Current Disruptions in Healthcare

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Current Disruptions in Healthcare

9 Nov, 1:30 PM

good evening everyone i am dr samadhya and on behalf of team netflix i welcome you all for today's session uh today we have with us dr sushant shinde a consultant physician with special interest in rheumatology practicing at and a co-founder of doom derma clinic mumbai he is also a the founder and director of quest medical academy along with this sir is also an experienced tedx speaker i'm sure everyone is eagerly waiting for the session today so i welcome you sir over to you sir okay so uh thank you doctor and thank you to the entire team of netflix uh it's it's a very interesting idea matrix in the first place uh to our audience uh those of you who have joined in right now or if you will be seeing the recorded version of this uh hello so the topic i am going to talk about is uh innovations in healthcare which is is not just in the context of covert that i want to talk about there is a lot happening in healthcare overall so you know let's think about the bigger picture and as we go ahead uh let's try to narrow down on things which might be really close to us and things that you and me can probably do uh i would like to see this next uh 20 minutes that i'm going to speak more like a way of hot provocation rather than saying that we know everything or you know rather than putting all the examples that we might find i would want to kind of give you a bunch of things which have been worked upon across the world in health care and innovation and so what is this idea of disruption in the process this idea came around uh maybe a decade back also in the whole idea of management sector and business it's not an idea which is inherently in healthcare you have to kind of understand that uh it was a clayton christensen he he coined this word disruption and innovative destruction as a world was coming by uh what was disruption described as or innovative disruption disruption described as he described it as something that would make things simple and affordable now that's something we all would want i mean who would not want things to be simple and affordable especially with products if there are going to be new products around if there is going to be new technology around and the buzzword with the innovative disruption has always been technology people have always thought of a new technology will come in and it will disrupt the field take an example you have you did not have an app you never thought of an app but now you have an app it's old actually it's an old example which can call a taxi and when the taxi becomes a little whatever your outdated might be that was disruption all of a sudden the whole market changes now uh at the theme at the basis of innovation is always going to be necessity i mean necessity is the mother of invention and if i just tweet that word a little that's innovation so we are looking at probably a necessity driven idea that we bring up an idea which changes the market it changes the whole game and that's innovation and disruption for you in the simplest of the times a lot of people have also criticized this or before i go to the criticism let me also add in in india especially for healthcare if i'm going to bring in innovation and disruption i just don't want it to be simple and affordable there's one more thing we want we want it to be accessible we want a lot of people to be able to use this technology or whatever new thing that you're going to do and that is a challenge though the original description uh does not talk about it because the original description was more for management and you know businesses which are non-healthcare related but in health care accessibility is a concern but what people have found difficult is to define this idea innovation is new but what about disruption for example if a new uh technology comes in let's say in healthcare let's say i get a new type of a scan uh why new even if i have a little older scan like a pet scan a pet scan can give me information which is really amazing but does that mean that can a bed scan comes at a low cost not really a lot of innovation that happens in health care actually drives up the cost last 200 years of health care have been magic we have been able to achieve amazing things which were you know probably health care people would not have thought of 200 years back so innovation is not new to healthcare but disruption doesn't really happen because it doesn't pick up pace if i have a new scan the availability accessibility which i said and the use because the cost is high the means remains limited this it doesn't scale up most of the things don't scale up very fast and because they don't scale up that fast the acceptance you know it could become slow so in that context i might have innovation but i might still not have disruption about this idea that when we talk about innovation in innovation uh innovation in healthcare does happen but disruption in healthcare has not been happening at that page because acceptance of new technology doesn't really happen very fast there is one more idea i would want to uh pitch in before i go ahead with another idea of innovation and that is what is known as the blue ocean strategy now blue ocean strategy is again an idea we draw from management and businesses we draw this idea not from healthcare primarily but from management schools or business schools at the heart of the ocean strategy and you know i would like to tell the names of the authors because i keep on forgetting uh the book blue ocean strategy written by chan kim and rini mao bognay if i'm pronouncing your name right so chan kim and vini marbogni they have written a very interesting book it's almost a decade old now called a blue ocean strategy what it says is we need to think always in context of value and cost matrix we need to think that if you are going to deliver something to people uh whichever field you are from you need to increase the value of what you're delivering and simultaneously reduce the cost of it so this this idea of blue ocean also says that we need to reach out to people who are not the traditional customers of your service now this is another way to me in healthcare to say that reach out to those people to whom your service is not accessible so i think whenever we are thinking of innovation in healthcare we have to think in terms of what value do we deliver at what cost do we deliver and do we reach out to all those people who are otherwise traditionally left out from healthcare now i believe most of you listening to this are related to the healthcare field if you are doctors or if your healthcare workers or if your managers who work with healthcare you understand this problem that accessibility cost and value have always been our problem and this idea of blue ocean developing the oceans is something at the heart of disruptive innovation does that mean that when i'm going to talk about disruption health care it needs to be only about technology the answer is really no i mean just think about it telemedicine has been around for ages drones have been there for a long time and yet it's only after co-edits us that we start using drones to deliver medicines it was done before i'm not saying it was never done before but at the scale in which it has been done now happens after kubernetes telemedicine has been there for a long time i mean it was held as something that would have solved our problem of accessibility and yet a lot of people have not used elements a lot of people have said that the resistance comes from doctors which i actually agree to apparently uh but it's not just doctors it also comes from our patients i right now try to really consult a lot of patients with a lot of resistance it's still a tug of war between me and my patients sometimes when it comes to telemedicine so it's not just the availability of technology that can disrupt i think there are going to be three parameters on which we need to think of if you are thinking of disruption in health care first is of course technology and i would like to state some examples and give you some some glimpse of what is happening at the world stage today second is the structure the organization of healthcare you have to understand it's a complex scenario a lot of us you know i remember this time when i first went to ames as a resident uh my seniors on my second day asked me to draw a map and said show me where you are right now and i could not do that it took me a week or two to figure out which lab is where and where am i situated that's just the architecture of it to understand the hierarchy of the system to understand who does what and to get it done is even tougher so organizations are also a bribe area for disruption but the biggest one i think is the community that we serve what i would put together as a society because the society has to accept whatever you want to deliver and they need to be asking for it so three headings technology our organization and the society we need to think on these terms well if i think of technology a lot of examples i think you have heard of the biggest one the most popular when we talk about disruption a lot of doctors especially my radiology friends might i know kind of talk about it and then brush aside the idea is of course artificial intelligence if there is going to be this huge technology called artificial intelligence and machine learning can can be doctors become obsolete is it possible that they don't need us right um i don't see that happening i was fortunate to be a part of one of our national conferences on artificial intelligence just before who editors and what i understand of that technology is it's it's fantastic it has used applications but the applications of ai today are not to change the position of the doctor doctor is still needed that's what for some time we are going to be in business but that said a lot of ai goes in medical records developing medical records it's a huge database that hospitals collect and to do work with that database to make sense out of that database is well machine learning and artificial intelligence will work but that's not the only thing in the recent past ai has also helped in developing you know the techniques for drug developments uh for vaccine development i would like to state an example i'm just again referring to the name uh a name a drug named halisin halisin that's a drug uh which was in 2019 it's a very recent example a drug named halisin was being tried for diabetes mellitus it was thought to be working in some way to reduce sugars and were probably helpful in diabetes medicines the trials did not show very promising results eventually and they decided to kind of shelf the drug and say okay this is not going to be used in diabetes understand that's a lot of r d probably going waste but ai comes to rescue and ai and machine learning together they were able to predict with their models that probably the drug might work as an antibiotic now think of it a anti-diabetes drug ai is able to predict because of its mechanism of action that it might have an antibiotic property and it turns out it does work against some bacteria it also works against uh a certain uh bacterium known as tuberculosis which we are very concerned about mycobacterium which at least in this country we are very concerned about now the trials are ongoing for that but this kind of development without ai would have been really difficult so ai is here to stay but of course probably not disrupt in the way that we see in our day-to-day but this level of speed that it is bringing to our work is amazing another technology which some of you might have heard about uh some of you might have heard about not in context of health care probably but in context of money and again not in the context of your usual money when you can take some of the most popular money that the most popular coin that you're hearing nowadays the bitcoin cryptocurrency uh some of you might figure out what i'm talking about i am blockchain so the blockchain technology which has been a basic idea of blockchain is to have a ledger the basic idea of blockchain is to have the information categorized one after another time stamp and you know a ledger which has good the inputs of different timelines and you might be able to kind of store all the data in a very secured way that's what the blockchain is now that idea can be used for currency which is the cryptocurrency but the same blockchain idea can be and is being used today already there are at least five to seven reasonably well funded startups working right now as we speak in developing blockchains for healthcare data preserving the data in healthcare and for using that for data management in healthcare so that is also a level of innovation and disruption which might be will eventually be able to bring down the cost the hidden cost that goes in managing hospitals and running the hospitals so blockchain is one ai is one we have all heard about robotic surgeries how there might be a situation where the surgeon is standing somewhere else and is able to operate in a distant remote location uh the question here is about the cost how can a village afford to have a robot there is a question we might have to answer but the technology is already here right so there is been a huge technology front that has been developing we should not forget covet with kovid also technology like telemedicine use of drones they have all stepped up we have been the people are saying that telemedicine finally has arrived though i have my personal doubts on that it ha it did arrive for a short frame when the peaks of covet cases come but otherwise it does weigh now so we need to be you know very clear about innovations yes but are they disrupting and what is stopping them from restarting as i said technology is one but there is there are other aspects also which kind of help us in in kind of framing the idea of innovations and disruption the second aspect is organizations now think about this a lot of you must be part of some other organization uh in healthcare and think about the hierarchy think about the structure think about the patient and also think about one big question who pays for healthcare another big question who owns that now can there be disruptions on this front there are beginnings here so for example a lot of us in india are used to this idea that well if i go to the doctor if i go to a hospital also i pay for meeting the doctor i pay for using a particular service that's called pay for service but there has been this no cry and no idea that you know we should also probably shift from pay for service to pay for value pay for the value that was delivered rather than you know for every visit i go to the doctor if i pay rather than for the value that i get for treating one particular thing can that be a payment and there are various ways to do that including how insurances see that that's called value-based healthcare so there has been a shift it's been a graduate again not a disruptive shift but a definite innovative shift from paper service to paper value probably bringing down the cost in the long run we might be able to bring down the cost in the long run which helps me to say that it is an innovation eventually it is making it affordable and probably more accessible but a big change again is in who owns healthcare a lot of healthcare across the world has traditionally been owned by either the big charitable organizations it has been owned by governments it has also been owned by our dear friends and pharmaceutical companies because a lot of healthcare is not just hospitals it's also the drugs right but there has been a big change in that also we see a lot of big players from the tech side entry we all have heard about how apple has shown interest how google has shown interest in health care how berkshire has shown interest in health care a lot of you must have heard about the example of heaven where there was this whole idea of dr atul gawande leading a team which was funded by amazon and funded by berkshire um and all these big names so funding it it has not been successful the project had to be stopped in the recent past but the theme has emerged that a lot of players who are not health care players who are not traditional health care players are entering into health care how will that change health care is a question that yet remains to be answered what happens when google owns hospitals around us what happens when amazon owns the hospital around us what kind of healthcare are we heading towards these are thoughts which can be mind-boggling we don't have answers to them yet but the organization of healthcare is changing very rapidly uh for those of you who are probably medical students or you know just passed out uh you know doing your piece you're about to do your future specialization watch out for this space who are you going to work for in next 10 years or i'm going to work for in the next 10 years might be a big question who is going to charge patients and how are going to how are they going to charge are we going to have i mean you guys have a medflix here but there's always a question of what netflix did to the idea of subscriptions is healthcare going to become subscription based when big players enter food for thought we don't have answers what level of disruption would occur when healthcare becomes the organization of healthcare changes i want to kind of slow down at this moment and you know focus on something which is very indian and i'm very uh i'm very thrilled that learning of that example because that example is also an example of how a wonderful organization how a wonderful organization and structure can bring down the cost improve the access and deliver world-class value right this is happening at an example i'm sure a lot of you have heard uh management guys definitely have heard that's urban day it's a hospital in india a lot of us have heard about it it's it's known across the world for having well know the number of cataract surgeries that they do is the volume is perhaps the largest in the world with the best results and the lowest possible complications now they are able to achieve this by various things but amongst them what stands out is their model of organizing their health care as a hub and sport that means they are one large health care center in in which is at their main center but they have these smaller outlets which are kind of draining into this so the volume goes up the number of patients that they are able to see goes up remember it's always a game of scale if you have more number of patients that you're going to see you would be able to utilize your resources better and bring down your cost and that you can transfer to the patient that means a good number of patient surgeries in argentina are free to the patient and despite being free to the patient the hospital is able to show benefits or profit sorry in its balance sheets now i mean how do you beat that how do you beat that you are able to deliver value for your stakeholders and you are able to deliver value to your patients also by increasing the numbers and to increase number you have arrange yourself in a hub and spoke model not only that uh urban i care is very special because of the way that they distribute their tasks who does what for example if you are able to train train a uh worker who is not not really a doctor or not really even a trained nurse but someone paramedical in the usual sense if you are able to train them to click the right angle of photographs using a smartphone and transmit that using technology which is available everywhere to the doctor sitting in the primary i mean the major center the tertiary care center you are able to do something phenomenal you are able to bring down the cost by using not the entire gamut of telemedicine but the part of telemedicine use the right part of the technology in the right way train the right kind of personal and develop so i said you know kind of giving this task to different people has been something that has done really fantastic it's it's known for its work across the world so i think looking at who owns who pays and how do you organize health care this is something which i feel uh we as doctors are not well trained at uh though we eventually learn it but our friends in management hospital management side they are really someone who can look at this and see where the hidden cost is can that cost be brought down can we you know kind of break that red ocean and enter the blue ocean where the value goes up and the cost comes down to our patients and to the entire health care system so technology yes but not just technology uh the structure of healthcare yes but probably not just that the biggest factor i feel which is what makes health care the most tough ground for innovation and the toughest ground for disruption and people say that the disruption of health care is like you know uh trying to bring in uh i read it in one of the journals and one of the articles they said that the bringing disruption to healthcare is like bringing star trek to flintstone now what basically it means is you are probably trying to bring this traditional structure of hierarchical uh healthcare which moves so slowly in its development and you're trying to disrupt it changes overnight that doesn't happen they're true in saying that that's because it's not just about technology it's not just about organization organizations it is about people at the heart of healthcare i believe is care it's not just health it's health care we need to care care about our people and there are many stakeholders in it not just our patients they are of course the primary but governments who are going to aid these programs there's a lot of political angle which is you know you can't just ignore it you change something in health care it will have repercussions across the globe let me give you an example of how society you know and politics and how the structure political organizations and the organization of society changes how we practice healthcare one classical example uh which you know india should be kind of very proud of how we have built ourselves proud and cautious i would say is the generic medicines without generics controlling the hiv pandemic of africa would have been next to impossible and india played a big role in producing and providing those generics but i mean she understand hiv is is a landmark thing in in medicine the way hiv hit us it was almost a fatal disease from there technology the new drugs that came in were able to bring us those drugs which are able to bring down the fatality we have changed our ways of treating these patients and we are now able to give them a good quality of life and a very long life very long survival which was not imagined even two decades back but yet those drugs have to be accessible and affordable those drugs have to reach the community which was not happening because of their cost and that's where comes in the role of generics where india led by example i mean you should read the work of siblings and how they have to literally lobby for getting those things passed and how it happened and how eventually they were able to provide those generics to the world and you know we say that india is doing very well with generally so that is no kind of an uh disruption that occurs where a drug which is in the affluent society not available to the poor sections of the society becomes available because of something like generics technology does play a big role over there but how society frames its rules plays an even bigger role let me give you an example very nearby i practice a lot of rheumatology a lot of patients i see come to me with arthritis and a lot of them have really crippling disease because of the pain the quality of life is not good since the year 2000 my my drug of choice is very often a drug called methodical which is not very costly it's easily available unfortunately it doesn't work for everyone since the year 2000 there have having a class of drugs what are together called as biologics these drugs have been there in india for close to two decades now and yet these drugs are out of range for cost wise for a lot of patients to afford even today even when the companies are able to give it at a very discounted rate these drugs cost something like 15 20 000 rupees per month and that's going to be long-term therapy which a lot of my patients can't afford year 2021 change is very interesting for me one of these costly drugs uh it is called a jack inhibitor one of these costly drugs or its patent gets over think of this its patent gets over before patent getting over that truck was available close to the tune of 23 to 25 000 rupees per month to india and this is lower than the cost in u.s by the way right but it is still a costly price i mean think about it who's going to pay 23 25 23 000 rupees 25 000 rupees per month for a drug for a tablet right and then this year generics come in the patent is over and the cost drops down to as low as remember the monthly cost drops down from 25 000 per month to 1600 that is affordable i am able to give my patients what i was not able to give for the last five seven years of my practice i am not able to give these patients these drugs i'm able to give them what what's bobbling to me is the technology was there we know what we need to give we knew the prescriptions we have been telling our patients use these drugs what changed is the patent goes away i mean imagine a world without those patents what would have been achieved i don't know i don't want to take away the patient it's the society which will take it away someday in some form i don't know how i'm not arguing for the patients to go away i'm definitely arguing for a way to bring down the cost now here remember the cost wasn't of the technology the technology to make it generic was available even earlier it was a society societal cost it was the cost of the infrastructure that we were paying and that the patient was paying and so many patients were suffering for so long even today hepatitis c has a drug has an amazing new drug available and yet a lot of countries are not able to afford those drugs right so affordability has to do a lot with these institutions that the society believes in patent is an institution that a lot of people believe these belief systems will change eventually they will be criticized they will be challenged they will be questioned they will be modified disruptions will occur there as well and in fact a lot of big disruptions will occur there because there is a whole field there and there is a lot of lack of knowledge there because the key players our patients don't really have that access to knowledge but internet is changing that the access to knowledge to these patients who are stakeholders is changing they are able to question why am i not getting this drug when the drug is available how is it that the drug can be sold for 25 000 in till december 2020 and january 21st it is being sold at 1 600. how is that possible isn't it the same drug i don't have answers to those questions but these are questions worth asking right these are questions which uh society will have to together come and think but when i think of society let me end this with two more examples there is there is one more question that comes up a lot of innovation now think of it i've been talking about innovation standing in india uh and i don't know if people outside india listen to this right now or not i'm not sure of that probably you are uh think of this now this is i'm not putting any statistics no data here i'm talking about for something that me and my one of my friends we were discussing that this is just me talking so my friend and i we were talking about this and he says you know what sushant uh i feel bad he is his good time into research he does a lot of work so he's like i feel bad he 80 percent of global population stays in poor countries poor or middle-income countries like india or you know asia or africa and yet not even 20 percent of innovations happen at darkness the population that stays in those countries where innovations are happening are not even twenty percent of the world population and they are making eighty percent of innovations and we with eighty percent of populations are not population they are not even making twenty percent of innovations or contributing to the world isn't that sad about today isn't that scared i mean we where are we in the innovation we're talking about disruption examples i'm taking is google or apple yeah again i'm not being all this nationalist on this issue because it's a global issue i understand that but if it's a global issue are we party to the solution or are we just being the problem or are we even understanding a problem now that brings us to this idea uh in innovation which i would like to really you know ask you to go back and think on read about called reverse innovation think of this cost of health care is structural it is in those organizations right when the organizations in the u.s when the organizations in europe have a certain paying structure where the government is paying in europe or the insurance is paying new u.s the stakeholders will design drugs where design treatments will design strategies will design guidelines that we follow hypnotic love spending one year double a triple kick these are policies which have cost pairings they are designed for that structure cost is for that structure our problems are different our solutions can be low cost and if we are able to deliver low cost solutions in india like urban network does can they be reverse transported to the western countries probably why not can't us or uk learn from india's innovation the answer is probably yes is it happening it is already happening that's called reverse innovation again i will have to refer to the name uh because uh yeah so this is a book called reverse innovation in healthcare by ravi rama murthy and vijay govindarajan ravi rav which is it's a fantastic book they're not just talking about india these are authors from us who are putting different examples from across the world there are examples from sri lanka from india from africa about how you might be able to learn from these low cost models and reverse it and take it to the u.s economy right now my interest is it can be done here urban high care is a fantastic world-class example dr devi shetty's narayan is a fantastic example of how cost can be brought down by innovating on structures on the aspirations of the society using the right technology with the right kind of political will or the leadership will that we need in these countries so think about rigorous innovations we might just be sitting with a huge opportunity because of the population that we cater to remember the scale and let me now kind of end with what i started with i started by saying that necessity is the mother of invention oblique in this case innovation probably disruption what i would want to end with is a question necessity whose necessity am i talking about necessity of those who own necessity of those who pay necessity of those who suffer necessity of the governments who need to be accountable necessity of the farmer who needs to be accountable and making profits whose necessity am i talking about well the answer is everyone we can't say just one it's it's all stakeholders whose necessity needs to be answered that is what makes this healthcare difficult there are very few examples or probably none where you have so many stakeholders in one business and so many implications in one business model if you don't look at healthcare as a business model the number of stakeholders are huge and yet we cannot forget that the most important stakeholder of all of them has to be our patient if anyone else is our primary stakeholder our innovations are bound to fail so here is what i think at the end of it if you are thinking of innovation in health care we need to ask the question for whom are we waiting are we innovating so that my profits go up are we inviting so that i am able to earn a lot so that my pharma company does well whatever i'm owner of that does well probably that will work but probably it will not be a disruption it will work but not disrupt it has to be channelized towards our patients but then what are our patients asking for are they aware of what they should be asking for there's a huge knowledge gap between what our patients need to know to ask the right questions and what they actually know right how's that gap going to be bridged one of the question that has you know kind of kept on coming back to me again and again in in my work is my patients require long-term treatments and a lot of them can't take that treatment because the treatment fails so here is what i did i started talking to these patients and while talking to these patients this is one of the solutions and this is you know kind of what i might call a micro innovation it's at a very small scale where i practice and my reason for sharing this with you is because well i put in a lot of thought in me so i would want you to hear it but more importantly is because i think it's possible to do it at a microscope mac all my examples still now have been big ones right let me give you my small example from my small world and it might just transport to your world where you stay and where you practice away and you work together so when my patients keep on losing out on follow-ups i ask them this happens in 2018 after you know you know kind of putting my hands in different ways of trying to help them i ask them why do you kind of eventually lose on well a lot of my patients have arthritis a lot of them are women a lot of them are middle aged and they are not working themselves a lot of them put the priority as the family and they say finance is also dry i can't get money from my husband i can't get money from anyone and i don't want to get that money because my son is studying intense standard i don't want to borrow that money from his classes and pay to you or to the drugs so that i get met i said yeah that doesn't make sense i mean initially it angered me that's how it usually happens and but that's wrong and eventually i realized that i'm wrong and get feeling angry about it i should be actually figuring out the solution so i feel okay i can't be angry on someone who doesn't want to take treatment i have no business being angry right i should try to figure out is there a solution one more problem i realized trust deficit they are not had to right so trust deficit and affordability two big questions that come to me in my practice so what we do uh me and my team what we did in 2018 15th of august we launched it we started something which we call as praying off it's been running even till late it was done today morning i saw patients in that project so what we do in trainer help is very simple we tell the patient that if you come to see the doctor the doctor's consultation fees this is happening in the private sector right so uh they pay for their service they pay per service technically so the doctor's consultation fees whatever drugs the doctor writes for whatever time frame one month two months three months i'm not talking about something which will go over in five days so we're talking about five years maybe more longer treatments so at that time whatever prescription the doctor gives two years three years five years after two years uh two months three months five months whatever time whatever investigation the doctors rent right this is where your cost is do all of that and pay as much you feel this delivers a value to you you don't need to pay the mrp you don't need to pay the cost that was told to you right if you know that the consultation fees of the doctor is let's say a thousand rupees if you know that the drug is going to cost you 2000 rupees if you know that the investigation is going to cost you another thousand rupees if it's four thousand rupees worth of cost is it that much of value to you do you think if your joint pains go away it's worth four thousand rupees this month do you think if this you pay and you feel better it is worth anything if you feel so give us 4000 rupees if you don't feel so or if you don't have money we won't judge right give whatever you think you want to give right if you give 20 rupees in front of this 4 000 bill it's okay if you give 2 000 it's ok if you give 4 000 it's okay but then the question is well people are sensitive i mean i don't want to tell the world that i don't have money so what do you do about that well you don't need to tell anybody what you're going to give take an envelope put whatever money you want to put in that envelope and put it in the donation box our staff will not ask you how much you have paid the doctor will not know how much you have paid only the back team will know what you have paid right nobody knows what you have paid there have been people who have taken that envelope and asked us can i pay it later on can i just take it away and you have said okay and they're gonna be that envelope but they come back after some time and put something in that i don't know what they would and the response has been fantastic for me as a practicing doctor it's very gratifying but here i'm talking about business models is it successful a lot of people told me you're going to tell patients to pay whatever they want to pay and how long will they continue this so is there a is there a catch is there a back hand where you're going to catch them somewhere right the patients so the answer is yes the condition here is simple the condition here is this project the brain of means project so this trainer will continue for you as long as you don't miss your follow my treatment results depend on your forums right if you don't decide if you decide not to come for a follow-up well if you come two months like three months late if you're non-compliant with drugs results won't happen you will deform i don't want you to deform the rheumatoid arthritis is known to cause permanent damages i don't want you to have damages so if you default on your follow-ups which is by the way not very frequent you are supposed to meet me once in three months so if you default on a follow by again a span of few months beyond what we have asked you to come then the project stops you'll have to pay if you don't do that if you continue to come keep on coming is there a criteria who can come into this will i practice in a low income country i have no criteria you come in at mercedes you come walking there is no criteria as long as you think you need it take it it's open for everyone who wants to join in right of course for the diseases that i am seeing for chronic disease the inclusion is based on what disease we are treating but the idea is in the last one and a half turning two years or more we had to slow down and stop the project we could cover it because well the whole structure had changed online so we have to stop it for that time but once in the clinic has again started afterwards we have not made losses i wouldn't say we have made use profits but i would say i'm very glad of this that we have not made losses we thought we'll have to pay from our pocket that doesn't happen i think the trust wins i think people understand i think this is a place where we ask our patients where we believe in micro innovations where we say the stakeholders matter but every stakeholder matters i matter they matter i need the gratification of working here i can't be working for free so i'm not working for free i'm working for value like it makes it's my stakes goes higher up because i need to work in a certain way so let me conclude by saying this innovations in health care are true they do exist disruptions in healthcare are difficult and they are difficult because if we look at only one aspect of technology we fail if you look at only one aspect of the organization we fail if we look at all of them especially the third one the society and what our patients need if we are able to under identify the oceans of taking up the value and bringing down the cost that's probably the way to succeed prayna has not disrupted anything let me be very clear i have not been able to offer it to a lot of patients uh a lot of patients have stopped coming after that many are still following up right most of the patients might be using training moving around with an iphone so it's not necessarily reached everyone that i wanted to reach right but it's a step there are going to be such micro innovations micro disruptions which probably will lead to the micro ones that are moving with that i would like to rest my case and i would love to take the questions thank you so much uh thank you so much sir what are your views on branch of healthcare getting benefited from the innovation around the world like telemedication and ai so i think uh innovations like ai are working at back end they are not society facing yet so their applications to the society need to be explored those are the responsibilities of managers and doctors alike and we need to figure out how is it going to deliver a direct value to our patients still that does not happen i believe that ai is a very good model but it will remain on the back seat it will perhaps not become the disruption that we would get to be uh second is telemedicine again i think there are huge limitations because of the kind of internet penetration that the country has right now i'm talking about india specific it has changed after government the acceptance has changed after google but despite that i think there are huge limitations in form of literacy i mean the legislations which have come up so 2020 we did see the government of india coming up with a set of rules which are important and which are good but at the same time we need more on that and the drug delivery systems are still limiting it so for example i may tell you concern with someone uh sitting here in mumbai i might tell you concern with someone sitting in vr but that person might not get the drug written over here so telemedicine needs to be integrated with other tele aspects of drug delivery and other things so that's why i said when amazon enters this i don't know what's going to really happen it might just be a very interesting place to look at so i think there's a bright future for telemedicine but there are questions to be answered the society's resistance both doctors and patient resistance has to be looked into these are not resistance which are coming just because they don't like it they see value in it but they also see problems which need to be solved by parallel solutions and like i said about urban natural telemedicine has specific applications like tele radiology or tele ophthalmology those specific branches can definitely be grown independently so we need to look at it not just as a big whole chunk of element but within it small branches and small applications might have bigger potential to disrupt so there is one more question because of covert online consultation and telemedicine saw major surge do you think this would continue or would india being a developed country would go back to traditional opd consultation right now we have already gone by uh i think the surge is is pretty much pretty much gone down and the reasons are as i said you know there are limitations both on my end so i end up spending much more time to convince or you know kind of communicate with the patient uh when i am online because network java which me the network is gone which means something has happened right now imagine we were talking in my my phone i mean the sound wasn't clear right to kind of slow down and go back again and this is going to happen multiple times there are some really difficult logistic issues here they need to be sold out once they are sorted out when when internet is good uh when the drug medicine delivery is also integrated with it i think it has a promise but right now after the code will be coming down the tele concerts have also come down that that has already happened so i don't think we are looking at an immediate surge as it was projected into 2020 right we probably will see it eventually but they have learned a lot during the code pandemic the last few waves of the last few years one a year and a half we have learned a lot about but there is a lot more to be done so dr ghancham dulled us asking what is your take on digital prescription and the dictate for marketing and uh dictate for marketing uh i'll just yeah as it has been done even in our day-to-day prescriptions i think it's it's a very very helpful tool uh we are aware of some of the companies which have come up with uh doc's one of them which came up with this digital writing idea uh it was a big pain point for doctors to type in everything a lot of people in india practice in small either nursing homes or private practices where having investments in this kind of equipment or not the database to manage everything was difficult so with this handwriting directly converting to digital records kind of technology i think it has really helped a lot of us to maintain our own medical records it is here to say i i feel and it again has a lot of scope for innovation for example right now i can uh can directly convert it into a digital format only few aspects like blood pressure i can date i can giving a call to the patient i can but i can't convert my entire digital note into uh you know kind of an excel sheet or something like that so there are ways that i think even those problems should be solved but compared to typing i think it's a big innovation to not be able to write in your own hand which most of us have been trained for in india and get it as a digital record and get those notes saved somewhere we know that now the clinical establishment act in india also requires you to have your uh kind of notes saved or the digital or the medical record saved with you as a doctor so i think it's a big leap there yes so um so dr shasti yanamanda said this is a thought provoking session and dr madev de saiser said great job excellent session and salute to your contribution to needy patience so i'll just go through one two more questions um with automation digital digitalization and ai and pathology and laboratory medicine is growing rapidly with major turnovers and great efficiency so in such situation will the idea of small clinical pathological laboratories uh become obsolete so uh i don't think so uh and i'm speaking now specific to india we have to understand uh we all do perhaps at some level do understand that india is a very very uh what you can say stratified society we have a huge spectrum of what we see uh in in talking about mumbai where i stay you know 20 years back when the big giant started coming in big multinational companies started investing into having these huge hotel sized hospitals that we have here they do a fantastic job but it's not like everyone is ready to go to them there is still a need for a person who is going to practice solo there is still a need for that person uh prana which i spoke about i cannot do that in a big hospital i can only do it in this micro setup probably i might be able to do it in the hospital if i'm owning it which i don't so i might as well able to do it here same applies to pathology labs or you know any any labs or any structure i think it's it's a far i try to say that ai is going to replace doctors i also feel it's a far cry to say that the big players are going to replace the small place i think health care in india is far away from being saturated overall the question is we have saturated centers and that's where that hub and spoke model should be thought of by a lot of us telemedicine i feel gives us the advantage and this is again a food for thought i am giving to all those doctors who are practicing out there whether you want a lab or whether you want a practice or you know something like that the hub and spoke model is something that you should look into how your practice is even as a small player can you have a practice at one center but have small spokes somewhere else which feed into your practice right and can those be developed over time can technology be efficiently used for that can telemedicine be used for that that i see the patient here but i follow him at his home for the next visit bringing down the cost of care and costs of traveling and then again for the next visit the patient comes back to my center these are ways that you know telemet uh can help and other technologies can also help and also of course the idea that we have a stratified society i think doesn't doesn't really say that the big players can eat away the small fish that we are it won't happen so fast i don't see that now not for a generation at least technology is not the key there is the society is the key there and the society needs to have accessible and uh affordable yeah what i need to watch out for is not the big players there not a traditional place the startups those guys might eat you away right so the startups if they are able to be agile that means they're able to kind of navigate through this whole idea of how traditional healthcare is in a certain way fee uh driven or a certain way service free driven and are able to uh innovate on the value front if they are able to do that i think that's a food for thought so small players might have to watch out for the startups on the horizon rather than the traditional players traditional player i think i've tried it for too long and have not been so successful dislodging the small place they are still not um so we have a question um is from dr devya gangoli she is asking what is the scope of integrative medicine and mind-body medicine in the future will this cause a disruption in the current health care system and she also wrote that i recently read the book called mind over medicine by dr lisa rankin also listened to a tech talk where she spoke about how the body can heal itself and she has provided numerous scientific evidences which support this in fact they have been picked up from the top journals like nejm bmj and jma she quit her traditional medical practice and is currently working as mind body medicine doctor also there are many others like dr deepak chopra dr joey dispenza who have cured patients with stage four metastatic cancers autoimmune diseases this puts a question mark on the current system of healthcare as we follow so what is your take on this is the questions enlightening and a wide question a lot of things that you have said in the questions are not available myself to just opinion a small opinion on what your question is uh i feel uh this is a you know kind of a subset of the fringe that we see in medicine medicine like any other subject like any other industry if you may call it will have its core and will have satellites around so i feel that what you ask for the mind or body or you know there are a lot of things people believe in reiki people moving mind over body people believing yoga has healing powers there is of course a huge spectrum of alternative medicine these are at the fringe there are going to be patients who will benefit from it and that's never been the question the question is does everyone benefit from it with uh you know cost benefit analysis being productive with a time benefit analysis being productive with the adverse effect risk benefit analysis being kind of favorable that is difficult to prove uh with all the ideas that we talk about we have to remember at the core of medicine is evidence-based and if we are not able to prove evidence beyond a certain point we might not be able to bring things to the code it might become the core of tomorrow but that is so far cry from today we need to build up that evidence so it might work again as i said the satellite of the whole idea of how medicine is built up but it's yet not the good how does it become the core is what will define whether it disrupts does it become a core by producing a solid evidence overnight let me give you an example surface moving which i am talking about as a drug for hepatitis c was able to show uh evidence we were able to show an evidence with bad drug which showed that we are able to take care of the virus once and for all it can literally cured hepatitis c now that kind of evidence can disrupt health care evolve from a disease which did not have treatment do everybody with hepatitis c i can say take this and you will be ground i am at a stage where i can say mind or medicine can cure everybody who has stage four cancer answer is today no will i be able to develop those technologies in the future the answer is i don't know it's speculative after this so if we are able to do that yes why not it will disrupt but till we are able to do that we have to accept it has a position in the whole ladder and the whole scheme of how healthcare is but that position is not of the center not on the goal if we keep our minds open i think we might do much more benefit to our patients rather than you know say that if i work in a certain aspect if i believe methodix it works it shouldn't be obvious methotrexate that was it could be much more than methodological type works but i need to give that kind of leeway and like maybe um they try trying to ask like about healthcare management so i think uh doctors need to be equipped with management on multiple aspects in the introduction you said mentioned about my ted talk uh 2017 idea of the tedx talk and in that also i had made this argument that uh if we want to solve the puzzle of how we charge our patients and simultaneously we offer care to our patients which can be paradoxical that are are you giving care because you are charging or do you care and you charge yourself separate issues so if we try to solve that problem from the patient perspective i think a doctor is ill-equipped with this traditional or her traditional education of knowing the medical science the medical science has these technology ends has these uh organizational lens has these societal ends all of them are fields of management my core is that of knowing hepatitis b hcv the surface body works but my delivery of that depends on whether i'm able to make that drug affordable so what should doctors be trained in management i think all of this we need doctors primarily to understand organizations and we need doctors primarily to understand how finance is low these two i think are indispensable for doctors to understand because without a good organization backing up something like urban media or marijuana is not possible without organizations the planar project that i spoke about is not possible i cannot run a project my organization can trainer cannot run if my finances are not planned ahead of time with you know the right right kind of parameters of their economics in place to understand them is where we need to learn so i believe finances and organizational uh you know whatever organizational management ideas those are the ones which should be definitely integrated beyond that of course there are going to be doctors who have specific interests and they can grow in them but this is my take on that question so dr satish gadi says excellent presentation so we have one race and i'll just accept the request hello hello hello yeah yeah please doctor please ask a question sir healthcare in periphery where peripheral far from cities like around 200 kilometers do you think like ph is mbbs doctors can set up centers in a coordinated way and help to reach the patients to higher centers what's your take on that so if i'm understanding your question correctly sir we are talking about our doctors mbbs or whichever educational background they are setting up their centers and they are able to refer the right patient to the right right place is that right yeah it is definitely a important thing uh our referral systems are not up to the mark in india we all agree on that and that has to be there the question is how do you make that sustainable and profitable for those doctors there we cannot have been referring and probably thinking that it is going to be a good uh economically viable model so if you want to make it an economically viable model what other aspects would be required what will they treat there what will be what will they send how will they earn out of this legally or what will be the framework of this who will have the responsibility of the patient for example i get a patient of my myocardial infarction at the primary health care center i decide to refer it and the patient dies in in in the way possible right this is a reality i mean that happens almost every day we lose patients on that so if that's going to happen who takes up the legal owners of it so i think the idea is important but if that's going to be the core if that's going to be the theme of that idea uh it's economic it's legal it's organizational uh no framework needs more more clarity we need to have more details into that idea before we can see what it works yes but does that make it high on value and low on cost no we have not yet described that we have not described what value did we deliver and what cost did the patient incur will the society accept it will the society accept to go to a doctor who refers okay if the word goes out that these are doctors will refer will the society today accept it not in these words but in some other words maybe they will right what models do we have of such a thing existing so that's where urban network becomes so interesting because instead of having doctors remember keeping and you know allowing an mbps doctor to sit there without the economic backup is going to increase your cost a doctor is not going to be ready to work for a cost of something like 5000 rupees per month but a local person from that village might be ready to work for five thousand ten thousand whatever and it depends on the village and where we are talking about as a part thing can we train them to do what argument did by training them to take up those photographs and send them can we give them the power and make them you know better than that so uh i lack of time i didn't mention but we have to see how the models of luke miranda but dr prakash were at him how health care can be delivered in you know tertiary level healthcare been delivered in tribal areas so there are models which exist in india i think anybody who wants to go ahead with the venture that you just described need but value and cost value to the patient and low cost to the organization and therefore profits to the organization because if the organization does not get profits it's not going to be sustainable i can't keep on putting money on out of my own pocket and asking patients to come to me some of us might be you know those great people but most of us are going to have families to manage we can't do that right so i think it's an important idea which needs more thought that's what i was saying thank you thank you dr is asking as per the medical legal point of view uh first the consultation should be face to face and uh the fallout consultation can be uh consultation so your thoughts about this so the 2020 uh guidelines have been very clear on this uh about what can be and what cannot be done uh so i agree on this but again it's not anywhere said in those guidelines to my knowledge that the first has to be face to face uh it has been left to the discretion of the doctor to my understanding i could be wrong on that of course uh but last when i uh kind of went through those guidelines i understand it is left to the discretion of the treating doctor to decide how things would be of course as a practicing doctor i would prefer my follow-ups to be online and my first visits to be in the clinic but we have also seen situations in covered where that was not possible so when we had patients who had family members having overweight and they could not move things were there there were uh there are gray areas also as far as i mean not as the grey is in fact is where the guidelines say that i cannot consider it someone who's sitting out of india and i have patients from india who had gone out of india and stuck there in kobe how do you consult with them and when you consult with them what are the medical legal applications of that implications of that sorry so medical legal aspect of telemedicine has a lot of scope lot of loopholes despite the fact that 2020 was a big year for telemedicine where new guidelines came up they clarified a lot of things but there are still a lot of things which will get clarified as years go ahead if telemedicine is used now if television is not used nobody will have a problem the guidelines will have no reason to device that that's what i'm saying so the last question uh is by dr ravi chandran br how are these new disruptive uh technology driven health care by regulatory bodies how are they yeah so see we all within healthcare work within a framework of what will be acceptable do no harm will remain the first idea uh most of the players big or small who enter healthcare enter with the idea that they have to first associate with doctors or existing players nobody starts disrupting healthcare when they are you know coming from a non-doctor non-medical background that's very rare most of the disruption has occurred directly by doctors or teens led by doctors as what we might call doctor managers or people where doctors had us and teams where doctors had to stay and we work within the existing framework once we have a pilot project in place at that time there is no question of regulation nobody is going to regulate an item before it establishes itself at that time it's about do no harm on a one-to-one level if you are doing it as a trial then of course you need to register them there are steps for that but if you are doing it as a business model not as a trial as long as the doctor in place takes the honest personal responsibility for it description can go once it scales up that's where the question will come is it crossing any existing guideline is it crossing any existing boundary that is when it will have to be going through the process of applying to the uh you know governments and applying to the regulators that this area needs to be clarified and so on one example of that is electronic medical record electronic medical record how what should be the end-to-end encryption of electronic medical record it took a long time before the government took uh kind of issued a guideline on that and that guideline also came very indirectly it was issued for something else and then uh kind of brought in over here it took many years before that happened and emer was there for a lot of time so so will happen with everything else that we do first the technology and the idea will have to prove that it works it will have to prove that it has a mass level before the regulators bother to even look at it but when we are starting if you are the person who is disrupting bonus is on you because if anything goes wrong in the court of law we have to justify as our individual registered medical practitioner why did i do that and did i put my patient in harm by doing anything which i thought was disruptive right so regulators will come very late when it scales up before it scales up uh we will have to first kind of deal it on one individual cases by the doctors so that's it thank you so much and hope to see you soon back on netflix thank you so much sir for the wonderful session thank you so much for the invitation for me listening thank you so much thank you so much

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As we face the most devastating infectious disease pandemic in a century, we must recognize that many more serious illnesses and preventable deaths are likely, not only as a result of Coronavirus Disease 2019 (COVID-19), but also as a result of the social disruption it has caused, including fear, lack of trust, and structural dysfunction in our current medical care model. Lets understand the consequesnces of this disruption with Dr. Sushant Shinde.

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