A problem with tele-health? Or is this structural?

In response to @Dr Aniruddha Malpani on “The problem with Telehealth”. I had to post this separately as my response to the good doctor ran out of the maximum word limit. Here is what Dr. Malpani said:

The problem with telehealth

Causes healthcare to become more fragmented, because of a lack of coordination between the doctor in the clinic and the online specialist

So here goes my reading of it:

Any more fragmented than what it is today? Healthcare lives in islands – especially in India. We go to an independent-practicing physician or a neighborhood clinic. That doctor has no visibility into your past health; actually, neither do you and you give vague responses about a past fever, pain, lab test, or health check and the findings thereof. Because you don’t have any records with you either and memory fades fast with time.

So this doctor you visit may treat you episodically, without a clue about any underlying cause or possible condition. Or ask you to take some kind of lab test. Or perhaps visit a specialist. The lab gives you results in – in hard copy – which you carry around for a few days and put it away, to gather dust as in previous cases. To be forgotten and lost. As with numerous similar lab tests done in the past. The specialist, if a visit is warranted, works equally based on several unknowns – she or he only has your immediate problem articulation by you and any recent lab tests you may bring. She would generally choose to order more tests. For little purpose as a momentary test could be negative, that does not reveal deep, asymptomatic, or dormant conditions that only reveal themselves in patterns over a timeline. We are not talking of infectious diseases that could be easily tested for and treated, though that itself from a public health perspective calls for pattern recognition and timeline spread in a geography.

Forget coordination; there is no basis to connect the dots. No records. No health status trail or trends. No exchange mechanism. Absent system of preventive care. Everyone works in blissful ignorance. This is our current state of healthcare.

Industry Structure

It’s not a problem of telehealth which is still new in using newer and less expensive technologies. It’s an industry-structural problem that will not be solved any time soon because we are a heavily private sector-led healthcare economy that exists in silos and the consuming public pays for most everything out-of-pocket. The government is nowhere to be seen as the role of government itself is fragmented with the federal government responsible for policies, standards, and funds disbursements (each itself representing a cordoned-off island) while the state governments are responsible for actual delivery. The fallout: states do their own thing, ineffectively and inefficiently, driven by political considerations that give health low priority. The consuming public equally treats healthcare as low in priority because it is human nature to discount the future and ill-health is mostly in the future.

That abdication by the State and indifference by the public has opened the doors for the Trojan Horse of the private sector which serves well in parts (eg: tertiary care in the metropolitan areas) but fall far short in equity – in terms of accessibility, availability, assessability, affordability, and one that is fully integrated.

Before we dream up EHR or telehealth or some other smart idea for specialist intervention, we need to work on the structure of the healthcare economy. For that, the government needs to understand the stakeholders, their specific interests and how incentives/disincentives could be made to restructure the current spaghetti that the current healthcare industry represents.

I am rather pessimistic about any of these happening anytime soon as the wheels of government machinery move slowly even as the several stakeholders – hospitals, clinics, pharmacies, distributors, manufacturers, educational institutions, etc – enlarge their interests and gain significant influence. India is experiencing in about two decades what the US witnessed over a hundred years and before ensuring the maturity of supporting institutions of regulatory oversight, standards, and quality of education and service. We have simply put the cart before the horse.