Q. Please share with us your vision of using telemedicine for the bettering of healthcare facilities in Germany?
A. I dont think anybodys vision for Germany is as exciting as a vision for India can be. However, I envisage telemedicine enabling and encouraging patients to become more proactive and better informed in furthering their own and others health (aided by health websites); enabling the old, frail and chronically ill to lead more independent and at the same time less isolated lives; and reducing the exploding costs of what is a good health care system to make it sustainable, by improving communication between health care providers and thus avoiding unnecessary repetition of procedures.

Q. What groundwork do you think is required for the successful implementation of telemedicine in a country like Germany?
A. I shall take successful implementation to mean implementation that is widely used in clinical routine. The success of telemedicine depends strongly on factors that can vary widely, even between seemingly similar countries, so I shall limit my answer to Germany. The necessary groundwork includes at least:

• Interoperability of patient data between health care facilities, or a universal electronic health record; complete interoperability or a complete universal electronic health record is not a prerequisite, nor is it a realistic short term goal, but increasing use of telemedicine needs increasing interoperability.
• Proof of net benefit (in terms of change in patient outcomes and/or costs) of a significant range of telemedicine applications.
• Changes in the reimbursement rules to enable health insurers to reimburse costs of telemedicine technology adequately.
• Acceptance of telemedicine by those who are to be involved – the patients and health care workers.

In Germany, developing the electronic health card (a smart card) and its accompanying infrastructure is currently a prime telemedicine activity and one which is intended, in the long run, to give access to an electronic health record, and thus indirectly support all other telemedicine activities. As regards the electronic health card, acceptance among patients is fairly good but not on the part of doctors.

Q. How different would the groundwork have to be in a country as large and diverse as India?
A. The interoperability and EHR requirement holds for India too, in the same relative sense as for Germany.

Proof of net benefit of telemedicine applications: In a country like Germany, in which the whole population is fairly well cared for already, this can be very difficult. But in a country like India with a vast underserved rural population, if telemedicine provides care in certain situations to people who could not access any care in those situations before, then it is obviously beneficial. That is why I find visions of telemedicine in India much more exciting than in Germany.
Reimbursement: If telemedicine is to improve the health care of Indias huge underserved rural population in a sustainable manner, it must enable a large number of health care workers to earn some money by contributing to this improvement. (I know several people, who regularly provide health care services free to the needy, and I believe there are many such people, particularly in India; but I suspect that even in India there are not enough of them to bridge the urban/rural health care divide on this basis alone.) As I understand the situation in India, the problem as regards reimbursement of costs of telemedicine technology is not a problem of existing counterproductive rules, but reimbursement is nevertheless an important issue.

Acceptance: I have been pointed by several people to the reluctance of rural people in India to accept opinions and people from outside their community, and the fact that this cannot be overcome by training someone from the community as a doctor because almost inevitably the person thus trained will soon move to a city. Sustainable telemedicine solutions need a health care worker who is accepted by the community.

Q. What factors according to you contribute to the overall success or failure of telemedicine projects?
A. I am not familiar enough with the situation in India to answer this question in relation to India, so I shall answer it by examples from Germany and the USA:

Lack of standards: technical communications standards; standards for the representation of patient data.

Cost of technology (both in Germany and USA): in the USA this is offset by a national law (universal service) to use part of the charges for advanced telecommunications services to support underserved sections of the population.

Laws that prohibit or discourage some forms of telemedicine – licensure laws in the USA, reimbursement laws in Germany.

Lack of acceptance by health care workers because of disruption of established workflow processes – this is a familiar problem in IT development in general, not just in the health care domain.

This seems to be a list of factors that contribute to failure, but of course anything that overcomes these problems contributes to success. And there are several examples of people who have been instrumental for success by a very positive attitude towards a project or by being warm-hearted and dependable.

Q. What should be the government interventions, in terms of policy, regulations and financial support, in order to facilitate telemedicine based public healthcare delivery?
A. As regards the ground work issues discussed above, the government can support the development of solutions for the interoperability / EHR requirement and implement appropriate legislation; it can address the reimbursement issue by giving financial support for telemedicine infrastructure that can be used by individual health care workers (for example by doctors in private practice); it can address the problem of acceptance in rural communities by training women in the community as auxiliary health care workers who will remain in the community with their family.

Q. Please share with us some insights and new learnings you may have received, during your stay in India on telemedicine projects undertaken by public and private sectors in India.
A. In the first six weeks of this year, I had conversations with many people all over India, from both the public and private sectors, about telemedicine in India, and discussions about possible ways forward. I have not yet had time to follow up all this information, so cannot claim to have a balanced view and shall limit myself to one observation:

I am very impressed by reports on the Aravind Eye Hospital, including its sustainable non-profit business model, which supports 70% of the patients with the fees of the other 30%. At first sight I took this to be just a successful telemedicine project; on closer inspection I found telemedicine came in at a fairly late stage, as a means of screening people in their communities for oncoming blindness in order to get them to the hospital if (and only if) they needed an operation; before that, the founder had, among other things, worked out a process which makes maximum use of the few available ophthalmologists by having all steps that do not require this qualification done by other workers. Maybe this is a good illustration of the fact that, for a telemedicine project to be successful, usually a lot of thought and work has to go into many facets; so mature ventures, in which many problems have already been solved, can be particularly good candidates for applying telemedicine.

Finally, I would like to thank all the people who shared their time and insights with me, and stress that I am a beginner as regards familiarity with telemedicine in India. If I have misunderstood anything, I shall be very grateful to anyone who enlightens me.

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