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I can be reached at danduckworth@gmail.

com

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My research literally spanned hundreds, if not thousands of documents. In the
bibliography I have captured those that were most useful. The bibliography will also
correspond to the soft copies that are available.

I wanted to leave this behind in an orderly fashion so that others who work with the
organization who need to learn about telemedicine, which is a relatively new
concept, will not have to start from nothing.

As with all of the deliverables and data referenced in this presentation, the
bibliography and zip file will be downloaded to the folder “111” in “All Modules.”

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I wrote this paper at the outset of my internship with Byrraju. It was the best way I
could think of to discipline my initial research to catch myself up to speed before
arriving in Hyderabad. The paper is a good overview of the state of telemedicine for
anyone who is knew to the field. Because I may attempt to publish this paper (or
parts thereof) sometime in the future, I would appreciate if it is properly cited when
referenced. If you desire to share it with someone outside the organization, please
contact me for approval first. See slides 11-14 for a discussion that includes themes
from this research/writing.

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The village census was conducted in 2004. 144 villages were surveyed family by
family. Data entry is suspect, and the census process itself is open to questions. To
make any use of the data, I had to combine the documents into 5 district-level files. I
then used Microsoft Excel to pull data from each separate file. The statistics I
gathered are reviewed in a later section of this presentation. The raw statistics
(tables, not charts) are available in an accompanying Excel spreadsheet.
Unfortunately, because the calculations were drawing from files as big as 80 MB (in
the case of West Godavari district) I could not retain the original formulas that were
used to pull out the data (otherwise Excel would crash every time the formula tried to
update the results). The titles of the tables, however, should be sufficient for the
reader to understand what data was pulled. See slides 28-41 for a summary.

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The only information available for FY07 is at the aggregate level. The data cannot be
broken down into subcategories or by geography. As Oracle is implemented going
forward, it will be beneficial to build reports that allow the health care managers to
see specifically what the costs of investment and operation are, and also to compare
across districts to find abnormalities. See slide 42 for a summary.

The cost of setting of a village health center is data that was estimated by the finance
department. Refer questions to it. See slide 43 for a summary.

The cash flow projections are included in the proposed model overview. I sat with the
health care people to document what assumptions they made to estimate the future
costs of the telemedicine model. I have a few concerns, noted in that documented,
over the validity of some of the assumptions. Unfortunately, because past data
cannot be “sliced and diced”, it is not as much help as it could be in projecting future
costs and revenue. It was my questions regarding the assumed revenue stream that
sparked the ongoing study of villagers’ willingness to pay for telemedicine services.
See slide 44 for a summary.

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There are three estimates for the costs of medicine. The first is taken from West
Godavari’s June report. Of course, it would be better to get the reports of all health
centers and for many months to estimate the monthly cost of providing medicines
per village. By the time I realized such a report existed, it was too late to spend much
time on a new round of data collection. There is also a project being conducted by a
group of Shiva Shivani interns, in which they have collected data on the costs of
medicines for three villages in Rangareddi District. It was from their data that I
extracted the price per unit of the medicines that I used to compute the average cost
of medicines per month. See slide 45 for a summary.

The salary information was given to me by the finance department. See slide 46-47
for a summary.

The age information was collected on my behalf by Arun Kumar and Venkata Rao,
with the help of Vasundhari Alluri. See slide 48 for a summary.

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Villages I visited include:
Vandrum
Juvvalapalem
Allavaram Kendram
Poduru
I-Bhimavarem
Jallikakanara
Kashevarem
And several others whose names I failed to record

See slides 51-53 for a summary.

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My ideas on this are well-fleshed out in the white paper.

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My ideas on this are well-fleshed out in the white paper.

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Byrraju Foundation, both in verbal and written communication, offers the same
promise as the telemedicine field in general: lower costs, greater access, the same or
better quality of health care.

Unfortunately, it also falls into the same trap: there is no proof of any of these things.
For the Byrraju Foundation, that is okay. Telemedicine is very new program here, only
6-8 months old. However, if the organization’s hopes to fulfill its mission to be a
platform by which other organizations can learn best practice, it should care deeply
to real evidence of the impact of its programs on cost, health, quality, etc. It should
also have data that proves its programs are the best option, at least for this area. That
means collecting data on alternative models, including the one it is using currently.

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Too many organizations have “fallen in love with” technology, and they implement it
just because they can. More thought should be given, and more research conducted
to prove, that telemedicine (in an form or fashion) is truly what it claims to be.

Currently, there is no way to know whether the Byrraju health model is the best
solution to the health problems of Andhra Pradesh. The impact of the program is
today as much a conjecture as it was pre-implementation.

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Data management is essential to good management, especially for an organization as
big as the Byrraju Foundation and whose headquarters is so distant from the on-
ground operations. Without information on what is truly going on now, the managers
can only make decision based on a gut-feeling. Gut-feelings are sometimes right, but
they are sometimes wrong.

Speaking as someone who spent two years on a project to improve the information
management of multinational agriculture, I cannot emphasize enough how important
it is to first clearly define the metrics and reports that management will actually use
to make decisions. Whatever those are, that is what should be collected and
processed – nothing more, and nothing less.

There is also a great opportunity now that Oracle has been implemented to
standardize the processes by which data is captured and reported on. The
organization would be wise to learn this system and to handle as many of its
information needs as is possible through this system.

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The benefits of a willingness to pay study are many. The Foundation benefits with
better information to make management decisions, and with which to convince
donors that its proposed model is financially sound. If a paper is published, it also
enjoys the limelight of a broad audience that will learn about its programs as they
learn about the study’s conclusions.

Professor Ravi Anupindi (University of Michigan) and the research community also
benefit, precisely because there is little to no quality research published in the three
areas here mentioned. I am confident that a paper that addresses these three
subjects will be well-received and widely circulated among the telemedicine
community.

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My time in Hyderabad has been largely focused on preparing for the study. I hope
that the information herein reported is useful to the study design.

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This is a side comment. The entire internship I have been thinking of a relatively basic
concept. When we say “sustainable” in terms of finances, we mean revenue meets
costs. When we say “self-sustaining” we mean that revenue is generated from within
the system by charging a fee to the consumer. When we charge a fee to the
consumer, we automatically decrease the optimal volume of transactions. In the case
of health care, that means that charging a fee automatically creates a population that
will not receive the service because it cannot afford it. Therefore, when we put
forward “sustainable” as our goal, we should also recognize that we are sacrificing
“universal” as another goal.

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Another side comment. There may be ways to blend “sustainable” and “universal”. One such
way is through price discrimination: charging patients according to an income scale where
the poorest are not charged at all. So long as the “wealthier” (in relative terms) are
overcharged by enough, their fees can subsidize the lost fees of the poorest.

Also, something that was mentioned by the villagers time and again is the income volatility
associated with being a day laborer. They simply cannot say for certain what money will be
available in the future. If Byrraju charged a monthly access fee as opposed to a fee-for-
service, would this help smooth out the costs of health care for day laborers?

Also, I believe there is a great opportunity to generate revenue from personal use of the
computer/internet setup. If Byrraju focuses on creating demand for personal uses (email,
browsing, even job-related functions), it may be able to generate enough revenue to
subsidize the costs of health care for the poorest. Right now is postulated that the internet
will be made available for free as a means of helping people get comfortable with the
technology. This may be a worthy goal, but I think a better goal is to use this opportunity to
generate revenue.

Organizational alternatives. Could nurses be better trained to reduce the demand for
doctors’ services? This would limit the number of doctors needed in the new model. Could
Byrraju coordinate better with existing health care providers, training them to do certain
functions well (well enough that Byrraju does not have a need to provide redundant services)
while Byrraju focuses more on services that can be easily accomplished through
telemedicine? Could there even be partnerships created with local providers much like HMRI
partners with district hospitals?

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The Foundation has two conflicting personalities. On the one hand, it has the
management personality that wants to move forward with new ideas now. On the
other hand, it has the research personality that wants to be a platform by which
others can learn best practices. As far as telemedicine goes, if the research is going to
be done in a way that it truly demonstrates the impact of telemedicine on cost,
quality, and access in comparison with the next best alternatives, then the brakes
need to be applied to the current plans to implement the new model by year end.
The Foundation is in a wonderful position right now to do the kind of systematic
research that the research community has been calling for (unsuccessfully) for the
past 10 years. It is my opinion that the good to be gained by doing the research the
right way is worth far more than the good to be gained by moving full steam ahead.

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I am not an expert in research design, and neither are the managers at the Byrraju
Foundation. But there are plenty of such experts who have spent their entire careers
perfecting this science who would be glad to join with the foundation to design and
implement such research. The Foundation should locate the top telemedicine
research institutes in the world and should begin talking with them about what
research could be conducted and what faculty at that particular school would be
interested in participating. For example, it could start by contacting the Telemedicine
Resource Center at the University of Michigan Health System
(http://www.med.umich.edu/telemedicine/).

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This has been a wonderful opportunity to gain first-hand experience in a number of
different areas, listed above. India is many different things, and to most people in the
U.S. it is still very much a mystery. I now have a much clearer picture of what India
really is, and what it means when we talk about India as an emerging economy, high-
tech hub, and developing country, and I now know what India’s cities and villages are
like (most Americans have only seen her cities and cannot comprehend what village
life really means). I have read many statistics from the WHO, the World Bank, the UN
that talk about those people in the world that live on less than US$1/day. Now I have
met them (I know, because I have asked them how much they and their spouses earn
and how many people they take care of with that income). I know what that
population eats and drinks, what their homes look like, what their schools and
hospitals are like, what their outlook on life is like. This has been very valuable.
Moreover, to do this while working with a leader in nonprofit management like
Byrraju has also given me the opportunity to see how nonprofits can leverage best
management practices to accomplish their missions.

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Coming from the U.S., the internship experience can be very frustrating, especially in
the first few days. It should be clearly laid out what the logistics will be for the first
few days. Also, a packet should be given to interns BEFORE THEY ARRIVE so that they
can navigate those first few days.

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This slide is just an example of what might be done. The point is simple. Too much
time is lost in the first 2 weeks. A well-planned regiment should be implemented that
will integrate the intern as quickly as possible into the work of the organization.
Personally, I think intern projects should not be stand-alone projects that only he or
she is responsible for. I would much prefer to work on a project that started before I
arrived and will finish after I leave, but to be given a sub-project(s) within the larger
project that will help the existing team to meet its overall objectives and deadlines.
There is a danger that this kind of work, if not properly planned and managed, could
become grunt work (making copies, etc.). Nevertheless, if well planned and managed,
it will create the opportunity for the intern to produce something that is immediately
and completely relevant to the work of the organization and avoid the possibility that
interns’ work will either miss the mark and/or be put forgotten in the fuss over what
the organization is actually working on at the very moment.

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What is the population we are trying to serve?

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What is the population we are trying to serve?

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What is the population we are trying to serve?

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Can the population afford health care by telemedicine?

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Can the population afford health care by telemedicine?

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Can the population afford health care by telemedicine?

There looks to be a problem with the “All” bar on this slide, though the formulas were
accurate. It seems like it should be closer to WG’s 1.6, though not necessarily higher
than it.

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What health facilities does the population currently patronize?

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What health facilities does the population currently patronize?

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What health facilities does the population currently patronize?

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What health facilities does the population currently patronize?

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Is the population prepared to deal with the technology associated with telemedicine?

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Is the population prepared to deal with the technology associated with telemedicine?

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Is the population prepared to deal with the technology associated with telemedicine?

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Is the population prepared to deal with the technology associated with telemedicine?

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A common argument at the Byrraju Foundation in favor of the telemedicine model is
based on the age and salary of the doctors. Management fears that the doctors,
many of whom are retirement age when they sign on with the foundation, with retire
en masse and the foundation will struggle to replace them. It fears that the low pay
(relative to alternate positions in cities) and the high burden of travel (traveling to
multiple villages) will make it difficult to continually restaff. The numbers in this slide
and the previous two slides reinforce that argument.

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HMRI employs 3 physicians for a four hour shift from 4-8pm. Management feels that
the capacity of its doctors is much higher than what is shown here because the
program is new and there are not enough patients to maximize efficiency. Of course,
the question must then be asked, why employ 3 doctors instead of just 2 or 1 until
the time comes that you need more?

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I designed a simple study in which 5 villages were randomly selected (restricted to
East and West Godavari districts, for management purposes). The nurse then
recorded over three days the length of each visit. These numbers could be used to
estimate how many doctors will be needed given the average time of a patient
consultation.

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My main concern here is whether the nurses can handle the technology. Both times I
have been out to the villages with a technical person, there have been serious
technical problems that even he was unsure of how to deal with. Can the nurses
really be expected to cope with technical issues that are sure to arise? Neither the
Ashwini model or the HMRI model places any of the technology burden upon the
nurses, but instead staff a technician who is there during the consultation along with
the nurse.

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The HMRI doctors are the only ones who have direct experience with primary care by
telemedicine. Their opinions were informative. They felt completely comfortable with
telemedicine in terms of the quality in 80% of the cases, but said 20% of the cases
they could not treat and had to refer the patients to come back to the hospital during
the daytime when a doctor could see them in person. In the 80% of cases they can
deal with, they said quality does not diminish at all with the telemedicine. When I ask
them what the most significant gain to the patient is, they emphatically say that it is
the after-hours access. It seems that telemedicine is not seen as a value of its own,
but merely as a means of extending the current health services. In other words, they
are not delivering any service that the patient couldn’t get otherwise, they are simply
delivering those same services at different hours.

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