From the BC era to Cyberknives

An interview with Dr. Krishnan Ganapathy, Neurosurgent of Apollo Hospitals, Chennai, India
Reporters room at the Geneva Health Forum 2010. Photo © V. Krebs
Reporters room at the Geneva Health Forum 2010. Photo © V. Krebs
Vish Mannava, Viola Krebs, traduction française Aude Elser, traducción al castellano de Miguel Ortiz
25 April 2010

From 18 to 21 April 2010, ICV's Conference Team has been on the move. 58 conference volunteers mobilized, involved in welcoming services and reporting. Within three days, volunteer reporters produced a total of 40 session summaries, seven interviews and two articles. Following his presentation on mobile healthcare (mhealth) in rural India, Dr. Krishnan Ganapathy of Apollo Hospitals, Chennai, India, granted ICVolunteers (ICV) an interview to discuss the impact of Information and Communications Technology on healthcare. As a pioneer in the areas of telemedicine and mhealth, Dr. Ganapathy gave us a balanced history of medical technology, outlining its benefits and drawbacks. He also critiqued the current state of medical Information Technology (IT), offering his recommendations to ensure a bright future for healthcare technology.

Q: Dr. Ganapathy, thank you for taking the time to discuss the current interactions between IT and healthcare. Could you share with us your impressions of current medical technology?

A: I belong to the BC era, before computers, and am one of the last group of neurosurgeons to be trained without using IT. I also started my career before the CT scan era, so I have had the opportunity of seeing the technology evolve and my experience confirms its importance.

In the pre-technology era, the doctor-patient relationship was crucial and very intimate. This is actually one of the downsides of technology, the fact that the personal relationship is slowly going away. The word ‘trust’ no longer exists in the vocabulary of the patient and the doctor. Doctors are now afraid of lawsuits…they distrust the patients, and vice-versa. Therefore, they do whatever they can to cater to the patients’ needs. Patients these days are demanding; they want expensive tests even for simple issues which used to be diagnosed more simply and cheaply.

Q: What do you think about commercial (private practice) medicine today?

A: I’m not so much of a private practice physician. I use technology when I feel it is necessary, and when I think that the use of the technology is going to alter the outcome for the patient. As a neurosurgeon, if someone came to me and complained of a bad headache, I would examine them thoroughly and if no diagnosis presents itself, I would reassure them and perhaps prescribe something. Today, however, in the same situation the younger doctors will ask for a CT scan immediately. It may be nothing serious, but still they prescribe all sorts of tests for the patient. It’s a vicious cycle in which both sides are participants. This is a misuse of technology.

In today’s medical world, you have CT scans, MRI scans, PET, Radio surgery, Robotic surgery and other various ‘hyper-technologies’. You can even treat patients with a cyberknife. This is where you can connect an electronic surgery knife to a computer and electrical pulses are delivered from the computer to the knife. The doctor on the other side of the Internet connection is initiating those electrical pulses! You have something called 320-slice CTs, which means that I can do a cardiogram in nearly 45 seconds. So the hospital where I work, the Apollo Hospital in Chennai, has some of the most advanced technology in the world.

Q: Why are you here at this conference? What attracted you to it?

A: I am here to talk about telemedicine, about mobile health. I first started practicing telemedicine in 1999. I started the first telemedicine unit in South Asia. There are now 93 such units in India and 10 outside, in places such as Bangladesh, Baghdad and Kazakhstan. One of the main themes (of this conference) is medical delivery and access to healthcare. Mobile healthcare will be a key strategy to increase medical access for rural populations in India and Africa.

In the past, we always lagged the West by 5 or 10 years in medical technology. With our adoption of the newest technologies, we no longer have to follow the West, but can in fact surpass it. So the key for us is to use technology to leapfrog the huge gap in medical care between us and the West.

Q: Please explain more about the state of technology in India.

A: As you know, India is a huge market with a tele-density of about 600 million mobile phone users, nearly 50% of the population. Tele-density is higher in cities like Delhi, where it can reach 115%. Computer penetration is almost 10%, with more than 120 million personal computers throughout the country. However, Internet penetration is still very low, around 4-5% of the whole country. Again, in cities like Delhi, the penetration reaches 20%. Wireless Internet is also big in the cities and is seen as a possible solution to narrow the digital divide. There is a lack of sufficient telecom infrastructure in the countryside; we could leapfrog entire villages into the wireless era.

Q: What about the educational applications of technology in India?

A: This is a crucial area to which we are paying much attention. We have the National Knowledge Commission, a government body, which operates the National Knowledge Network. This is a countrywide database of 30,000 educational institutions linked together on a secure network that can run at 1 gigabyte per second. That is roughly 120 million connected pupils, sharing knowledge across the spectrum.

Q: What improvements would you like to see in healthcare technology?

A: In the banking sector personal financial information is immediate at the point of payment. This could also be true for a person’s health history at the point of healthcare contact. Ideally, a doctor attending an emergency should be able to contact a patient’s physician wherever they may be in the world.

Q: What about current healthcare technology in India?

A: Investment in IT is financially very interesting because it is possible to fully recuperate the investment. Health care investment globally is less than 5% of total investment. In developing countries, it’s a mere 1.5%. However, I would say India is in a state of transition. India has a great advantage compared to the West because we are not wired. Because we did not go through the different stages of technological evolution, like the West, we can go directly to wireless. Since most rural Indians do not have experience with cable or dish TV, they can be introduced to satellite TV immediately. We do not have to unlearn and unwire.

Q: What is the state of healthcare in India, in general terms?

A: Currently 80% of health care specialists take care of 20% of the patients. Skills are geographically concentrated, with most specialists practicing in the principal cities. There is no scope for these skills to be located in villages or towns in the foreseeable future. This means that the villager has to come to the city to get specialist care and that takes considerable time and money. If a patient is paralysed, then chances of reaching a city are diminished.

Q: What is the solution then?

A: Using tele-centre medicine through broadband technology we have performed nearly 60,000 tele-consultations. Bill Clinton actually inaugurated our first telemedicine centre in March 2000. Since then, we have expanded into 450 hospitals; about 70 are in big cities and the rest are located in small towns.

Q: Do you think medical technology in India is being used to its full potential?

A: No. Utilisation is low. Almost 80% of available technology is not being used. Of the 20% that is being harnessed, some of it is not used properly. One of the best examples of technology use is tele-ophthalmology. We have two tele-ophthalmology centres, each having performed more than 150,000 eye operations. We have a bus that goes to the village, patients then go to the bus to undergo eye exams and other procedures. There is a webcam that is used to transmit real-time videos of the inside of the eye to a consultant in the city. The same feed can be sent to a hospital, where a surgeon can guide a doctor sitting in the bus performing an operation. Telemedicine is well positioned to take advantage of the demand for mobile phones; it is time to embrace this technology to serve the masses.

Q: What do you think about the privatisation of medicine in emerging countries like India?

A: The supposed evils of privatisation are a misconception. I do not see any reason to differentiate between not-for-profit community hospitals and corporate hospitals. In India, a great part of the health care system was spearheaded by the private sector. The government has realised it can only do so much and so public hospitals often outsource their work to private ones. In the city where I live there are only two MRI scanners in public hospitals, but many more in private hospitals. To provide care at affordable prices, Public-Private-Partnerships (PPPs) work well. Corporate hospitals are needed. Provided that they deliver the service for which they charge there is nothing wrong with privatisation.

Q: What is the future and where do we go from here?

A: Technology for the sake of technology will never lead to progress. It must be used well. It can definitely lead to huge cost savings. Instead of organising a big conference, where many people will travel from across the world, you can do video conferencing for a fraction of the cost. If the money saved was used on food, think about the impact. It is now possible for any care professional to go to a patient’s home, use a special stethoscope that connects into a USB port and transfer an audio file of the patient’s heartbeat over the Internet. The doctor at the other end of the connection can listen to the heartbeat, diagnose the patient and recommend treatment. That means I can be anywhere in the world and listen to the heartbeat of a child in Rwanda. We also have Bluetooth enabled endoscopes, where you can transmit images of a person’s stomach to anywhere in the world.

Gone are the days when someone had to go to the doctor or hospital. Why cannot the hospital and doctor come to you? In this new era, technology will have more and more importance. A one-time investment in IT yields many returns. However, transmitting information and interpreting it are two different things. It still takes six years to train a doctor who can then interpret the image and take appropriate decisions.

Q: Any concluding remarks?

A: No one knew about brain tumours 35 years ago. Now, a patient comes to me already knowing that he has a brain tumour. He knows the advantages and disadvantages of radiotherapy. He decides which doctor to see, he does his research online beforehand. Everything he needs is online anyway. Information is power and the patient knows everything. Earlier, doctors were put on a pedestal but this no longer the case. I am selling a commodity, just like everyone else, and I get paid for it. If I make a mistake, I get dragged to court. There is no longer a halo around a doctor’s head.

For more background on Dr. Ganapathy, please visit www.kganapathy.com.

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