Lecture: Post COVID Lockdown and Eye Care Services – What is in the offing?

Resuming normal eye care services after the lock down is lifted will not only be an overwhelming challenge but a management nightmare for the programs all over the world. There is a need to understand that to reach the same levels of services that existed prior to it is not going to be possible going forward in the immediate future. This presentation will attempt to provide a road map from the management perspective of how we should attempt to address the service delivery initiatives going forward.

Lecturer: Mr. RD Thulasiraj, Executive Director, LAICO, Aravind Eye Care System, Madurai


Mr. RD Thulasiraj: Thank you to the always Cybersight team especially Rishi for giving me this honor of – being one of the speakers in the Cybersight series, in this challenging times. So, to start off, I think this has been one particular situation where the rules, regulations and the realities have been constantly changing. You know, so I want you to recognize that, whatever I say can become quickly out of context. And I guess you need to apply your own judgment and then respond to whatever is the local regulations and whatever. So, this is an important I think to consider in this particular instance.

So my talk is largely around this theme. You know, all of us have, or kind of challenged by this pandemic. I just want to take this stands that you should never let a serious crisis go to waste, to see how we can come out of this better than what we renting. So that’s going to be the theme of my presentation. So when we look at any organizations that have different lenses that one can apply to kind of look at an organization. And then one useful way used to look at it from the supply and demand perspective. Because we organization is organized to supply goods or services, like in our case eye care, and for that we require, facility, buildings, equipment, technologies. Now you need the staff, the right skills and the right attitude. You need the right kind off operating systems, processes, protocols, all of that to produce good quality services.

And for all of this, one requires, enhance as per to keep things going. And then we also need to have processes for the demand side nor to create awareness, to create access to remove barriers, you know, make, make our services affordable. You know, retain patients and so once the whole lot of work that happens on the demand side. So, I kind of used this paradigm to kind of see, what are the stress points that happen in this situation? You will recognize that on the supply side, pretty much everything is in place. In the sense, the hospital buildings, the equipment, everything exists. Not everything, I think for many of the many of those on this webinar, finance maybe one of the stress points. But otherwise, the staff are there, your protocols, your policies, your rules, but all of them are dimension place.

So this is just to recognize that where the focus needs to be. Even though finance is probably what we look at as the most critical point, I think there are other aspects that we need to also address whichever quickly transition to. On the demand side, we’re going to have issues around access because, therefore most of the country there is still no public transportation and most off customers or patients depend heavily on public transportation to come. And even those private transportation that are not a lot of hurdle in movement getting permits and so on. And of course, outreach is all those with question now. And my guess is that it be out of, out of questions for several more months to come.

So broadly, this tends to be the stress points that we recognize. And even though finance is a challenge, but I think some of the other areas would be staff retention and engagement. Because with revenue is trying up a little bit in the month of March and probably complete in a month of June and into May, I think many of us will be stressed even to pay salaries. And also, there I think the only option is to work on some mutually agreed upon arrangements, either if they’re able to pay them or [indiscernible] [00:05:19] them or, this is ought to be very much locally done.

And then we need to figure out a way of engaging the staff, you know, for us majority of them are on the critical routine. And also, so given that when that is not happening, how do we keep them engaged, you know, with the organization. That’s the big challenge I would think. Probably the most significant challenge in which I’m spending most of the time will be on capacity reduction. You know, because of the norms that have come in of social distancing and decontamination protocols between patients and so on. We just cannot see the same number of patients that we’re used to see.

So this is what is going to have a lasting impact on the organization if you don’t figure out a way of coming out of this conundrum, and that that’s going to be a big part of my presentation. Then on the finances, I think the essential challenge is having the cash flow, that is making sure we have enough money coming in to make the requirement of money going out towards salaries or towards purchases and so on. And of course, they need to keep the patient care going.

And in this, I particularly want to draw the attention to staff attention. Because all of us are recognized. Our HR is the most critical and also the most valuable resource because every organization, big or small including hospitals like Aravind maybe 45000 on staffs. Our kind of free and limitation comes to the chart, getting the right people and, you know, having them stay with us. And this is pretty much universal, all over the place.

And in our context, we need to realize that given that there is short supply, they’re not easy to replace, it takes time. It takes time because it’s not just getting a person into the system. Because you want to have this person aligned to your own goals, to the culture of the organization. I mean a lot of effectiveness of individuals [indiscernible] [00:07:42] knowing others between the organization and that takes time. So, this is your strong reality, so we need to really focus on retaining the people, because if you let them go, you’re not very sure that they want to come back. So this becomes critical, so it’s not only retaining them, but also engaging them in the organization in the context of having less or availability of work.

And of course, this goes back to the same problem cash [indiscernible] [00:08:17] of financial resources. And then, so when it comes to financial, we have to figure out how we can quickly build back the patient coordinates. And also, this is where it becomes very, very critical. And when [Indiscernible] [00:08:37] back the patient volumes, we also have to make sure that the patient camp goals, you know, which are essentially, I would say three.

One is, the prime thing to ensure staff safety by this weekend. I think there enough and more protocols are not going to get into that. Then how do we build patient trust in this new change norm? And that’s would be through safety protocols, awareness and so on. And again, I’m sure you had enough and more [indiscernible] [00:09:12] talking about this. And the third one is that how can you make the patient flow more efficient? And this is an area where I will be spending time.

And before I proceed further, I just want to state that this presentation is not going to be talking about solutions, which lot of the clinical webinars on how to manage things in Covid situation [indiscernible] [00:09:38] whether it is or otherwise. But this presentation will be about developing a thought process, you know, that could lead to, in my mind lasting solutions. So again, going back to my starting slide, you know, we should never let a good crisis go waste.

So, I’m going to throw a few ideas as the whole we can deal with capacity direction. I think now there is a unique opportunity especially for those who don’t have an appointment system, which I think would be a vast majority. Of working on making the demand uniform so that we can, so we tried this, within Aravind, we don’t have an appointment system, we’re completely walk-in service. And with any walk-in service there is lumping of patient’s arrival. So, in our case and moderate, we will have a huge crowd of patients and we open hospital. These are patients who come from long distances.

You know, then around 10:00 or 10:15, we will have another influx of patients. And pretty much by about 12:30 or 01:00, we’re about 85%, 90% of that day’s patients have come in. So, we typically have a pretty lax afternoon. You know, very few patients in the system. So, we realized that okay, going forward you cannot have, beyond a certain number of patients at any given point of time. And which is forcing us to schedule the patients, they’re still not looking appointment system. But then we’re looking at can we spread out this demand to a uniform process, you know. And towards that the very first step was that, what would be our capacity at any given hour, if you have to follow all this, norms of social distancing and data domination and so on.

And then what, what came as reality was that our capacity will be determined by the number of chairs in the waiting room. Now if you had capacity for seating, say 75 people. Now if you have to keep the middle chair or the adjacent chair free, you know, that is going to drop down probably half of that. So, we’re now looking at what will be the situation if the demand became uniform from 7:30 to say 05:00 o’clock in the evening. And then to our surprise, what we realized was that, if we succeeded in making the demand uniform, our capacity will really not go down. And we will be able to cater to almost the same number of patients.

So that was a big revelation to us and I would think this may apply to most of it. You know, which means that we don’t need to get into a situation where some of the larger hospitals might decide on cutting down to 25% or 30% off their current volume, which would also mean that the revenues will go down by 70% to 75%. These are hospitals which have already done this uniform distribution through appointments, so to me this is an opportunity. I say it’s an opportunity because changing patient behavior is not easy. But today, you have an opportunity on a [indiscernible] [00:13:22], you know, wherein the protocols and everything demands that you cannot handle more than a certain number of patients. And the patients to recognize that and they also don’t want to be in a crowded place. So, all of this is to our advantage, so can we use this to changed patient behavior and thereby be able to serve the same number and also benefit by.

So this second idea that I want to throw is to recognize that our bottleneck now will not be the building equipment or staff, it will be the capacity. You know, because of whatever the new protocol that is coming in. So one of the cardinal principles is that the bottleneck source should never be idle or do unnecessary work, okay? So here the bottleneck is the capacity. So, the capacity that we have should not be wasted. So, one way of looking at is to look at, patients always come with the problem, we call that as in the episode. They come with watering eyes or some foreign body or for a pair of glasses or for a cataract surgery, you know.

And then they may resolve it in one visit or we may resolve it in four visits. Today, I don’t think we monitor this. You know, so if you can do it and start monitoring this spirit and serve and then work towards minimizing it. Can you make it as a single visit? You know, like for in our case, if a patient comes with cataracts and has come ready to get operated, then in our case, we will do all the investigations, you know, admit the patient, operate the patient the following morning and then the patient can go home. So, we’re able to actually do that on a single visit.

So, but in certain situations, are you in for a pair of glasses and known hospitals where the product required the patients to come three times. You know, which means the number of visits that you take to resolve an episode as got direct bearing on how well your capacity is used. So, this is a second thought I’m throwing for you to, to kind of pondering to where you can start, look at your own practice and the protocols to bring this to play.

The third idea is in some sense, revolutionary in some sense not. So can we take a fresh look at our workflow protocols, policies and everything to kind of see, to ask this question, does this have to happen in the hospital when the patient comes in? Or can happen outside the hospital? And you recognize that this is already in play in a lot of other industries. You know, banks have done it beautifully. I’m sure many of you have not gone to a bank in the last decade or so, certainly I haven’t. You know, because the bank has done very smartly, shifted everything onto the patient, outside the bank, no drawing money or make money transfers or looking at how much balance I have, for none of that you need to go to the bank.

Also, they leverage technology to do that. The airlines have done the same. Railways are doing this the same. So can we ask this question, what can we shift outside the hospital? Because I think these are all little, little things which would have an impact on the capacity. You know, can the registration be done outside? You know, can we have some kind of a chat board or something like that which can take good history of the patient? You know which can automatically get populated to the medical related. And all the insurance work be done outside. You know, can it help education be shifted, you know, under different techniques for doing that?

So can we work towards engineering this shift? You know, this idea of, this thought process came to me when I got a chance of studying the practice in the US, whether there are two retina specialists, and each specialist, when they’re working on a full day, will see 110 patients. Okay, this is a retina practice, it is not a simple [indiscernible] [00:18:07]. And then every patient gets a whole CT done, you know? And more than half the patients will get an injection in that aspect, okay? So, in that practice, it is very interesting for them, indication their metrical failure is if they find the patients sitting in the waiting area. So, they have source came line the work that there is no one sitting room. They’re all coming in, getting into one area or the other and going out.

And there the average throughput time, entry into the clinic, leaving the clinic is 45 minutes. And when it kind of went deeper into the process, all that I have listed here, you know, can these things be done outside? Every one of them was being done outside. Okay, but none of this was happening inside the hospital. And obviously for those people to get 110 patients coming day in and day out, they have to have a very high level of patient satisfaction and engagement in an extremely complicated environment. So, this is something which I think we should start exploring

Fourth idea is to, looking at what I’m calling as the patient care cycle time. You know, that is a time from registering for leaving the hospital, you know can we minimize that? Because the less time your patient spends in the hospital means that much more capacity you have to deal with more patients, okay? So this is their direct benefit both to the patient because no patient wants to spend a lot of time in the hospital. You know, so they would also like to leave soon. And then so, it’s like a win-win kind of a situation.

You know, so we can look at whether we can rationalize investigations, cross reference, you know. And wherever you need to do a cross reference can be solved [indiscernible] [00:20:12] consultation without moving the patient and go to another place. And all this, we have to realize whatever protocol or rules that are there currently is all over doing. You know, so it is not set in stone and they all can be changed. So, in this context, so if you set some benchmark, let us say for the sake of argument the patient coming with a simple condition where no evaluation is done or required. They should leave let’s say in 45 minutes, you know, with the evaluation they should leave rather 15 minutes. Supposed we establish some the benchmarks; then can we do a detailed root cause analysis that RCA on every patient who exceeds this goal.

You know can we do a deep analysis or more cost, you know, and then, addressed it for the next day. You know and often times you may need to expand your capacity in some little area, maybe extra trip, equipment has to be tolerate, appoint another person or something like that. But these investments I think will pay back in a moment almost within a month or two, you know. Because this is a kind of fiddling with some minor imports which will, which will give back enormous returns by way of increased capacity. So, this is a full idea of can we minimize the patient care cycle time, and the next one is, can we start exploring remote care not telemedicine et cetera, which still now was something which many office didn’t take seriously. I think the time of COVID I think what if you people have started exploring this quite seriously. And I guess everyone is experimenting with their own version of this.

I’m showing a slide, the image is not very clear, so I’m showing a larger version of the image. This is from a health system called case moment input. They are largely in California. And then if you look at the number of visits, it is staggering. At Aravind, we do see a large number of patients, we handle about five million outpatient visits, but we’re very humble when we saw these numbers. You know, they’re having about 148 million patient contacts each year across through the system of hospitals. And then what was very interesting to us was there almost two thirds of these contacts are digital or electronic or delicate. And this could be a number of things, they’re patient wanting to see the lab results, not to wanting something else. So, they have come up with a very robust way of engaging patients digital.

And of course, the US, slightly different context but not a whole lot different, given that in India also pretty much everyone has got mobile phone and many of them have smartphones. And they’re also witnessing 30% growth year on year on video business. So, this telemedicine thing is something that is really, it is not something fancy or sci-fi, so people who are able to do this. So and then, part of this growth also be shifting care to lower levels, you know like so you have a diabetic complications. Say minor case, so you’re seeing them every year. So can you have the patient go to your primary care center if you have one, you know?

And then use technology to deal with the patient right there. So, all these ideas, you know, are going to help. I think if we can achieve by exploring these ideas, a certain amount of efficiency. Let’s say, I’m throwing a figure of 30% which I think is quite conservative, because it’s really worked hard on this, we can almost double capacity. I think within Aravind, I know for a fact that when you start working on this episode monitoring and cutting down, I know that in the specialty clinics, like that in a coma and so on. The number of visits from the current pull of patients are almost come down to [indiscernible] [00:24:59].

So, we’ll also recognize that the way I have described reducing the patient visit is not compromising on quality, just eliminating unnecessary visits or unnecessary examinations and so on. So, on one hand, the quality is not compromised, but then you’re having less number of patients or patients spending less time in the hospital. All of this has got a huge benefit to the patient, not my way of increased patient satisfaction and reduced cost to the individual, to the patient.

And then one big outcome of this is enhanced capacity for us to take in more patients. So, I’m basically building a case that because of this COVID, if you do things right with what we have, we can probably see 1.25 or 1.3 or 1.5 times the number of patients. And all of this will have a significant impact on the revenue aspect. So, the money that we lost, we should be able to make it up by the end of this year, you know, if we work as smartly around this.

Now kind of going back to the demand side, what is unknown, probably what’s on everyone’s mind is, what will the demand rebound if the patients come to the hospital, if they don’t come to the hospital, because no they have not had revenues and some, many of the people have lost jobs or were not paid. So, there’s a lot of anxiety in our mindset to how they demand the rebound. Some of us may already have some experience if you started working for the last week or so. What we also don’t know is, what were the patient’s expectations? You know with all this, will they get more sensitive about decontamination protocol, social distancing and will become the new norm? All those things are unknown. You know, and what is certain to me is that the outreach is not going to happen for several months. You know I don’t think the government will give us the permission to do this.

So, in this context, I had over the IT department take a look at our, we open, started seeing patients since last Monday. And then, this is what the figures show in the first three- or four-days’ data. So basically, I told them to find out the number of patients we saw the month of May in 2019, they took that as normal, as 100%. And against that, what has been the patient footfalls, post- Covid starting to see patients. And you’ll find in the, this is something which I hopefully expected and I was quite pleased that my thought was validated.

You’ll recognize that in the vision centers, between the first day or two volumes ramped up to almost 66% of our inaugural. The secondary hospital was hovering around 32%, 33%. And we have one hospital which is in between secondary and tertiary where the number was around 25% also. The tertiary hospitals around 11% of the normal volume, like in Madurai VC close to feed in those all patients, now we’re seeing around 300 to 350 also. It’s increasing day by day. But then what is coming very clear is that when there are challenges around affordability and access, it is a local facility that becomes more attractive or accessible. Now as a result, the vision centers are having, they think their demand re-bond happening very, very quickly, and this to me is insight that we have.

So, can we innovate on the demand side? Again, I’m throwing a few challenges. Because the community you realize fights for a lot of things. They fight for electricity; they fight for water supply to the villages or they fight for a bus route or whatever. So the same way, can we make the community organizations as the primary Warner of eye care problems? Today we want to broaden. I mean in many hospitals, they want it to the extent that they would go make all the publicity, they will do all the arrangements now for doing an eye camp. So can you flip that around to kind of shift the burden onto the community and the community organizations that they become the primary Warner. There is somebody that cannot see the community. They should do something about it.

Same way, can the school teachers do something about this student who was not able to see well. And today, the organization which are into school eye care, will recognize the challenges they have getting permissions and so on. The same industries, you know, industries employee people and many of the employees need glasses, you know? Can the industries make sure that their employees have good eyesight? And all of these things are to the benefit of industry or the school or the communities, everyone can see well. So, it’s a question of shifting that ownership to them and this will take some work. And we have had great success in doing this. Like for example, the very first time we went to [indiscernible] [00:31:03] to screen their employees, there’s a lot of resistance. You know, they were not willing, but some more, we went to the very highest level and got the permission and did the screening, and gave them more free glasses. And their work request a near vision, and most of the employees, they’re above 40 because [indiscernible] [00:31:21] whole company.

And then within three months, [indiscernible] [00:31:28] realized that the productivity of these highly unionized, difficult employees jumped up by 13%. So, when this happened, they came to us running, saying that can you please do the screening in all of our other factories in other locations? You know, and then once the word got around between textile industries, it was very easy to get entry for doing screening and giving glasses to the patient. You know, same way, we were able to win over some schools, but it’s all work in progress. Because once this is done, we can build an effective referral network, you know from this a group. And then that way itself should keep the steady flow of patients coming to us.

So the other issue of how much you charge and all of that to separate discussion. But then I think we can build a very, very robust, probably even a better network the doing outreach work. And then what is very clear is that we will giving primary eye care or vision centers. And then we have a lot of evidence to show that, like for instance, with about 80 vision centers, 79 to be precise, we’re now handling about seven lakhs all patient visits a year. And then that vision center area about CSR of 6000 comes out of vision center efforts.

This is a graph going back about 35 years. And wherein you can see the blue line which I’m showing here is the eye camp. You know, which grew for a about, till about 2000, but kind of stayed plateau in spite of putting a lot of efforts. But then we are actively engaged community in organizing camps and referring patients to us, working with industries and so on. So as a result, this pink line which are walk-in free patients who come to the free hospital and has steadily increased under, under the year 2009 or 10. The lines cross which means we get many more surgery from patients walking in directly to the hospital produced but then coming through eye camps.

You know, and then overall the impact of this change behavior of patients coming in directly, our paying patients go that’s been given more robust. You know, so I think in this current situation, it is being very much accentuated because of the access challenge.

So, in conclusion the take home messages are one to realize that the current pandemic by itself is not going to change the eye care need scenario. The cataracts will continue to exist, so effective [indiscernible] [00:34:32] or any of the other conditions. So that the demand base is not going to change at all, you know, it will continue to exist. Second realization is to recognize that whatever challenges that we have now, you know, on demand side, patient access side, all of that is universe. It is affecting everyone, all health care providers, all industries, everyone. So it is, it is something quite universal, you know. So, recognizing that feeling victimized and complaining is not going to help at all. So, it is really for us to innovate and stay relevant. Thank you very much.

So there is one comment or a question from Madhu from Shri Kiran, again he has given another innovative idea that we’re able to maintain capacity just we’re not allowing any attendees. This is a good, good approach, you know. Because in our estimate for every patient there is 1.3 attendants, we’re just eliminating them from entering into the clinic area itself increases the chance for social distancing and other requirements.

Counselling can also be done online, that’s definitely true. There is one question from Vilnu Sudir [Phonetics] which is, post any surgery, if symptom of Covid is detected in the patient, what do you think will be the consequence? So, this is a little bit out of my scope, of my talk. And I think here the consequence will be largely dictated by the regulations. And what I heard recently was that they might ask you to close the facility for two days or doing the contamination, is what I heard as the most current, this thing which I think is probably the right thing to do as well.

Will this pandemic will affect future practice Ophthalmologist, how would the upcoming few years after the [indiscernible] [00:36:56] especially elective surgeries? In my mind, I think after passage of sometime, I think there would be a slightly new normal. Because like I said earlier, on the demand side things are going to change. You know, cataract will continue to occurrence, we need for glasses and so on. So from that point of view, there will be no change in the scenario. But then because of this condition for some time, there will be a different way of working there will be mandated. So, when [indiscernible] [00:37:34] we don’t know. So, to the extent that we get released for that there should be no change in the situation.

Can we develop some technology also, the system patients can, exactly I think this whole notion of can be leveraged technology for kind of providing care, you know? I think, I think fundamentally if we can use technology to kind of provide care which doesn’t need to happen in the hospital or activities you don’t need to have in the hospital. Now if you can mature technology to that level, I think that would be a huge way of being prepared for similar situation.

Arun states, why not develop uniform software for all members? Yeah. So, this would – I think all these kinds of things will happen, yeah. And so, I think in my mind the industry is more prepared. When I say industry, the IT industry is a lot more prepared to do it. And probably the best matter of doing it is to form some kind of a task force amongst the practitioners so that we are able to give them the right specification scenarios. You know, for the application, otherwise the IT developers develop something and then you find [indiscernible] [00:39:08]. But I think this will emerge by itself over time.

Can we shift some of the activities? Definitely there is something which I mentioned as well. How to avoid unnecessary patient visits to eye health? So this is, I think can be done quite scientifically in how to avoid unnecessary patient visits. I think there are, there are two or three approaches, one is to internally focus about your own protocols. Because I clearly remember visiting your hospital, you know, wherein to get a cataracts surgery, a patient typically had to make about five or six visits as for the protocol. Because on day one is a diagnosis of contract and they’re asked to come back for that examination. Then they’re asked to come back, the results come out not to fix up a date for the surgery. And so, at least four visits they have in that set up.

So that is completely the organization for protocol. I think that’s one area to look at. The other area to look at is this that, are we adding value when a patient comes and visit us? Are we doing it for the patients benefit, are we doing it for our own satisfaction? I think once you get information on that, you can rationalize the number of visits that is required.

Recognition to the reduced capacity with your recommendation [indiscernible] [00:40:49]. Absolutely, and the ideal [indiscernible] [00:40:52] can happen outside the hospital. This is where technology can help or this is where like having a vision center or a family Eye center can help, wherein they only send you the cases that needs to come to the hospital. Like I said a complete example. In our vision centers, we handled roughly about seven black visits a year not through 80% centers. From that less than 10% of the patients are referred to us for surgery or advanced care. So, you can imagine the huge benefit that we get, you know. Those seven lakh patients with simple conditions came and cope the system. So, technology is there today for us to be able to notice.

So, Madhu’s also made an observation that single practitioner recovering faster than larger hospitals. But this is completely due with access. A smaller practitioner or single pertinent typically have patients coming from their own neighborhood which means easy and quick access. So, that is very true. So, in our case without translate this by opening primary care centers. For it should – there is one question which is inadequate. What the parameters we should follow a vision center? I’ll introduce about critical parameters. I think there’s a Webinar coming up on Friday. It should answer a lot of these questions, more about camps can be conduct.

So, on the conference I think we really have to wait for the regulation to do that. And then have a comfort level that they spread is really flattened and reduce and stop. You know, otherwise reveals aggravating the situation kind of [indiscernible] [00:43:14] or whatever. And I think at that point of time, we can take a look at what is the best way of conducting the camp. But my basic pleas that India should — India started Eye camps more than 100 years ago. You know, people like Mathura Das and [indiscernible] [00:43:36] other conducted camp. My plea is that we should not be conducting camps 100 years from now. You know, because today we have hospitals in accessible locations. It’s a question of creating access changing patient behavior. So, I think one in between stage would be what I described. If we can develop very robust community based, consult in the camps. You will start getting patients coming and getting care.

Because if you look at all well-developed countries like Germany, Sweden and whatever. No, they don’t have eye camps. They have more eye camp than what happen in India. So, we need to be also thinking how do we use for leverage this kind of a force situation to start working towards that. So, while we will continue cancel some more time, I think part of our [indiscernible] [00:44:28] also go in that direction. At this moment we’re all affected industries, so.

This is something we have to wait and see. You know, this is the question that I talked about. We’re not fully certain about the demand rebound, but from what we’re seeing from how is that as long as access is good, patients are coming back. So, each one of you if you look at, you know, patients from where they’re coming big hospital or small hospital, you realize that they’re all coming from their local areas. So, as of now we don’t know the burden or the impact of the economic downturn on demand which I think will only be felt when it becomes fully normal. But we should anticipate that it could have a slightly dampening effect which is where the whole efficiency part becomes critical. In the sense that you can earn the same revenues with necessary of by having patients come through our times and so on to that extent your bottom-line improves.

Meenakshi, how can outreach and utilized? Yes, this is good question Meenakshi from Jaipur. Like I said can this team start working with the communities to build up [indiscernible] [00:46:02]. And we have done that in the past many years back when Albin [Phonetics] started out working the communities. We did a lot of work to establish community investment. And we used our own outreach team to do that. So, I would really encourage you to explore that.

Madhu, medical paramedical education – in the short-term scenario. This might get a little bit challenging especially on a clinical training. But I think what we can do in this breeder time is to kind of reflect or review our own training curriculum and process to see things that happen and improve. Like we are now completely taking a deeper look at our curriculum and then shifting completely to competency-based training, something that always also pioneered a few years ago.

While in the training yourself becomes much more tighter, much more efficient, where in the people who come over become much better trained. So, doing that kind of homework or preparatory work, when you are not able to do the clinical training. It’s probably a good use in the short term. Hopefully, this will all change in the next a few months also. Being a small individualized certain by how to make these challenges, I mean like Madhu observed, you should anticipate quicker rebound of your patients coming back. Because I’m sure you will recognize that most of your patients come from the local neighborhood. So, you should anticipate that your patients will come back sooner than for that than larger institution like us, so for us to get back to our volume of 3000 probably will take almost a year also, so we created this advantage.

Are the vision centers available as friend Jason’s model? So, this is a little bit out of the context of this thought, so maybe if you can send your email, we can, talk about that. Can reduce the workload or how we come to start? This is a pretty good question. So, depending upon your set up. Probably, usually when you’re running your hospital, there is a lot of development that which have done, which doesn’t get done because of the day to today operational pressures. So, I think you can use these few months or the time on each day when you are a little bit of a slack take on those developmental activities which would be training to maintenance or what on. So, that probably is the day, so we’re going to do it is to make a complete list of development activities and systematically on the case resource with time frame.

I think that’s the best you can. I think that we have a twin goal of keeping the staff engaged doing useful work and also get some of this development work done. Munir, when we can start cataract operations and what message which would be done? So, I’m not going to this, there is a technical aspect of this question which I won’t mention because that’s not my core area. And I’m sure there have been asked to [indiscernible] [00:49:53]. I know something happened and some will be definitely happening. So, at this point of time we are a little bit governed by the regulations.

And I know in India, they have recently announced that from government of India level that elective procedures can begin. So, the respective states have to operationalize that. So, I know that for all practical purposes many of the hospitals have started taking on a routine work. You say that we need to have war reduced comprehensive examination. So, this is the call that you have to take at a local level. Because I think the reality is that some of your own staff may not be co-operated. You know, for doing certain procedures which are in close approximately with the patients.

So, this is the call that you would have to come into consensus between the organization. But of course, what we should do and what we can do is to make sure that your staff are fully educated on the importance of personal protective here. Because many of this – because it is so uncomfortable to go out with the mask on the outpatient especially when the weather is hot, so there is a tendency not to complain with that. So, I think focusing on that I think I would go a long way as we start getting into more comprehensive procedures.

More has been your biggest again increasing. So, we are yet to get the benefit, so internally we’re challenging ourselves to start working on whatever I shared with you, which I also shared with our internal team. So, one big gain would be that we are now developed the software package to smoothen the scheduling of patients. You know, so that the inflow happens throughout the day. So, were put up gateways for patients calling in or through emails or things like that. So that I think will be a big gain for us. In the sense that if we’re able to succeed in doing this which we will know in the next month or so, we should be able to work and almost our full capacity and see no revenue reduction.

You know, so to maintaining the revenue today for larger hospitals by itself is a single largest gain. And then as we start working upon increased efficiencies. We should be able to in fact, increase their revenues. We can follow patients screening.

Female Speaker: I’m sorry, sir. I’m interrupting you in between. Can I read the questions because I guess a lot of people cannot see the questions?

Male Speaker: Okay, okay.

Female Speaker: Yeah.

Male Speaker: And we’re also close to the end of the hour. So, I let you moderate as to when we should close.

Female Speaker: You can follow patients screening and monitoring done at home with smart phone. With smartphones and virtual reality visuality?

Male Speaker: The answer is yes, but the technology is still evolving. In fact, Shankar actually has done some very innovative stuff, you know, telling patients to go stand in front of mirror and then use the rear camera which is what better resolution taken image. And then attached and simply through the whatsApp message for tele consultations. And then, they showed many examples of where that really work and they could really help the patient. So, I think these are all the thought processes that we should work on.

Female Speaker: So, if we move to a technology driven care, then how do we address the human psychology interface?

Male Speaker: I – so, I think if we develop technology in a sensitive and conscious manner, you could kind of use technology to – in a way that it benefits the patient. You know, wherein the patient really appreciates that aspect of the technology. Like for example, today none of us complained that we don’t see a cashier in the bank to get our money. Now, they are more than happy to go to ATM and took out the money. So, this about how we grab this technology so that they’re human interaction can actually become even better. So, this is left our imagination I would say.

Female Speaker: Thank you, sir. Ms. Priya is asking, you know because of the pandemic is global, so obviously it is affected the international funding. So, how — what is the impact of Covid on international funding?

Male Speaker: So, this is a good question. I think, because in many countries a lot of the eye care happens to international funding. Through agencies insights diversity and mortgages and so on. So, because on those industries those organization different upon grants coming into them from other agencies and also governments. So, now we know that a lot of the governments are completely out of results and some of them are even going bankrupt. And this also happening for some of the industries as well.

So, my prediction is that there could be some dampening of resources coming in. So, the few organization which have in government may be able to live through it. But for a large part I think we should be gearing up for a certain reduction. But I think the individual organization should realize that their own communities can support, you know. Like in India, pretty much every organization has the potential to become financially and self-reliance.

Female Speaker: And when we will see the new normal in the future of eye care?

Male Speaker: What will be the new normal?

Female Speaker: What will be? Like, of when?

Male Speaker: I somehow don’t think it will be a lot different. But I think because of the pressures that are being brought in, I would think their telemedicine on those kinds of technologies would take much more of center stage. I would also anticipate the governments also more aggressively pushed those technologies and hopefully create an enabling environment for them to thrive. We might also see patients being a little bit more sensitive about how care is given with respect to the contamination and so on.

Female Speaker: Is it possible to do cataract surgery in this Covid period?

Male Speaker: I think so, yeah. I think the government itself had said yes, we can do.

Female Speaker: And sir, do we need to do, I mean do we need to do Covid test before we do the surgeries?

Male Speaker: I will refrain from answering this question because one of its clinical in nature. So, it’s kind of outside my purview. My only hope is that it doesn’t amount of that because it would act to unnecessary huge financial cost to the system developed the whole phase for it. I’ve got this test cost close to Rs.5000. And then we know that the positive rate is a single digit person daily.

Female Speaker: And when do you think we can commence the outreach activities especially in the rural areas? Ms. Prema.

Male Speaker: It is very difficult to guess, Prema on this. Because I think this will be driven largely by government allowing us to do that. Because the outreach I think by the same requires that people congregated high density, you know, which is what we have to avoid now. So, it will be quite some time before that can happen.

Female Speaker: And is mask screening safe and all the possible precautions at this time? Ms. Deepali.

Male Speaker: Yes, Deepali, against the same question about outreach mask screening basically is outreach. So, today the answer would be, no today. The smart thing to do would be to referring mechanism from document.

Female Speaker: Mr. Kuldeep has asked, can you please explain the role of vision center in the world with Covid-19 and after it. And the time when the resources are limited how can how an organization would invest further on tele ophthalmology and related intra. What are the different ways to deal with it in going forward?

Male Speaker: Yes. So, I think with the side which is sure about the demand re-bond with the highest vision centers. I mean to me signifies the critical role that vision centers would play. Not just for Covid, I think we’re having this demand the high demand happening in vision centers for higher demand largely due to the access issue. So, even beyond Covid, just the notion of providing care of everyone, I think vision center would be more critical.

And then in terms of resources today pretty much everyone is having IT some form of idea of the under, they’re not expensive. You know, in relation to setting up vision center that cost of putting IT infrastructure would be in the order of [indiscernible] [01:00:24] 4% or 5% or so as investment. So, basically talking about a laptop or a PC or something like that and brought back. There’s always need for telemedicine, you don’t need any a fancy equipment. Let’s talk with our workflow, you know. So, to me there’s not real a challenge yeah.

Female Speaker: So, the many more questions. I just read out this one, which, you know, which is related to Aravind. Does Aravind has an existing technology to provide any consultation and can Aravind help smaller hospitals working in the tribal or rural areas to build a technology to provide tele consultation? This is Mr. Anand’s question.

Male Speaker: Anand, I don’t see it, okay. So, the answer is, yes. So, Aravind does have telemedicine application which is now predominantly deployed in the vision centers which are run by ophthalmic technicians. It is largely software driven on using simple webcam and things like that. So, the backbone is the electronic medical record. And this is available for other institutions to use. But as a matter of fact, Bangladesh, Tripura, Chhattisgarh and is already being used, and quiet and few other places as elsewhere.

May 12, 2020

Last Updated: October 31, 2022

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