The cliffhangers after crossing the telemedicine cliff

We possibly needed a pandemic to realize how far and fast can telemedicine help in bridging the healthcare gaps in India. But there is a lot that needs to be figured out now that we have scratched the surface of this genie. Data privacy, data security, rural outreach, device integrity, regulatory rollbacks, bandwidth, and a lot many slippery spots stare at this long jump that India took during the lockdowns. We ask Raghavendra Prasad, Founder of Project StepOne how his start-up like NGO took the first leap and what’s step two now?

Tell us something about StepOne first. You prefer to call it a start-up genre of NPO. Why? And what was it like to achieve what you achieved so staggeringly well with telemedicine during the crisis?

Yes, it is a very unique Not-For-Profit organization. It’s a technology NPO. We call ourselves an NPO start-up. We never planned to start something like this but when the pandemic struck India in the early stages, a bunch of us got together and wondered how we can help in fighting the healthcare crisis. Several ideas came out but the one that stuck with us was that of providing easy access to care to patients. India did not have a public telemedicine network. We went out and asked Doctors if they were willing to help and surprisingly the idea became viral with lots of encouraging responses. Now we have about 12,000 doctors. We also roped in medical students as volunteers and other corporate volunteers for triaging, operations and communication. We have 1500 medical students and our volunteers are trained on medical protocols. It was a great way for people sitting at home to contribute to the fight against the pandemic. We became the Uber that could connect patients and doctors in real-time. We collaborated with many State governments and handled many helplines. It was a big success because our effort could people at homes and help in social distancing—but without compromising on healthcare and diagnosis, consultation, and treatments.

We need stringent quality standards for devices because this is what Doctors would rely on a lot for delivering Telemedicine.

I am proud that we have grown to impanel more than 10000 doctors, 15000 medical and dental student volunteers, and 5000 non-medical volunteers, and we are live across 21 states – that is a remarkable achievement for a non-profit organisation that is just a year old.

So you managed to cross the Telemedicine Cliff. Would the path get easier or tougher now especially as we confront the possibility of government rollbacks and data-related issues?

Overall, we have taken a big step forward. I do not think there is any stepping back now. The fear and hesitation about telemedicine have been taken away. Now people are comfortable with the use of technology. Today things like Pulse Oximeter or Oxygen Concentrator are normal to find in an average household. That’s a big shift. So, telemedicine and technology are here to stay. But India needs to catch up swiftly on privacy areas. A lot of this data is online and can be misused. We need strict legal mechanisms as seen in many countries globally. Everything new and good comes with its set of challenges. Look at how useful UPI became but it also comes with UPI frauds. So, we will evolve as we grow. It will take some time.

Was it easy for you to grow as an NPO entity? How did technology help in terms of scalability?

The pandemic stretched our resources. We had worked on an open-source network and were enabling nine million consultants on the platform. In March the scale went up considerably. We also applied to a State Government which wanted us to manage their helplines, and support in triaging. But doing this would have taken a month given the need for infrastructure here. That’s where AWS came in. It came forward and helped us with solutions to scale easily. They gave us credits so the whole shift was not heavy on the financial side. It was also light on the tech-skills side as Project StepOne built and managed its technology platform without having any DevOps engineers in-house. We relied on the simplicity and manageability of AWS services and a team of volunteers who managed the tech deployments. It became easy to spin up servers. It was because of a simply managed offering by AWS. We just needed to provision it. Later as we took other State government helplines under the ambit, AWS helped us to re-architect the solution for a bigger scale.

How well did technology help you scale–especially when the time was a sensitive factor?

We could address many problems quickly and efficiently and build an innovative telemedicine solution on AWS Cloud. It also worked as an integral part of the government work processes and systems to fight Covid, bringing appropriate telemedicine interventions to bring care to Covid affected citizens. Especially during the second wave of the pandemic in India, when Project StepOne witnessed an increasing demand from 162,000 patients per day in April to 310,000 patients in May 2021, with an average of 1 million calls per day for these two months. This translated to an average of around 5 million events and an incoming traffic load of around 2 million sessions per day which it seamlessly scaled by 8 times since March 2021 by leveraging AWS services.

So, going forward, do you see technology playing a bigger role in such areas–especially we are getting ready for the Unique Health ID idea? Are we ready from the perspectives of data security, data loss, and equity here?

Yes, data security is a serious issue. More so, as we have clearly seen during some stages of the pandemic–we have witnessed how some medical data can be a source of stigma and societal ostracisation. Basically, medical records are enablers. They make the job of a doctor easier. With a unique ID, we have started a good framework, but implementation is slow and limited to a handful of areas. Such digitization efforts will be enveloped with challenges like cost and interoperability.

Why can’t we consider Zero-Knowledge Proof systems to handle this dilemma between privacy and data requirements?

A lot of the healthcare issues are still present predominantly in the rural parts of India. So, there are fewer incentives for entrepreneurs to develop such applications. We also need more surplus of medical schools in India. It is time we replicate the footprint and level of engineering colleges in the sphere of medical education too. And we need professionals and software who can understand and converse in the local dialects.

Technology is both a boon and a challenge. We as a society have to find a way to tackle such issues. Education and awareness are needed among people to achieve the right pace of development.

You tried something brilliant and resourceful with the use of medical students on this platform. With the huge scarcity of medical professionals in India, do you think licensing rules can be relaxed so that the small doctor base of India can use support from such talent pools? Especially now that AI, NLP, and automation are around?

It is a controversial topic. But if you look at any advanced healthcare system in a western country, there is a cadre of professionals and associates who support doctors but do not provide prescriptions. To use this base, the level of education and training for nursing in India has to be elevated. The Accredited Social Health Activist (ASHA) endeavor is a good example from the maternity care area. AI has a role to play and I guess US FDA is already clearing AI. But in India, this aspect is in nascent stages. We cannot afford to stay behind. It is extremely important to embrace innovations. AI can augment the reach and work of doctors to a great extent.

We cannot afford to stay behind. It is extremely important to embrace innovations. AI can augment the reach and work of doctors to a great extent.

What else stands as a challenge for telemedicine today?

Another challenge that India needs to work hard on is the quality of medical equipment. We have seen a phase during the pandemic where the market was flooded with Chinese oximeters. We need stringent quality standards for devices because this is what doctors would rely on a lot for delivering telemedicine. What also worries me is the Digital Divide here. A lot of urban customers will take advantage of tech-driven services but we should not forget that we are in a country where a lot of doctors have still to be convinced to work in villages. A lot of hands should join and NPOs like us could now focus on people that suffer from access issues.

What can tech professionals do? Any advice or words for our readers if they want to help?

Certainly. If you are a tech professional, you can join initiatives like ours. It is not only a way to help the country, but it also provides immense learning and helps a professional to sharpen one’s skills. As I pointed out, we need devices and apps to reach a lingual comfort for local languages so that disease or symptom need not be explained only in English. One key learning that I can pass on is that we were just a bunch of well-minded people who could make a huge impact. We had no experience, no expertise to work with governments and doctors and, still, we were able to help in solving a big problem. So can you!

Raghavendra Prasad Founder, Project StepOne