In 2007, Indian neurosurgeon Ganapathy Krishnan founded Apollo Telehealth Services, a division of India’s giant Apollo Hospitals Group. Despite obstacles ranging from frequent power failures to thorny regulation, the company has expanded to more than 200 telehealth centers, mostly in India but also internationally, making it the oldest and largest multi-speciality telehealth network in South Asia. Krishnan also founded and runs the nonprofit, research- and education-oriented Apollo Telemedicine Networking Foundation.
When did you become involved in telemedicine?
I’ve been associated with the Apollo Group since its inception in 1983. I had the privilege of working under Dr. Prathap Reddy, founder of the Apollo Hospital Group, Asia’s largest healthcare provider. We have a chain of 72 hospitals, eight of which are JCI accredited, and about 80,000 employees. We have a significant number of overseas patients including from the U.S. and Canada, but mostly from the Middle East and other parts of the world.
I heard the word telemedicine for the first time in 1999. By 2000, though I was busy practicing neurosurgery, I became interested in information technology. By then I was working with telemedicine in a very limited capacity, which kept growing over the years. Two years ago, after 40 years of neurosurgical practice, I decided I would dedicate all my time to telemedicine, which we call remote healthcare.
I’m now the head of the telemedicine division for the Apollo Hospitals Group. We have given about 250,000 primary consultations via video, and others are voice-only consultations. We have a large medical response center in Hyderabad, where more than 90 people -- paramedics, nurses, and doctors — are sitting at any given time to address health-related issues.
Before we founded Apollo Telehealth Services, we founded the nonprofit Apollo Telemedicine Networking Foundation. I continue to drive telemedicine primarily under the foundation’s teaching and research strategies. I’m on the board of directors of the telehealth company, but I leave the operational details to others. Both organizations’ boards of directors include directors from the Apollo Hospitals Group.
How does your background as a neurosurgeon inform your telemedicine services?
There are at least four senior neurosurgeons in the country today who are actively involved in telemedicine. Neurosurgery by definition involves a lot of technology, particularly radiosurgery, robotic radiosurgery, intraoperative MRI, and so on. So we are a little more exposed to medical technology than other specialities. And as a neurosurgeon, I saw patients coming to me from remote parts of India, at very late stages of disease. I was very frustrated that though we had all the technology in the world, we couldn’t do much to help 800 million people who live in suburban and rural India. There’s enough data to show that 80 percent of specialists in India, whether they are cardiologists or rheumatologists or oncologists, cater to only 20 percent of the population in India.
We designed a virtual tumor board, we may be the first in the world to do this. Our board now consists of some of the best specialists. Let’s say a patient has an abnormality in the brain called arteriovenous malformation. I, as a stereotactic radio surgeon, will be on the panel. There will be another doctor who will be a microvascular surgeon, and there will be a third specialist who will be an interventional neuroradiologist who will be able to offer treatment of the same problem through embolization. In other words, three different physicians with different specialties will be able to manage an organ-specific condition without having the patient physically go from the first to the second and then to the third doctor. The board will review and come to a treatment decision for the patient, wherever he might be.
We have also developed an online consultation portal called ASK Apollo, which caters to more affluent clients, not only in India but everywhere in the world. This is another virtual service that doesn’t require a patient to visit a clinic. Two out of every three people today in rural India have a mobile phone, and a third of these people have smartphones. We are very confident that five years from now broadband and mobile internet connectivity is just going to continue to grow. So we thought, why can’t we use information and communication technology to extend the reach of the city-based specialists?
Is Apollo Telehealth Services profitable?
We are not a philanthropic organization. We do have to raise funds. But having said that, our margin is extremely low at the moment. We have a long way to go before telemedicine becomes profitable. The sources of our revenue include our telemedicine consultations, which are 100 to 200 consults on any given day. These are for brain surgery or open heart surgery or bone marrow transplant patients from all over India — we remotely examine their progress. The other revenue stream, which we have started about two years ago, is a public-private partnership with state and federal governments in India.
What are some of the challenges you face in working with telemedicine?
When we started the foundation in 2000, we obviously did not have smartphones, we did not have tablets. We had to deal with very low speed and connectivity issues. Today access to the internet is more widely available, but we have connectivity issues going into rural India because of power. Even if the bandwidth is there, there are power fluctuations that can impact audio and video quality. We have started establishing solar power for some of the telemedicine units.
The other thing is patient empowerment, or knowledge empowerment. Promoting health literacy is a big deal. Through telemedicine services like multi-point video conferencing, patients get to learn to prevent having a stroke, for instance. One example of how we promote health literacy is twice a month my doctors present to around 16 villages, in the local language, using PowerPoint presentations and animations via video conferences. From our office in the city, my department is able to reach 300 to 400 villagers.
What are some of the obstacles you face in trying to expand?
I have coined a term that I use in my lectures called “WIIFM,” or “What’s in it for me?” At the end of the day, unless there is an incentive or a disincentive, it’s very difficult to motivate a young doctor to spend time in tele-consultation. The U.S. is a perfect example. At the American Telemedicine Association meeting, Kaiser’s CEO reported that 56 percent of all consultations by Kaiser are virtual, but only because health insurance companies in the U.S. today accept teleconsultations for reimbursement. Other major health insurance companies like UnitedHealth, the Veterans Administration, and BlueCross BlueShield do the same. It’s still evolving, but states in the U.S. where teleconsultation is being reimbursed have seen a 10 percent growth in virtual consultation services. A major reason why the growth in India is limited is because we still do not have adequate reimbursement policies in place.
Lack of infrastructure is certainly a problem, we have a long way to go there. And another obstacle is acceptance by society and the community. In the last two to three years, the federal and state governments of India have slowly but surely accepted the fact that telemedicine is the answer. As I mentioned, we’ve partnered with the Indian government on three projects, and 10 percent of our teleconsultations are for the government of Andhra Pradesh.
We have to be accepted by the people too. Unlike in Western countries, in India a doctor is considered a demigod. Even educated people today are not very comfortable seeing a doctor on a screen. They still want the doctor to touch patients, physically feel them in order to treat them.
How has public policy impacted your business?
The major public policies have been the “Digital India” Initiative and the “Make In India” Initiative. About 70 percent of health in India is out-of-pocket expenses. Unlike most countries, the private sector accounts for 78 percent of healthcare. The total expenditure on health is about 5.7 percent of GDP, compared to 10 to 20 percent in the U.S. The government bears only one third of the total health expenditure in the country. The government is slowly increasing the expenditure on public health, but most interestingly, funds are going toward technology and also allowing private partners to deploy that technology.
What advice would you give to doctors hoping to get into telemedicine?
You have to be patient. There will be a good return on investment, but it’s a slow and time-consuming affair. Having said that, I’m absolutely sure patients will one day stop going to hospitals — hospitals will go to patients. It has already started. A doctor in your pocket. A laboratory in your pocket. Your smartphone will essentially serve 90 percent of what a hospital can do today, including the surgical part of it. Telemedicine will no longer be regarded as a subspecialty or as a separate discipline, but it will be an integral part of every single department. I will be the happiest person if say, after 10 years, there is no longer an American Telemedicine Association. They have done a phenomenal job in spreading telemedicine awareness, but ultimately telemedicine should be a part of routine healthcare delivery and not viewed as a distinct subspecialty.
— Sony Salzman
Sony Salzman is a freelance writer based in Brooklyn, New York.