“Connecting the patient on video with a doctor is not digital health, there is much more to it”

October 13, 2021 0 By CH Unnikrishnan

Digital health is the way forward for the world at a time when it is going through one of its most uncertain phases during which mobility has been affected, the economy is in peril and human health is in danger. In June, New York Stock Exchange saw the listing of a company that can truly impact the future of world healthcare in this context. UpHealth Holdings, Inc., which was born through a reverse merger of four companies, combines the four essential components of digital healthcare — a low cost, but accountable system of care, an integrated care management platform, a tech-enabled behavioral health service unit and a full service e-pharmacy capability. The new entity, which began trading on the NYSE at $9.29 a share on June 10th, was formed by the merger of Glocal Healthcare, a social venture and one of India’s pioneer digital health companies, and three US-based entities Thrasys, BHS & Transformations, and MedQuest. The company focuses on the three As of future healthcare — access anywhere, affordability for everyone and accountability of health outcomes. The founder of Glocal Healthcare and the chief architect of this new global healthcare fusion, Dr Syed Sabahat Azim — a physician and former Indian Administrative Service (IAS) official, envisioned this a long time ago when he founded Glocal in 2010. Glocal was conceived as a social enterprise bringing quality healthcare to rural India through a combination of low cost primary and secondary care hospitals and digital dispensaries powered by technology. However, says he, the majority of the world, including people engaged in the service of healthcare, is yet to fully understand ‘digital health’ and ‘telemedicine’. Dr Sabahat says the term digital health is often misinterpreted even by healthcare providers, in an exclusive interview with Editor CH Unnikrishnan.

 Glocal, though founded as an Indian technology-led social venture to cater to rural healthcare, has now become a true global entity by merging into UpHealth. What does this transformation mean for Glocal as well as the patient community?

 Yes, that’s true. Glocal has become truly global after the merger with UpHealth and we have become live on the NYSE. This has actually strengthened our position as a global player and this will reflect in all the socially relevant healthcare projects that we have been pursuing in several parts of the world. 

For instance, we have signed up as consortiums for hospitals and other healthcare projects across continents, including Africa, Asia and even the Americas. As a part of this, one major project — 260 e-PHCs (primary health centres) in the Republic of Congo — will be completed and run in the next three months. We have also signed consortiums for similar and even bigger projects in countries like Namibia, Mongolia, Philippines and the US. 

In India, we are now completing a proper 200-bed acute care hospital for the government of Nagaland. This is, in fact, a breakthrough project which was developed out of an innovative model prompted by the Covid-19 crisis after the first wave. 

While we were working constantly to improve our concept of digital dispensary, which can be installed in a small space of 200 sq.ft, sometimes even less, within no time, we realised the importance of being prepared to set up even bigger hospitals as quickly if the need arises. So, this project, which we could complete in exactly three months’ time, was another technology-driven leap forward in response to the COVID crisis. 

Since this Indian state had no facility at all to accommodate severe Covid-19 patients, it came forward to accept this proposal of building a proper hospital as quickly as possible.  We now realise that digital hospitals, which are built quickly and mostly run digitally, are required not only in India but also several parts of the world during any pandemic-like crisis and not for Covid alone. So hopefully, we will be able to significantly scale up globally with all kinds of healthcare projects using our technology. 

 As you say, these are digital hospitals, where the physical presence of scarce human resources is minimised, and the care management, except surgeries, are mostly driven by remote monitoring. Because of its modular design, it is erected anywhere in the least amount of time. Could you explain how all this is actually being executed?    

 As far as the building is concerned, we use a pre-engineered structure of steel and glass, which can be transported or airlifted anywhere and assembled in the shortest time. It is robust and designed for seismic zone 5 — the highest risk zone — so that it can withstand even the most dangerous natural disasters. Inside the hospital, the facilities are designed in a modular concept, where all the beds are monitored. The patient monitors, ventilators, injection pumps, medical gas, etc. connected to each bed as independent units and each bed is monitored remotely so that any doctor from anywhere in the world can bring in their expertise and manage the patient. The complement of the skills required on the ground for the acute care side could be even managed by technicians as long as you have resources trained to put the central line, intubation etc. There are e-ICU software available which go into a central nursing station, and can also be logged onto for remote monitoring. However, our platform is far more advanced with not just patient monitors but also injection pumps and ventilators being connected and doctors being able to do a remote examination also besides monitoring. So, in short, it is designed in such a way that every bed is a machine, which could be airdropped anywhere in units of 10, 50 or 100 according to the need, and assembled in a modular structure and can be logged in and managed from anywhere. In the 200-bed Nagaland hospital, the configuration is 88 beds in the ICU and 88 beds in the HDU, 4 beds of dialysis and 20 beds in the pediatric neonatal care. This is also often interchangeable and upgradable. For example, if you want to upgrade an HDU to an ICU, you need to plug in some more ventilators and everything else is the same. The surgeries are still physical in nature, as that hasn’t yet reached a level where it can be managed digitally and is still a near-field function. Robotic surgery would still take some time to advance to a stage where it can be managed from afar. Otherwise, a digital hospital is a very flexible model where every bed is monitored independently and the equipment is added and/or removed according to need. Ultimately, it not only enables access to healthcare anywhere, but makes it more robust and cost effective.     

This is truly a scalable model as we can easily do 12 hospitals in a year with the team that we have now. As a concept, it is a sort of productization of the hospital installation and care management where everything is the same and built on modular architecture in the shortest time of three months, irrespective of space and the location. As a matter of fact, our second order is also for India by a US-based philanthropist who belongs to Bihar. This is coming up in Barhaiyya in Bihar — his hometown, and the work starts from October 1st and will be completed by December.

 Is this, in a way, an improvisation or rather an enhanced version of the ‘zero base’ concept that you introduced with Glocal hospitals, where you could deliver low cost, increased access and improved care outcomes?     

 Partly yes. But, at the same time, there were a lot of novel ideas and innovation that kept happening while we were thinking about multiple situations and concepts in parallel. For us, it was never a one-trick pony. Therefore, we kept innovating our models. Of course, the basic goal has been to overcome the multiple challenges on the healthcare front, faced not only in India, but elsewhere as well. We had taken up a very ambitious task. Had it been a pure business aim, we could have simply followed a single successful model and made money. I left the government not because I want to do a business and make money. Whatever money came was just a byproduct. The objectives are different. These are — how do you bring healthcare costs down, how do you improve outcomes of care and how do you make it accessible to everyone. This is across primary, secondary and tertiary care fronts. Yes, the earlier hospitals which we set up helped us generate enough data on the technologies behind it, reduce the cost and protocolize healthcare in such a way that it can deliver better outcomes. As you know, the heart of our enterprise is the semantic algorithm-based decision supporting system. This needs real data, which was also one of the key objectives of the earlier setups. With digital hospitals, we have now achieved quite a bit, building upon the data that we generated from earlier hospitals, and what we are going to do now is to go back and integrate these ideas and technologies back into the working hospitals for further improvement on all fronts. These achievements include a further reduction in cost; the development of key healthcare protocols — we have created about 38 protocols covering the management of almost all known emergency and critical care cases; much better healthcare outcomes; the zero base model; modularity in design and others. So these new technologies are going to be used to retrofit working hospitals which earlier served as the real testing ground to develop the data.  

 The term digital health or telemedicine is often interpreted in the limited context of primary consultancy, rather than in the broader context of clinical care and the use of technology to overcome the issues around health care costs and access and the shortage of skilled human resources. But your model and experience gives a holistic perspective of digital health. Can you elaborate on it? 

 When you make a digital hospital, you are actually blurring the lines between various departments because every bed is monitored and all 100/200 beds can be used for critical care with some additional equipment. They can also be used for general patients and they are also being monitored the same way a patient in an ICU is observed by doctors from wherever they are — from a clinic or home. If you want to upgrade a bed from HDU to ICU, it’s just a matter of adding a ventilator or so as a plug-and-play module. Here, you are also removing human resource constraints as the need for the physical presence of human resources is very minimal. In fact, if you look at it in a purely technological perspective, all non-surgical units in these hospitals, including even ICUs and critical care units, can be run with no physical presence of doctors, and can be run by technicians who can put the central line and such emergency procedures. But, as the law always lags behind technology, the Clinical Establishment Licensing  doesn’t permit this right now. 

The average size of human resources, consisting of mostly nurses and technicians, that you actually need to run these hospitals is just one third that of a traditional hospital. In fact all kinds of investigations at this hospital are point-of-care, and technologically speaking, you don’t need a lab technician, which means they use dry biochemistry, rapid immunological tests etc, though the law requires one to run a lab. With digital health in play, anyone who can draw the blood can put it in the disc and insert it in the machine and the results are immediately available to the nurse, the doctor and even the patient. 

If I talk about digital dispensaries, in which we are again actively present with a technically far advanced system, the patient can not only consult the doctors from afar, he/she can also get the tests and investigations done at the point-of-care machine sent to the doctor instantly. During consultation, the protocol driven system can even prompt the doctor for further queries and an automated machine can help the patient and the doctor with multilingual translation. Once the prescription is generated, medicines are also dispensed by the automated machine. So, the term digital health doesn’t mean just connecting the patient on video with a doctor, but has a lot more to it in true health care. 

 One of the key goals that you set when you embarked on the concept of a technology-driven healthcare system with Glocal Healthcare was to reduce the cost of care to as low as that of public healthcare schemes. Have you achieved that in practice? 

 Certainly yes. This is one of the key achievements of leveraging the cost effectiveness of technology-led care and our zero base model for infrastructure and management. With this, we have ensured that the price of the best as well as accountable care delivery is actually lower than what the government or the community or most people can pay. This makes our collaborations with all state and central government schemes like Ayushman Bharat, RSBY and other state insurance plans work easily. This is in fact the solution to the affordability issue that we achieved with this system. The protocols that we have developed for efficiently managing most of the known acute cases, including severe Covid cases, have helped maintain the cost lower than even government rates.