Int. J. Services Technology and Management, Vol. 6, Nos.

3/4/5, 2005 449

A telemedicine platform: a case study of Apollo

hospitals telemedicine project

B. Bowonder*
Tata Management Training Centre,
No. 1, Mangaldas Road, Pune 411 001, India
E-mail: [email protected]
*Corresponding author

Mohit Bansal
131, Central School Scheme, Air Force,
Jodhpur 342 011, Rajasthan, India
E-mail: [email protected]

A. Sharnitha Giridhar
Plot No: 420 Road No: 78 Jubilee Hills,
Hyderabad 500 033, Andhra Pradesh, India
E-mail: [email protected]

Abstract: This paper analyses the application of information communication

technologies for the delivery of medical services, namely telemedicine. As an
attempt to understand the working of telemedicine, the Aaragonda project by
Apollo hospitals has been studied. Various aspects of telemedicine such as
implementation and infrastructure and possible lessons from the
implementation of such a project have been highlighted.

Keywords: information and communication technologies (ICTs); medical

imaging; video conferencing.

Reference to this paper should be made as follows: Bowonder, B., Bansal, M.

and Sharnitha Giridhar, A. (2005) ‘A telemedicine platform: a case study of
Apollo hospitals telemedicine project’, Int. J. Services Technology and
Management, Vol. 6, Nos. 3/4/5, pp.449–466.

Biographical notes: Dr. B. Bowonder, Director, Tata Management Training

Centre, India. Prior to this he was the Dean (Research) at Administrative Staff
College of India, Hyderabad. He works on Innovation and Technology
Management. He has over 200 research papers and case studies to his credit.
He has also worked on various consulting assignments for United Nations.

Mohit Bansal, is a MBA in Marketing from ICFAI University, Hyderabad.

He is currently working with ING Vysya Bank, Bangalore as
Executive – Operations.

A. Sharnitha Giridhar, is a MBA in Marketing from ICFAI University,

Hyderabad. She is currently working with Times of India at Hyderabad.

Copyright © 2005 Inderscience Enterprises Ltd.

450 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

1 Introduction

Telemedicine is the use of the information communication technology (ICT) platform for
the delivery of health services. It has enormous potential for increasing the access to
medical services by increasing the reach. As the transaction costs are coming down,
telemedicine is likely to become widely acceptable [1]. ICT has changed almost every
aspect of social and economic activity, within the last two decades. ICT can provide a
powerful platform that could benefit the poorer citizens of developing countries.
By enhancing access to education and healthcare through distance learning and
telemedicine, ICT can improve the quality of life for poor rural communities who do not
have access to these facilities. The most critical requirement of telemedicine is a reliable
high-speed network.
However, access to digital technologies remains highly unequal globally, and even
among the developing countries themselves. The digital divide, simply put, is the gap
between those people and communities with high-quality and consistent access to
information technology and those without it [2]. There must a stable communications
strategy that connects the users with the global internet, if the telemedicine concept has to
become widespread. In addition, there should be a security framework that protects health
professionals and their patients from electronic snooping. The relatively new advances,
viz. firewall technology and public key cryptography will make high-level security
possible in the future [3]. Telemedicine has the potential to alter the landscape of health
services. The paper presents the experience of conceptualising and implementing a
telemedicine platform in the context of a developing country.

2 Methodology

This case is an analysis of the implementation of ICTs in the field of medicine with
specific reference to Apollo’s Telemedicine project in Aaragonda, a remote village in the
state of Andhra Pradesh in India. The Aaragonda project of Apollo Telemedicine
Enterprises Ltd., a non-profit organisation, was set up for the purpose of implementing
the telemedicine project. Administrative personnel and doctors were interviewed for
getting the first hand experience of managing this project. One live case is used as an
illustration to analyse the operation of telemedicine.

3 Evolution of telemedicine

The idea of performing medical examinations and evaluations through the

telecommunication network is not new. Shortly after the invention of the telephone,
attempts were made to transmit heart and lung sounds to a trained expert who could
assess the state of the organs. However, poor transmission systems made the attempts a
failure. Einthoven, the father of electrocardiography, first investigated ECG transmission
over telephone lines in 1906. Telemedicine dates back to the 1920s. During this time,
radios were used to link physicians standing watch at shore stations to assist ships at sea
that had medical emergencies. In 1955, the Nebraska Psychiatric Institute was one of the
first to have a closed-circuit television to provide mental health services from the
University’s medical centre to a state hospital over 100 miles away and was later linked
 A telemedicine platform: a case study of Apollo hospitals telemedicine 451

with the Omaha Veterans Administration Hospital and VA facilities in two other towns.
The National Aeronautics and Space Administration (NASA) played an important role in
the early development of telemedicine. NASA’s efforts in telemedicine began in the early
1960s when humans began flying in space. Physiological parameters were telemetred
from both, the spacecraft and the space suits, during missions [4] These early efforts and
the enhancement in communications satellites fostered the development of telemedicine
and many of the medical devices in the delivery of healthcare today. In the 1970s,
paramedics in remote Alaskan and Canadian villages were linked with hospitals in distant
towns or cities via ATS-6 satellites. Telemedicine’s second generation was based on the
use of digital compression and transmission technologies in the late 1980s, allowing
point-to-point interactive videoconferencing to and from anywhere that had access to T1,
fractional T1, or ISDN lines. In May 1998, AT&T created a telemedicine network
between Mount Everest and the United States Network to provide live-video
telemedicine sessions from the highest point on earth. Designed and integrated by AT&T,
the network will transmit the status on the wellness, endurance and physiological
characteristics, such as heart rate, respiratory, circulatory and other data on climbers in
the Everest Extreme Expedition. The data will travel via satellite, transoceanic fibre and
global ISDN from physicians at the climbers’ base camp on the mountain to an AT&T
location in the USA [5].

4 Concept of telemedicine

Telemedicine is defined as “rapid access to remote medical expertise through

telecommunication and information technology” [6]. A telemedicine system creates a
‘virtual’ medical consultation where the local medical attendant becomes the eyes, ears
and hands of the remote medical expert, collects the necessary information for decision
making, and serves to implement the necessary actions and treatment.
Telemedicine is a novel concept in field of healthcare, where ICTs is being used by
hospitals to provide specialised services to patients living in the different parts of the
globe. By using the computer-aided transmission of audiovisual data, a doctor can
diagnose the case of a patient in a distant location using an identified specialist from any
location [7]. Telemedicine provides tertiary healthcare to people in remote areas through
a virtual reduction in distance. Text, sounds, pictures and videos are being merged and
interconnected in completely new way. For example, the use of live video to examine
patients, electronic transmission of patients’ records and X-rays, recording of ECG data
and transmission over telephone, is possible, and this is termed digital convergence [8].
Telemedicine has the potential to revolutionise the whole of the healthcare
industry by:
• building bridges between clinicians and patients to overcome the barriers of distance
and time
• developing virtual communities that interact and share knowledge
• improving access to healthcare in remote or isolated areas
• enhancing continuity of care.
452 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

Telemedicine has three generic applications, namely:

• clinical applications
• administrative applications
• educational applications.
Clinical applications include handling urgent consultations, scheduled consultations,
remote visits of patients and the video reviews of certain studies done in advance.
Administrative applications covers telemedicine systems for promoting and accelerating
the replication, update and transfer of clinical information including medical records,
examination data and financial information. Educational applications include applications
that facilitate the process of sharing the material available for teaching and examination
purposes in the medical field. Interesting cases from a conference room, auditorium and
teleconference to physicians and residents scattered throughout the network are presented
using this technology.
Telemedicine has a number of benefits, namely:
• reducing the cost of service delivery
• easy and quick access to the specialist
• cost-effective post-treatment consultation
• travel time reduction
• enhanced quality and efficiency of medical care, hence increased care
turnaround [9].
As an emerging area, telemedicine has many unresolved questions. There is a need for
specific evidence of efficacy, therapeutic and diagnostic impact and cost analysis in many
areas of telemedicine. Issues of diagnostic/therapeutic efficacy, privacy and security of
information transmission, clinical standards and guidelines for practice, technical
interoperability of systems and technology and human resource planning are examples of
the questions, which must be addressed by telemedicine applications/projects.

5 Telemedicine in India

Public healthcare in India is not evenly distributed amongst the rural and urban sector,
both in terms of services and geographical proximity. It is to be noted that 60% of the
Indian population resides in villages with low financial resources, whereas 80% of the
healthcare facilities are in urban areas. The rural Indian population is dependent on a
Primary Health Centre (PHC), managed by a single Registered Medical Practitioner
(RMP) [10]. Most often, an RMP is a general physician who handles only outpatient
cases, and these PHCs are not equipped to handle tertiary care services. In its
introductory phase in India, Telemedicine was launched by the Pune district
administration along with the Tata Council for Community Initiative (TCCI).
Three PHC’s were linked with the District Administration of Pune and the Specialists.
A major challenge for the introduction of telemedicine systems in India is to provide the
service at an affordable cost using available telecommunications infrastructure.
 A telemedicine platform: a case study of Apollo hospitals telemedicine 453

The bandwidth limitation in POTS (plain old telephone service) is the major bottleneck,
which has to be overcome [3].
The prime objective was better exchange of information between doctors and to rush
medical supplies in case of emergencies that is one of the very basic uses of the
Telemedicine concept. Apollo Hospitals pioneered in the effective use of ICT’s through
the telemedicine project, covering a large number of locations.

6 Apollo Hospitals Ltd.: company profile

Apollo was the first corporate hospital set up in India at Chennai. Dr Pratap C. Reddy,
who had been a practicing cardiologist in the USA for over 10 years, established Apollo
Hospitals Enterprises Ltd. in 1979. The company commenced its operations in Chennai
with 150 beds, in 1984. The other companies in the Apollo Group engaged in similar
lines of business are Deccan Hospitals at Hyderabad and the Indian Hospitals
Corporation, which renders consultancy services for setting up and managing healthcare
services. The company is one of India’s few multi-specialty hospitals providing superior
diagnostic facilities and specialty treatment departments that can support major
operations in India. It has established itself as a centre for excellence in cardiac care.
Apollo now is a group of 27 hospitals comprising of 24 in India and one each in Nepal,
Bhutan and Dubai. Apollo has three main hospitals located at Chennai, Delhi, Hyderabad
and Madurai. Its major hospital at Chennai has 450 beds and 53 medical specialties.
In order to reach out to more people, and increase both the quality and awareness about
Apollo and its services, a new company called Apollo Health Street Ltd. was established.
Apollo Health Street banked on technology to reduce distances between the patient and
the doctor and launched a health portal, named, apollolife.com, in collaboration with
Satyam Technologies Ltd. The portal allows online consultation with the doctors and
gives information on prevention of disease. A general query on health information is not
charged but an online doctor’s opinion is based on payment. To provide Apollo’s medical
expertise to people in remote areas, Apollo Health Street introduced the Telemedicine
project [11].

7 Apollo Telemedicine Enterprises Limited

Over the last ten years, there have been numerous telemedicine projects and
demonstrations in many different sectors, which have been initiated to attempt to provide
consultative services to isolated, remote or rural areas while also utilising different
technologies to facilitate educational and administrative activities from a distance.
The telemedicine concept, as Apollo is implementing it today, was originally generated
by a group of Hospital Administration students. To foray into the field of Telemedicine,
Apollo Telemedicine Enterprises Limited was established as a non-profit organisation in
September 1999. It specialises in giving remote consultation and second opinions to both
patients and doctors for whom access to quality healthcare is difficult due to distance and
spiralling costs. The Apollo group started a Telemedicine project in Aaragonda to
demonstrate the use of telemedicine for general practitioners and to evaluate the project
in terms of economy and user satisfaction. Telemedicine can simultaneously enhance the
454 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

richness and reach of health services. Richness is quality of service and reach is access to
a service. Universal access through the internet can help in reducing the digital divide.
Aaragonda is a small village in Chittoor district of Andhra Pradesh, in India, having a
local Registered Medical Practitioner and a Mandalam PHC looked after by a single
doctor. Patients in Aaragonda had to depend on clinical labs in Chittoor for diagnostic
facilities. Aaragonda being the birthplace of Dr C. Pratap Reddy, Chairman and Founder
of Apollo Hospitals Ltd., was chosen for launching the first rural telemedicine centre.
This involves conceptualising, designing and implementing an ICT platform that can
deliver a variety of medical consultation experiences. The Aaragonda Apollo Hospital is
a INR50 million project catering to Aaragonda and the neighboring 24 villages with a
population of 50,000 and more. It is a 50-bed hospital offering primary and secondary
care. The Telemedicine facility at this hospital allows villagers to remain in the village
and still get access to specialists for a second opinion in case of complicated cases.
The first big success came when a doctor at the Aaragonda centre consulted specialists in
Apollo at Madras, when he was unable to help a lady on the operating table recover
consciousness. A specialist from Apollo, Hyderabad, used the videoconferencing facility
to guide his colleague in Aaragonda [12].

8 Project goals

The Aaragonda project was started in order to increase the rural segments’ access to
Apollo’s tertiary care sector. The purpose of the project was to save time and cut costs for
delivering health services for persons living in remote villages. There was a need for
standardisation of its activities in all its hospitals. The telemedicine concept will help the
hospitals to handle emergency cases in remote areas with sophisticated medical expertise.
The group plans to commercialise the concept by offering their consultancy services to
hospitals all over India wanting to replicate this project. The group plans to connect all its
hospitals (managed and owned) to its three specialty centres in Chennai, Hyderabad and
Delhi. First, the concept was implemented in Hyderabad and Chennai, and then, in Delhi.

9 Technology

The Aaragonda project comprises of a specialty centre and a consultation centre linked to
each other. A specialty centre is a well-equipped room where a specialist can converse
with a RMP in a remote area. The equipment required is a high-resolution video camera
(polycam), web camera, document camera, microscope, PC, microphone, speaker,
telephones, facsimile machines and a modem. The technology involved is the internet,
digital imagery, trans-telephonic ECG. The specialty centres are set up in Chennai and
Hyderabad, where experts from different fields of medicine are available in the Apollo
multi specialty hospitals. A consultation centre is set up in the 50-bed Aaragonda
hospital. From here, the RMP and patient can consult the specialist in the specialty
centre, using the same technology. The equipment manufacturers are GE, Wipro and
Citadel.
The consultation centre at Aaragonda and the specialty centre at Hyderabad are linked
to each other through an Integrated Services Digital Network (ISDN). A 128 kbps
(kilobytes per second) line was provided by the Department of Telecommunication
 A telemedicine platform: a case study of Apollo hospitals telemedicine 455

(DOT) for this project and was cross-subsidised by the Central Government of India.
As a back up at Hyderabad, the hospital is uses a VSAT line of 2 mbps (mega bytes per
second). Furthermore, Sriharikota and Aaragonda are directly connected to the Chennai
specialty centre through a Very Small Aperture Terminal (VSAT) of 2 mbps connection
through the Indian Space Research Organization (ISRO). It took two years to lay down
the VSAT line. The VSAT connection is a costlier proposal but much faster than an
ISDN connection. But for all practical purposes, villages can be easily connected using
ISDN lines. Calcutta and Guwhati are two consultation centres that are linked to
Hyderabad directly, through a dedicated ISDN line each. One of the essential devices
used for consultation is a polycam. A polycam is a video conferencing tool accompanied
by a voice transmission enabler. The polycam is connected to the ISDN lines and to the
TV both at the specialty and consultation centre as shown in Figure 1. From the
consultation centre, X-rays, CT-scans, colour Doppler, ultrasound images, etc. are
transferred over the ISDN line with the help of an interface. In the specialty centre, the
medical records are received on the system and can be alternatively viewed on the TV
through the polycam using an interface. In the absence of a polycam, a web camera is
used between Hyderabad and Calcutta, which is a consultation centre. For better
transmission of x-rays and echocardiograms, a high resolution/luminosity subsystem is
used. In the specialty centre, high-end scanners are used to capture negative and positive
images. For the transfer of ECG, special trans-telephonic equipment is used that is
connected to the ECG machine on one side and to the telephone line on the other.
The ECG readings can be seen and heard on the system at the specialty centre.
An electronic or digital stethoscope can be used to hear the heart beat. The equipment is
placed on the patient and connected to the telephone line and the doctor at the specialty
centre can hear the heart beat on the system or the telephone directly. In case of video
conferencing, the voice is transferred using a voice-enabling instrument attached to the
polycam. It has features like echo-canceller and noise reduction units for better
transmission of heartbeats, etc.

Figure 1 Telemedicine network

456 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

10 Implementation of the telemedicine project

Apollo has an in-house team of five members involved in software development and
maintenance, for the purpose of teleconsultation. In the telemedicine project, the usage of
software can be divided into three stages. First, the data is transferred from the
consultation centre; second, the process of accepting the patient record and fixing up a
teleconsultation takes place; and lastly the process of viewing post consultation details
takes place. The three phases of the telemedicine process is schematically shown in
Figure 2. Patient details, called the electronic medical records (EMR) are transferred from
consultancy centre to the specialty centre through a desktop version of software called
Emedscope developed by General Electric Medical Software Information Technology
(GEMSIT). This is a software which is available in the market and can be used by any
doctor and not specific to Apollo. In this software, each patient’s records are identified
and retrieved by a unique health identification number (UHID) given to every patient
who uses the Apollo hospital services. This UHID system is limited only to Hyderabad
and Chennai Apollo Hospitals and later would be extended to other centres. This is a
one-time registration number for both telemedicine patients and general patients.
All patient records are maintained online at labvalues.com and can be viewed using a
UHID and password. Apollo Life is offering to upload all the patients’ diagnostic reports
on labvalues.com for a period of five years at a nominal charge of INR200. The hosting
charges per report are only INR2. Each patient’s records are saved on a centralised UHID
server on the basis of a UHID number. Fresh records of the patient are updated using the
same number and, thus, data consistency is maintained.

Figure 2 Schematic representation of the telemedicine process

 A telemedicine platform: a case study of Apollo hospitals telemedicine 457

Using the UHID number, the patients’ visit details are entered into emedscope.com at the
consultation centre. All essential information like name, age, ailments, symptoms,
diagnosis-so-far, etc. is entered. The software provides information on the availability of
doctors in the different departments of medicine. The patient requests the time and date
and chooses a doctor from the available list. The patients’ X-rays, CT-scans and other
related images are transferred using the emedscope software a day before the
consultation. Radworks is a software used for online transmission of images and is
developed by GE. ATEL is trying to integrate Radworks with their telemedicine
software. Presently, for online transmission of images, equipments like the CT-scanner,
X-ray machines etc. are connected to the polycam. Emedscope is ICD 10 and PCS
enabled, which are international standards for drugs and surgery, respectively. Radworks
is dicom enabled, which is the international standard for online transmission of images.
In the second phase, the patient’s EMR are transferred to the client software from the
emedscope software. There are three alternative ways to transfer this information,
i.e. internet, physically (i.e. by post) and remote access service (RAS). RAS is a feature
of Windows NT, which allows direct connectivity using telephone lines between two
systems placed at distant locations. At the specialty centre, the telemedicine client
software consists of two parts, i.e. the appointment accepted/rejected page, and the
post consultation page. Depending upon the availability of the doctor requested,
the teleconsultation appointment is accepted, rejected, cancelled or kept pending.
The appointment details are sent using a reference number, to the consultation centre.
In the last phase, the personnel at the consultation centre views the appointments page to
check the status of the patient’s appointment. The centre can either cancel or accept the
appointment. After the consultation takes place, the doctor gives his opinion on the case
and instructions for the patient through a post-consultation page. This post-consultation
information, which includes conference details, diagnosis and treatment plan is viewed at
the consultation centre. All patient information is stored on a centralised database
maintained by Apollo Telemedicine Enterprises Ltd. The group has a centralised database
server at Atlanta where the records of all Apollo hospitals will be maintained. As a part
of its apollolife.com site, the hospital plans to offer online medical records maintenance
to its patient at nominal extra cost.
The first person to be treated through Aaragonda telemedicine happened to be an
11-year-old girl having a hole in her heart valve. This was discovered after her
echo-cardiogram was beamed to experts in Hyderabad. The procedure of using
telemedicine is quite simple. In case the general physician cannot diagnose a patient
admitted to the Aaragonda hospital, then he will transfer the patient’s records to the
specialist in the specialty centre. Personnel required in both the centres are at least two in
number for general administration and equipment handling. The specialist studies the
patient’s reports and depending upon the seriousness of the case, fixes up a date for
teleconsultation or just gives his opinion through the telemedicine software. On the fixed
date, through videoconferencing, the specialist, general physician and patient at the
remote site interact and further treatment is decided upon.
The Apollo Hospital in Chennai had monitored one operation through telemedicine
since the inception of this concept, and the staff wants to gain expertise in this area.
Dr Alok Ranjan believes that the Apollo will explore all opportunities to conduct
surgeries, and not just limit itself to teleconsultation, via telemedicine in the near future.
For increased access to medical expertise, Apollo plans to tie up with renowned hospitals
in Europe and the USA.
458 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

Box 1 Telemedicine consultation case study

A live case handled by Dr Alok Ranjan (Consultant Neurosurgeon, Apollo Hospitals, Hyderabad):
A patient named Shanker Chandra was undergoing treatment in Calcutta under Dr Tamal
Bhattacharya at the consultation centre in Calcutta. In the course of the treatment, a specialist’s
opinion was required and Dr Tamal Bhattacharya referred the case to Dr Alok Ranjan at the
specialty centre in Hyderabad. Calcutta has a full-fledged telemedicine consultation centre and is
connected to the Hyderabad Apollo Hospital. The patient’s records were sent in advance and the
appointment was fixed according to Dr Alok Ranjan’s schedule. Before the consultation begins,
both the centres have to enter each other’s IP (internet protocol) address for a web camera meeting
in the absence of a polycam. The meeting took place for 10 min, in the course of which Dr Alok
advised the patient on his future treatment plan.
The billing for a telemedicine consultation is done at a flat rate of INR500 in case one
specialist is involved and INR750 in case of two specialists. In case of overseas referral cases
ATEL charges $50 if one specialist is consulted and $75 in case of two. This web consultation has
saved Shanker Chandra quite a few expenses he would have incurred if he had to travel to
Hyderabad to consult Dr Alok Ranjan. Web consultation has its own problems like connectivity
delay, image and voice distortion.
Dr Alok Ranjan, Consultant Neurosurgeon, Apollo Hospitals, Hyderabad, feels that
Information Technology will radically change the working of medical science. Telemedicine has
revolutionised medical consultation by cutting down the distance between the rural patient and
urban specialist. Dr Ranjan feels that the direct benefits of telemedicine for patients are
convenience, better care, cost effective care, state of art care and best possible care.
Dr Alok Ranjan feels that the number of cases will increase from two per week now to close to
20, which will make their task more challenging. Wider acceptance of the telemedicine concept
will increase the number of referrals for a doctor and his compensation will commensurate with the
same, accordingly. Doctors on the telemedicine panel should be tele-savvy, should be able to
understand and answer the patient’s problem precisely and fast because of connectivity constraints.
The doctor believes that, presently, telemedicine in India is only for second opinions and is not
a means of performing surgeries, due to lack of infrastructure. He feels that Apollo, being one of
the first corporate hospitals to use telemedicine, have large growth prospects in terms of
technologically backed quality treatment and in creating a niche segment in telemedicine care. In
India, confidential information cannot be transferred using the existing network as it is prone to
web hacking, etc. To overcome this problem, Hippa, a European standard for data protection can be
implemented to transfer confidential information between two different hospitals. Apollo has not
adopted this standard for its current project, but is considering it for its future telemedicine projects.

11 Replicating the concept of telemedicine

In order to create awareness about the telemedicine concept, ATEL’s in-house marketing
team conducts seminars and presents research papers to interested government and
private bodies. In this manner, ATEL secured the Karimnagar and Ellore telemedicine
project. Both the hospitals are government run hospitals and ATEL was invited to link it
to Apollo, Hyderabad. ATEL also bids for tenders of telemedicine projects. In future, it is
planning to enter into turnkey projects that includes telemedicine consultancy to the
interested parties and also providing end-to-end solution to them. The Apollo brand name
and their personal contacts helped to sell the idea in its initial phases. ATEL got two
 A telemedicine platform: a case study of Apollo hospitals telemedicine 459

overseas projects from Tanzania and Dhaka, respectively, due to this reason. A sales
executive is appointed to create awareness in the regions around the consultation centre
and also tap potential opportunities. The doctors involved in the telemedicine project
explain the benefits of this concept to their patients and encourage them to use it if
necessary. Efforts are being made to involve the local doctors, also, in this project, even
if they are not directly associated with the Apollo group for transferring the interested
patients to the consultation centre. Health camps are being conducted at the consultation
centres where a specialist from the specialty centre participates to create awareness about
the telemedicine concept. Pamphlets in the local languages are distributed to explain the
concept in detail. The telemedicine concept is also described in detail on apollolife.com, a
website targeted at urban customers.

12 Project management

The project management team at Hyderabad comprises six people, from the field of
marketing, software and general management. As soon as a proposal to set up a
telemedicine consultation comes by, the marketing team assesses the viability of the
project and comes up with a formal agreement with the interested party. Prior to that,
they market the concept among Government and corporate hospitals and grab every
opportunity that comes their way through newspaper advertisements or formal bidding
process. ATEL then seeks connectivity between the proposed centre and one of its
own specialty centres. Depending upon the scale of operations, establishing VSAT
(ISDN-back up) connectivity takes up considerable time. The next phase involves setting
up of equipments and installation of software at the consultation centre. ATEL gets the
best bargain on the equipment because of an established vendor network created by the
Apollo group. The equipment and software installation and takes 2–7 days in case of
small consultation centres and 20 days for a corporate hospital to be converted into a
specialty centre. The seven-day period includes training of doctors and telemedicine staff.
The minimum set-up cost for a small consultation centre is INR 500,000. ATEL gives
project consultancy to interested party not a part of their group and offers to sell their
software to the client. ATEL has developed competency in implementation of the
telemedicine concept, which has led to time saving and cost cutting measures. In case of
their Kohima project funded by Japan, ATEL was successful in bringing down the project
cost from 4.8 million to 3.4 million.
ATEL, since its inception in 1999, has conducted 3791 telemedicine consultation
through its three specialty centres. The specialty centre at Chennai has handled 2409
cases, Hyderabad witnessing 1344 and Delhi, which is the Apollo group’s latest centre to
enter the telemedicine field, has handled 38 cases. It is their endeavour to further gain
expertise in this field. The above figures show that Apollo is steadily gaining a foothold
in the telemedicine concept of treatment and may begin to seriously consider a business
model for future expansions.
460 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

Figure 3 Region-wise telemedicine consultation

13 Future plans

After its pilot telemedicine project at Aaragonda, the company is providing end-to-end
solutions for the purpose of telemedicine consulting. The end-to-end solution involves
providing only operational support in terms of setting up medical and technological
infrastructure for data transmission and connectivity. End-to-end solutions are provided
to private and government hospitals and then the hospital decides whether it wants to
connect to one of Apollo’s specialty centres or any other hospital of its choice, for
telemedicine consultancy. Currently, Apollo is not looking at constructing new hospitals
primarily for the purpose of telemedicine, but only providing connectivity to the existing
ones. ATEL is going to connect the government hospitals of Karimnagar and Ellore to
the Apollo Specialty Center, Hyderabad, in the near future. The Andhra Pradesh (A.P.)
government, Apollo hospitals and the medical equipment providers GE are
cross-subsidising both the projects. The A.P. government is providing the VSAT
connection. Apollo will pay half of the medical equipment cost and remaining will be
paid to GE over a period of seven years. Apollo’s in-house technical team will provide
operational assistance free of cost. The Royal family of Jodhpur has invited ATEL to
replicate the telemedicine concept. The plan is to link 25 primary care hospitals all over
Rajasthan, in India; to the secondary care hospital in Jodhpur called ‘Raj Dadhi Hospital’,
managed by Apollo. The Raj Dadhi hospital, in turn, will be connected to Apollo’s
specialty hospital in Delhi for tertiary care consultancy. The telemedicine project will be
financed by the NRI fund managed by the Royal family of Jodhpur. The initial plan in
Jodhpur is to provide free telemedicine services for the next two years and perhaps later
develop a business model.
In the eastern part of India, Kohima, the capital of Nagaland will be connected to
Apollo’s specialty centre in Delhi. This is a project that is being funded by the Japanese
government and the Ministry of Nagaland. Apollo and GE provided medical equipment,
which is the major cost, at a subsidised rate. Apollo’s recent expertise in providing
end-to-end solutions has helped to save close to INR 1.2 million for both the parties
involved in this project. ATEL has been approached by ISRO to connect 40 clinics all
over the country, for telemedicine consultations to the Apollo hospitals. ISRO will
provide free bandwidth and also bear the cost of equipment used for the entire project.
ATEL has been approached by the Indian Air Force to extend ATEL’s services to the
country’s defence wing by connecting 200 centres all over India. With increased
acceptance of telemedicine, ATEL has identified the need to upgrade its telemedicine
 A telemedicine platform: a case study of Apollo hospitals telemedicine 461

technology. It has tied up with Central Research Lab (CRL) in London for implementing
wireless technology in order to access telemedicine services on mobile devices. ATEL
plans to launch the telemedicine concept in Madurai, Thundiarpet, Coimbatore, Mysore,
Ellore, Sriharikota, Dhaka and Tanzania.

14 Issues concerning the telemedicine project

The implementation of the telemedicine project has shown that three sets of issue need
particular attentions so that the effectiveness of the project could be substantially higher.
These are essentially, cultural issues, legal issues, technological issues, economic issues
and end user satisfaction.

14.1 Cultural issues

In spite of ATEL’s effort to create awareness about the telemedicine concept through
their specialists (doctors), marketing team, health camps and other forms of mass
communication, doctors at rural centres still find resistance to teleconsultation. It is the
doctor at the consultation centre who plays a major role in explaining the concept and
making the patient comfortable with this form of distant consultation. This is the major
cultural issue involved. The costs and benefits of telemedicine are shown in Table 1.

Table 1 Patient cost effectiveness

Costs Benefits
Individual interaction via Telemedicine Patients save on travel and post treatment
platform expenses
Marketing cost Savings on physician expenses

14.2 Legal and safety issues

Confidentiality in the transfer of electronic medical record is of prime concern in this
emerging field of medicine. There exists a question mark on adequacy and accuracy of
electronically transmitted data for establishing a correct diagnosis. If, due to technical
malfunction, the patient’s data is not transferred correctly, e.g image degradation in an
echocardiogram or in a histopathology slide that will alter the diagnosis, who will be
responsible – the attending physician, the hospital, the manufacturer or distributor of the
equipment, or the telecommunications department? These are important aspects to
consider before venturing in to a telemedicine project [3].
ATEL uses software that captures post-consultancy details and the authenticity of the
data is maintained through e-signature of the doctor. It also follows some US guidelines
for security of the data transmitted. It plans to adopt Hippa standards, which are
guidelines for transferring confidential information between two hospitals. It will also
follow Dichom standards, in future, which are European standards for transferring
medical data over the net.
462 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

14.3 Technological issues

Bandwidth plays a major role in the success of teleconsultation. VSAT is the preferred
connectivity between centres, but the availability on a large scale is costly and time
consuming in India. For some of ATEL’s major projects, ISRO was a provider of
bandwidth on subsidised rates. While connecting different centres, large investments are
incurred by way of equipments and a tie up with major equipment vendors may reduce
costs. ATEL has a tie up with Wipro for hardware, GEMSIT for software and GE for
medical equipment [13]. The costs and benefits associated with the telemedicine
technology platform is given in Table 2.

Table 2 Technology cost effectiveness

Costs Benefits
Setting up of technology infrastructure Ease of use
Reliable
Quality of data transmission
Service maintenance facility

14.4 Economic issues

ATEL does not have a well-defined business model in place and operates as a non-profit
organisation. The Apollo group along with participation from organisations like ISRO,
GE, Wipro and State governments has funded all the centres set up so far. In order to
sustain the current model, the organisation needs to reap back the investment of INR
500,000 made per centre. Each consultation generates INR 500 and to break even and
cover operational expenses at least 1000 consultations per centre per year is necessary.
ATEL should look for a more self-sufficient model. The economic aspects of the
telemedicine platform are compared in Table 3.

Table 3 Economic cost effectiveness

Costs Benefits
Start-up cost Revenue retention at referring site
Operating cost Revenue generation

14.5 End user satisfaction

The efficacy of any service can be judged based on end-user satisfaction.
The end users of telemedicine are very diverse and include:
• patients or patients’ relatives
• primary care providers
• consultants
• instructors
• students
• business users.
 A telemedicine platform: a case study of Apollo hospitals telemedicine 463

Patients expect foolproof and convenient treatment and telemedicine should ensure that
their expectations are met to their satisfaction. Telemedicine should give substantial
returns on investment made for the business users of this concept. Maintaining a large
panel of specialists and compensating them satisfactorily will require substantial efforts
by the telemedicine management team, to create the required volume and manage the
costs.

15 Lessons from the above experience

This being one of the first corporate telemedicine experiences, it will be worthwhile to
analyse the experience and derive lessons for replication of the concept to other locations.
• Patient requirement analysis. In this case, the first centre was selected as a pilot and
other 15 locations were subsequently added. For the 15 locations that were added,
they used partners so that they could pool the required resources, including
government support to minimise the cost. The main lesson is that there has to be a
detailed requirement analysis before identification of the location. Areas deficient in
medical services need to be assessed properly.
• Capital requirement assessment. From the experience, it is evident that each centre
requires a capital investment of USD 10,000 (INR 500,000), apart from operational
and maintenance expenses. It essentially means that each centre has to generate at
least INR 2000 per day to make the operation viable. In poor communities, this
requires coordination of action by government and private service providers like
ATEL.
• Connectivity. The success of telemedicine comes from reliable linkages and excellent
connectivity. As rural areas have poor infrastructure availability, ensuring
trouble-free connectivity is the problem in telemedicine. This will require good
VSAT connectivity. In most of the current locations, they were able to achieve low
cost connectivity through the help of Department of Space, Government of India.
For many areas that are poor and that lack connectivity, this option, thus, is not
feasible. Cost reduction and pooling of resources are the areas that need attention.
• Replicability. The business model used by ATEL cannot be replicated easily as
ATEL is a non-profit organisation. Apollo Hospitals limited is a corporate multi
location hospital group and they could use a non-revenue-earning model, as it is only
a complimentary activity. Other hospitals have to use appropriate revenue models
that could be sustained over a long period of time. Since technology is changing and
customer expectations are rising, only models that could ‘invest and grow’ can be
sustained.
• Telemedicine consultation experience. If the concept of telemedicine has to grow,
there have to be reputed doctors in the network. A non-revenue-earning network
cannot sustain a large panel of experts. Apart from this, telemedicine requires a
proper time-planning and coordination so that the designated specialists are available
at the required time at the given location. Also, the doctors have to be trained in
telemedicine if the concept has to be propagated.
464 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

• Concept acceptance. The crucial issue is the acceptance of remote consultation

procedures. This has both cultural and psychological overtones. In medical
consultations, one of the essential behavioural factors that is needed for success in
telemedicine is patient–doctor trust. This requires either personal trust or institutional
trust. Brand building could be one option.
• Legal issues. Another issue that needs to be managed in telemedicine is the legal
aspects. Confidentiality and legal responsibility under legal medico rules are
prerequisites that have to be evolved. For direct consultation, it is easy to fix liability,
but it is not easy to define liability in virtual consultations. As medical records
become electronic, security becomes a growing concern; as electronic
communication with physicians becomes standard, doctors will be faced with a
24 hours flow of information, with some vital messages requiring immediate
response – raising both health and legal concerns. As computers integrate more fully
into practice, physicians will continue to have primary responsibility for diagnosis,
but will be assisted by powerful computerised tests and expert systems. Increasingly,
physicians will become less responsible for keeping direct medical knowledge.
The knowledgeable guide concept will become the option.
• Competence development. Developing good technical experts who can handle
medical equipment and medical information are yet to be trained in large numbers.
Skill development in such interdisciplinary areas is a currently a ‘no man’s land’.
There has to be a significant level of institutional development activity in this area at
the national level, at the institutional level and also at the regulatory level.

16 Conclusions

Telemedicine is a multiple application ICT platform. Though telemedicine has enormous

potential to reduce the digital divide by increasing the reach, good high-speed links are
essential for its success. The volume of transactions is likely to be the critical success
factor and, hence, the strategy has to be to create more transactions if it has to be made
sustainable. The concept is not quite as it is a virtual consultation practice with a different
cultural experience. The success of telemedicine depends on connectivity and volume of
transactions. Probably, a viable strategy could be to introduce telemedicine in small
towns where there is lack of facilities but connectivity extension could be easier. But, the
cultural acceptance of telemedicine is still limited.
Apollo Hospitals is a large organisation with a substantial number of computer
experts and doctors; such a backbone may not be available in other developing countries.
Development of institutional capability through the concept of shared services may be
explored as a viable institutional option. Telemedicine assists in providing us with
multiple delivery options as shown in Figure 4. Telemedicine is technically a feasible
concept, but it needs substantial investments. There are only two ways in which it could
be made economically viable, namely:
• by obtaining government support for the infrastructure
• by providing a bundle of shared services using the same infrastructure.
 A telemedicine platform: a case study of Apollo hospitals telemedicine 465

Figure 4 Telemedicine delivery options

Developing countries have to evolve low cost service delivery options, as healthcare
services are moving from the public to the private realm. This will need
operationalisation of a public–private partnership. In ICT platforms for medical
consultation, reputation and trust are the critical success factors. In ICT platforms for
medical consultation, behavioural issues take the forefront along with the reliability of
the platform to provide the critical service. Building both trust and reputation are
time-consuming efforts. Hence, the rate of diffusion of telemedicine continues to be low.
This analysis and subsequent interviews with the concerned experts indicate three critical
success factors for sustaining telemedicine network are:
• low cost (economic sustainability)
• connectivity (technological efficiency)
• trust (behavioural acceptability).
Given the scope and potential of telemedicine in India, and the initiatives taken by the
private players such as Apollo and Care demonstrate the evolution of telemedicine
platform.

References
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466 B. Bowonder, M. Bansal and A. Sharnitha Giridhar

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Appendix

Source: Apollo Hospitals, Hyderabad.