The Computerworld Honors Program
Honoring those who use Information Technology to benefit society
LOCATION:
Scarborough, ME, United States

YEAR:
2008

STATUS:
Laureate

CATEGORY:
Non-Profit Organizations

NOMINATING COMPANY:
Satyam

ORGANIZATION:
Byrraju Foundation

PROJECT NAME:
TeleMedicine Intervention



Introductory Overview
India’s recent exceptional economic performance is well documented. However, most beneficiaries of this boom are urban. Hundreds of millions of villagers remain desperately poor, which severely limits their access to healthcare.

The Byrraju Foundation is a not-for-profit organization that builds progressive, self-reliant rural communities through a holistic, transformational approach. It provides comprehensive services to rural communities, including Healthcare, Education, Literacy, Water, Environment, Sanitation, Livelihoods, and Disability Rehabilitation. To date, The Foundation has helped more than 3 million people in 185 villages, in six districts of Andhra Pradesh state.

When it targets a village for improvement, the Foundation initially focuses on Healthcare, since healthy people can work, study, and contribute to the enhancement of their community. As such, the Foundation rapidly establishes a healthcare infrastructure by donating to villages a ready-made facility, complete with a doctor and modern medical equipment, with which they can provide basic services, such as immunizations, and more advanced treatments. Many patients treated at Byrraju facilities have never before seen a medical professional. Consequently, numerous relatively minor maladies, and even some serious illnesses that would have likely worsened if untreated are managed and/or cured.

This submission to the Computerworld Honors Program focuses on Healthcare, specifically, the Foundation’s delivery of electrocardiograms to rural Indians. The EKG is a relatively routine test to monitor heart health. The way the Foundation delivers EKGs to rural Indians, however, is anything but routine.

Recently, Byrraju research indicated that rural, poor Indians had an unusually high incidence of two serious diseases—Diabetes Mellitus and hypertension. Consequently, these high-health-risk groups needed to be screened for heart abnormalities. However, giving EKGs to rural people is difficult. It required bringing patients to a with an EKG machine. That usually meant travel, an expensive proposition for rural folks. Transportation, food, test and analysis fees, medication, and lost wages became a real financial burden.

To address these problems, the Foundation established a telemedicine program. In doing so, it created a broadband, wireless Internet platform to deliver numerous healthcare services to rural people—virtually. Via the platform, doctors in city hospitals use videoconferencing to dispense medical advice to colleagues and patients in a Foundation medical facility, often hundreds of miles away. Villagers exploit this transformational healthcare capability with enthusiasm. Doctors, originally reluctant to use the remote platform, also appreciate its utility.

Early manifestations were helpful, but not optimal. Sometimes, a brief videoconference was enough; a doctor would recommend minor treatment remotely, and villagers would go on their way. Frequently, however, patients were asked to visit a doctor in person, which meant travel. As such, people needing an EKG still had to endure costly and time-consuming travel. Those who could not afford the trip did not receive the care they needed.

The Foundation partnered with Narayana Hrudayalaya, a Bangalore hospital specializing in cardiac treatment. It also secured several Schiller EKG machines from the Indian Space Research Organization. Next, nurses and doctors in Byrraju Ashwini Centers were trained to use the EKG machines. Today, when tests are finished, a Tele-EKG solution developed by Satyam and SN Informatics sends results to Narayana Hrudayalaya. Within 15 minutes, a cardiologist provides analysis. If an abnormality is discovered, further investigation is recommended, along with simple, over-the-counter medications.

Patients who receive an EKG in a Byrraju healthcare facility pay only $1, a savings of about $25 in diagnostic, transport, and related expenses, compared to a city hospital, and a significant sum for most villagers. Additionally, there is a considerable time savings. Villagers have been delighted to receive this care, which saves lives.

The Importance of Technology
How did the technology you used contribute to this project and why was it important?
The TeleHealth system configured for solution described above requires at least two locations: a "Patient End" and a "Doctor End." The Patient End is located in each of the 32 villages featuring an Ashwini Center; the Doctor Ends are in town/city hospitals.

Satyam helped the Byrraju Foundation integrate its solution by providing data processing hardware and software at both the Patient and Doctor Ends. Essential diagnostic instruments, such as the EKG machine, are located and interfaced at the Patient End.

A centrally located server functions as the main data repository, and controls the various Patient Ends. It can process data, image, and video in accordance with healthcare standards. The connectivity between Patient End and Doctor End is established through IP-based communication technology.

Satyam’s Healthcare technology enabled remote EKG interpretation, usually from 400 to 500 miles away from where patients live. The Internet was crucial to this innovation. Nurses had to be trained to operate the Schiller EKG machines, and on proper placement of electrodes. Furthermore, machines had to be connected to a computer; software had to enable communication with a remote server. More importantly, villagers became accustomed to tele-consultation, and felt comfortable with technology that connected them virtually with faraway doctors. The speed of analysis—results were interpreted within 15 minutes—also was a major factor in the program’s success, and a particular cause for customer satisfaction among rural patients.

Two additional important technological aspects of the program are highlighted below:

REAL-TIME VIDEOCONFERENCING FOR CONSULTATION, TRAINING, OPERATIONAL, AND RESEARCH SERVICES
Satyam’s Healthcare Provider Solution considers the compelling need of real-time collaboration through IP-based Videoconferencing for the Foundation’s healthcare initiatives. Satyam professionals deployed Web and multiparty video technology for Consultation, Training, Operational Review, Continuing Medical Education, and Clinical Research services. The latest generation IP-based software is far less expensive and more flexible than yesteryear’s hardware-based videoconferencing. Additionally, it is easy to install and starts immediately, in addition to reducing travel expenses and the stress that involves. The point-to-multipoint, IP-based videoconferencing facility is installed among 32 remote villages. Secondary and tertiary care diagnoses and consultation are provided, as are health worker training and education.

ASHWINI BROADBAND NETWORK
Ashwini, a joint project by Media Lab Asia and the Byrraju Foundation, has established a broadband wireless network based on 802.11 b/g technology, connecting 32 village centers in the East and West Godavari Districts of Andhra Pradesh. Its hub is in the town of Bhimavaram, in point-to-multipoint and mesh configurations. The network facilitates broadband access in rural population of all six districts.

Benefits
Has your project helped those it was designed to help?   Yes

Has your project fundamentally changed how tasks are performed?   Yes

What new advantage or opportunity does your project provide to people?
Although the savings and benefits are indirect, villagers easily recognize the value of the EKG facility. They realize that superior healthcare makes an important difference in their quality of life. Satyam’s TeleMedicine is a simple, wonderful tool that enables rural people to make informed healthcare decisions. It also prevents them from patronizing unlicensed charlatans and quacks, who represent a serious problem in rural India, and who often fleece money from unsuspecting villagers.

Moreover, the Tele-EKG Program virtually links exceptional cardiologists with villagers for EKG interpretation and cardiac consultation. Additionally, delivery of Tele-EKG training is easy thanks to real-time collaboration between health workers and instructors. The TeleHealth program provides numerous additional benefits to the Byrraju Foundation, including:

o Integration with existing disease management modules
o Enhanced community screening and paramedic/nursing checkups
o Optimization of Ashwini Center resources
o Dramatic reduction in cost of EKG interpretation and cardiac consultation (from US$25 to $1)
o The ability of healthcare workers able to administer EKGs and send them to specialist hospitals
o Tele-EKG supports evidence-based tele-consultation
o Equitable access to care in remote settings
o Linking doctors with centers of excellence for training, including Continuous Medical Education (CME)
o More appropriate referrals and reduced professional isolation for doctors
o Cheaper care through reduced clinician travel and elimination of unnecessary patient transfers
o New models of care through nurse-led clinics and home-monitoring
o Local retention of patient care, rather than through referrals
o Small capital investment to establish care
o Capitalizing on ICT advancements; facilitation of affordability
o Increased utilization for local hospital resources
o Maintenance of relationships between patients and doctors while new treatments are explored
o Efficient training and retraining
o Rapid knowledge transfer
o Instant information thanks to real-time reviews




And, in what may be a surprise to people in developed nations, the Tele-EKG program actually helps reduce suicide. Extreme debt is a major contributing factor to rural suicide in India. When people become ill, they often must borrow heavily to get well. When the financial strain becomes unbearable, suicide sometimes ensues.

Becuase of its extremely low cost, the Tele-EKG program actually helps reduce acts of desparation. It also makes a significant difference in villagers' quality of life, and helps rid communities of quacks and other charlatans who prey on unsuspecting rural poor.



If possible, include an example of how the project has benefited a specific individual, enterprise or organization. Please include personal quotes from individuals who have directly benefited from your work.
The following excerpt from a New York Times op-ed piece illustrates the benefits the program can have on individuals. Other specific anecdotes follow the excerpt.

If I.T. Merged With E.T., By THOMAS L. FRIEDMAN: October 31, 2007, The New York Times

“Well, here’s something you don’t see every day. I was visiting an Indian village 350 miles east of Hyderabad and got to watch a very elderly Indian man undergo an EKG in a remote clinic, while a heart specialist, hundreds of miles away in Bangalore, watched via satellite TV and dispensed a diagnosis. This kind of telemedicine is the I.T. revolution at its best.”
More http://www.nytimes.com/2007/10/31/opinion/31friedman.html?ex=1194494400&en=fc6af3d777601fdf&ei=5070&emc=eta1

Two other episodes stand out from the telemedicine program, specifically when Tele-EKG was introduced. In the first instance, a gentleman of 70, or older, was found to have an unusual EKG. The hospital cardiologist (500 miles away) wanted him to be hospitalized immediately. Upon being told he required immediate medical attention, the patient balked. He told his family he felt fine, and that in any case, the expenses related to a hospital stay would be too much to bear. However, his family members and doctors persisted, and called an ambulance which took him to the nearest town. Though he refused to be admitted, he received appropriate prescriptions and went home.

Another time, Byrraju technicians were setting up Tele-EKG equipment in a village. After installation, they wanted to do a test run, and invited a man walking by to participate. The gentleman agreed, and before long, electrodes were connected, and the test was done. Shortly thereafter, the EKG information was sent to cardiac hospital. Within five minutes the EKG report revealed that the man’s heart was normal, and that he was in very good shape. Overjoyed, he went to the nearest tea shop and bought everyone in sight a cup of tea to celebrate.




Originality
Is it the first, the only, the best or the most effective application of its kind?   Most effective

What are the exceptional aspects of your project?
The Tele-EKG program is the most effective of its kind. The technology enables rapid, accurate EKG results, combined with the processes in the villages and the specialty hospitals, ensure that it sets the standard for remote delivery of medical care. It also leverages entire ecosystems—doctors, nurses, the Byrraju Foundation, Satyam, SN Informatics, and others—to ensure success.

The most exceptional aspect of the program is its cost—about $1 for an EKG. Receiving a sophisticated $25 service for a fraction of that has led to tremendous participation. Additionally, the instant, albeit virtual, availability of doctors in rural areas has led to remarkable results.

Referrals also make telemedicine a success. Telemedicine interventions are really only for screening. Actual treatment is performed by doctors at hospitals to which patients are referred. When this occurs, patients usually request a specific doctor they have consulted with via videoconference when they arrive at a hospital. Often, patients travel all the way to a hospital, and refuse to see any other doctor than the one they have dealt with all along. Not surprisingly, this engenders deep commitment from doctors, who are usually flattered. They also increase their client base and receive more word-of-mouth referrals.

Consequently, telemedicine benefits patients and doctors. Patients can make informed decisions at practically no cost, while doctors increase their client base.



Difficulty
What were the most important obstacles that had to be overcome in order for your work to be successful? Technical problems? Resources? Expertise? Organizational problems?
As with any large-scale implementation project, problems arose. Some of them are detailed below.

Installation and activation featured technical problems. These were overcome by the strong efforts of professionals at SN Informatics, as well as Satyam engineers, who worked very closely with the Ashwini Centers.

Resources. In addition to the Schiller EKG machine, other needs at Ashwini Centers could not immediately be accommodated. Even seemingly simple needs were in short supply. For instance, the facility lacked the gel that is placed on electrode ends when a person is hooked up to an EKG. Privacy screens for patients were also scarce. These items had be purchased in larger towns and sent to respective villages.

Expertise. Local doctors provided a crash course in EKG basics—proper placement of electrodes, connecting to the computer, etc.—to Ashwini Center operators and nurses at various health centers. They were also taught how to record an EKG and send its data across the internet. The trainees were all women, which helped female patients be more comfortable undergoing tests.

Organizational. The Foundation faced no issues from senior management or field professionals. Instead, the new and exciting program generated considerable enthusiasm. However, some issues remain:

Commitment. Getting the medical community to use TeleHealth Technology to diagnose and consult remains a challenge. Even now, more than 80 percent of the problem is changing the mindset of doctors toward the technology . The remaining 20 percent has to do with user friendliness and the technology itself.

Cost. Though the cost of communication and videoconferencing equipment is lower every day, the cost of real-time Tele-Health services is not affordable by a majority of patients

Infrastructure. Development of rural telecommunications is not profitable to large companies, so the infrastructure is inadequate and expensive to put in place.

Power. People in rural areas also must contend with poor and intermittent power, which can affect service delivery. Moreover, they have difficulty in staying up to date with technology advancements. They lack technical manpower and expertise, and thus, cannot troubleshoot problems or train their colleagues.


Often the most innovative projects encounter the greatest resistance when they are originally proposed. If you had to fight for approval or funding, please provide a summary of the objections you faced and how you overcame them.
The program benefited from the fact that the Schiller EKG machines were provided by the Indian Space Research Organization’s Village Resource Centre program (of which the Byrraju Foundation is a partner). The expert EKG nodes ISRO had linked with were being set up. Due to the internal setup of ISRO and its implementing agency, providing access to the cardiac hospital was not an option. The Byrraju Foundation took the Schiller machines and installed and activated them in the Ashwini Network. From these initial 14 machines, the team was able to show that Tele-EKG was possible, and that people would pay for it. Consequently, from the pilot, it was possible to convince management to invest further in the program. Normally, funding would have been hard to obtain. But since the initial investment was low, and showed feasibility, achieving approvals and funding for the proof of concept was easier.

Success
Has your project achieved or exceeded its goals?   Exceeded

Is it fully operational?   Yes

How do you see your project's innovation benefiting other applications, organizations, or global communities?
Riding on the success of the POC, which was designed to screen 2,000 patients in December, 2007, the team convinced management to review all other telemedicine interventions. They also convinced executives that the service needed to expand. For instance, the team set a target of screening 15,000 patients by December 2008. It also intended to extend Tele-EKG to more than 100 centers, and will work with different forms of connectivity. In the 32 Ashwini Centers, the team uses existing broadband connectivity. In the ISRO village, it has established satellite links to expert centers. And, in more than 50 Byrraju Foundation health centers, mobile phones will transmit data. It will also use dial-up on copper.

Lines. Since mobile phone networks are far more ubiquitous in India than the Internet, and since there are more than 250 million cell phone subscribers in the country (compared to 8 million or so Internet users), it is imperative to prove that this technology could be deployed quickly over networks with much broader reach.

Based on the program’s success to date, and given the availability of low-cost, remote EKG machines like those made by Neurosynaptic in Bangalore, along with simple PCs like the Intel dot station, a complete EKG solution running on a GSM network can be implemented for about $375.


How quickly has your targeted audience of users embraced your innovation? Or, how rapidly do you predict they will?
Villagers were quick to embrace the Tele-EKG system for two key reasons: First, its price is excellent. At about $1, it is a sum most rural people can manage, and it is certainly more palatable than the $25 an EKG at a hosptial costs (without factoring in lost wages).

Second, villagers are extremely pleased with the tests rapid results--cardiologists usually analyze EKGs within 15 minutes--which has also led to the program's widespread adoption.

In December 2007, the Foundation undertook an intense campaign to mobilize patients, and provided 2,000 EKGs. After that push, lower numbers were anticipated. However, the program's popularity increases constantly, and as of Feb. 29, nearly 3,100 tests have been given, 576 of which indicated abnormalities. Among villagers, word-of-mouth reviews are exceptional, and lead to impressive numbers.


Digital/Visual Materials
The Program welcomes nominees to submit digital and visual images with their Case Study. We are currently only accepting .gif, .jpg and .xls files that are 1MB or smaller. The submission of these materials is not required; however, please note that a maximum of three files will be accepted per nominee. These files will be added to the end of your Case Study and will be labeled as "Appendix 1", "Appendix 2" or "Appendix 3." Finally, feel free to reference these images in the text of your Case Study by specifically referring to them as "Appendix 1", "Appendix 2" or "Appendix 3."

Currently Uploaded Appendices:
Appendix1.jpg