E-RETAILING OF MEDICAL SERVICES IN THE CONTEXT OF TELEMEDICINE

Babu P George, PhDLecturer, School of Management, Pondicherry University, India

Email: myselfgeorge@gmail.com

Mercy Antony, MFCRetailing Consultant, Pondicherry, India

Email:mercymfc@rediffmail.com

Abstract: Globally, the re-engineering of healthcare services is being carried out with the aid of improved usage of information and telecommunication technologies. One important advantage of ICT incorporation into healthcare is that it facilitates the retailing of healthcare services in multiple ways. Retailing of complex and critical services like medical services has always remained as a serious problem, upsetting the policy makers as well as the entrepreneurial and managerial communities, alike. In the absence of effective retailing, patients had to go to the service provider, often located thousands of miles away, and end up spending more time and resources. The service provider too faced a lot of problems in managing large crowds in the centrally located and resource limited physical premises. The present paper examines how telemedicine can be used to effectively resolve some of the pressing issues in the retailing of healthcare. It argues that modern telecommunications technologies have to be integrated into the retail healthcare delivery process to decrease the centralization of India’s public healthcare service, to improve the access to specialty care, to reduce transaction cost, and to enable quick response in the event of disasters.

Keywords: e-Retailing, ICT, Telemedicine, Pros and Cons, e-meditailing call centers, Public-private partnership, Scottish telemedicine initiative, and India.

INTRODUCTION

E-retail, also called e-tail, is the sale of products and services to consumers for their personal use employing methods that involve the use of the information and communication technologies (ICT) for whole or parts of the sales process. An e-tailer is a B2C business that executes a transaction with the final consumer. Thus, e-tailing is a subset of e-business. In the contemporary practice, it occurs when retailers use the Web to sell their products and services (Lee and Tan, 2003).

In the “post-dotcom euphoria” era, the sentiment surrounding e-retailing in general has gone from one of all blue skies and unlimited possibility to one that is more tempered. Yet, the e-retailing landscape continues to evolve, in large part as a result of the new economic realities epitomizing all the leading industries, as well as because of e-retailers’ desires to differentiate themselves from their competitors. In the healthcare sector, the extent to which an organization is engaged in e-retailing varies from hospital to hospital. Some hospitals restrict their activities to the mere dissemination of information to their

patient-customers, while others are active in every field of e-retailing, like the provision of information to the customers, ordering medicinal products and services, e-consulting, payment, insurance processing, provision of medical touristic services, post-treatment services, etc.

The present paper is woven as a conceptual paper and has got the following broad objectives: provide an introduction to telemedicine; depict the current debates on telemedicine, especially in terms of its desirability; present public-private partnering as a viable model for the e-retailing of medical services; introduce the concept of telemedicine call centers as brick-n-click retailing spaces; and, critically examine one of the noted telemedicine initiatives in the world, the Scottish Telemedicine Initiative, as a model for the national level promotion of the e-retailing of medical services.

TELEMEDICINE: AN INTRODUCTION

The three core elements that constitute the public health infrastructure of any country are the organizational capacity, public health workforce, and the healthcare information systems. The revolutionary strides made by our generation in the area of information systems management has the capacity to synergize the other two, resulting in the overall enhancement of the scale and scope of healthcare

Telemedicine is the managed use of information and communication systems to provide and support healthcare when distance separates the participants (Parsons, 1994). Although interactive video may be the most common medium, the term encompasses a wide range of telecommunications and information technologies and many clinical applications. Telemedicine need not necessarily involve using the most cutting edge and sophisticated technology available. The humble telephone has been enabling health care providers and patients to communicate for the best part of a half century and, with a large number of households now having at least one telephone or mobile connection, the use of the phone for tasks other than mere social or business exchanges has been increasing rapidly. The first telemedicine programs were established almost 50 years ago, but the technology has grown considerably in the past decade.

Decrease in price and complexity of this technology over last five years makes it economically viable. Yet, the volume of patients receiving services that use the technology remains relatively low. Research on the effectiveness of telemedicine is somewhat limited, although the work that has been done thus far supports the hypothesis that, in general, the technology is a worthwhile alternative to the traditional medical care. A typical remote telemedicine system is shown below (© International Medical Exchange, Inc.):

Two different kinds of technology make up most of the telemedicine applications in use today (Perednia and Allen, 1995). The first, called store and forward, is used for transferring digital images from one location to another. A digital image is taken using a digital camera and then sent to another location. Teleradiology is one such example. The other widely used technology, two way interactive television, is used when a face-to-face consultation is necessary. It is usually between the patient and their provider in one location and a specialist in another location. Videoconferencing equipment at both locations allows a real time consultation to take place. Linking Geographical Information System (GIS) and telemedicine has been achieved with the help of dedicated satellites. GIS is not the complete solution to understanding the distribution of disease and the problems of public health but is an important way in which to better illuminate how humans interact with their environment to create or deter health.

The next generation internet will operate at speeds up to a thousand times faster than today. Sight, sound, and even touch will be integrated through powerful computers, displays, and networks. Patients will be able to videoconference with their healthcare providers, security problems will be resolved, and the internet will increasingly be used for transmitting clinical data, linked with and integrated into educational resources. Also, until now, the web has been primarily used for human to human communication. The vision of the web, however, goes beyond this-the second side to the web, yet to emerge, is that of machine understandable information. Also, the likely use of innovative

technologies like micro engineer machine systems (MEMS) represents new opportunities for telemedicine. Hence, the scope for telemedicine is on an ever-increase and, in all likelihood, it has got the potential to reengineer the contemporary healthcare system (Ackerman et al., 2002).

TELEMEDICINE IN INDIA: TO BE OR NOT TO BE?

Health policy in India has shifted its focus from being a comprehensive universal healthcare system to a selective and targeted program based healthcare policy with the public domain being confined to family planning, immunization, selected disease surveillance and medical education and research. Since 1990s, the public health system has been collapsing and the private health sector has flourished at the cost of the public health sector. The decline of public investments and expenditures in the health sector has further weakened the public health sector thus adversely affecting the poor and other vulnerable sections of society. There has been increasing calls for the government to reenter the sector to correct the past mistakes. However, governments feel that, in the traditional sense, this is prohibitively expensive (Gangolli et al., 2002). Telemedicine offers a viable alternative.

The benefits of medical service retailing using telemedicine cannot be neglected by a country which has for so long been grappling with the issue of low penetration of healthcare facilities, especially in the rural areas (Bergman, 1993). Almost ninety percent of secondary & tertiary healthcare facilities located in cities and towns are away from the rural India where more than two third of its population lives. Whatever primary health care facilities available for the rural population are gravely inadequate. If telemedicine facilities are made available, the medical needs of a significant proportion of patients in the remote locations could be successfully managed locally with guidance from specialists in cities, without having them to travel to the specialists. In other words, telemedicine is one of those technologies that can make geography history. Use of telemedicine reduces the patient’s financial burden, too; especially those incidental expenses such as the cost of travel, accommodation for relatives, food, etc can be minimized. The general practitioner in the rural area often feels that he would loose his patient to the city consultant. With Telemedicine the community doctor continues to primarily treat the patient under a specialist’s overall guidance. The urban medical centers are facing an acute shortage of beds and promoting telemedicine would help them to alleviate the strain on some of the physical resources as well.

It is noted that the brightest core of Indian medicos have migrated to the West and are practicing there. Even the younger generation of doctors is highly induced to leave home for more lucrative overseas assignments. However, many of the NRI doctors have expressed their willingness to voluntarily serve the nation during the slack hours. Telemedicine could become an ideal means by which their services may be utilized. In act, this could be made as a condition for permitting to go abroad for those young medical graduates who completed their studies under state subsidization.

Yet another advantage of telemedicine is that it helps to train medical personnel across the country, especially those who serve in the remote areas. In a typical telemedicine system, such practitioners will be the ones that operate the local nodes and it is only through their intermediation and involvement that patients are treated. In this process, the specialists and super specialists give them both direct and indirect learning opportunities in diagnosis and treatment. Also, with the addition of some extra hardware and software, medical personnel placed at these remote locations can see treatments like surgeries being performed elsewhere. The availability of the Web, video-channel linkage, will facilitate: case conferencing; real-time and recorded demonstration of clinical procedures; access to expert information; remote supervision during clinical tasks; and distance learning programs. In any case, collaboration between healthcare professionals supported by telemedicine technology networks is likely to provide new challenges in the enhancement of skills for some, including nurses and the non-specialist medicos.

The anti-telemedicine tirade is equally strong. It is claimed that communities most likely to benefit from telemedicine are those least likely to afford it or have the requisite communication infrastructure. Hence, it can not be of any help to the illiterate and the needy. However, this need not be so. In contrast to the bleak scenario in health care, computer literacy is fast developing. It is far easier to set up an excellent telecommunication infrastructure in suburban and rural India than to place hundreds of medical specialists in these places. And, in any case, the patient need not be techno-savvy to reap the benefits of telemedicine.

Many doctors feel that the very thought of diagnosing a patient when he is physically absent just on basis of the data provided through the net turns them blue. However, this is merely a problem of adjustment to a new reality and can be overcome through training and development programs. Practitioners in the rural areas too have a misperception: that they may be made redundant. This, definitely, is not the case. Some critics argue that the cost of telemedicine technology is unaffordably high. Also, the infrastructure to support the technology like electricity and telecom networks is not available in many places. They also point out that, for the rural patient to consult a remote consultant, language barriers will be a major problem. Yet another issue raised is on how to ensure telemedicine service quality given that there is no proper governing body to form guidelines in this respect and motivate the organizations to follow. Well, these are real problem, but not surmountable.

A PUBLIC-PRIVATE PARTNERSHIP MODEL FOR E-MEDITAILING

In India, the current stage of telemedicine initiatives are supported by the Indian Space Research Organization (ISRO), Department of Information Technology, State governments, Technology providers in the private sector, and a few private hospitals. The ISRO has commissioned an exclusive health satellite. The North Eastern Council Telemedicine program for the North-East is an active program under this collaboration. As part of this, district-level telemedicine centers were set up connecting Apollo hospital Delhi with hospitals in the states of Mizoram and Sikkim. In the private sector, Apollo group and Asia Heart Foundation have emerged as the key players. Madras Medical

College is the first government medical college to have E-Medicine installed in INDIA.A project for the development of telemedicine technology using high speed communication network interconnecting the national hospitals of SGPGI Lucknow, PGIMER Chandigarh, and AIIMS New Delhi has been completed during 2005-’06. The Centre for Development of Advance Computing (C-DAC) has developed Mercury, indigenous telemedicine software and this is the software platform used by the aforesaid hospitals’ network. CancerNet is a telemedicine system for the service of cancer patients in Kerala. In addition, there exists a score of other projects being at the various stages of completion (Source: Ministry of Information Technology, Government of India). Despite all these, no significant breakthrough in the massive dissemination of telemedicine systems for public healthcare has been achieved so far. The major challenges faced by the government for this are prohibitively high costs, human resource inadequacy, and technological and legal issues. Though not much experimented, starting from the early 1990’s, public-private partnership (PPP) model had been recognized as a solution to the ailments of the Indian healthcare system (Bhat, 1993). It can be a viable alternative to the fully-government funded model for the development of telemedicine as well.

Public-private partnership is a variation of privatization in which elements of a service previously run solely by the public sector are provided through a partnership between the government and one or more private sector companies. Unlike a full privatization scheme, in which the new venture is expected to function like any other private business, the government continues to participate in some way. The PPPs enable the public sector to benefit from commercial dynamism, the ability to raise finances in an environment of budgetary restrictions, innovation and efficiencies, harnessed through the introduction of private sector investors who contribute their own capital, skills and experience. It helps in the cross-fertilization of skills and experiences, too (WHO, 2001). The positive characteristics of PPP arrangements for infrastructure development appear particularly attractive to developing countries like India given the enormous financing requirements, the equally large funding shortfall, the need for efficient public services, availability of a pool of private finance, growing market stability and privatization trends creating a favorable environment for private sector participation (Subramaniam, 2005). According to OECD (1997), good partnership involves a clear definition of roles, competencies, responsibilities and advantages both in public administrations and private enterprises. In particular, the public sector, as an agent of development, may help achieve optimal exploitation of public resources and services, safeguard the environment, and develop human resources. Partnerships must be based on agreements which show the economic benefits for the public/private sector and/or centre/periphery.

Important variants of public-private partnerships are (Source: National Council for Public Private Partnerships, USA): Build/Operate/Transfer (BOT) or Build/Transfer/Operate (BTO); Build-Own-Operate (BOO); Buy-Build-Operate (BBO); Service Contracts (SC); Design-Build (DB); Design-Build-Maintain (DBM); Design-Build-Operate (DBO); Developer Finance: Enhanced Use Leasing (EUL); Lease/Develop/Operate (LDO) or Build/Develop/Operate (BDO); Lease/Purchase; Sale/Leaseback; Tax-Exempt Lease; and Turnkey Arrangement. In the telemedicine sector, any of the aforesaid generic

models or a mixed model could be adopted after an analysis of costs and benefits associated with each of them.

To comprehensively interlink the healthcare establishments in India, intra and inter connectivity at the various hierarchical levels have to be established. A three tier hierarchical connectivity structure can be contemplated for implementation in phases to include: a Primary Heath Centre /Community Health Centre connected to District level hospital; a District level Hospital connected to a State Level Hospital/ Selected Specialty Hospital; State Hospitals and selective District hospitals being connected to a super specialty hospitals at the National level (Bedi, 2004). Private and public hospitals may be interlinked via the communication infrastructure already in place. The service of public and private sector mobile service providers may be used for this. There exists almost no place in India where at least one mobile or plain old telephone (POT) service provider is not available. Private entrepreneurs should be encouraged to establish telemedicine kiosks in the rural and remote areas, preferably within the premises of the extant community clinics. This way, the services of the doctors working there as well as other facilities already available there could be put to the best possible use. A user fee could be charged from the patients for the special care that he gets through telemedicine and forms the business model for the entrepreneur. Wherever the services of a remote private consultant or hospital are sought through telemedicine, a part of the fee may be credited to its account through an electronic transaction.

E-MEDITAILING CALL CENTERS

Call centers, already ubiquitous in industries such as banking and insurance, are fast becoming key features of the provision of front-line primary care services in the West (Stanberry, 2000). A call center model for telemedicine can have the following objectives:

to help the public understand what is a health care emergency – the majority of the general public does not understand the severity of many medical conditions;

to assist the public in dealing with health care emergencies themselves whenever possible;

to direct those needing assistance to the appropriate source of care; and

to answer questions and provide information to the public.

Ideally, trained doctors, or, at least, nurses, should receive calls from the general public and provide information and advice with the aid of computer-based algorithms. The software package should be designed in such a way that it prompts the nurse to ask callers a series of questions designed to ascertain the nature and seriousness of their condition and to direct them to the most appropriate source of treatment: self-help at home; a visit to their general practitioner; or, transferring them to the local ambulance service for immediate emergency admission to hospital. Follow-up calls can be made by

the nurse to check on the progress of individual callers. By requiring the nurse to answer a series of questions in a logical order, the computer software used by the call centre can obviously come to its own conclusions regarding the most likely diagnosis, designed to suggest to the nurse the safest possible course of action. It must be noted that the continued expansion of managed care in countries like USA is built on a greater reliance on decision-support systems working in parallel with electronic health records, to identify and manage courses of treatment. Given below is the model of a diabetic call centre developed by the Biolab of the University of Geneva.

Two distinct categories of e-tailers are pure plays and bricks and clicks. A pure play e-tailer uses the Internet as its primary means of retailing. A key component of the pure-play e-retail business model is the supposition that it is more profitable to deliver products directly to the consumer than it is to build retail stores, staff them and fill them with inventory. Pure play allows for a retailer to be able to reach customers world wide, whilst still only maintaining one location for each and every customer to visit. However, this is not possible in the healthcare sector except for the dissemination of clinical information, basic monitoring and treatment, primarily due to the cost of equipments required to be installed at each household. In this regard, call-centers offer a good via-media solution.

The most influential element in the service experience is the relationship between the service provider and the customer. The Internet is a poor service delivery medium; it lacks the capacity for direct personal interaction enjoyed by non-Internet based services (Kolesar and Galbraith, 2000). E-retailing of medical services though call centers can

satisfy at least the minimal high-touch requirement expected of credence services like healthcare.

PROMOTING MEDICAL E-TAILING IN SCOTLAND: A CASE STUDY OF THE SCOTTISH TELEMEDICINE INITIATIVE

As discussed elsewhere, so far, there have been only a few, small scale, and mainly private sector driven initiatives in implementing telemedicine in India. In order to see the evidence of clinical and economic benefit it will be necessary to develop a strategy for implementation on a much broader scale. The Scottish Telemedicine Initiative (STI) has been constituted in the year 2000 by the Scottish Executive Health Department to promote the implementation of telemedicine in Scotland and the Indian public policy makers have a lot from this Scottish example.

Guiding STI’s work is a clinical forum - the Scottish Telemedicine Action Forum (STAF). It is a group consisting of clinicians, academics, managers and technologists who have been appointed to oversee the development of telemedicine within Scotland by:

gathering information about past and present telemedicine activity in Scotland and in other countries and identifying individuals and groups that are active in the field;

developing a strategy for implementing telemedicine; promoting telemedicine in the NHS in Scotland and disseminating information

about its potential through workshops and conferences; setting up and supporting a number of demonstrator projects; advising on funding projects; encouraging Health Boards to consider the application of telemedicine in their

Health Improvement Plans and Trusts in their Trust Implementation Plans; identifying and promulgating standards relating to telemedicine.

The STAF will provide advice and encouragement for the continuing development of telemedicine projects in Scotland that are in line with national policy and are seen to represent best clinical practice.

The STAF gives top priority to communication systems development and deployment for telemedicine since it believes that improved organization of communication systems is the most vital factor in the success of any telemedicine initiative. This has impacts upon the improvement in accessibility to services for patients in remote settings; equity of access; new models of care; improved access to expertise and knowledge for clinicians; and improved and more efficient transfer of referral and discharge information. The STF proposes self managed clinical networks that will involve significant reconfiguration of clinical services including the empowerment of the non-specialists to provide specialist medical care. Such networks of necessity will require better communications in providing opinion and supervision and more effective links with centers of excellence.

The STAF proposes to establish training centers to enhance the IT skills of the clinical workforce since the real risk to the success of telemedicine projects is that clinicians are not able to use the technology with confidence. It is essential that initial training should be agreed and underway for all staff before the start date of the telemedicine project. Nonetheless, the training effort should focus not only on technology needs but on a possible re-configuration of the clinical roles.

The Scottish Telemedicine Initiative foresees drastic changes in the primary healthcare sector. Telecare is a growth point of telemedicine where housebound patients can have their condition monitored and advice provided by a trained nurse in a centre. The STAF proposes to redesign the traditional primary care services given the impact of these changes on Primary Care workload. The redesign process must involve the Primary Care team in partnership with Secondary and Tertiary Care Services.

Legal-security-privacy issues, although not part of the treatment, have potential enough to derail the entire initiative. The STAF proposes to address these issues through negotiations with medical defense unions, NGOs, and other concerned stakeholders. For the security and confidentiality of patient data, technologies already being in use in other online initiatives may be adopted after suitable modifications. Some of the services that have already been successfully implemented under the STI are: teleconferencing; videoconferencing; teleradiology; casualty service at community hospitals; antenatal monitoring; telepsychology; teledermatology; teleorthodontics; telpathology; telecardiology; etc.

In addition to the STI, there are many other initiatives in Scotland, like the South Scotland Telemedicine Network and Grampian Telemedicine Initiative, notes Debnath (2004). This author concludes that, Scotland, in spite of being the most likely beneficiary in UK, has lagged behind expectations in telemedicine schemes. The review suggests that tele-education needs urgent review. The importance of training for telemedicine users, the importance of identifying a telemedicine champion, the pitfall of health economics and the fact that telemedicine services must be needs driven were some of the findings of studies commissioned in the late 90’s (Brebner et al., 2001). The new initiatives were expected to improve along these lines, but did not happen. Many pilots are not being converted into routine service and that work processes are not being redesigned around the technology. Multi-site trials and a combined approach involving the government, health professionals, technologists, and patients’ representatives would facilitate such developments and help widen the application of telemedicine (Lewis and Moir, 1995).

Scotland, with a considerable percentage of its population living in remote and rural areas and with its surrounding islands, is ripe for re-design of healthcare delivery facilitated by technological solutions. In addition to correcting the past mistakes, the next stage in the expansion of telemedicine initiatives should also be to integrate such initiatives with similar initiatives in England and Ireland. In the economics of networks, usefulness of a supply increases with the supply.

CONCLUSION

The term telemedicine characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally and worldwide by using information and communication technology. It is important to develop a co-operative approach whereby examples of good practice can be shared and the necessary infrastructure established by agreement. There is a need for health boards and trusts to examine how telemedicine might contribute to health improvement in their area (Davis, 1995).

It is important to learn the lessons from the problems experienced in earlier IT developments and ensure that this initiative is not driven by technology, but by matching appropriate technology to clear clinical needs. It is also important that telemedicine is not perceived as simply a project but that it is built into day-to-day clinical practice. E-retailing of medical services demand that corresponding reengineering is made in the traditional processes as well. The efficient utilization of equipment, space, and human resources is paramount to achieving high levels of patient service and hospital profit. For instance, to optimize usage, a retailer may have to split the resources into different storage regions with different densities of relevant variables. Also, the low barriers to entry on the Internet will require successful companies to be able to defend their position through the use of proprietary systems and procedures and services that cannot be readily replicated.

Ethical issues in the e-retailing of medical services are of pivotal importance and should not be neglected in the blind drive to achieve excellence. E-tailers must also abide by the rules, regulations, and legislation set up by the various governmental and inter-governmental organizations. Even though in the developed countries like the US there are competent organizations such as the Federal Trade Commission and the Electronic Retailing Association to ensure that e-tailers remain ethical in their practices and do not misrepresent products online, among many other things, similar frameworks are yet to be developed in many other countries. The disparity and the resultant ambiguity extant in different national trade systems are often exploited by unscrupulous e-tailers for their own vested advantages. Another distressing thing is that telemedicine as a means of medical service retailing is yet to get wider acceptance, which effectively prevents more telemedicine specific and customized e-tail regulations from coming up.

Excessive reliance upon technology should not be to the detriment of traditional clinician–patient relationship and no complacency should be allowed regarding the risks and responsibilities that retail-ed medical intervention, consultation, and diagnosis carry (Stanberry, 2000). The skeptics of using telemedicine as a means of medical service retailing are right to insist that it should only be used where a clear case can be made for its implementation based upon clinical need, cost–benefit or the improvement of the quality of a health service, because the inevitable result of our overenthusiastic development of technologies for distant consultation and treatment – no matter how fast we can be treated in the future – will be the loss of the one intangible thing that we most

value about traditional health care: the comfort and compassion human beings can only truly bring each other when they are face to face.

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