The use of IT will bring the latest medical knowledge to India, says Dr. Rohini Chowgule

Dr. Rohini Chowgule
Lasers, robotics, nuclear isotopes, CT-scans, X-rays, magnetic resonance imaging (MRIs), these are some of the technological tools that doctors have utilised to fight disease and to improve the health of the people. Today, India has turned into a centre for the best medical care – at a fraction of the price paid by patients in advanced countries – and people from all over the world have been coming here to avail of the excellent medical facilities.

This welcome development has been attended by two phenomena that can no longer be ignored. One, thanks to the advent of ever-new technological innovations, patients have started searching for details about their illnesses on the Internet and telling doctors about their “findings”.

Two, while some members of the medical fraternity appear to have taken umbrage to this fad (one of them jokingly said he was changing his name to Dr. Google), there are others who believe that it’s better to flow with the tide rather than resist the sweep of technology.

c, the renowned chest physician who is recognised both as a champion golfer and an asthma specialist, belongs to the second category. She has worked hard on bringing the benefits of information technology (IT) to bear on modern medicine through innovative software systems for health data management and remote consultation.

Speaking on “Information and communication technology in health care delivery” at the last meeting, she pointed out that everybody talked about health care, nobody about health care delivery, a subject that she would concentrate on in the course of her talk.

Tarjani Vakil introduced her as a “Goan, full of life and one who loves fish, music and dancing”; she had been and would be a role model “for India’s children who are getting lost in a globalising world”.

Dr. Rohini started by pointing out that although it was the people who were driving doctors to use new technology, its benefits were enjoyed only by those in urban areas while people living in rural areas were being ignored. But IT was a powerful tool to take good health care to rural populations.
Most countries used 9% of their GDP on health care. The USA, France and Germany spent 10 to 17%. India spent 4% and other Asian countries 2 to 3%. However, these figures represented the amount spent by governments. Large numbers of people in India paid for health care from their pockets and these figures were not included in the GDP spend.

“And because it is the government that spends this amount, that’s why it is (becoming increasingly) bothered about health care technology.”

The trend was set off by American President George Bush in 2004 when he noted the money being spent on health care and felt that something had to be done about it. He drew up a ten-year plan to develop and implement an electronic medical system across the US to improve the efficiency and study of health care.

Research conducted by Rand Health Care showed that if the USA pulled up its socks, it would save $81 billion, reduce adverse health care events (which were often created by doctors and hospitals) and also improve the quality of care.

Finally, in 2009, President Barrack Obama brought a law. He offered a carrot to the health care industry, telling it that if it gave up paper and shifted to electronic medical records, it would net a windfall of $19 billion.

He set aside $2 billion for healthcare providers to implement HIT (health care IT) and a whopping $17 billion in incentives from Medicare and Medicaid funding if they adopted HIT by 2015. Obama also offered incentives to healthcare providers implementing electronic records (again through Medicare and Medicaid funding).

Dr. Rohini said that apart from the US, the UK and other European countries were also spending huge sums of money to move towards electronic health records.

What made them go for this change? They realised that health care IT (HIT) provided the umbrella framework to describe the comprehensive management of health information across computerised systems and its secure exchange between the stake-holders such as the consumers, the providers, insurers and government and quality entities.

Further, HIT could yield several benefits: (a) improve the quality or effectiveness of health care; (b) increase health care productivity and efficiency; (c) prevent medical errors;

(d) reduce health care costs; and (e) improve administrative efficiency by decreasing the paperwork.

When a person went to hospital, there was needless repetition of that person’s medical data. This was done first at the registration counter, then upon arrival in the ward and also when he was taken to the operation theatre. Each one of the nurses/clerks at these places required the patient to repeat the same information over and over again.

This was a colossal waste of everybody’s time. (And time being money, it was no surprise that Rand Health Care had shown that if the USA pulled up its socks, it would save $81 billion, reduce adverse health care events and also improve the quality of care.)

If a system of electronic data storage and dissemination was put in place, doctors and medical personnel attending to the patients would not have to make or receive phone calls or rush to visit their wards – all that they would have to do would be to check the status of patients on their respective tablets (not medical pills) or i-Pads.

Once put in place, this system would also help track diseases in the community. For example, if some patients in Patna were down with a particular infection and if a similar trend was noticed in Pune or Bombay, it would indicate that the infection was spreading in the community. Chronic diseases could also be tracked in the same way.

While working on chronic care and management of diabetics in Washington, said Dr. Rohini, it was observed that older people did not have relatives to take them to hospital; the authorities then opened a cell where online data could be transferred from their homes to the centre. Nurses were posted 24×7 and kept a watch on patients’ data.

When a patient conducted a glucose test, the reading went through a phone to the cell. If the nurse felt that the blood glucose was down, she immediately called and asked what was going on. If the person said he felt a bit dizzy, she told him to stop taking insulin.

This was one way of managing chronic patients so they that didn’t have to first go for a blood sugar test, then go to a doctor, wait for him, meet him, chat with him, show him the report and return home. That was a three-hour process best avoided, thus reducing costs all round.

At present, most big hospitals in the US were giving tablets to their junior doctors that were loaded with guidelines for treatment, side-effects of drugs, information about drug interactions, reactions and so on. When one went to the main page, one found full information, including, for example, which medicine to avoid if a patient was going for an abortion. This was another way to prevent doctors’ errors.

Another benefit was that when they were in the company of other, senior doctors, they could turn on their tablets and discuss the modalities of treatment for their patients.

Dr. Rohini revealed that one of the major hospitals in Bombay was on the verge of starting a similar programme. When that happened, it would ensure the quality of care provided even by junior doctors.

What were the concerns about, and objections to, adopting IT? The biggest fear was about loss of confidentiality. But if the widespread use of IT in banking had not raised concerns on that issue, then ensuring the same level of security for health records would not be very difficult.

A few other fears were attached to that about loss of confidentiality. First, people did not want it to be known on record that they had a condition such as HIV, diabetes, blood pressure or mental problems because that could affect their chances of promotion at work.

Second, they feared that if information about these conditions became known, then they would be embarrassed or shunned by their friends, relatives and associates. This information could also be a major drawback in custody battles with estranged spouses.

Third, insurance companies would immediately raise their premia because of the risk of these conditions.

“But all these things can be taken care of,” said Dr. Rohini.

She said hospitals were worried about the initial cost of HIT being high; but if they looked at the overall and all-round savings, then the cost was not so high.

Worries were also expressed about connectivity, hardware and so on. It was felt that there would be a need to set up computers here, there and everywhere. But this was no longer a major problem because of improved connectivity and cheaper hardware.

“But the real crux is this – who will pay for the HIT? This is bothering hospitals, doctors and everybody else. But let us see who benefits from it. The patients benefit, the insurance people benefit, the hospitals benefit. So what is the hitch?”

Turning to electronic health records, Dr. Rohini pointed out that the same HIT could be used for telemedicine. Already, Time magazine had given a name to tele-medicine, viz., “heal-wire”. And more and more people were using IT for delivering clinical care. But there were two types of tele-medicine, real time or video-conferencing, and the store-and-forward kind.

Real time was a difficult proposition. Many people in India were opting for video-conferencing because they felt that it was the way forward.

But it required hardware, software, the presence of two doctors on the same level and in the same time zone. Moreover, when a video-conference was over, there were no records.

Under the circumstances, those using the web said that it was the best way out because it didn’t require infrastructure. But that was not telemedicine.

Increasingly, people were adopting the store-and-forward technology. Here, the patient didn’t have to go anywhere; his relatives gathered all the information and digitised it, whether X-rays or angiograms. These digitised files were then sent to experts, whether in Japan or America; that person would see it and also show it to other experts and then collate the information and form an opinion.

The advantage of this system was that it was cheaper, it didn’t require much infrastructure and was quite quick.

In India, most people rushed to doctors when they had a problem, nobody bothered about preventive medicine. Information technology could give a boost to preventive medicine, too. If a man had a family history of diabetes and if he kept track of his blood sugar levels, because he was collating his data, he could note when his blood sugar was going up and hence he could take steps to prevent the onset of diabetes. Thus, the cost to people would go down if they detected diseases earlier.

What about rural health care facilities? Dr. Rohini said it was not possible to build big hospitals in villages because the population was dispersed. Besides, there were no facilities such as cheap public transport for people to go to even the nearest hospital if it was, say, five km. away.

Optimum utilisation of rural hospitals was made more difficult by the fact that few doctors were prepared to go there because (a) there was no incentive (b) there were few patients and (c) poor infrastructure. In such circumstances, it was futile to expect doctors to work wonders there. But with IT, those doctors could be better equipped with proper guidance. This would ensure “capacity-building” of doctors.

The time had come for the Indian government to make electronic medical records compulsory at all government and private hospitals, at pathological laboratories and so on. This would improve the outcome and reduce the cost.

Even in a small country like Taiwan, when it was decided to give health insurance to all, electronic records were prepared for each and every citizen. After that, a person could go to any doctor in Taiwan and he would immediately get the person’s data and proceed with treatment without duplication of X-rays, tests and other investigations. The country was thus saving a lot of money.

New private hospitals in India had doctors who were often not up to the mark. IT could be used to train them and to improve their abilities.

Of course, everything would have to be customised for India because there was no point in taking up the American system and applying it here.

Dr. Rohini pointed out that the Agriculture Minister, Mr. Sharad Pawar, had set up two mobile vans that regularly went to every mandi in Maharashtra State. Each van had software that captured patients’ records and a staff member who did blood tests and X-rays. The information was stored and the service offered for a mere Rs. 50.

Of course, Mr. Pawar was doing all this mainly to get votes at the time of elections, but this was another way of improving health care in villages and for what was called the “capacitybuilding” of doctors.

In conclusion, she urged members to opt for those doctors and hospitals that stored records in an electronic format or those who would store and upload the data on a website for easy access by the patients concerned.

Answering questions posed by Mudit Jain and PP Arun Sanghi, Dr. Rohini said that she was using indigenous software to store records in an electronic format.

Besides, she also had tie-ups with experts from all over the world who were sent data for diagnosis or prescription. In this way, the best and latest medical research was made available to Indian patients.

So far as costs were concerned, the charge for data entry and storage for one year was about Rs. 1,200 and Rs. 10,000 for a lifetime. There was no limit on data size and storage, Dr. Rohini added.