Steve Garguilo

Emerging Markets, Johnson & Johnson


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What can a sustainable telemedicine business model look like, and how do we get buy-in from those with the resources to make it happen?

In developing regions such as sub-Saharan Africa, the ratio of people-to-doctors is as high as 50,000:1. In the US, this ratio is 390:1. This means patients have to travel long distances at a considerable expense just to reach a doctor.

I worked with a team from Penn State University ( on a unique, sustainable telemedicine solution comprised of highly low-cost, ruggedized biomedical devices designed specifically for the developing world. Devices will collect medical information including weight, body temperature, lung capacity, pulse rate, blood pressure, stethoscope rhythms, photographs and basic hygiene and nutrition information. These readings would be paired with a healthcare questionnaire, medical history, and pictures which describe their symptoms, and then sent to a doctor for remote triage. The doctor then provides feedback through the same device. The solution would enable doing the initial triage and would provide the patient with remote health advice.

Though there have been MANY telemedicine projects in the past, most of them were experiments - they were VERY expensive and lacked an entrepreneurial outlook to ensure economic sustainability. A major constraint is that 95% of the biomedical diagnostic equipment used in Africa is imported, extremely expensive, not ruggedized and not repairable when it fails. This will be a low-cost, ruggedized option for decentralized diagnosis and triage of patients.

Three years of work in Kenya and Tanzania shows that people are willing to pay for a service like this because it cuts down on travel time/costs, and a pay-per-use business model will make this a sustainable venture rather than philanthropic. What should the model look like to really make it work? What are the flaws with this concept? How can we manage/mitigate/be willing to embrace the complexity? I want to influence decision makers at J&J, but don't have all the answers. I look forward to responses from the TED community!

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    Feb 20 2011: [Part 2 of thread from Mark Treat / was cut off]

    • New payment and reimbursement models which cover remote care – which is dependent upon proven financial models for remote care which justify the payment and reimbursement models. Justification is measured both in terms of health outcomes and cost savings

    Our observation is that even in the United States, where much of the health and technology infrastructure already exists, telemedicine programs often fail. The reason is that many of the pilot programs focus on one piece of the system (such as the introduction of an individual new technology or device), not the system as a whole. The changes in delivery processes and impact on other parts of the system are often ignored. Most importantly, the necessary support of the people who are stockholders in the system are also ignored. There must be a concerted effort to not only train the actors who participate in the system, but also properly communicate with them in order to overcome the natural human resistance to change.

    There is much discussion on the lack of money or reimbursement models which have certainly delayed the adoption of telemedicine. We must also recognize, however, that significant funds have been invested into pilot telemedicine programs. Unfortunately many of these programs have failed to take a holistic or systemic approach to the overall health delivery model and therefore have failed to demonstrate the promised value proposition. These failures can create reluctance to invest more heavily in rolling out telemedicine technologies. My sincere hope is that future programs will take a more holistic systemic approach to telemedicine.
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    Feb 15 2011: Steve, I think this telemedicine concept is great in theory, but I can't see it working in poorer countries with very high patient to doctor ratios. Instead, I could see it being viable in a place like the US for people who live very rurally or are house bound due to disability or illness--but as a supplement to an in person visit, or for clinical visits that don't require touching (eg psychiatry). As a doctor who's worked in rural and urban areas in the West, and in rural and urban areas in low income countries, I can tell you that you gain a lot of information from being in the same room as someone. Telemedicine with video capability would be good for triage and follow-up visits, but nothing beats the laying on of hands for diagnosis. In a place like the US, telemedicine could work as a cash service (eg via PayPal until insurances cover it), based on time spent with a patient. In poorer countries for non-wealthy patients, doctors usally don't spent more than 2 minutes per patient, and in that case, telemedicine is no substitute for an in-person visit. And figuring out payment systems there would also be tricky. Of course it would be ideal to have more doctors and to have them better distributed to rural areas. But, in the absence of that, community health care workers and auxiliary health workers (rural midwives, nurses) are a better solution than offering a doctor by telemedicine. If you want me to give you a detailed view on this telemedicine device, I'd be happy to examine it and give you more feedback. Here's how I can imagine telemedicine working in a developing world context--as a support to the country's doctors, to allow them to communicate with experts outside their country (eg for diagnostic dilemmas or 2nd opinions or for clinical mentorship). Hope this is helpful to you. Best of luck.
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      Feb 15 2011: Nassim - thank you so much for the valuable feedback.

      Your point about community healthcare workers and auxiliary workers is especially true. In our work in Kenya and Tanzania, it proved valuable where these workers played a key role as the operator of the device, either in remote locations expanding the radius of the doctor's practice and using the device when necessary to communicate with the doctor, or at a doctor's office so that this triage could happen before a patient needed to see a doctor. This unburdened the doctor so that he/she is only seeing more critical matters.

      Great idea surrounding connecting doctors to other doctors, definitely an area I need to research more as I'm sure there may be some programs like this that I can look at.

      Perhaps a better question to be asking is one that is more broad and not device/solution-specific: What role can you see an organization like J&J playing in helping to solve this challenge? Given that a device alone certainly won't solve the challenges, what would be the best model of partnership with NGO/MOH or projects that we can execute that would help? So many organizations separately want to tackle this problem, but I wonder what truly is an effective way to contribute to the solution?

      Thank you again for providing your expertise and guidance.
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        Feb 15 2011: Ha, I'm grappling with this question myself. See my idea thread on effective, long-term global health interventions. One obvious action that a company like J&J can do is to make life saving drugs available at a fraction of their US cost to poorer countries. And even better, to help revitalize the generic drug factories in those countries. Working to strengthen local health efforts and government health infrastructure make more sense to me than starting a brand new, foreign-inspired venture. Solidarity should be the model, not charity. See Dr. Wendy Johnson's excellent talk on this subject from TEDxRainier:
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      Mar 5 2011: Steve, you may be interested to see this TEDx talk which doesn't go into a lot of detail but appears to show a model that works in several developing nations and also in the USA -
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    Feb 20 2011: There is no doubt that remote technologies which can measure patients biometrics and move the point of care from a physician to the patient have matured to the point where they are reliable, safe and secure. There is no greater opportunity to improve the healthcare system.

    Our company [] is focused on solving this exact question: how to create a sustainable telemedicine program in order to improve patient’s health, quality of life, access to care – and save money. Our focus is in the United States, which is challenging enough, however when you expand that to third world countries which lack much of the basic infrastructure (such as reliable connectivity) the challenge is even greater. The largest challenge however is not in overcoming the technology barriers (even the connectivity issues can be resolved with new secure wireless technologies) but rather in modifying the healthcare system as a whole such that the new business processes which are enabled by technology take hold.

    My belief is that a systemic approach must be taken in order to create sustainable improvements in any healthcare system. There are a number of critical success factors, which include:

    •Facilitating a process for individuals to find a physician and have a meaningful encounter with the physician, even if the physician is remote
    • Doctors adopting new ways to practice medicine and manage their patient relationships
    • Support for patient self-monitoring and management of their own health
    • Sophisticated remote patient monitoring, with analytics which trigger alerts and interventions targeted to specific needs of individual patients – before the patient requires hospitalization
    • Remote, low cost, care coordination by skilled professionals in both health and information technology to facilitate new remote care delivery models. Technology alone will not do it, people will be required.
  • Mar 5 2011: Telemedicine in a developing world context is a wonderful opportunity for mental health parity inclusion at the inception of a new system. I would be willing to develop templates, informed by cultural and universal values, for health care professionals to screen for abuse and social-emotional well-being.