Lecture: How Do We Emerge Stronger on the Demand Front in the Possible Absence of Outreach?

VISION 2020: The Right to Sight-INDIA Knowledge Hub Presents this Webinar.
We see, on one hand, COVID vaccination drives at a good rate, while on the other hand, people get affected by second/third wave of COVID faster than the previous scenario. There have been curfews and restrictions (some facilities to operate only at 50% and 30% capacity, etc.) in many areas in the country. And there are projections that the country will witness the highest scenario by the end of April. Although the government did not impose a ban on outreach for eye care as on date, some of our member hospitals have decided on their own not to conduct screening in outreach areas to prevent further spread for high risk populations. It seems that the real challenge is how our member hospitals look to manage uncertainty. “How do we emerge stronger in this COVID scenario?” is the key question that many member hospitals are contemplating.

Lecturers: Mr. Thulasiraj Ravilla, Executive Director-LAICO, Aravind Eye Care System, Madurai
Mr Suresh Kumar, Senior Faculty- LAICO, Aravind Eye Care System, Madurai
Dr. R R Sudhir, Head of Dept of Preventive Ophthalmology, Senior cornea consultant, Head of Medical Informatics, Sankara Nethralaya, Chennai

Transcript

[Phanindra] Good evening, everybody, hello. I’m Phanindra, CEO of Vision 2020, The Right to Sight, India. I welcome you to this webinar on How Do We Emerge Stronger on the Demand Front in the Possible Absence of Outreach? We will run this session for an hour and half. We will look at today’s session in the context of the uncertainty caused by COVID second wave, probably third wave as well. Although the government did not impose a ban on outreach for eye care, as of date, some of our member hospitals have decided on their own not to conduct screening in outreach areas to prevent further spread and for the safety of their own hospital as well as the safety of the community nearby. It seems that the real challenge is how our member hospitals look to manage the uncertainty. Accordingly, we have identified two sets of issues. The first set of issues that we will discuss today now. And the second set of issues we will be discussing I think a week later.
Today we will discuss the three important aspects. Number one is the leveraging current and past patients. Number two, effective strategies for community work to address the current issue. Number three, the role of technology in these difficult times to reach out to people. I’m sure these solutions, ideas, and perspectives from this session will add value to your thinking and that will ultimately help you in to better preparing for service provision.
Thank you, everybody, thank you esteemed speakers, thank you audience. Thank you very much for joining on time. And so I now request Thulasiraj to talk on leveraging current and past patients.
[Thulasiraj] First, thank you, Phanindra, for the introduction and for the opportunity to share some of my thoughts. And I think the broader context for my talk, and I would also mention it would be the same for the other two speakers as well, is that what we cover is probably relevant to normal times as well. Sometimes an external pressure or a necessity forces us to innovate and come up with newer ways of doing things. For instance, we are now faced with the challenge. I know that it was true during the first lockout of almost having no patients, our revenues dropping down, and we had very trying times. And it looks like we’re again heading towards a similar kind of scenario maybe in the immediate month or two.
I think we need to take this on as an opportunity to see how we can do something in addition to whatever is the routine things that we are doing. I will be focusing in that context of leveraging our patient base, all of our service area base.
How would I also want to mention, this talk is not about leveraging the patients through over treatment or over diagnosis or being over aggressive. I’m not talking of any of those where we may be crossing the ethical lines. This is not about that. But it’s really about doing what is best for the patient and then looking at some other best practices that can do it, how we can empower our patients. And to me, fundamentally, all of this becomes feasible if we can also reflect on how we think about eye care services.I think the next slide will highlight what I’m saying about how we think about services. Because we look at the care pathway of providing service to a patient. It starts off with the patient being able to seek care so that they come to the hospital or to an eye camp or vision center, whatever it is. And when they do, we’re able to provide them diagnosis and advice. And then it is up to them to accept the advice given to them, then we’re able to provide treatment. Followed by, then there is an element of self care which the patient has to do. But then all this, if you see, what we typically want, as a hospital, is essentially diagnosis and advice. And after that, if the patient is willing to follow through with the advice, which could be surgery or whatever, we provide the treatment. By and large, our practice tends to be reactive. And we have self-imposed some boundaries saying that they’ll be those who come to us, to an eye camp or to a vision center or whatever.
The first thing is, can we challenge this? Can we extend our boundaries to enable people to seek care? Or empower patients, or make sure that they’re aware of what the options are? Can we enable them to follow through with the advice given to us? I think this is what I mentioned in the previous slide about how we think about eye care.
In this it is important for us to recognize that even after the patient comes into our fold, we first will need to ask the question, and again I’ll show some data and statistics. Are we diagnosing and getting everyone into the care pathway? Are we doing it sufficiently diligently? Is everyone who can benefit by some intervention, are they being advised? Even something as simple as cataract. Because in all of these things there are leakages. It’s very common in eye camps, we predominantly look for cataracts. Which means we are, by design, missing 40-50% of the patients who may have other conditions.
Then about compliance. Is everyone who’s advised is able to get the surgery? And again, there is a big gap between the advice and those who get operated. And then very few hospitals actually invest in figuring out did the intervention work or not? In terms of doing the follow up. Because without that feedback, there is very little scope for other services to improve. Of course, as we follow up a patient, we may be able to tweak and make things better for the individual, but our own systems and processes will never improve without this feedback.
Even just narrowly focusing on increasing uptake and compliance leads to better outcome to the patients, so the patient benefits. And to the institution, it is largely the treatment which is surgery, or glasses, or medicines, whatever, is what increases our revenues. And this win/win paradigm is also what increases the patient volumes as well. Because there’s only with increased compliance that the patient gets better, gets vision, or whatever, and that is what also gives the word of mouth and builds the reputation of the institution.
Let me share some evidence essentially about compliance. At Aravind, we work with a number of institutions to guide them in various aspects. And this is the data of one such hospital, this happens to be in Bangladesh. As you can see, they had about five to 6,000 outpatients coming each month. About 200 plus patients each day. And they’d been advising about 500 to 600 patients to undergo surgery. And most of them have been counseled. There have been certain periods where there has been some drop in the number of patients counseled. But if you look at the surgeries done, it is well below 40% over all. Which means 60% of the patients who had cataract did not get surgery. Which immediately implies that their vision or being able to see did not improve at all.
And then all the percent, this is a very, very low acceptance rate. Even if it became marginally more, to ⅔ or 65%, which still isn’t the best. Then what this would imply is that this hospital could have done more number of surgeries each month. Which totals up to almost 1,000 surgeries could have been done during that eight month period. And it’s not only surgeries that could have happened. There also had about almost 50 lakhs, or 5 million rupees more in terms of revenues. And you can clearly see, this is the challenge we are now facing during the COVID period. Now our service provision has come down and so has the revenues. And what I’m proposing is that some of the service provisions which is not happening now, can be brought back by plugging in these leakages between advice and compliance.
The same hospital, they saw these figures and then they were mentored with trying some new ideas and things like that. Were immediately able to increase their acceptance rate to 64-67%. Which means each month they did close to a hundred surgeries more, which should have also given them higher revenues. In this instance, the actual revenue increased about a million rupees. These are approaches which can give almost immediate benefits.
The other question that we can again ask is, is everyone who can benefit from cataract surgery being advised? This may seem like a very simple question. We looked at the distribution of pre operative visual acuity in the operated eye. This can give you some idea about who’s getting operated and which will also translate to who’s being advised. We compared the data of one of the hospitals, which I’m keeping anonymous, with our own data. And that’s because we have access to the data. And you can clearly see this hospital, for whatever reason, is advising patients who are, most of the patients are those who are blind. If you look at the numbers, over 75% of the patients advised by the hospital, that is that grey bar, had vision less than 6/60. While if you see that with Aravind, that’s about a third of the volume.
Today, for your information, our WHO is now coming up with new guidelines for threshold. What they are now proposing is that hospitals should advise all patients whose vision is less than 6/12 due to cataract. Even this simple act of reflecting on whom you’re advising, systematically measuring it, doing whatever it takes to now advise those who can actually. And today, I think people need this quality of vision, now because there are so many things around us now. Like your mobile phones, smartphones, a lot of visual things that are around that we are now getting used to. This is another huge opportunity. This hospital which is now advising patients, essentially, with 6/60 or less. If they went on to follow WHO’s pattern, their advice rate would more than double. But the number of surgeries would also commensurately be more given whatever acceptance level they are at.
Having said this, it may be useful for the hospitals to follow some rule of thumb. For advising surgery, this is not set in stone, you can tweak it based on your own experience and your own setting. Roughly 10% of the patients should be advised for surgery, especially in secondary hospitals. And this is dependent on how good, how comprehensive and thorough is the examination. And of course, their level of lens changes is also a factor.
And then it also reflects the level of confidence that you have in the outcomes. If you’re going to be advising someone who is, say, 6/15 or 6/18, due to cataract and lens changes. Then you really need to be confident that you can give that person much better vision than whatever they have now, 6/6, 6/9, whatever. And then you need to have good documentation of this advice being given, so that you can systematically review whether your advice rate is good or the acceptance rate is what it should be.
Again, when it comes to acceptance, you can keep your own benchmark. I would suggest that you work towards a benchmark of at least 75% of those who advise get operated. And this will depend a lot on counselling. Pricing, which should also include the services offered. And how systematically you’re following up those who are not operated on.
And then similarly for glasses as well. So where the acceptance rate, I would recommend to be 90% or so. And here again, having an optical shop within the premises, or a dispensing service, choice of products, and price which is inclusive, all of them help in this.
We have seen, I think many of the hospitals now do have counselling, to be a very powerful tool for both the patient empowerment. Which, over time, also enhances the acceptance rate.
And then in the design of services, it is important that you focus on the dropout rate and focus on reducing it. And there are a number of factors which can help in this. One is the pricing. Is it inclusive? In the sense you are only offering high-end product or promoting only high-end product, then you lose out on those who cannot afford that. And same if you’re only promoting low-end services, those looking for something better like phaco or something like that, don’t come to you, they might go somewhere else or not do it at all.
Having the physician and lab support. Even if it’s not in-house, but having some system by which you’re able to control that. Reducing the number of visits to undergo a surgery. All of these things help in minimizing the drop out between advice and getting the treatment. And then some way you’re building trust and typically having a package rate brings in a lot of transparency. And the transparency is fundamental to building trust. And having fixed ratesm and being consistent, they’re all certain tactics which can build trust.
Just very quickly, in a situation if you’re only giving prescriptions for glasses and not providing the option of buying the glasses itself. The number of, this is a study that was done in the eye camps, we found that less than 30% of them actually end up buying glasses. This is after going back to their homes and verifying after three months. The similar cohort of patients when you offer them glasses right at the campsite itself, the prescription glasses, the uptick is around 85%. You can recognize that a lot of this enabling compliance is within our scope. But the only thing we need to recognize it and own it as our duty.
For example, this is another hospital which we mentored with a couple of years back. They were seeing about 56,000 outpatients and did 3,600 surgeries. And they had a target to increase these surgeries by 20%. And the various strategies that followed was one standardizing advice, they improved their counseling, and they did daily monitoring of reasons for dropout. Why did a patient not come up for surgery after agreeing to?
And each of this monitoring gave them certain insights as to what might be happening. And in their case they found a lot of droppages and the same patients out for physicians opinion and clearance. So they tied up with the physician just across the road for this service. And then they started also doing surgeries on a daily basis, which means the patients now had a greater option of when they can get operated. And also make sure that they never had to postpone a surgery for want of lenses or other consumables.
And you can see all of these are within our scope of doing. And within a year, the following year, they did close to 1,000 surgeries more. In this instance, his income went up by one crore rupees. Or 10 million rupees was the increase and become about 27% increase.
The other example is empowering the patients by giving all the choices. This is data from our own hospital so I’m happy to share the name of the hospital. There was a time until 2010, for whatever reason our team in the hospital was predominately promoting SICS. So the phaco surgeries was not keeping in line with what we’re seeing in the other hospitals. Once we monitor and found this, we counseled the hospital team that they don’t have to push phaco, at the same time they don’t have to underplay and not offer it as an option. Once they changed the counseling, immediately within the next year, you can see the rates have shot up by more than 50%. All these are within our control.
And then the converse, also, we have to be careful because we worked with another hospital which is a three-year-old hospital, where their acceptance rate was only 38%. And when we looked at their advise rate was healthy at 10%. So we found at this hospital, they’re only pushing phaco surgery. When we looked at all the surgeries done, 96% were phaco surgeries. All the patients who could not afford phaco surgery, someone thought this hospital doesn’t offer that even though they did. And once they changed their counseling, the acceptance rate again shot up to 65 or 70%.
In all this, the most important ambassador for hospital is patients. And I think we need to actively make sure that they have their trust. Getting the feedback is an important aspect to give us ideas for improvement and things like that. And patient feedback is what also keeps the organization vibrant.
And in conclusion, some of the other ideas is one can reach out to patients who are advised surgery who did not come. Proactively find out and encourage them to come. And we also recognize that in this period of COVID, we also looked at all the patients who underwent the first eye cataract surgery, whether it’s eye camps or in the hospital, and who’s medical record would also indicate the status of their vision and their lens in the other eye. Based on that, we reached out to them for the secondary surgery and through that we’re able to get several hundred surgeries done. Through the camp, those were free surgeries, very big awesome revenues as well.
I want to again conclude by saying that there are a number of things that we can do today to tide over the COVID challenges. But at the same time, also recognize that all these strategies can hold us all good in the long run as well. Thank you.
[Phanindra] Thank you very much, sir. And now I request Mr. Suresh Kumar to please talk on effective strategies for community work.
[Suresh] And greeting to all. It is always tough to go next after Mr. Thulasiraj. He has given a very good detail about all these aspects. And he ended with a slide which is the beginning of my talk.
In this presentation, I’ll be touching upon three of the strategies which has been going good during this COVID situation. Actually, this COVID lockdown has given us an opportunity to think of an alternative approach to reach to the unreached population to serve them better.
If you see, as all of us in this current situation, are facing a problem with the demand. Because which is basically, due to the crowd restriction and other things. And we also don’t know what are the expectation of the patients, even during lockdown and outside lockdown is the new normals. What will be their expectation and perspective learning that eye care and to access it. Unfortunately, we know that we’ll not be able to conduct any outreach programs until months to go. Because even now they’re telling there is a third wave to come. So we don’t know when we will be having our regular outreach program that we used to do in the year 2019 and such. These are the challenges which all of us are facing in today’s situation of this COVID.
And given this scenario, we also know this fact that even though all of us who have been participating in this webinar are doing organiztion in our countries, they’re organizing outreach program. We know that in the outreach program, the people who felt need only access the eye care in the outreach program when it is contacted in their own area. And more than 90% of the people later wait for the next opportunity, for the next camp, so they wait. They don’t access the camp which has been organized in their locations.
This gives us an opportunity that whether living in this situation with it, we can think of supplementing their service which can supplement their regular eye camp. This is the thing which is giving us an opportunity so that we can innovate new ideas to work on the current problem.
Given this thought/idea, we have been thinking that whether currently the community which is to some extent, in some parts of the world, who owns the eye care problem? Why don’t we practically make the community organizations and other stakeholders own the eye problem in their specific community? For an example, whether the schools can own the problem eye health of the students? That then we gradually making all the schools screening programs and other things, the schools can own that it’s their own problem. And whether the industries can own that the eye care of the employees is their own problem. So that it is on their own interest so that their productivity goes up, their revenue goes up. How do we max out these things and build on the effective referral network from the community so that we also benefit, and the community also benefits as a way.
In summary, I would like to say that whether we can think of an approach we’re still now all the outreach program is entirely driven by the hospitals. We can facilitate our own. Instead of a hospital-driven community outreach program can it be a community-driven outreach program? Let the shift if we think we can make during this COVID situation.
Keeping this in mind. This is also the thought process that came into us during the last year lockdown period. And we shared this concept with a number of eye hospitals, not only within India, even across the globe we shared this as one of the concepts. 16 of the eye hospitals who showed interest and they thought that we could collectively work together towards this program and try to see how we can address the problem of the community given the critical situation.
We rolled out an eight month program which has been all hospitals that are part of this program, even among the participants I see there are two hospitals like Aravind who is also one of the member in this. Like Bansal Eye Hospital and then the Sitapur Eye Hospital is part of these twelve hospitals. We had two hospitals from Bangladesh and one from Kenya and one from Nigeria. And in this particular program, Aravind is a co-learning also. Because we had all our own three hospitals being part of this process of learning. And in total, all of us brainstormed and came aboard with then seven approaches that can be taken forward to reach the community in the absence of an outreach program.
If you see, actually, this was rolled out in the month of January. Everybody, this is the data of 14 hospitals, what you’re seeing now in the screen. Everybody started working, all these outreach hospitals started working in the month of February. And we collected the data, it was a data-sharing process. Every week they shared a month we had a part. The last two months, if you see this collectively, all these 14 hospitals has done roughly near about 21,000 cataract surgeries, all these 14 hospitals. In which roughly 4,000 cataract surgeries are done through this new, innovative method that they are operating in their hospitals. Which turns around roughly to be an 18 to 19% of their total cataract surgery is through this method. Which I feel it is a good number.
It is roughly 125 surgeries, per hospital, per month, without any additional. I will not say without, but with minimal outreach, they would be able to do additional surgeries, which in fact is benefiting the community. If you see, if this 18 number is throughout the year, if any hospital is able to get at least 10% growth in their volume. It’s a very good number. This is what these 14 hospitals average volume in just two months of time. We will go in detail with all these seven approaches, what they’ve implemented in their hospital.
These are all the seven approaches which has been suggested in this presentation with the method of counseling for the other eye cataract surgery. And then he also made a point of patients of the ambassadors. How do we use satisfied patients in referring the patients? And then in the absence of outreach program, how do we mobilize a patient keeping the social distancing, the organizing, and miniature screening camp? And we all have a part of huge people in the community who will normally sponsor outreach program. Whether we can utilize those people, community members. And there are certain other initiatives like using the existing resources that is available like using an optometrist who are already working practicing in the community. And there are health workers who is already in the community, how can we use those people who refer patients to our system?
If you see, even though we started as a community affirm system, but these first three ideas operated, other eye cataract surgery, are satisfied, or a miniature camp, it is everything in our control. We’ll be able to make a lot of these things. And whereas all of these other four operators are external dependence. Where we need to depend on external people for their output. For accordingly, we need to design the program, how do we implement it in our own setting? Out of these 16 hospital, many of them have taken two or more ideas to implement in their own setting.
When we come back to the first idea of other eye cataract surgery, it is basically to increase the cataract surgeries through second eye cataract. Because how the hospitals went about doing is that every hospital has a database of their patients who have undergone a cataract surgery in their hospital. That is one thing they have the detail. And also they have the visual acuity of the patients who have been with them in opery. They try to pull out the patient’s details who are already pseudophakic and aoso have bilateral cataract. It was a rigorous follow up with the patients to inform them that you can undergo the second eye surgery.
And also there was another method, the patients, those who visit the hospital, those who had a cataract in both eye based on the visual acuity and visual changes, there was a method to collect the information, process, there’s a protocol on research design, that they designed the protocol. And they double up the IEC material to counsel this type of specific bilateral cataract patients. And there was a daily, weekly, and monthly monitoring plan which helped them to redefine their entire process.
For an example, this is what you see is an IEC material, which is downloaded by Sitapur Eye Hospital in highlighting what is the benefit of a patient to undergo both eye cataract surgery within a period of 30 days or so. What are the benefits in maybe getting?
Same thing, one of the hospitals was following another. This is in a hospital in Midnapore, West Bengal, where they’re trying to identify both eye patients in the outreach program and try to contact for the second eye surgery. There’s another hospital who is trying to put a sticker in their medical report form once they are identified as a pseudophakic patient. And this patient is ready for the next eye surgery, so that the counseling starts from the beginning so that people are now ready to undergo a second eye surgery. And everything is done with the caution that we just based on the clinical protocol and also with the lens changes, all those things.
These are some of the areas which have been implemented by the hospitals in taking this approach of how do we motivate the patients to undergo other eye cataract surgery.
And the second thing is that we all know, patients is our best ambassador. How do we effectively engage the satisfied patient who have already been into our system, and he knows our system, and he’s been served, and he’s been already satisfied with the service in what we provide. This is another approach which actually… We all know this is a good approach but this broader structured level by identifying those patients by doing a satisfaction survey. Designing a preferred form and also sharing with those patients and motivating them to refer the patients. And one of the key thing is that the satisfied patients, those who are referring is, they need to be given feedback for their referrals and times.
Again, I’m sharing this is one of our referral card that has been designed by Sitapur Eye Hospital. Who has been referred and what date, all those things, so that the patient is sent a thanks letter and has been contacted, all those things. These satisfied patients are the good people who can really refer the patient. And in their setting, even they got new sponsors who are satisfied patient who agree to sponsor outreach camp for them in which they are able to do more than hundreds of these surgeries with a satisfied patient himself. This is one of the good approach of how do we engage the existing customer to refer patients those who need eye care? This is the second approach.
And the third one is, as we all know, for the last one year all of us have had to organize a camp like we normally used to do. This is an approach of mini screening camp, where it has been considered eye camp. In a camp, we normally have more number of old patients. We publicize the camp for five to 10 kilometer areas so that we get a huge number of patients. But in these mini screening camp, it’s an approach where we try to target only one village at a gram panchayat, where we can expect outpatients of probably less than a few odd patients and not many, less than 10 surgical patients.
In this, there is no cost to the community because they’re not doing any publicization, no cost to the hospital for all of those activities. And we can use the gram panchayat leaders or the school headmasters to publicize that there is a mini screening camp that is happening within this particular village. And it can be done with following all the COVID restrictions: social distancing, sanitation, everything can be. Because the load is very less. And transportation also is very much possible. Because if you want to normally make one patient sit in one seat. Because it’s only going to be 10 patients per camp, maximum of 10 surgical patient.
But I feel that it is not a cost-effective camp, but in the absence of a regular screening camp, because it’s all of the strategies that can be applied to reach out to the community. And in this, manpower is very minimal. Because the hospitals, those were implemented. For example, once a hospital has implemented the strategy and Sankara Eye Hospital in Berhampur has implemented. When they used to send only two or three people from each camp, and one was a driver, and another person was in for a BP and other examination. So there is not much dropout when they come back to the hospital. This is one of the approaches which we can figure out and do in the absence of our regular small screening program.
And the fourth one is really a strategy which was because this, we thought, even before we outreach this program. At Aravind, because all the outreach camps are organized only because support of the community members. In many parts of the country also is similar. What we try to do is, try to identify the potential community members. And we try to do a virtual meeting, like what we’re doing now, we try to understand their perspective. Because in the absence of outreach programs, which they have been conducting. There are many people who are approaching them that they need to underway a cataract surgery. When will the camp be organized? They also should be giving a response to the community members. So they actively participated and we provided a referral letters with a clear instruction if they are unable to pay they can come to the free section, those that are affordable to pay, they can very well come to the paying section. And those who want us to try phaco surgeries, they can always approach the pay section. Based on their economic status, they can refer the patients.
And also we assign a specific camp organizer attached to that specific district to follow up with those sponsors so they’re in touch, they’re able to inform, give feedback to the sponsor and other things.
If you see, this is one of the letters that has been worded about the program to the community sponsors. The language, because it is in Tamil, so I’m explaining what has been done. This is one of the pamphlet which one of the sponsor, in absence of an outreach program. Since we are not able to conduct an outreach program, you’re supposed to give the names to eye care services, you can give the name to us, we will organize Aravind Eye Hospitals to come and screen and take you, and you can directly go to the hospital. So this is the banner that has been put out in one of the sponsors.
And then there is a rigorous follow up of the patients who have been referred and also has been operated upon by each community sponsor organization. Everything is categorized for the organizer of the hospital who has been in contact with the sponsors. So then this is rigorous monitoring and there is feedback always given to the sponsors, so that they’re also satisfied and they’ll also get motivated in referring the patient. In all these referring mechanism, we saw that giving feedback back to the people who are referring is very much important, which keeps them motivated.
And the fifth one is a cataract finder. This idea we picked up with one of our experiences working with an African hospital. So then we’re trying to implement and customize as for our own setting in India. Basically it is employing a person with a two wheeler, it need not be always a health worker, it can be a simple person, other person. But you need to give some sort of training, some sort of field training in identifying cataract. And work up a plan for him to do a door-to-door screening in the community. And these require, if he’s able to screen a patient and in their own place, even he can do a screening, otherwise he can directly send the patients to the hospital.
This is one of the hospitals which was taken up by one of the hospitals in Kenya only. Whereas the cataract finder doesn’t have a motorbike, the hospital is able to give them a brand new motorbike and they have been able to go out and screen the patients in the community.
And as all of you know that those who are from the Maharashtra, western part, this is one of the strategies which has been in practice currently in a huge way. Actually there’s a practice in a very systematic manner. Because it’s basically tying up or working with an existing optometric in the community level. But only thing is that we need to tie up with a like-minded optometrist. Because that’s very crucial. And then have some sort of referral mechanism, how they are doing. This is one of the area where optometrists will be able to refer both the paying patient as well as the free patient. Because there are customers that are attached to them as even the paying blank pay. Also there is a monitoring process with them, a referral mechanism.
And then this final one is how do we utilize the existing community health workers? In Indian scenario, how can we use the ASHA workers? Again, we got this idea from northeastern states where it is happening very well. Again, there are a few hospitals which is trying to engage with the existing community health workers by giving them a basic training on measuring visual acuity, identifying cataract using a torch light, and providing them all with all those work materials. And then a regular process, and visiting them, and giving a feedback to them on the accuracy level of referrals. And also sharing their data of whatever they’re referring, sharing the data with them. This also seems to be a very helpful approach which is working currently very good in one of the hospital in Maharashtra. They are seeing a very good impact in these last two months of working with the local ASHA workers.
If you see with some changes, even in this we came only with the seven strategies, which we are engaged with. There are many strategies that can be rolled out, but these are the seven things which we felt which since we are working with all these hospital. So we thought it would be good to share.
If you seeing this, all the studies of whatever I’ve sharing, there is a way that a negligible or no additional investment expect preparing some seeing material or brochure. But in some context like engaging with an optometrist or cataract finder or ASHA worker, you may be, I don’t know. It depends upon the situation to incentivize them for that cataract surgery what they’re offering. Otherwise it is not an additional investment that needs to be done by the hospital. And in this reference, not only for free patient, still see some from the community, even the affluent patients they’ll be there for approaching you for their care. And they’ll be a lot of paying patients and phaco patients too in this reference.
And all of us are thinking because slowly the approach is they’ll be coming from the outreach camp, there’s a shift towards the vision center. And this community approach also can change the health seeking behavior of our community. And in turn, if it is working well, this can even help us to advance our capacity to a better. Because the surgical load is better distributed than through our outreach program. And who knows? This can be a very good approach even during the new normal. And also throughout India we see lots of seasonal variations during summers. And this approach can be adapted to overcome those seasonal imbalance too. So as I was mentioning, it will be a win-win approach both for the hospital as well as for the community at large.
I would like to end here my presentation and thanks to Vision 2020 for the opportunity given for me to share that perspective. Thank you very much.
[R.R.] Thank you, Dr. Phanindra, for inviting me to be part of this webinar. I’ll be talking to you on the role of technology in patient engagement during COVID and post COVID and what strategies we followed and some of the examples of what we have done.
As we all, this is on patient engagement, it’s the main question what we have, the patient acquisition. How do we get more patients coming to my facilities? Or patient retention. How do I get my patients continuing to use my facilities? And patient winback. How do I bring my patients who haven’t used my facilities for some period of time? And new movers. How do I attract prospective patients in my facility’s footprint?
In this scenario, I’ll try to address this in the role of technology in leveraging patient flow through telemedicine and integrated with electronic medical records and hospital management systems. And using CRM and PRM, which is a customer relationship management tools built up in the management of increasing the patient flow.
Coming on to the first scenario, telehealth has always been there. It’s basically to improve the availability of services and include access to care. Unfortunately, telehealth was not embraced to it’s 100% because of various reasons. It was considered as an only option in the scenarios where the accessibility was not there or it was only considered as a free treatment. But when you look at telehealth there are three trends which are seen. One is basically to improve the availability of expertise and access to care by increasing the convenience and reducing the cost that is efficiency of healthcare systems. And expansion from acute and episodic chronic conditions, only when needed it was being used. And the last one is the migration of telehealth from hospitals and satellite clinics where it has been practiced is to the home and mobile devices, which is being seen currently with the patient-technology.
The benefits, that we all know, of teleophthalmology. It has a huge amount of benefits, widespread outreach of patients, promotion of hospital, professional opinion, and current scenarios against contagious infections. Benefit to the patient, you can access it from any inaccessible areas, saves travel costs, saves time and effort. And again, protect from contagious infections. And benefits at rural level, again, the availability of facilities to an expert opinion to be reached to any nook and corner of the country.
Looking at ophthalmologic conditions which are suitable for teleophthalmology. You can use them for various conditions when we are looking at teleophthalmology at home care. Simple conditions reasonably which can be diagnosed by video consult where you don’t require any equipment like chalazion, red eye with no loss of vision. Or for follow up medication for optimizing medications, follow up of surgery patients with no complaints where you can reduce the number of visits. Counseling, which is again, important for patients with LASIK, diabetic retinopathy, glaucoma, or computer vision syndrome. And cross consultation between multidisciplinary, where you need second opinions from a dermatologist or any other specialities. You can use this where the consult can happen. It increases in inaccessible areas and also the consultation to patient in remote areas where optometrists can do the initial work up and share with the consultant so that it can complete their workflow.
Just going through scenarios, where in pre-COVID when we started with the mobile teleophthalmology. This is where the scenario happens, most of the times it is done as a camp in a free setting, not as a payments. Other examples where from Aravind where they have done excellent teleophthalmology at the vision centers connecting patients outreach. Another example is in diabetic retinopathy where the business model where you can set up a fundus camera in any of the diabetic clinic and the patients who are being screened there can be, the fundus images can be read and can be communicated back to the patient and to the treating diabetologist. It’s also widely used in retinopathy of prematurity where actually the retinal camera can be placed in the neonatology centers and where they can do the screening and whenever required, the ophthalmologist can go and treat the patients. These were the examples which were, pre-COVID, teleophthalmology was used.
But coming on to the scenario with COVID, telehealth became very popular. I think it is a reemergence of telemedicine where it was a 500% increase in the use of telemedicine because of the social distancing and all this. If you look into the report, it said almost all the specialties were using. There is ophthalmology, there was an increase by almost by 700%. And immediately when the COVID came, when the lockdown was announced, the government came out with telemedicine practice guidelines. Which gave access to all the resistant medical practitioners to go ahead and do telemedicine practice. And that gave a big boost for tele consultations.
So I’ll take an example of Sakara Nethralaya where we could use our tele consultations during COVID and how we could do it, and how the scenario could be easily handled in a very simple and easy way. When the lockdown was announced, we had almost 3,000 plus surgeries where patient follow up required for glass appointments and almost 700 regular patients appointments had to be canceled as the complete lockdown was there. Patients could not come for their regular follow up. And this was a big challenge. We needed to handle these patients and how to handle them from an appointment perspective, how to access their record, and how to integrate everything.
Is it possible for all the people to work from home? This was a scenario which we wanted to raise. Many of the collegeques said IT people can work from home, we can also work from home, and we can do tele counseling and tele consultations from home. But we need to provide the entire situation comfortable for them to work from home. We started with, we incorporated all the telemedicine guidelines and went with our approach.
The first approach was to prioritize all the appointments. We have about 10,000 appointments which has to be cancelled, so we prioritized them so all those with the post operations were prioritized as the number one, where we need to get access to them. And we requested all the consultants during the lockdown to at least work a minimum one hour so that they could talk to each of their patients individually and capture their findings and address their needs. We also tried to see how we can integrate with EMR, so the entire appointments which were cancelled, we could identify them from our database. And we could send them an SMS to the patient asking them whether they want to go ahead with tele counseling. If they give a consent, the appointment gets fixed automatically, and they can even choose the time and date when they want to do a tele consultation.
Most commonly, what we did was we tried to link them with their own consultant, so that it is easy for them to communicate. So we also sent an email to them. Once we integrated all of them, all the appointments scheduled, was sent as an email to the consultant so who can look into it and then start the link for doing a tele consultation was provided. We referred all of these things using Gmail and integrated them with appointments and EMR. And this was an SMS which was sent to them. Once they give a consent and agree to the consent. The consultant get an access to view those appointments which were there. So the link was sent to the consultant. And we also developed, immediately, a patient portal. Patient can also book an appointment through this, they can look through their medical history there, they can fill in their medical history on the net, and they can also navigate through various processes looking at their old reports and all that.
When we could do this, this is how the list goes to the consultant. And the approach was they linked up the EMR so they can also see the case sheet, go through the entire summary of the patients. And once they discuss with the patient, they can also ask them if they can send pictures, or if they have recent reports which they have done with any local ophthalmologist which they can share, all the opportunities are given to upload them. Once the tele consultation was over, they upload their findings and their conversation with the patient into the EMR.
We integrated in such a way that we can call the patient directly from the link what we have. So we used an internet telephony and we also used a Google Hangout for video calls. And if we want to communicate to the patient, we can also send an SMS to the patients directly from the appointment system. The advantage which we found with the cloud telephony services, sometimes when we call the patient, patient does not pick up. We can write a program and see only when the patient picks up the call, the call gets connected to the doctor. And the call is also masked, so that the patient does not come back and keep disturbing the doctor other than they require. We used masked phone number of our secretaries so that in case the call is not possible, they can communicate with our secretaries and who can, in turn, help us in connecting with the patient. This was actually a plan B, which also worked up in scenarios where the internet telephony did not work.
And we can also communicate with a patient by sending them prescriptions on SMS and in case the patient is not available on the video call, we can send them that we are available and you can directly link up with a video call.
We also put up all these things onto our webpage, how to get connected with using a tele counseling appointments or if you’re planning a hospital visit, how to go about. And we also had a new program which is integrating with a collaborator like with a TITAN @yourcity where they have an optometrist who can do a complete workup, do an initial checkup, they also do slit lamp photography, fundus photography, and upload them. We can completely go through their entire workup and then do a tele counseling. So this was the third approach which we could do. This is where we did. This facility was already available, we had an optometrist, we had the entire infrastructure available. Only thing which was not available is a fundus camera and applanation tonometry, which we upgraded all these stores. And with the help of which, once the entire tele consultation could be done seamlessly from all these stores.
This is how the entire workup happens. Once they take a history, do a refraction, do a slit lamp examination, do also intraocular pressure, and do a fundus camera, and upload to them.
We also once the initial lockdown was over, we started working for the hospital. Once we started working from the hospital, we wanted to integrate it with our EMR. These appointments were completely integrated so we can actually see the normal patients appointments and where there are cases where we have links from TITAN tele consultations or even from tele counseling appointments which are scheduled, so the doctor can go ahead and do the tele consultation directly from the EMR. And the call goes automatically by clicking on this button, the phone automatically, the internet telephone rings, and connects with the patient. And in case the patient wants a video call, we can also do the video call directly from the EMR.
So this is how all these happen and this is a scenario where it was done as a tele consultation from the TITAN store. So these images were uploaded, they can look into it, the patient has an old summary, we can look into it, and then go ahead with the tele consultation.
We can do a really very good remote eye exam. In case of tele consultation, we can break this into patient history, self assessment, if you’re doing it from home. You can also do a vision testing from home, imaging, again, a self photography can be done. And then which, in case of a counselling. This in case where you don’t have a tie up with any optometrist.
We also do a history screen which was whenever the patient fixes an appointment, we send a link of a history screen, so that they can fill the history on their own and that gets reflected all. We also developed the bots where the patient can automatically check and confirm their appointment, fix an appointment, and the tele consultation can be scheduled. For history, we are working on the same scenario where even the bot can do a history taking and capture all the important findings and then can be transferred to the doctor.
Where the self assessment is concerned, you can do a very simple questions to ask the patient. Is your vision the same as before or deteriorated? Compare with the right eye versus the left eye if they are not equal. Check your eyes in the mirror and ask your family member if they have anything different with your findings. These are self assessments which can be done by the patient themselves.
Coming onto the vision there are multiple apps which are available which can be used to measure the vision at home. And they are very simple apps. We evaluated all of them and one of the best ones was Peek. Where we could compare it and evaluate it with the normal visual acuity and it was as good as the clinic, because it adjusts the brightness on the screen and the patient actually keeps this at a particular distance and do all the visual acuity and then report to us.
And we also guided the patients how to take good pictures. These are the pictures which once we could send them a video link of how to take good pictures. They were able to do a beautiful self photograph or with the help of their attenders. These were the photos which were sent. Simple scenario, the patient at home, I did a penetrating keratoplasty, had a loose suture, and he sent a picture. And I could immediately diagnose and tell them if you can go to a nearby doctor, and get it done. Because this patient was from northeastern state and he could not travel during the COVID lockdown was there. And he could get it done and then he could send me a picture. So how beautiful it can all be done. This is, again, with the complicated cases where patient can do the good photography and send. We can blow them up and they do a very good photography.
Once this consultation is over, we take a feedback and just check how good these, whether they benefited and any feedbacks we have which we can use them for improvement. To our surprise, most of the feedbacks are excellent. Except until they have some technology issues where they were not able to connect properly, there were some delays. Otherwise, to see almost all of them they scored five out of five.
We also did a lot of things for converting workflows in the hospital and for tele consultations completely automatic and digital. Patient registration, we made them, empowered them to do the registrations themselves. Previously, when the patient comes to the hospital they have to fill everything on the paper. Now, whenever there is an appointment fixed, we send a link for them so that they can do complete registration on their own. They can also do billing or appointments with the payment so they can do a payment directly, when they come directly here, they may not wait for registration or for payment. So all these could reduce the waiting time in the hospital. Billing, also, we stopped printing the bills. So we could usually send an SMS link of the bill. We also developed the patient portal, all these things helped us in improving the patient engagement.
Post-COVID, how do we do this where we could really help them? Immediately after the first wave, or during, we could reduce the number of tele post op visits. All those patients who had cataract surgeries or intravitreal injection, whom we used to see on the third day have stopped coming to the hospital, they come final appointment. Most of these appointments are now fixed on tele post ops. Where we connect with the patient and talk to them and find out if they have any issues, check with their vision and all that. We could do this for tele reviews. Some of the patients who could not come for final check up we could link them with our local illuminy and where they can do a glass appointments and then connect with us on tele, so we also know what happens. We tried this for tele rehabilitation and tele vision therapy.
Coming on to the second part of it, which is very important, how do we build up all these things using various tools? We had multiple tools in our hospital management system and EMR, where we could use the clinical data and integrate them. We tried to see how the customer relationship management can be made effective. What is CRM? CRM is a concept concerned with creating, developing, and enhancing relationships with carefully targeted customers and customer groups for maximizing the total value for the customers and the provider.
We tried this for various scenarios like patient counseling, opticals, appointments, special services, even for contact lens, and tele vision therapy. I’ll try and explain to you on how the entire process, how the tele counseling for surgery counseling happens. Whenever we advise a patient for surgery, as Dr. Thulasiraj explained, the entire process we lose patients at multiple levels. And if we want to increase this conversion, if we can follow them at the time when it was advised until the surgery, the whole network, and we can identify and capture why the patient has lost follow. And if these reasons can be captured, we can go back and do a special tele counseling.
We also tried looking at how this healthcare outreach scenarios work. We can do a targeted campaigning where if we want to send an SMS to a targeted patients. Like all diabetic patients who need a regular follow up after one year, or glaucoma patients who need, we can send an automatic SMS messages to all these patients. Or patients who are already scheduled for follow up after six months, we can send an SMS or an email to the patient. One would be for asking them to fix. These kind of targeted campaigns can be done using outreach scenarios.
We also need to see on how to improve the seeking care behavior of these patients. So educating the patients on health and wellness. We tried creating YouTube and we also put it up in Facebook links. And these servings were also shared with them. And this also improves promoting services and offerings. And when the tele counseling was offered, we need to send these messages to all the patients that if you’re not able to come, we could use them. This all worked out very well. (timer beeping)
And we also looked at healthcare scenarios in coordinated scenarios. Like improving the patient’s admission, instructions to the patients, or for just before coming to the surgery, referrals, on effective communication among healthcare teams, and even pre admission information and instructions can be done in this way.
And case management scenarios, which is again very important in the chronic cases where we want to improve complaints. Just give me a second. Improving complaints in scenarios like glaucoma, diabetic retinopathy, ARMD, intravitreal injection, we have collaborative case management scenarios where we can have automatic effective communication specific only to these patients. And we ask them to be proactive patient management where patient doesn’t come for regular follow up. Improving the complaints, this works out well.
Benefits are numerous. It improved customer retention, attract new customers, decreases the cost, improves campaign efficiency. And there are intangible benefits. Increase customer satisfaction, improve the product and pricing models, increase your understanding of your customers.
So all these meets in our data, which leads to both internal data and external data, which you already have. We need to integrate them and build up this entire CRM data warehouse. Once you have this clinical data integrated with your demographic data, all these can be done seamlessly. We also can use this for various forecasting how many appointments are going to be, patient are coming, and use them for improving your services. Resource management, floor design management, how many optometrists should be there, how many appointments should be increased, all this can be done.
This was one simple campaign which we used for World Diabetes Day, where we wanted to send to all of our diabetic patients and ask them to come to a free checkup. And we sent it using a telephony where the doctor himself calls up, a recorded message of the doctor goes to the patient saying that the importance of regular checkup and how do they need to come. And we can actually link up these telephone calls, how many patients turned up, how many of them really utilized these services and you can follow them on that.
We also did a similar link for EMR patients during a regular visit. Whatever has been advised, we can follow them on the surgery advice, for glass prescription, or for a follow up. These are the data which gets automatically captured. And based on the data which is coming out of EMR, you can generate all these leads for campaigning.
The SMS, which I told you, we can for confirming appointments, reminders, reminding letters, or we can use it for complaints, for medication, for amblyopia treatment, scheduling and attending appointments through an SMS.
And we also tried doing it for feedback reports. The feedbacks are also sent to these patients to see how well they are pleased with these services and if they have issues, we can even learn from the feedbacks. This same thing is related with the campaign feedback reports.
And we also used and tried the multitasking of all our staff during this time. When the number of appointments are less, they are free in the last two or three hours in the afternoon. We tried to make everyone a counselor and asked them to call up their old patients who are due for appointments. Ask them if they need any help, if they’re not able to travel, at least try and help them in fixing tele counseling appointments. And we can do this at least 20 to 30 patients every day. Every secretary was doing this and this also helped us in increasing our inflow of patients through the hospital and also increasing tele counseling.
Same thing we did it with opticals. Again, this is very important, this is one of the important revenue. Whenever we advise glasses, most of the patients do not take advantage of the optical store which we had there. We tried linking up the advice which we gave at the optical center, to place the services, what are the problems, and this also could be integrated and we could see and track what status the patient is whether they had purchased the glasses.
Looking at patient engagements, we can use them for reminders, creating alerts to them, giving them health tips. At the event if there’s a new therapy we can use them for sending messages to them, educating them, and if there are any events you can send event reminders, and also brand awareness. And important like creating a patient portal which also improves the patient engagement.
The lessons we learned from all these is, we need to keep communicating with the patients, it’s a team work.Try to do a multitasking, every resource is important, you can pitch in and improve other patient’s inflow to the hospital or through the tele counseling. Distribute the work and manage stress, train the staff for new workflows, which is very important. Manage surprises, have a plan B for every contingency. And incremental innovation, no big bang approaches, go in a slow manner. And a good EMR with cloud capabilities and integration has helped us with building up all these things. This has created a good business impact, a patient’s delight, and saving time and costs to the patient.
I thank you for your patient listening and will be happy to take questions during the Q&A, thank you.
[Phanindra] Thank you very much, Dr. Sudhir, I think we have many questions, very important questions that already have come to us. And I’m requesting for Aaron to take up this session and post the questions to the speakers.
[Aaron] I would like to start by the first presentation to Thulasiraj. I tried to clump the questions to try and make sure that we can answer as many as possible. To Thulasiraj, the first question is how can hospitals motivate patients to come to the hospital for any procedure during COVID? And how can they help develop trust and restore confidence of the same in difficult times?
[Thulasiraj] My response will be related to both. One is to recognize that we will never know which patient wants to come to us, because they’re just out in the community. The building trust has got to be through largely word of mouth. Having really good protocols within the hospital. We’ve heard anecdotal information of patients saying that, “Oh, I brought my own blouse,” and this and that and all that. But once they came here I realized I need not have done this because all the precautions are being taken. I think that’s how you build confidence amongst the patients. And also doing it professionally, systematically. And then also being patient-centric, then the word gets around. You go there, you don’t have to worry about contracting infection or whatever. At every step, if you are doing that. Slit lamp exam, now you’re wiping it down before the next exam, all those kind of regulatory things is what builds up. And that’s what, I don’t think it can be done through a magic bullet. It will be through consistent, safe practices.
[Aaron] Now this is a question with regard to pricing. With increased costs of PPE, safety measures, how do hospitals go about their pricing for OPD and IPD procedures? And if we find patients who are willing to pay only 50% of the amount, how should we go about responding to that?
[Thulasiraj] About pricing, I think it’s got to be entirely the institution’s philosophy or their own policies. I don’t think one can dictate anything. But the only thing to keep in mind is that if you don’t remain affordable, then I think you’re going to lose patients. That’s the only catch that is there. And if you want to know what Aravind did, we didn’t increase the prices. If a patient had to wear a mask, which is only PPE that we required of the patients, if they didn’t bring their own, they had to buy one for whatever amount, five rupees or whatever we were charging for that. There was a slight markup, but overall it would work out to a cost level.
And the other thing about concession, I don’t think it’s specific to COVID time. My advice, or it is what we have seen to work efficiently, is to have your pricing to be inclusive. So that all price points, to some extent, you can make it in our case, we also have a free section of zero is this thing. And some other hospitals I know that if a free patient comes they will direct them to an eye camp. In the sense they have an inclusive mechanism. I think once you have it in place, it doesn’t help to give concession. Then you get into a bargaining process. Just as your trust and reputation gets around, this practice also gets around. One patient gets a deal and say, “Oh yeah, you go and tell them you can’t pay, they give you some concession.” So it becomes not a very helpful process to do that.
[Aaron] Another question regarding specific to COVID. Are patients being screened IPD patients being screened before surgery at Aravind? And what is the COVID infection rate of any Aravind hospital staff and how have you advised or motivated the team in these times?
[Thulasiraj] With respect to screening, we do generous screening for outpatients, which is just limited to temperature and then they have to wear a mask and then sanitize their hands and that’s the routine process. Because we’re completely walk-in, we also done the scheduling system to regulate the intake of patients into the system. So that’s the social distancing and so on.
About screening, we do that for surgical cases. That are limited to general anesthesia cases and the long surgeries like orbit or reattachment, where it’s a long procedure. So only for those cases we do RTPCR or COVID screening as a mandatory protocol. For all the other straightforward, short duration, cataract surgery, which is 10 minutes on the table, those kinds of procedures we don’t mandate a COVID screening. But then the routine screening for symptoms and physician clearance, all of that is done.
[Aaron] Thank you so much.
[Thulasiraj] And to the second question about staff infection rates. We don’t have the rates regularly available but then we have been tracking these things. And then what has come out very clearly is that bulk of the staff who get infected, do so by exposure to families and friends. In the sense, we have a lot of our staff staying on campus, both doctors and nurses. And they’re all engaged in patient care, following the protocol. When we look at who’s getting infected, most of them, the split could be something like 80/20. 80% of infections happen from people who come to work from their own homes. We’re pretty convinced that the more active way of transmission is through their own family and social networks. Within the hospital it has been pretty low and this also was substantiated when we did a mass antibody load testing. Those who have come from outside tested to have something like 50-60% load. Anyway, that’s the answer to that question.
[Aaron] Thank you so much, I will be moving to the next panelist, Mr. Suresh Kumar. The question for you, sir, the first question was are the surgeries that you had mentioned as part of the community program, was it done during the COVID period? That was the question.
[Suresh] Yes, over the month of February and March.
[Aaron] Sure, sir.
[Suresh] 2021.
[Aaron] The next question is, with regard to cataract referral for optometrists. How did you finalize the model while remaining ethical, as far as incentives were concerned, to provide them enough incentive to go ahead? And how was this designed?
[Suresh] If you see that and this is one of the brochure point. We have a couple of partners who are working with this. First point I mentioned in the presentation itself is try to identify a like-minded optometrist. Because that is one of the crucial things for us to engage in this program. Again, we also need to give them a benefit for offering. So that’s another aspect. How we went about is that there are patients, they will get an optometrist who are okay to get only for the glasses with the prescrip post operatively. So that is the benefit that some of them will be getting. So that after surgery, the postoperative glasses will be given by the optometrist, so this is one of the benefit.
The other thing is that wherever they are not able to provide the glasses, there is another thing is that there is an understanding that each hospital has a different way of working with an optometrist and it’s not a package one that everyone can adopt the same approach. So some of the hospitals one of the item is that for three surgeries there will be no cost for the referral. Whereas for paying surgeries there will be in proportion or there is some percentage that is agreed upon where it will giving you the benefit.
And there are some hospital which also is an agreed upon with the system is there. We may not be paying you in cash or incentive something. But for example, in a month, if there is some relatives or family members which has been referred by you, they’ll be getting a 50% discount or something like that. Or in a month, you can refer one paying patient for a phaco surgery which will be free of cost like that. There is various methodology that has been worked out which should each partner in a different manner.
But similarly, we need to keep in mind that because the hospital’s name is at stake, we need to follow, agree upon a method which is ethical in practice. That’s the reason I was mentioning that, all these approaches which are excellent depending there is not only consistent with the person who are working, but also in constant getting feedback from the people who are benefiting about the program also. Because there are chances that it can also give a bad effect through the hospital if there is something mishandeling of money or something’s happening within the community. It varies from hospital to hospital.
[Aaron] Thank you so much, sir. And one more question, does the outreach team that are conducting these programs, are they getting tested for COVID at regular intervals? And if yes, at what frequency?
[Suresh] Actually, I am not sure about the frequency but all the hospital staff who have been working in the outreach program are vaccinated. That’s one of the things which I know. But not on the testing part of it. But all the staff members are going to the outreach field and everything, all of them and all of the hospitals have been vaccinated.
[Aaron] Thank you so much for the answers, sir. I know move to Dr. R.R. Sudhir. We’ve just passed on the six o’clock time so I’ll try and make sure that we get and address as many questions. And for those questions which cannot be answered in this session, we would request you to kindly send that across to the Vision 2020 secretary and we’ll follow back and answer the questions shortly. To Dr. R.R. Sudhir, the first question, what are the legal implications for an institution that is checking patients through WhatsApp photos or teleophthalmology software? And is there any given mandatory format for tele consultation consent?
[R.R.] Coming out of the consent, it is a simple consent the patient need to agree on to that he is willingly coming and doing a tele consultation. And whenever you do a tele consultation, you need to state that it doesn’t match with their direct examination. So there are difficulties and it is basically to address the patients and to triage the patient and in case of medication or sharing the reports, we can do all this. And with the photographs, again, there are no hard and fast rule. There are certain guidelines which the ETO guys put forward, only certain medications could be prescribed over telemedicine. Like steroids should not be done or immunosuppressants should not be done. A few of the basic antibiotics can be given.
And the consent should be as simple as possible. We have seen it in our SMS message, as I showed you. The patient gives a simple consent that they’re willing to go ahead and that is good enough for them.
[Aaron] All right, sir. The next question, what tele consultation’s chargeable? And if yes, how are they priced relatively to the physical visit charges?
[R.R] That, again, depends on hospital to hospital. There are hospitals who charge as heavy as possible because many of the times what we found is that the time taken for tele counseling or tele consultation is much more than what we do with a direct examination. In that scenario, I think the charging depends on the speciality involved or the specialist who’s spending enough time with that patient. I can’t give a figure for that.
[Aaron] Impossible.
[R.R.] It is impossible. I’ve seen in some hospitals, they charge even up to 2,000 rupees, whereas a senior most specialist is available. Even for COVID, I’ve seen there are homecare specialists or senior infection disease specialists available and doing a tele counseling. And I think it is important, the time is important, the access to care, should really put the cost, the time spent by the consultant, the time taken for the patient to go and get a direct examination, paying direct, all that is absolutely nothing. In that way all tele consultations needs to be charged. Whereas, initially when we did, it was our duty because we cancelled so many appointments we had done almost 3,000 to 4,000 consultations completely free, initially. Later on we built up the payment gateway and we started charging them.
[Aaron] All right, sir, there’s one question from in terms of service delivery. How could we reach out to children through tele consultation for eye screening and provision of eyeglasses to underprivileged sections in the pandemic time? As screen time has also increased due to online classes?
[R.R.] Screening for children is very difficult. Again, we can have visual acuity apps which are there, so that clearly helps them to know whether the child really is seeing well or not. Because most of these children are able to read letters. On any of these apps they can really see and read the letters and we can know how much vision has dropped. If there is a drop in vision then we can attribute it to the refractive error. But we can’t correct them. Either we need to have a tie in to an optometrist near to the place where they can go get a refraction done and then have a tele counseling done. That is one way of collaboration which helps in tele counseling and tele consultation.
[Aaron] Now there’s a question specific to the Essen software. In terms of what is the scope of replication of this teleophthalmology suite or software suite in smaller hospitals. And is it feasible as an online complete process only due to the travel restrictions that are present currently?
[R.R.] Actually, if you look into this, when the COVID lockdown was announced on March 23rd, so immediately what I did was everything I did manually. The entire process, whatever we put automatic, we could do it manually. With the help of my secretary who could connect with my patients who could look into my list of appointments. And only thing was, the EMR was access to it, specifically the network to see them. That was the only thing. And all that can be done if you have a staff set in the hospital, who could do that. I could give them lots of ideas of how to do that without any software. Using only thing is a payment gateway, again, you can send a payment link to them asking them to deposit the money in case you want to do that. The process of the software helps in automating the entire thing so that it happens seamlessly, without intervention between person. Who really looks into appointments, scans it, who the patients want a tele consultation, and the counseling and all that can be reduced by doing an automatic software. And if anybody’s interested, I can give them the ways in which how you can use with WhatsApp or with Google free software how they can do it, anytime. They can get connected with me.
[Aaron] Thank you so much, sir. So the last question is how should we communicate technology an option to patients from rural areas in case of tele screening? What is the Essen experience and what can be done from that, sir?
[R.R.] We also had our free patients whom we used to tele consultations. Unfortunately, they may not have a smartphone. But many of their children have access to a smartphone, so they can even use them. But you can connect with a normal telephone. So basically we wanted to reach out to a patient who had an intravitreal injection and to find out what happened to them during their post op visit. We can call them and talk to them and they’re very thrilled whenever we call. Whenever I do a tele post op call, they have also seen the patient where they came for a final glass appointment, this patient was a wheelchair patient. And they could not come for a follow ups. But what we did, we did a tele post op call and the patient was so comfortable and the attendant was saying was so thrilled, these kind of facilities should be available all the time not only just during COVID. Because patients are so happy to replace technology and whenever it is required, they can get connected. I try giving access to my phone numbers to all my one eyed patients whom I have done a PK. They can keep sending the images, you can see those images how good. And I just try and train them how to do it. So these are very simple things and anybody can do this.
[Aaron] Thank you so much, I would like to thank all three panelists from Thulasiraj who talked so effectively about levering existing patients, to Mr. Suresh who spoke about community work, and to Dr. Sudhir who stressed on enabling technology, as an enabler in terms of provision of service delivery, I think I’ve tried to answer as many queries that I possibly could with the limited time. We’re already eight minutes above schedule and I’ll hand it over to Dr. Phanindra to take it forward from here. Thank you so much.
[Phanindra] Thank you. And thanks, Thulasiraj and thanks to Suresh Kumar and thanks to Dr. Sudhir. And thanks to Aaron, and thanks to all the participants to have joined us. We’ll be sharing the link of this webinar, which has got an audio visual link, to all the participants until next week. And the recording, whenever you need it, you can refer to it at any point of time. Thank you so much, thank you, everybody.
[Panelists] Thank you so much.

 

May 9, 2021

Last Updated: September 12, 2022

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