Final Presentation (With Notes)

8/14/2019 Final Presentation (With Notes)

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I can be reached at [email protected]


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My research literally spanned hundreds, if not thousands of documents. In the

bibliography I have captured those that were most useful. The bibliography will also

correspond to the soft copies that are available.

I wanted to leave this behind in an orderly fashion so that others who work with the

organization who need to learn about telemedicine, which is a relatively new

concept, will not have to start from nothing.

As with all of the deliverables and data referenced in this presentation, the

bibliography and zip file will be downloaded to the folder 111 in All Modules.


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I wrote this paper at the outset of my internship with Byrraju. It was the best way I

could think of to discipline my initial research to catch myself up to speed before

arriving in Hyderabad. The paper is a good overview of the state of telemedicine for

anyone who is knew to the field. Because I may attempt to publish this paper (or

parts thereof) sometime in the future, I would appreciate if it is properly cited when

referenced. If you desire to share it with someone outside the organization, please

contact me for approval first. See slides 11-14 for a discussion that includes themes

from this research/writing.


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The village census was conducted in 2004. 144 villages were surveyed family by

family. Data entry is suspect, and the census process itself is open to questions. To

make any use of the data, I had to combine the documents into 5 district-level files. I

then used Microsoft Excel to pull data from each separate file. The statistics I

gathered are reviewed in a later section of this presentation. The raw statistics

(tables, not charts) are available in an accompanying Excel spreadsheet.

Unfortunately, because the calculations were drawing from files as big as 80 MB (in

the case of West Godavari district) I could not retain the original formulas that were

used to pull out the data (otherwise Excel would crash every time the formula tried to

update the results). The titles of the tables, however, should be sufficient for the

reader to understand what data was pulled. See slides 28-41 for a summary.


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There are three estimates for the costs of medicine. The first is taken from West

Godavaris June report. Of course, it would be better to get the reports of all health

centers and for many months to estimate the monthly cost of providing medicines

per village. By the time I realized such a report existed, it was too late to spend much

time on a new round of data collection. There is also a project being conducted by a

group of Shiva Shivani interns, in which they have collected data on the costs of

medicines for three villages in Rangareddi District. It was from their data that I

extracted the price per unit of the medicines that I used to compute the average cost

of medicines per month. See slide 45 for a summary.

The salary information was given to me by the finance department. See slide 46-47

for a summary.

The age information was collected on my behalf by Arun Kumar and Venkata Rao,with the help of Vasundhari Alluri. See slide 48 for a summary.


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Villages I visited include:

Vandrum

Juvvalapalem

Allavaram Kendram

Poduru

I-Bhimavarem

Jallikakanara

Kashevarem

And several others whose names I failed to record

See slides 51-53 for a summary.


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My ideas on this are well-fleshed out in the white paper.


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My ideas on this are well-fleshed out in the white paper.


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Byrraju Foundation, both in verbal and written communication, offers the same

promise as the telemedicine field in general: lower costs, greater access, the same or

better quality of health care.

Unfortunately, it also falls into the same trap: there is no proof of any of these things.

For the Byrraju Foundation, that is okay. Telemedicine is very new program here, only

6-8 months old. However, if the organizations hopes to fulfill its mission to be a

platform by which other organizations can learn best practice, it should care deeply

to real evidence of the impact of its programs on cost, health, quality, etc. It should

also have data that proves its programs are the best option, at least for this area. That

means collecting data on alternative models, including the one it is using currently.


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Too many organizations have fallen in love with technology, and they implement it

just because they can. More thought should be given, and more research conducted

to prove, that telemedicine (in an form or fashion) is truly what it claims to be.

Currently, there is no way to know whether the Byrraju health model is the best

solution to the health problems of Andhra Pradesh. The impact of the program is

today as much a conjecture as it was pre-implementation.


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The benefits of a willingness to pay study are many. The Foundation benefits with

better information to make management decisions, and with which to convince

donors that its proposed model is financially sound. If a paper is published, it also

enjoys the limelight of a broad audience that will learn about its programs as they

learn about the studys conclusions.

Professor Ravi Anupindi (University of Michigan) and the research community also

benefit, precisely because there is little to no quality research published in the three

areas here mentioned. I am confident that a paper that addresses these three

subjects will be well-received and widely circulated among the telemedicine

community.


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This is a side comment. The entire internship I have been thinking of a relatively basic

concept. When we say sustainable in terms of finances, we mean revenue meets

costs. When we say self-sustaining we mean that revenue is generated from within

the system by charging a fee to the consumer. When we charge a fee to the

consumer, we automatically decrease the optimal volume of transactions. In the case

of health care, that means that charging a fee automatically creates a population that

will not receive the service because it cannot afford it. Therefore, when we put

forward sustainable as our goal, we should also recognize that we are sacrificing

universal as another goal.


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The Foundation has two conflicting personalities. On the one hand, it has the

management personality that wants to move forward with new ideas now. On the

other hand, it has the research personality that wants to be a platform by which

others can learn best practices. As far as telemedicine goes, if the research is going to

be done in a way that it truly demonstrates the impact of telemedicine on cost,

quality, and access in comparison with the next best alternatives, then the brakes

need to be applied to the current plans to implement the new model by year end.

The Foundation is in a wonderful position right now to do the kind of systematic

research that the research community has been calling for (unsuccessfully) for the

past 10 years. It is my opinion that the good to be gained by doing the research the

right way is worth far more than the good to be gained by moving full steam ahead.


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I am not an expert in research design, and neither are the managers at the Byrraju

Foundation. But there are plenty of such experts who have spent their entire careers

perfecting this science who would be glad to join with the foundation to design and

implement such research. The Foundation should locate the top telemedicine

research institutes in the world and should begin talking with them about what

research could be conducted and what faculty at that particular school would be

interested in participating. For example, it could start by contacting the Telemedicine

Resource Center at the University of Michigan Health System

(http://www.med.umich.edu/telemedicine/).


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This slide is just an example of what might be done. The point is simple. Too much

time is lost in the first 2 weeks. A well-planned regiment should be implemented that

will integrate the intern as quickly as possible into the work of the organization.

Personally, I think intern projects should not be stand-alone projects that only he or

she is responsible for. I would much prefer to work on a project that started before I

arrived and will finish after I leave, but to be given a sub-project(s) within the larger

project that will help the existing team to meet its overall objectives and deadlines.

There is a danger that this kind of work, if not properly planned and managed, could

become grunt work (making copies, etc.). Nevertheless, if well planned and managed,

it will create the opportunity for the intern to produce something that is immediately

and completely relevant to the work of the organization and avoid the possibility that

interns work will either miss the mark and/or be put forgotten in the fuss over what

the organization is actually working on at the very moment.


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What is the population we are trying to serve?


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Can the population afford health care by telemedicine?

There looks to be a problem with the All bar on this slide, though the formulas were

accurate. It seems like it should be closer to WGs 1.6, though not necessarily higher

than it.


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What health facilities does the population currently patronize?


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Is the population prepared to deal with the technology associated with telemedicine?


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HMRI employs 3 physicians for a four hour shift from 4-8pm. Management feels that

the capacity of its doctors is much higher than what is shown here because the

program is new and there are not enough patients to maximize efficiency. Of course,

the question must then be asked, why employ 3 doctors instead of just 2 or 1 until

the time comes that you need more?


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My main concern here is whether the nurses can handle the technology. Both times I

have been out to the villages with a technical person, there have been serious

technical problems that even he was unsure of how to deal with. Can the nurses

really be expected to cope with technical issues that are sure to arise? Neither the

Ashwini model or the HMRI model places any of the technology burden upon the

nurses, but instead staff a technician who is there during the consultation along with

the nurse.


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Documents

Final Presentation (With Notes)