Implementing Digital Healthcare

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Lessons From India

The need for innovation is well understood and much trumpeted – in September 2015 National Health Service England declared “supporting innovation across the healthcare system is more important than ever and will be central to securing transformation and improved patient outcomes”. But innovation is too often interpreted simply as creating snazzy new equipment or techniques. Important though these are, successful implementation of digital healthcare (meaning the actual delivery of proper benefits) needs clear thinking and energetic management as well.

Western countries are feeling their way towards a digital healthcare future. Great hopes have been raised for new technology providing breakthroughs in early warning, treatment and care provision. In the UK, the goal of digitally “joining up” health and social care has attracted attention from both consumers and suppliers, and cash from the government. But progress is patchy.

India, a country with many of the same health challenges as Western countries (including diabetes, cardiovascular and other “lifestyle” diseases) only on a vaster scale, provides signposts for the successful implementation of digital healthcare. Many are in contrast to approaches in countries like the UK and US, and hark back to basic, but sound, management principles well understood and well delivered.

  • Frugal innovation (or coming up with smart, cheap solutions to problems). Digital healthcare innovations in Western countries are often expensive – the head of one US bio-design laboratory believes many suppliers have “looked at need but been blind to cost”.In contrast, as Navi Radjou a Silicon Valley innovation adviser confirms, Indians are the“masters of the art of doing more with less” – finding technology that just works and not getting distracted by hype that delivers little value. He quotes the example of GE Healthcare in India, who have developed a low cost, portable electrocardiogram device, the MAC 400, which is sturdy enough to operate in extreme conditions in rural areas. Instead of designing a new printer from scratch for the MAC 400, GE’s R&D team adapted a printer being used in buses to print tickets. Dr Alex Yeates, medical director of UK software and services provider Advanced Health & Care, came across another example in an Intensive Care Unit (ICU) in Hyderabad. There, staff use technologies such as remote camera monitoring of ICU equipment to enhance patient care, coupled with the WhatsApp messaging service (free, with end-to-end encryption) to share patient notes and scans. Highly trained ICU nurses and clinicians manage and monitor multiple wards in remote locations, delivering critical expert care to patients who previously had no access to it. WhatsApp is being used in clinical settings in Western countries, but combining it with other digital technologies in ICU delivery is rare.
  • Patient, bottom-up local networking (not central bureaucracy) to achieve “platform” scale – Apollo Hospitals, an Indian private healthcare pioneer, has been in business since 1983 and has carefully built an entire health network (or “ecosystem”), including 69 hospitals, primary and specialty clinics, a health insurance company and a chain of more than 2,400 pharmacies.  In 2008, the organisation launched Apollo Reach Hospitals for smaller cities and their surrounding rural and semi-urban areas, to provide facilities with a limited but robust set of medical services. Apollo well understands “network effects” that simultaneously build bigger economies of scale and bring benefits to more people. Lots of management attention is therefore paid to increasing the local network for each hospital: deploying air ambulance services for remote and life-threatening emergencies; providing telemedicine (Ask Apollo email, voice and video consultations) to further improve reach to the at-risk population; developing a fast-track career path to attract high quality doctors to semi-urban and remote areas; increasing the number of low-income patients by cross-subsidies from higher income customers. With this long term-focus on the management of network effects, Apollo is effectively a healthcare “platform”, able to deliver further major potential benefits. The organisation now has a huge dataset providing the building block for implementing Artificial Intelligence – in turn giving an ability to undertake analysis and proactively deliver preventive healthcare for conditions like heart disease. The focus on local delivery is most significant. Western world healthcare consumers’ attachment to large centralised brands such as the UK’s NHS may be, literally, unhealthy. Another healthcare innovator operating in India, Josh Nesbit (who runs Medic Mobile), believes in the future “there will be many new types of health workers, all supported by mobile technologies. Health systems will be decentralised, local and preventable.”
  • A relentless focus on costs– in contrast to simply be given more consumers’ money (for example a recent call in the UK for “an extra £50bn a year above inflation for the NHS by 2030”), Indian managers address the cost side of healthcare provision as an ongoing day-to-day activity. At one globally renowned health care provider Narayana Health (NH), founder and chairman Dr Devi Shetty applies economies of scale to surgery, believing that under the right circumstances higher volume leads to higher quality (“the more operations surgeons perform, the better they get at it.”) A US surgeon typically does three or four surgeries a week. At NH, they typically do two or three surgeries a day – six days a week. Business Today in India details other successful NH cost management techniques:
    • Leasing on a pay per use basis, rather than buying all the equipment that’s required (this keep capital costs low)
    • Tight procurement controls, driving down prices by negotiating directly with equipment manufacturers, and in some cases, encouraging domestic companies to make in India inexpensive local versions of costly imported medical supplies
    • Convincing other equipment suppliers to install their machines for free, earning their revenues from selling the “consumables” required for tests or procedures (suppliers are often prepared to do this to ensure high quality reference sites for their products)
    • Placing a big emphasis on maintaining equipment and extending its life

Crucially, NH uses a scalable cloud-based Enterprise Resource System to help optimise its processes (incidentally saving 65% over conventional IT database system costs). Receiving information via text message, the organisation’s management team study the profit and loss account on a daily basis, enabling them to make quick healthcare decisions (for example on requests for free or subsidised surgery).

Dr Shetty has confidence in his model – so much so that he believes India “will soon become the first country in the world to disassociate healthcare from affluence.”

Using only providers with a track record of delivery to implement digital healthcare projects.Western consumers have become familiar with poorly executed digital healthcare projects, for example in September 2013, an NHS patient record system that would have been the world’s largest non-military IT system was abandoned, leaving it dubbed the most catastrophic IT failure ever seen by the government. The failed centralised e-record system cost the UK taxpayer over £10 billion, £3.6 billion more anticipated. A Dutch government project to introduce an Electronic Patients File ran into similar difficulties.

Western consumers have become familiar with poorly executed digital healthcare projects, for example in September 2013, an NHS patient record system that would have been the world’s largest non-military IT system was abandoned, leaving it dubbed the most catastrophic IT failure ever seen by the government. The failed centralised e-record system cost the UK taxpayer over £10 billion, £3.6 billion more anticipated. A Dutch government project to introduce an Electronic Patients File ran into similar difficulties.

A lesson from India is to engage the “right guy for the job.” The Times of India recently reported that according to IT veteran and tech investor T V Mohandas Pai “there is only one person capable of delivering the infrastructure for India’s proposed National Health Protection Scheme” – Nandan Nilekani, co-founder and non-executive chairman of Infosys (India’s second largest IT company). Nilekani’s track record includes building and operationalising Aadhaar, of one of the key pillars of “Digital India” (and the largest government database of personal information in the world), as well as designing the national Goods and Services Tax Network. Pai believes Nilekani has shown he can recruit a team that understands both technology and how to navigate past bureaucracy. “Nobody else globally would be able to develop the IT infrastructure for NHPS in as short a time as Nandan and his team.” Nilekani is “eminently suited for this” and has “the ability to attract best of class global talent” to work with him on conceptualisation, design, architecture and implementation. The NHPS aims to provide medical cover for poor and vulnerable Indians – about 40% of the total population. The digital infrastructure will be of a similar huge scale to that required for Aadhaar (capable of handling one billion plus transactions per year) and, because of the massive range of the programme, will need to be scaled up gradually.

Professionals with a track record of successful digital implementation, whether locally or like Nandan Nilekani on the national stage, are valuable. But their talents, and those of the teams they assemble, may be worth seeking out (and paying the market rate for), in order to maximise the chances of successful digital healthcare implementation.

Countries such as the UK and US should learn from India’s growing expertise in implementing digital healthcare. India faces many challenges (including shortages of healthcare workers and infrastructure) resulting in few country-wide solutions. But, as Dr Alex Yeates observes, “in spite, or perhaps because of this”, India is “ripe with examples” of innovations in digital healthcare delivery, providing better outcomes for fewer resources. Indian healthcare professionals don’t generally go in for snazzy digital designs, but instead have a clear understanding and an energetic willingness to do the basics of implementation management well. Their counterparts in Western countries should take note – and so should Western healthcare consumers.