Healthcare in India is at an exciting phase in its evolution. On one side we have government policy that has ensured that standards have been set for EMR, medical Records and Standards, while on the other hand we see very large hospitals adopting digital in order to increase access and improve care outcomes. But the key to innovation in healthcare are startups and new ventures coming up with innovative care models that are changing the course of the healthcare industry in India.
At the Philips Digital Health Conclave, I had the opportunity to discuss and exchange ideas with many thought leaders in the healthcare space. I spoke to Dr Pinak Shrikhande, Principal at Healthquad and Director at Critinext, a India’s largest Tele-ICU service provider. Below are some of the excerpts from the discussion.
Dr Vikram Venkateswaran: We see a major uptake in Tele–ICU as far as the policy is concerned, how easy or difficult is it to implement it on the ground?
Dr Pinak Shrikhande: Tele-ICU is an exciting concept especially for patients being treated in smaller hospitals which lack 24*7 trained clinical staff to manage critically ill patients. These patients can potentially get evidence based, standard of care therapies closer to their homes with the instructions being provided by the Command Centre to the team at the Spoke Hospital.
The biggest challenges to implementation are the
- Acceptability- the physicians don’t see a compelling need to improve the standard of care for their patients and many take it as an affront to their autonomy.
- Accessibility: Last mile internet connectivity especially the bandwidth required for such care models, has been an issue but things are definitely improving in this area.
- Affordability: The Capital Expenditure (Capex) and the Operating Expenditure (Opex) costs for running a Tele-ICU have traditionally been significant. Many of the patients who require Tele-ICU the most, may not be able to afford it. However, we with our purely Opex model, we have been able to significantly decrease the cost to less than Rs 700/day/bed.
Dr Vikram Venkateswaran: I think Rs 700 per day per bed is a phenomenal achievement but in your opinion do the hospitals currently have the processes and the technology available to implement Tele- ICU? We have spoken to some hospitals that struggled with the implementations in the past.
Dr Pinak Shrikhande: We certainly at this stage cannot afford the full-fledged Tele-ICU solutions available in the developed world like the ones in the US. Hence, customizing it to the Indian scenario is paramount. Our Tele-ICU technology is not a complex one. It requires a Central monitoring system to which all the monitors are connected from where we get direct live feeds, including alarms and smart alerts into the Command Center. This is supported by continuous Audio Visual streaming of images from the ICU. If the hospital has Lab Information Systems (LIS) or Picture Archiving and Communication System (PACS), then these can easily be integrated into our system. If the hospital wishes to go paperless, we can integrate their entire Electronic Medical Record (EMR) we also provide the solution if required into our systems. The only rider to this is that all devices that need to be connected have to be HL 7 compliant.
Dr Vikram Venkateswaran: I think that’s a fair ask and I see that you have built the required expertise and processes into your service capabilities, but what are the people challenges in these implementations, do you have to focus on change management as well?
Dr Pinak Shrikhande: It is important to understand that the Tele-ICU can at best be a monitoring and advisory service. The final implementation of the suggestions is the discretion of the doctor at site. He also needs basic ICU skills to be able to execute the suggestions. Hence, buy in of the local medical teams is of absolute importance to get the desired benefits of a Tele-ICU.
Also the management sometimes tends to view it as a cost item. However, they don’t seem to take into account the direct benefits in terms of patient retention and better clinical outcomes and intangible benefits like establishment of clinical credibility of the hospital.
Dr Vikram Venkateswaran: How do you see this model scaling in India?
Dr Pinak Shrikhande: The potential for this growing in India is significant. With a lack of trained manpower to provide 24*7 coverage to the ICU patients, all hospitals with 8-10 ICU beds can benefit from the Tele-ICU concept which supports these ICUs with Intensivist (critical care physicians) cover especially at night.
Dr Vikram Venkateswaran: A lot has been written about Tele-Medicine and the Jury is still out if it has made a difference, Tele-ICU is different but is there is something the government may need to do to increase adoption?
Dr Pinak Shrikhande: Again I would like to not compare the situation here with that in the US. In the US, ALOS is a very important parameter that is tracked and most Tele-ICU in the US have shown a reduction in Average length of stay (ALOS) and cost of care. We, have published our data on more number of patients undergoing Thrombolysis for Acute Myocardial Infarction with lower mortality due to the support from the Critinext Command Centre especially at night. We have also published data on lower infection rates and lesser use of antibiotics in Critinext supported ICUs. The number of cardiac arrests prevented by timely action on alarms and smart alerts has also been significant. More importantly, we have been able to standardize care by implementation of treatment protocols and care bundles in our spoke hospitals. The ongoing online training of the nursing staff and doctors is a definite value add.
The government on its part needs to define minimum clinical and quality standards for setting up an ICU, including a cover by an onsite or a virtual physician trained in critical care to give round the clock cover. This will prevent the rampant mushrooming of so called wards with monitors from being labelled as ICUs. Also the medical insurance companies should start reimbursing e-ICU services as it saves them significant costs by preventing the transfer to a large tertiary care set up.
Dr Vikram Venkateswaran: I agree and from these discussions I see we are half way there but much more has to be done to make Tele-ICU more mainstream so in that context what is your vision for the hospital of the future ?
Dr Pinak Shrikhande: The hospital of the future will definitely be extensively networked. All the data including patient data, lab and radiology data will all be on the cloud with the authorized personnel being able to view it remotely and take necessary actions. Most radiologist will report on the scans sitting in the comfort of their homes. The ICUs will have an additional level of support in the form of an e-ICU and a small team of 20 doctors will be able monitor and guide treatments for more than 1000 ICU beds from a Command Center.
Thank you Dr Pinak Shrikhande for your time today.
I think this discussion has brought to light many things including the progress we have made in adopting digital and other advanced technologies in improving care, the challenges we continue to face specially in terms of regulation, policies, infrastructure and change. But my biggest take away is the potential for the improved care outcomes for India, leveraging the Tele-ICU model. It is amazing to see organizations like Critinext and thought leaders like Dr Pinak Shrikhande who continue to push the boundaries to improve healthcare in India.
As always questions and comments are welcome