As we experience paradigm shifts in healthcare delivery, it is time to look at modern solutions for traditional problems. Healthcare sector has been forever grappling with the iron triangle of equity, affordability, and accessibility. Listen to our podcast with Dr Dhruv Joshi and Dr Dileep Raman from Cloudphysician as they elaborate on how technology can be a mainstream enabler, rather than a fringe benefit to bridge the gap in healthcare infrastructure and make it truly future-oriented.
Keywords: Technology, healthcare, healthcare delivery, data solutions, hospitals, NDHM, pandemic, COVID-19, telemedicine, ecosystem, framework, digital technology
The future of healthcare is shaping up in a way that nobody had envisaged. The prolonged pandemic and its subsequent variants laid bare the widening gaps in what was lacking already in our hospitals, both state and private run. However, like all the other sectors technology saved healthcare, too. In future, healthcare will be driven by digital transformation enabled by interoperable data. In today's podcast, we will be discussing the future of healthcare with technology as its fuel, its impediments and more with Dr Dhruv Joshi and Dr Dileep Raman, Co-founders of Cloudphysician, a health tech firm having an in-depth expertise in the adoption and implementation of various technologies for delivery of advanced critical medical care in diverse hospital settings. Dr. Dhruv Joshi is a Pulmonary and Critical Care specialist and Dr Dileep Raman is a pulmonary Critical Care Medicine and sleep medicine specialist. They trained at the Cleveland Clinic foundation, USA. Welcome Dr. Dhruv Joshi and Dr Dileep Raman. Let's start with your experience over the past one and a half years, during COVID, given how your business model runs primarily on technology as its fuel, and COVID exposed how our healthcare system has been creaking, and how technology came to its rescue.
Thank you, Smriti. And happy to be here on this podcast. I think both Dileep and I, at the time of starting Cloudphysician strongly believed that the existing healthcare delivery models were not addressing a lot of the healthcare delivery problems that existed. And technology could be a huge enabler to make that change and to help address some of these problems. We've been working on this and we're of the strong belief that going forward, technology will form the backbone for a lot of the solutions that come through in healthcare delivery. While we always knew that this sort of transition would eventually take place where technology as the backbone moves from a fringe solution to a more mainstream one, I think the past one and a half years with COVID upon us has certainly accelerated that movement. There has been an enormous amount of awareness that has been created across the board. Everyone from consumers of healthcare to providers of healthcare to policymakers and regulators have all seen the shortcomings that existed in the healthcare delivery paradigm, and how technology can be used as a lever to help overcome some of those shortcomings. And so that has certainly helped us at Cloudphysician in solving some of the challenges that we have, which has been, what we do at Cloudphysician is address the shortage of expertise in critical care units or ICUs. Dileep over to you.
Over the last year or so.. while it's certainly obvious that technology is a fuel, as it is perceived to be, what has been revealing and more humbling is that technology is more of a means to an end. It's a platform. It's an enabler, and it's a tool. And what we are trying to do is make the technology work for the healthcare providers and the people who are actually delivering the care in such a format, that the service angle is actually going to leverage technology more strongly. Because what is happening, at least during COVID is that there's a plethora of technology services that are out there that can be scaled, but what is more difficult to scale is a service angle. So, what we had to do and reinvent is to figure out workflow processes, and service and operational ideas that could in fact, leverage these new technology solutions that were coming into play. So, some of that I think will mature over the next few years as now the technology platforms have suddenly mushroomed. It's really up to the providers to use those tools and see how we can create an impact because technology by itself, without the service angle coupled to it is unlikely to make an impact. And that is what teams with domain expertise will tell you. And the key learning in COVID has been while, you know, we've had dozens of solutions come out, very few of them have actually had that patient impact that has been sustained, and that has been evidence based and documented.
Now there are three key parameters in healthcare—equity, accessibility and affordability. In what ways can digital technology play a pivotal role in making healthcare more equitable, accessible and affordable especially in a country like India?
Technology is the way in which we can address all three of these vertices of the iron triangle, as we call it in healthcare. Like this has been a constant issue in healthcare delivery, where every time we try to address one of these issues, we negatively impact the other two. Every time you try to make, get a more high quality or accessible, the affordability comes into question. And I think with the advent of technology, with the advent of connectivity that has taken place in the last two decades, with the advent of data science and improvement in productivity, efficiency, quality, there is no doubt that technology can be the basis for addressing all of these three without negatively impacting any of them. And we have sort of been doing that in our field in critical care over the last four years. So, at Cloudphysician, if you were to see what we do right now, we're providing access to some of the most highly trained ICU specialist doctors to hospitals that would never have been able to access them, would never have been able to afford them. We are building an entire sort of ecosystem of high-quality care in these hospitals on a digital platform, enabling hospitals as widely flung, spread across as, you know, Leh Ladakh to Kerala, from Gujarat to Assam, get access to high quality care at an affordable cost. And it is like Dileep called it the fuel of technology that's making it possible in our space, and certainly in others as well.
You know how the demographics are very different in India, you know, language, level of education, location and age of patients and even their caregivers. Will the dependency, the dependency on the technology make quality health care more out of bounds for the people than it already is?
See, the really exciting thing about technology is its inherent flexibility and malleability. If you were to take a parallel, you could ask similar questions about the technologies or you know, integrated in the economic space. So, for example, there were questions about Aadhaar and how the UPI paradigm will affect traders and small business owners and how it will link to the vast amounts of rural economy and the farmers at large. And what it turns out is that if you design the technology to be sufficiently simple, and you design it for the users in mind, it is just a matter of time before the uptake happens. And once the uptake happens, you now have user level data, that’ll enhance the technology further. While healthcare is far more complex, the basic premise would still remain the same. You can't have a cookie cutter model where you have an advanced technology, say from the west, that you transplant into India and expect it to function out of the box. You are going to have to go into the hinterland, figure out what the user needs are, come back and then design it for them and then scale it. And this is. This is exactly what we are seeing.. is that if the technology is designed, right, the uptake is actually pretty good. And case in point being some of the ICUs that we are able to run in remote parts of India are actually going paperless because of the way they are able to use the technology that was designed with them in mind. And yes, regionalism, language, these are barriers. But we are not the first people to be encountering these barriers. So, we can take learnings from other industries, parallels there and incorporate into healthcare, the key focus would have to be user centric. And I think that is the priority, that that the designers and technologists would need to make sure that this, this happens. So, I'm not in the camp that think technology will actually take healthcare out of bounds because of how advanced it is. I think it all rests on what the intent of the health tech, you know, team is, and here the intent is accessibility and democratisation. Again, back to the line about malleability. technology is so flexible that you can actually make it happen.
Smriti Sharma: 09:26
What role do you see the stakeholders such as our government agencies, NGOs and private hospitals playing to make the telemedicine a household concept and, you know, to make it a more holistic success for everyone?
I think there are perhaps different roles that each of these will play. I don't know if it's a one size fits all. I think when it comes to government agencies, I think it's pretty crucial because these are the regulatory agencies. They are sort of going to decide the landscape for innovation to either happen or not happen depending on, you know, whether it's incentivised or disincentivised. I think largely speaking, and from our experience in this, in India, in the last couple of years, there's no doubt that the government and regulatory agencies also view technology and telemedicine as something that is going to drop the barrier of adoption of healthcare delivery, with high quality for the population at large. And so, they are, you know, making the, I think the making moves in the right direction. Everything from the telemedicine guidelines and the gazette that was released last year to, I think there are definitely the personal data protection bill, when it comes through will have significant impact on how the industry is going to function, and what the boundaries are within which the industry needs to function within. Similarly, I think even NGOs have found that the, that technology can be something that can be used to, to allow for provision of high quality care and access to high quality care in in a cost affordable in a cost effective manner. And as such have been, again, from our experience, working with several of them have been encouraging technology solutions to help address some of these problems. Private hospitals, I think, will need to see a business case for this. And I think that's also coming through, certainly in the last one and a half years, it came through pretty strongly. We have seen pretty much every private hospital rapidly adopt telemedicine as you know, one of the ways in which they are going to connect with patients and going forward as well. We see them continuing to do that. So, I certainly think that the general direction is moving in favor of technology, is moving in favor of you know, quote unquote, democratisation of provision of quality healthcare, using technology and certainly COVID has helped it to a large extent.
COVID has actually acted as a catalyst in so many ways. And I think that is the only positive way to look at it. Could you also elaborate on the National Digital Health Mission (NDHM) policy that the government is coming up with?
Dr Dileep Raman: 12:39
Yeah, so there are a few other things that we think that the government could take the lead on. Some of the good things that the government is doing here is the entire NDHM policy that is in process, and there are various interconnected concepts, ideas, and, and frameworks that are in place. For example, they're creating a consent manager framework and a sandbox, so that technology providers can use that to universalis the consent management. They are trying to create a framework where different technologies can communicate with each other, so that the patient data that the patient owns is accessible to the patient's health care providers, no matter where the patient goes in the country. So, I think these are very good head winds to have. However, the realisation of some of these frameworks is where the government would need to enhance its push. And that is a direction that we feel can be significantly changed by the amount of pressure that the government can put on various organisations, both private and public. In particular, I think there should be some form of incentivisation where the government can mandate that if your platforms and healthcare mechanisms are technology focused and can communicate with each other, you are actually incentivised to do that in some form either in the form of a single payer managed incentive that says that if the hospital is credential and needs these technology and health tech related benchmarks, there is an additional reimbursement that is incentivized too.
COVID-19 fast tracked our reliance on technology-based healthcare. While it made the transition easier to start with,what are some of the challenges or barriers that still need to be addressed if we were to rely on technology based healthcare?
Healthcare delivery is pretty complex. There are so many different settings and there is a role for technology in pretty much all of those settings. But I think it's hard to just have an umbrella term that would encompass everything. So firstly, I think is we need to realise that patients are heterogeneous. Hospitals are heterogeneous and there are, there’s unlikely to be one solution that fits all. Right. So, so we need to tailor solutions for the different settings and different people that we are going to be addressing. And some of them may be more technology reliant, some of them may be less technology reliant, but I think overall, one thing that is for certain is that technology in some way, shape or form will help all of these. Firstly, we sort of need to, to understand that moving a system that has operated in a certain manner for decades and decades, to a different one is no mean task. And especially when you're talking about healthcare delivery, which is operationally complex, right? It is not straightforward. There are lots of things from, you know, the different touch points that a patient has with their provider, with their hospitals, lab results, previous tests, maybe past records, comorbidities et cetera. There are so many things that influence the care of a patient. And so, to move all of those to a technology dependent mode of delivery is no mean feat. Know what's the type of ecosystem that we are going to create from a regulatory(standpoint)? How are we going to incentivise people? How are we going to train people, you know, to sort of change there? How are we going to take away the inertia that people have against change? How are we going to build technology that is user friendly, that makes this change easy and simple.
Do you think medical education needs overhauling to ensure that our medical professionals become early adopters of digital technology and are truly future ready?
No doubt in my mind about that. I think our medical education system is fairly antiquated and needs, I don't know if overall, is maybe a little bit of a strong word there, but certainly need some injection of more innovative training and future readiness as part of training and apprenticeship of doctors. Often, we see a lot of technologists come in, coming into the healthcare domain to solve some of the problems that we have, and not enough of doctors solving the problems in the healthcare domain. And I think that is some reflection of the type of training and apprenticeship that doctors go through. And, you know, problem solving at scale, is going to require some amount of adoption of technology. And, doctors should be part of that entire process, which they are not enough of a part of right now. So, I think that that should, that will work.
The patient doctor ratio is inversely proportionate in India, and the second wave of the ongoing pandemic exposed the lack of doctors and hospitals, even in Metro cities. What is your take on this huge gap and how it can be addressed.
So, let's assume that you want to explore what the best solution is to deliver healthcare at scale. And you are evaluating is a technology or something else. This something else would ideally be ramping up the doctor capacity and the nursing capacity and all the allied health capacity. That would mean having a medical college or training institute every 100 kilometers. For example, when you think about having enough trained personnel at scale, you realise that just doing that quickly, even in a span of five years is at quality is very hard to do it. On average, to make an ICU doctor, it takes about 12 years. And that is a fully trained intensivist comparable to someone in the west for example. By the time you do all these things, you are probably looking at a 25 year horizon overall, from the time of your idea being executed till the time you actually see a sufficient number of healthcare professionals to handle this. So clearly, if you ask me, in a perfect world, if I could expedite this and do all of this in five years, we should do it the traditional way. But that is how you would come down, evaluate these problems, and then end up with the conclusion that technology by miles is your quickest way to act as a force multiplier. Training and service delivery both have technological tools that can help them to scale. So, we already have serious platforms out there in the healthtech world that will, in fact need to be incorporated into mainstream healthcare teaching and training as well. And this is where I strongly think that when you said about an overhaul or a revamp of the education system, not only will you need to teach new healthcare providers, how to use technology, how to communicate better with technology, you will also need to use technology platforms to train them at large as well. So, you know, for example, IIT Kanpur is actually looking at having a medical college in its own campus, which is a telling idea because you want to have cross pollination of engineers and doctors in the same campus. And that is really where we are thinking that this might act as a crucible of health tech innovation, planting the seeds of that today.
I would just add that, you know, you keep hearing about these doctor patient ratios, and, you know, compared to Western European countries, how our doctor patient ratios are very, very different, right. And, and I don't think that we will necessarily get to the same doctor patient ratios as they do have in many of these much smaller countries. That having been said, the other thing that I would say is that perhaps we can address some of the problems in delivery of quality healthcare in a cost-effective manner, without reaching those same doctor patient ratios, leveraging technology, and that's where again, the platform of technology can help us in in that in that aspect, right. Using connectivity, getting access, using all the engines of technology, AI ML, Data Science, etc. We hear a lot of these buzzwords, but there is definitely scope for us to be able to provide high quality health care to patients without necessarily reaching those same doctor patient ratios, as we see. And that is very much what we're doing at Cloud physician.
So how are digital technologies such as artificial intelligence, data analytics, and big data fuelling the next level of healthcare?
And you, when you think of quality healthcare, you typically think of a large corporate hospital. There are lots and lots of specialists in that hospital catering to a very few number of patients in that particular hospital. And if you were to look at these hospitals, you know, they provide access to high quality health care. But for them to be successful business models, they are dependent on one of the metrics that they use is the average revenue per occupied bed. And, and you will see that for them to be, growing concerns and for them to be profitable, the push is to see how do you increase the average revenue per occupied bed, while delivering high quality healthcare. So, what we're doing and what technology can do, and what we're doing at Cloudphysician is to see is to sort of turn that entire thing on its head and say that using technology, we will provide high quality healthcare, not requiring the same level of average revenue per occupied bed that a large corporate hospital would require. And if we are able to do that you are suddenly open up the availability or the access to quality healthcare to a much, much larger population of patients, because they are very few. If you were to look at our population, a very small fraction of our population can actually access that quality healthcare in these hospitals. That's where these digital technologies, big data and analytics and predictive modeling come in.
So, one of the interesting things that I always think about in this space is, you know, there is this urban legend and a myth that you only use five or 10% of your brain, right? That's clearly not true. We use 100% of our brain all the time. Healthcare data is sort of suffering from this, right now. We generate in advanced ICU with all your monitors and data points, you're generating gigabytes of data every day per patient, this is six to 10 gigabytes of data. And, and the myth sort of is a reality with respect to healthcare data, where we're probably using less than a single digit percentage of this data to actually help the patient, whether it is with predictive analytics, or even helping with clinical decision-making therapeutics. All of this is untapped and unused. What needs to happen is, this needs to be actionable and tied directly to patient outcomes. Without that link falling in place, your uptake is also going to be low. So, for example, you can have a machine learning tool that can pick up an X ray and say if it is abnormal or not or pick up an X ray and say if it's COVID or not, you're not going to find any impact if there is any real life change here. And there was just a paper published a couple of weeks ago, that in fact said that majority of the ML and AI tools that were designed to pick up COVID X rays were lying unused. And that's the whole point that I was trying to make about. You know how this data is actually been utilised. So, it is still an unrealised dream. And I think, going back to the point where we were talking about technologists working hand in hand with domain experts, they really need to be in the know and understand is this a problem worth solving? Otherwise, going back to this vast pool of data, that will be, will be an exercise in futility.
What are the impediments in scaling up a business model based on digital technology given the questions over data safety, lack of availability of medical records and patient confidentiality?
Some of this has to do with human factors and process factors. It's more about having this data universally and freely available through interoperable platforms. So, keeping the human issues aside, the operational and process issues are what the NDHM and various private enterprises are trying to address so that these data points are not in silos, because that is certainly a problem. And again, you can go to the Aadhaar and UPI example, the UPI is a single framework. And various banks like ICICI and Axis, or whoever it is, have agreed to be on that same platform so that they are interoperable, and the payment conduits are in sync with the patient's account or the other user’s account. So similarly, you will have to have a mandate where these models can scale up, because they can actually talk to each of these platforms, including the patient, now ensuring confidentiality after the due consent process that can help this environment be an integrated environment. So that's certainly one major impediment that we see being in this sector, especially in the ICU, which is so data heavy. The other impediment we've of already discussed this in the regulatory framework and the single payer model where there needs to be some sort of an incentive or a business case for the private enterprise to do this and make it happen. So, these are the two major impediments that I see.
Yeah, I would just add that any digital healthcare technology business model simply needs to incorporate components of data safety, patient confidentiality, and availability of medical records into it. Right. So, your solution needs to incorporate it into it, your business model needs to incorporate into it. There's no question about it. I think that that just has to be part and parcel of what how the business model works and how the solution works. So, I think there's no separating the two. I don't think that it's a separate concern. It's just part of the same problem that you're solving. You're solving the problem of access, you're solving the problem of provision of high quality healthcare, you're solving the problem of cost effectiveness of healthcare delivery. And you're also solving the problem of data safety, and patient confidentiality, and availability of medical records. These are all part of the solution of the digital health.
So, would you say that the pandemic has created the urgency for people to share their data more openly?
Sometimes, while the ideal is that, you know, we should have safeguards, the pandemic sort of recalibrated that, but now we actually have a breather where the legal system can actually catch up and prepare ourselves for a better data sharing framework, which is the right way to go about it. So, for instance, this is a suggested improvement in the telemedicine guidelines and telemedicine guidelines draft policy 2020, in fact, said it was okay to use a Skype or some social media platform to share data. But I'm extremely confident and certain that the formal way to do it is to not use those things unless they are compliant with NDHM policies.
Yeah, I would just say that, you know, I never really have seen that people have been averse to sharing their data in the construct of healthcare delivery, actually. You see, if you were to just see the situation on the ground, in fact, I'd say that people share it too freely, you know, with personal data in all sorts of platforms unsecured and otherwise. And I think it's important that that healthcare providers like us and others and other healthcare digital technology platforms and companies, who are entrusted with patient data, to build systems that are compliant and adequately protect the data of their, of the people that they are helping and taking care of, irrespective of whether they ask for it or not. Right, and it is also important that the regulatory framework build in these protections for the patients and consumers.
How will an integrated healthcare system in India look like in five years from now and what will be its essential components in a developing country like ours?
The healthcare delivery will be augmented, will be bolstered by, by technology, which will move from what is now, you know, a fringe sort of solution to a more mainstream one with much greater amount of adoption. But like I also previously alluded to, you know, technology in and of itself is not the solution, technology is merely the enabler. It's merely the fuel, that is helping augment the healthcare delivery that needs to happen. Right. And so the integrated healthcare system will be integrated in many different ways. So, there'll be different components of technology, there'll be different components of services, there will be different components of training, again, perhaps enabled by technology, data science will obviously be play a huge role, where we're seeing some of the solutions coming through already. And then it's pretty exciting in this space to see some of the solutions coming through. And I think one of the things that we need to realise is that the people building the solutions, it is incumbent on them to build solutions that are easily adoptable, by the user and by the consumer, I don't think if the expectation is that the onus is going to lie on the user to adopt your solution no matter what, then that change is not going to happen. So, I think the onus lies on us, the ones that are making these solutions to be able to prove that they work, to be able to prove that they help patients, to be able to prove that they improve the experience of patients, patients, families of the caregivers, and their deliverers of care as well. And then if we are able to show that I, there's no doubt in my mind that adoption will quickly follow. Right. And so, I think, I think there are a lot of people working in this space, like us, a lot of talented folks, there's a lot of money being invested into the space. So, no doubt in my mind that it's going to be exciting few years ahead.
Dr Dileep Raman: 32: 24
It's easier to answer that question with a one-to-two-year horizon. And sometimes it's actually a lot easier to answer what you want to see in 10 years or 15 years. The approach we took was to define a vision statement that we want, and we think will happen in India, and then see if we can actually achieve it in a certain timeframe, preferably sooner than later. So, what we think the ideal situation would be is that you want a patient centric ecosystem. Period. If there was, you wanted to sum it up in one sentence, that is the sentence to use. Now, there are many ways to get to patient centricity. And what we are imagining is that the patient should be in control of their, their healthcare in whatever language they speak in whatever geographical location they are, they should have access to both basic health care and sub specialist healthcare at any point in time in their patient journey. And they should be assured of outcomes that are in line with standard of care across the world. This, this is a fairly simple statement. I don't use the word technology, I didn’t use any word here that is complex. But when you put that in perspective, you can now add technology and healthcare and add layers to it. And those layers are what you want to realise in the next five or five years. And those layers include connecting the patient with the right provider using either tele telemedicine, or having outreach centers that are technology enabled, making sure that every chain in this care pathway that includes registration or passing information to the patient and passing information from the patient to the provider, making sure that the lab informatics and the pharmacy system and the ecosystem is patient centric. You could imagine say a drone-based delivery of medications or labs results to the patient in a remote area. This is already being piloted, for example, you would want this entire ecosystem mapped out. And that can be virtualised. It can have logistics components to it. But these are the things that you want realised going down the line. So, in the patient's palm of their hand where they use their handheld device, as much of this ecosystem should be mapped out. So sure, you can't remove the human element of healthcare where you need someone to be at bedside and if you have a hub and spoke model that takes the patient from where they are remotely and puts them in a location that actually enhances their care for tertiary care. Say for example, you still want that ecosystem to be plug and play. So, the simpler what I want, and then the more complex of how I want to do it, is what needs to be linked. And, of course, it starts with the why. The why is what we started with, is we want to have good patient care. That's what that's why we are doing. So, we know that there'll be multiple players here. And we should all work together to make this happen, because that is the end goal that that can happen if you're lucky five years. But if we are even moderately successful, let's try and do it in ten.
No doubt technology is transforming healthcare in unimaginable ways. But like Dr. Dileep Raman said, it is about creating a patient centric ecosystem where the patients have access to both basic health care and subspecialist healthcare at any point in their medical journey. And they should be assured of outcomes that are in line with standard of care across the world. And then one can add the layers of technology and efficient healthcare to it. On that note, we come to the end of this podcast.
Thank you, Dr. Joshi and Dr. Raman for a thought-provoking peek inside the future of healthcare.
Dr Dileep Raman, Co-founder and Chief of Healthcare, Cloudphysician Healthcare
Dr Dhruv Joshi, Co-founder and CEO, Cloudphysician Healthcare