For, it is the section of the populace resident in the non-urban hinterland that feels the most pressing need for health-care services. Says a spokesperson of the Telemedicine Technologies Center, a Mumbai-based organisation in the business of offering telemedicine consulting services: ''We see most of the demand coming from smaller centres; most enquiries about our services already do.'' The Centre set up www.telemedtechnologies.com in January, 1999, to offer customers consultancy.

Hospitals like Apollo hope to address the cost issue by adopting a differential-pricing mechanism. The consultation component of the cost for a call coming from a rural centre will be nothing; that for one from a semi-urban area Rs 200; and from a metropolitan city, Rs 500. Apollo also has plans to charge between $200 and $500 for calls from other countries. Explains Reddy: ''Some years ago, such an idea would have been called nothing less than visionary. But today it is just a dire necessity.''

For telemedicine costs to decrease, bandwidth costs should witness a corresponding fall. This is certain to happen over a period of time. Agrees Madhav Phatak, 43, General Manager, Siemens Medical Engineering Division: ''Once the fibre-optic broadband networks being built by companies are in place, bandwidth costs are bound to fall. When that happens, telemedicine costs will fall.'' Already companies like Reliance, Spectranet, Powergrid, and Zee are in the process of setting up such high-speed fibre-optic broadband networks. Till the bandwidth that these companies promise is available, however, expect to see innovative revenue-sharing agreements between the healthcare service providers and bandwidth companies aimed at making telemedicine affordable to those who are willing to brave it.

True, most equipment now being manufactured by companies like Agilent Technologies, Wipro-GE Medical Devices, and Siemens are Net-enabled. What does this mean? One, these machines can interface with the local area network of the hospital, or the Net, and transmit images and data. Two, companies that manufacture a piece of medical equipment can keep track of its performance through the Net, and undertake preventive maintenance activities if required.

However, the equipment being used by most Indian hospitals-particularly second-rung towns-does not meet the Digital Imaging And Communication In Medicine (DICOM) standard. That is a critical barrier: unless machines are DICOM, they cannot talk to each other. Agrees Phatak of Siemens: ''Today, 98 per cent of the equipment in hospitals is not digital. But that will change over time.''

Exacerbating the problem is the fact that most medical equipment used in rural India is usually a hand-me-down from some hospital or diagnostic centre in the cities. Given the high cost of medical equipment-an MRI machine could cost Rs 6 crore or more, a ct-scanner between Rs 2.5 crore and Rs 5 crore, and a high-end digital X-ray machine could cost a whopping Rs 1 crore-the companies that aspire to set up remote access networks will need to make substantial investments on such state-of-the-art equipment. Avers Aggarwal of Diwan Chand Aggarwal Imaging Research Centre: ''A fully-functional remote diagnostic centre could cost as much as Rs 30 crore.''

Thus, 10 such centres could end up costing in excess of Rs 300 crore. Even a project that seeks to build fully-functional centres and other pared down centres would cost around Rs 150 crore. Ergo, any company that plans to build a telemedicine network will find that the costs are prohibitive.

Companies are betting on the economic logic that the wider reach that telemedicine puts at their disposal will translate into more volumes, and form the basis of a low-margin mass-service business model. Most modern medical equipment are built for volumes, and, as in the case of industrial equipment, per unit costs are bound to go down as the numbers increase.

That apart, many players in the organised healthcare market who are in the process of setting up remote diagnostic centres, view them as entities that can channel the traffic of patients to either secondary hospitals in mid-sized cities, or large hospitals in the metropolises. That could well be the case, but for a business application built around the premise of remote access, profits look remote at this point in time.