Heart to Heart

Innovative software brings diagnostic cardiac care to remote villages in India.

Millions of people live in poverty in the vast rural regions of India's Andhra Pradesh state. The country's tech revolution and subsequent economic boom apparently passed them over.

But the Byrraju Foundation had faith in technology and its ability to transform lives, even in the remote reaches of India.

The foundation aims to help build self-reliant rural communities by providing a variety of comprehensive services, including health care, education, environmental programs and the delivery of clean water. And its work harnesses IT to deliver increasingly complex services, such as virtual medical consultations and, now, virtual electrocardiograms and cardiac diagnoses.

"There was a crying need that wasn't being met at the village level. But we realized if we could not get the patient and the doctor together in the village, we could take the patient virtually to a doctor in the city," says Verghese Jacob, head of the foundation. "This was precisely the intervention we needed."

The Computerworld Honors program named the foundation the winner in the category for nonprofit organizations, for its innovative use of technology to deliver electrocardiograms, or EKGs, to rural Indians.

The foundation first focused on providing primary health care to rural communities before launching other initiatives designed to improve the lives of impoverished villagers.

Although these programs have reached many -- to date, they've helped more than 3 million people in nearly 200 villages -- the Byrraju Foundation saw opportunities to do more, particularly when it came to providing critical health care services.

The foundation already had doctors and nurses working in the villages, but Jacob says many villagers required specialized care that they could receive only in distant cities.

More specifically, many villagers needed cardiac care. A significant number of them had diabetes, hypertension and other heart-related conditions, and they had to travel hundreds of miles to urban hospitals for EKGs and follow-up consultations with cardiologists. Such trips could cost $25 or more and generally took several days -- daunting prospects for people whose family incomes are often $1 a day.

"The result was that unless it was absolutely necessary, they postponed going to the doctor," says Dr. Srinivas K. Iyengar, lead partner and integrator for the foundation's health module.

Although the Byrraju Foundation already had some videoconferencing equipment to link rural health clinics to urban hospitals, Jacob says foundation officials believed that villagers needed more than virtual consultations. To meet that need, the foundation expanded its telemedicine program in 2007 beyond consultations to diagnostics as well.

Today, the foundation has the capacity to perform EKGs on villagers in its rural health clinics and transmit the data to cardiologists, who then consult via teleconference with the patient -- all at a fraction of the time and money it would take to provide the same services face to face.

Nurses in the villages connect probes from a computer to a patient to perform the EKG. When the test is completed, a Tele-EKG application, developed by Satyam Computer Services Ltd. and SN Informatics Pvt., sends the results to Narayana Hrudayalaya, a Bangalore hospital specializing in cardiac treatment. Within 15 minutes, a cardiologist provides analysis and recommendations for treatment or follow-up care.

Approximately 5,000 people have already undergone these virtual tests and consultations, Jacob says.

Villagers are pleased to have this service available to them, says Dr. K. Sivaji, a medical officer at the Byrraju Foundation. They recognize the importance of having easy access to potentially life-saving EKGs, and Sivaji says he believes such services should be part of every health center that the foundation establishes.

The foundation's success hasn't escaped the notice of other humanitarian organizations.

"The initial good response to the telemedicine work has resulted in further piloting of a more scalable model making use of data cards on mobile platforms," says John Borgoyary, program officer at the New Delhi-based poverty unit of the United Nations Development Programme. UNDP India has helped finance two of the foundation's information and communications technology projects for development.

Taking the Next Step

The Byrraju Foundation already had a strong base from which to build when it started its EKG initiative. It had provided its health centers with medical equipment, nurses and doctors. The group had installed teleconferencing equipment in many centers so its rural health care workers could consult with doctors at urban hospitals.

"Then we figured we could use the telemedicine for diagnostics. If you connect probes from the computer to the patient, the EKG can be sent to cardiologists in the city, and then both the doctor and the patient can see and talk to each other," Jacob says.

To coordinate this cardiac care between villagers and city doctors, the foundation needed hardware and software that was reliable, functional and user-friendly, says Joseph Thomas, who leads IT at the Byrraju Foundation.

The foundation opted for a Satyam application that provides real-time collaboration through IP-based videoconferencing. The point-to-multipoint videoconferencing system is installed in more than 30 villages. According to foundation officials, this software is less expensive and more flexible than older, hardware-based videoconferencing.

The system works on a broadband wireless network based on 802.11b/g technology, Thomas says. The foundation built it with Media Lab Asia.

Thomas says the foundation's IT staff, along with Satyam consultants, developed the software to make all the pieces work together.

B. Swami Nathan, Satyam's IT point person for the Byrraju Foundation project, says the system consists of data-processing hardware and software at both the patient and doctor locations and essential diagnostic instruments, including the EKG machines themselves. The foundation chose EKG equipment from Schiller AG in Baar, Switzerland.

A server in a central site functions as the main data repository and controls the various patient locations. It processes data, images and video in accordance with health care standards. Patients and doctors then communicate through IP-based technology, Nathan explains.

It's a project that could be done only through IT, he adds. "Though the cardiac hospital provided its services gratis, the hardware and software enabled interpretation of patients' EKGs from remote locations, using the Internet as the key enabler," Nathan says.

Last-mile Obstacles

But, as with most technology implementations, the foundation faced challenges in delivering its virtual medical system, Jacob says. And it still faces challenges maintaining it.

In some areas, for example, the foundation had to provide the last mile of connectivity. "The information highway is still [being built] in India. We looked at the nearest fiber-optic links, and if it was close to the village, we could build it out; if not, we did mobile," Jacob explains.

Meanwhile, the foundation has to contend with occasional blackouts, network outages and fluctuations in bandwidth, Jacob says.

Despite these obstacles, the foundation remains committed to implementing EKG services at as many rural health centers as it can. As of the fall, the foundation offered those services in 46 centers, with most using broadband and others using Indian Space Research Organization satellite connections.

Jacob says he expects that 80 health centers will soon offer telemedicine services, including EKG diagnostics.

In the future, Thomas says, the foundation should benefit from the explosive expansion of India's mobile telecommunications infrastructure. He adds that the foundation should be able to extend telemedicine and telediagnostics capabilities to centers using mobile phones rather than building out the last mile of land-based connectivity.

As the expansion continues, the foundation plans to offer additional virtual diagnostic services using kits of medical equipment and computer hardware and software from Neurosynaptic Communications Pvt. in Karnataka, India, Thomas says.

To do that, foundation workers are already planning strategies for dealing with the challenges they encountered implementing the EKG offering. Thomas says the new diagnostic kits will be able run on renewable energy and backup batteries in case the health clinics lose power.

Setting up the IT infrastructure and Schiller EKG equipment costs approximately $6,000 (U.S.) per health care center, with most costs going toward hardware and connectivity, Jacob says.

The foundation doesn't invest in technology for financial gain, of course, but Jacob says the financial results are telling. Because the costs are relatively low, he says, the foundation can break even in less than a year -- even if it charges patients only $1 each.

But the real return, Jacob says, is seeing the social gains made in villages because of the technology. He says more and more villagers are now getting the care they need; in some cases, the technology is even prolonging and saving lives.

"Every person should have access to the best health care. It should be a universal right," Thomas says. "And technology connectivity solutions can be used to bring this about."

Pratt is a Computerworld contributing writer in Waltham, Mass. Contact her at marykpratt@verizon.net.

Copyright © 2009 IDG Communications, Inc.

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