 Great. Thank you. Okay. Thank you, Keith and Liliana and Parmendra for this opportunity and the introduction. Some of you might have heard about the telemedicine program that we have embarked upon at PHFI. So what I'm going to do is just to give a background of what we have been doing and the technologies that we have prepared and how we are reaching to a larger population in India. And we look forward to having a fruitful discussion with all of you in terms of scaling it up beyond India. So let me start sharing my screen. I hope you're able to see my screen. Yes. Yes. Okay. Right. Oh, sorry. I have forgotten to put my name here, but that's fine. The topic given to me was telehealth for low and middle income regions. So I just wanted to start off with this quote from the tale of two cities by Charles Dickens. So if you look at the health of populations across the world, it's clear to us that it's the best of times as well as the worst of times because a large majority of, I mean, a small minority of the population across the world enjoys the best possible care, care that uses several advances in medicine such that, you know, people have started living longer, not only they're living longer, but with the best quality of life. On the other hand, we have even worse than 20th, the 19th century type of care in many parts of the world. And therefore we require innovations in terms of improving care across the world and providing a continuum of care starting from prevention to rehabilitation for individuals. And in this regard, the question that I posed was, what are the technologies that can address health disparities and what is needed. So the first thing is we need to keep a good count of what is happening and we need surveillance and for that we look at electronic health records biomedical sensors and data collection through mobiles and tablets. There's early diagnosis and screaming of the population. And again, here there are several technologies that are available for us that includes computerized risk assessment and so on. In terms of the management we have the electronic decision support system, pharmaceutical innovations newer drugs, but also simplified drugs, I mean usually repurposing drugs. So there are many of the things which have been given up in the past have been repurposed at low cost and have been used. And the next one is the telehealth program. The last includes capacity building on scale on massive scale, which can be which we can use online and learning management system, improving drug, drug distribution, digital clinical trials using geographical information system to identify hotspots of disease and so on. But due to paucity of time I'm going to talk about only two aspects today the electronic decision support system and the telehealth program that we are conducting. The first question that people ask us in terms of ML technologies this was published way back around eight or nine years back as to what the role of ML technologies will be for the consumers it provides improved convenience, more active engagement in self care and greater for clinicians it reduces the demands on their time and refocuses on the art of the art of medicine, and it had the potential or has the potential to change every aspect of the healthcare environment and do to do so while delivering better outcomes, better quality and substantially lowering costs. But at that particular point of time there was a real need for clinical trial evidence to provide a roadmap for its implementation and innovation that is low cost and potentially scalable and sustainable and make real differences to people. So we had done a costing analysis of task shifting because I mean one, the other thing that we needed to do was to pair these technologies simple technologies with community health workers and non physician healthcare providers so Dr Tom gaziano from Howard and I worked on an economic modeling to see what would be the benefit of just providing a three day pro training program and training community health workers in the management of hypertension and we estimated that there would be almost $700,000 in hospital savings for million population annually and this was done for India actually 700 cardiovascular deaths awarded for million and 750 hospitalization for stroke or am I awarded. Now this repeat the annual salary of the community health worker at around $3,500, but given the fact at that particular point of time, the annual salary of community health workers was close to $1,500. The program itself was cost saving, but there was this was just an economic modeling and there was a need for a proof of concept, as well as to see whether it was it could work. The second thing was a plan to develop disruptive innovations that would change thinking and practice. So we embarked upon this journey where we paid task shifting and task sharing with technology enabled improved health quality delivery models and quality improvement studies. So these were the principles that we used in all the study we have some representative studies in the last 10 years that we have done I'm putting it up here that included electronic decision support system integrated care quality improvement program. Rehabilitation because I work in this piece of cardiac cardiovascular disease we said cardiac rehabilitation and team based care. So this studies were conducted across the whole spectrum of the health system, starting from the community to primary care to secondary care. We have surpassed several innovations, including traditional approaches such as yoga for rehabilitation quality improvement program through audit system within the clinics and integrated care for example managing diabetes and depression together. So there are several features that we studied in the last 10 years and showed that actually these ML technologies apply to elaborate upon that a little bit later. So what is this ML system we call it the empower hard ML system, which is a clinical decision support system for evidence based care. So it had three packages a clinical decision support system, which provided a holistic approach for evaluation screening investigation clinical management and follow up schedule. It was based on accepted guidelines. There were algorithms validated by experts and proven in clinical research. There was a personalized lifestyle recommendation for patients. There was inbuilt record keeping trending and charting at patient level and at practice level. And there were other required features for care and delivery management. In fact, in the back end we had put in 2500 case studies and paid it to the machine learning algorithm so that every patient could get a personalized management plan when they use when the system was used. In terms of the task shifting we empower non physician workforce to deliver quality care by using technology and we've provided training and access to expertise through structured training program, well research and international knowledge clinical models with regular refinements by experts in clinical and technology domains. Now this is how the workflow looked for these people who use the empower platform. The patient would walk in and get referred by the auxiliary nurse midwife or an equivalent worker and go to the nurse care coordinator who would enter the initial assessment exam and examination details into the nurse portal. Now in India, the nurses are not allowed to prescribe drugs. It's only the medical officers, a trained physician who can do that. So we created a system in which the nurse entered all the data that was required from the patients. It would take around seven to eight minutes of time and that would be printed. I mean based on the inputs, there would be a personalized management plan, the diagnosis as well as the details of the patient which would be printed and sent across to the medical officer. I might ask why are we using this non environment friendly method of printing paper but the reason was because medical officers doctors at that time were very, very reluctant to use tablets or any kind of ML device and therefore we gave them the printed information. They could accept the, they would accept whatever was suggested, or they could rewrite the prescription based on their thinking but majority of the time nearly 70% of the time it was accepted and therefore we thought it was quite a big success at least in terms of the physician acceptance. Then the patient would come back to the nurse care coordinator who would update the patient recording their app and in addition provide lifestyle advice because the doctors are not providing the lifestyle advice, nurses are providing lifestyle advice. They would actually schedule the next appointment and there were auto texting features so that the patient can come back once again once they get the alert or the nurse can call the patient if the patient doesn't turn up. So this and then the patient walked out with the prescription. I mean this looked like a great model but it required evaluation and this is what we did. I mean prior to this we had done randomized trials and showed that it worked. Now we wanted to see does it work in real life settings where we're using the at a community health center where we are using the health system staff, as well as some assisted research staff. So we did this demonstration project in the state of Himachal Pradesh which is around 350 miles north of Delhi. It's a hilly area and over a period of 21 months in six outpatient clinics. We screened around 21,000 patients which means that anybody who was above the age of 30 years was screened for hypertension and diabetes, and we found that nearly 6,800 of them. That's close to 30% had either hypertension and diabetes, but the important point that I want to make is that nearly 50% were first time detections and therefore it was very important that these people would have gone without detection, because the general crowded OPDs, patients who have just been managed symptomatically, like for example if they came with a fever they would get a Tylenol or some investigation and go away. No opportunistic screening for hypertension or diabetes will be done and in this case this was done. The second thing that happened was we ensured that the simple drugs were available in these clinics and what we found was the end of three months. The systolic blood pressure had fallen substantially and not shown diastolic blood pressure which is also the same, but a very high fall in the fasting blood sugar which persisted till 18 months. And in fact we were surprised when you saw the result that there was a 15 millimeter drop in systolic blood pressure, 7 millimeter drop in diastolic blood pressure, and nearly 50 milligrams per deciliter drop in glucose levels. And this we published in the Journal of American Art Association where back in 2016, there were no fancy drugs, no fancy investigations, all that was done was a very simple model of care which used easily available drugs that were inexpensive for the system. So building on this we actually scaled this up in a state in northeast in part of India called Supra and in Mizoram and we recruited more than 200,000 patients from all the healthcare centers, the primary and the secondary healthcare centers in the state of Punjab which is widely accepted by the clinicians and also by the government. Now we are attempting a national level scale up that includes referral linkages and other innovations in multiple in a city in the state of Punjab which again is to the north of India and it's ongoing so we'll get the results in another one and a half years or so. We also assisted the WHO in digitizing its M-PEN package and we call it the M-PEN package and it's being used in Maldives. So we have covered the following diseases over the last several years which includes hypertension, diabetes, depression, alcohol use, tobacco use and dyslipidemia, but we are moving towards symptom based decision support system because the patients don't come with hypertension they do come with symptoms and from those symptoms we try and branch off into identifying non-communicable diseases or even if they come with antinatal care, we have created a system in which we can detect pregnancy induced hypertension gestational diabetes early and we are moving towards identifying co-morbidities. So this was the background of the package that we have developed. Now came the COVID pandemic and the government actually liberalized the rules for telemedicine and that gave us an opportunity to integrate many of the innovations that we had carried out into this integrated telehealth package which I'm going to talk about. Now despite this liberalization, there were several technological divide that existed. There was poor penetration and acceptance of the telemedicine in rural areas and subpar utilization in urban areas. So the challenges were three-fold. The first challenge was in the patient level. There was challenges in accessing telemedicine services due to illiteracy language or even digital illiteracy among patients and most of the system that we have in telemedicine is just getting a virtual consultation with the doctor and they had to initiate the consultation. They would go to the wrong physician or wrong specialty and therefore the doctors would get frustrated. Moreover, the doctors did not have any details. There was a lack of good clinical history. They had to get it from the patients. There were no physical examination findings and many times laboratory parameters are not available to aid physicians in the evidence-based decision-making. And in the terms of the health system itself, there are several multiple innovations freestanding in digital health technology. Interoperability was a big issue and so we needed to put them on a single platform and that's what we attempted. So we call this Digi Sahayam. Digi is for digital. Sahayam is health in many Indian languages. So we just paid that and called Digi Sahayam an assisted telemedicine solution. So the aim was to improve access to quality healthcare through bridge personnel trained in providing assisted telemedicine solutions. So what are the salient features of this program, Digi Sahayam? First, it involved upscaling skills of health workers in providing assisted telemedicine. It aimed at improving access to primary and tertiary care through trained personnel. It improved quality of care, point of care diagnostic and electronic clinical decision support system. It also reduced the need for follow-up visits to health facilities and there was real-time monitoring and feedback mechanism that ratio quality standards. Yes. So just to summarize, these are the three important barriers which I had mentioned earlier and the solution was for the first thing, literacy language and technological barriers among patients. The trained healthcare workers connected, conveyed findings to facilitate doctor-patient interactions and also prevent wasteful visits. The second was at the physician level. So here the trained health workers collected history, performed physical examination and carried out lab investigations before initiating tele-consultations, thereby saving time and improving quality of care. In terms of interoperability, the PHFI telemedicine platform emits electronic health records, point of care diagnostics, in-built electronic clinical decision support system and numerous state-of-the-art digital technologies. So we call this the PHFI innovation cortex to just rhyme with the brain cortex and let me describe the platform. So the platform comprises of electronic health records, point of care diagnostics, electronic decision support system and numerous state-of-the-art digital health technologies. The first is the Empower electronic clinical decision support system which I spoke about a little bit earlier and I'm not going to delve further into it, but it's a very robust electronic decision support system format. The second technology that we paid was the Saucis Hyde device which is a point-of-care diagnostic device which is an affordable Android-based point-of-care device that integrates multiple diagnostics to cater to the needs of the frontline health workers to facilitate service delivery to the population they serve. There are two versions of this. The basic version is aligned to the Indian public health standards, mainly aimed at anti-natal care, but the advanced version that we are planning and we are actually in the process of developing would get investigations that are relevant to non-communicable diseases such as serum pre-attendant, lipid profile and hemoglobin A1c. We added an ECG machine called CardioScreen which is a scalable 6-to-12 handheld portable ECG device developed by an Indian company. It's quick to use and works in conjunction with other Android devices. It has a cloud-based system with AI interpretation and risk classification. It has actually been certified by the FDA and CE. The next two devices are the conventional stethoscope, but this is a digital stethoscope which is a fully-assembled stethoscope that travels between analog and amplified listening modes. It enables remote oscillation by the treating physician and serves as the physician's ears at the telemedicine center. I'll actually demonstrate that a little bit later for you. The next one is we wanted to give eyes to the physician, so we paired it with a high-definition camera which could be operated by the physician who was sitting remotely to examine the patient and to talk to them. This is how the software looks like. So if I go to the next slide, I can just show some of the features actually because of the positive time, I'm not demonstrating the whole thing, but I'm just kind of explaining the various features in this platform. So when you press on this general physical examination provides general physical examination findings which are captured by the healthcare worker. There's a template-based history. I spoke about the symptom-based DSS. This is a variant of that through which a presenting personal past family and drug history are captured. Then we get vitals from the visits with the trends. Like, for example, you could get a trend of the blood pressure over three or four visits. Pulse are likely, if you're managing COVID patients, actively you can get the heart rate and you can get the SAO2 and many other investigations. Lab results also will be provided with trends. Then ECG readings will be available based on the AI report but will require a physician interpretation. And the electronic decision support system is there for diabetes, hypertension, cardiovascular disease, chronic obstructive lung disease and asthma and will give the personalized management plan for the patients. Finally, there is an e-prescription entry and a prescription history that's provided and a markup for follow-up visit and markup for reference. The interesting feature about the auscultation you can hear, there's a noise cancellation feature. You can very clearly hear the second heart sound at the level C. We have marked this so that the nurses or the community health worker can place this step for the physician to hear remotely. And you can very clearly hear the second heart sound at the second heart level. And we can clearly, the split of the second heart sound is clearly audible here. So this is the system that we have. Now coming to the mode of service delivery, there are various modes we are adopting and we will adopt in the future. The conventional mode is a brick and mortar model where the telemedicine center is run by a trained nurse and the lab technician that provide assisted telemedicine solutions under the supervision of a project quality assurance officer. The general physician specialist as well as super specialist tele consultations are made available through this assisted telemedicine platform. Existing private as well as publicly facilities can be upgraded to perform assisted telemedicine. Now the workflow was very similar to the electronic DSS program. Here the patient visits the clinic, the trained nurse takes history and examination. Any lab tests are done if necessary with the point of care device that we have provided, a consultation with the doctor is initiated, a virtual consultation with the specialist doctor if required can be done. Actually this also can be done away with but because this is an initial proof of concept program we thought to have a doctor would be useful. But actually this particular thing is redundant because we can actually position this doctor at this level and escalate the higher consultations from there. So the post consult counseling is provided by the nurse. I'm not getting into the full details of this because this is how the Indian public health system works with multiple levels of care. So at the lowest level we have the health and wellness center, then we have the primary health center, then we have the urban health center and we have the community health center at the secondary level. And we have actually identified the human resources for each of these which is given here, but what I want to say here is this is generally applicable to any part of the world because most systems are with minor variations are similar and the, and because the lowest level of provider is involved, even in very low resource settings, we can use this telemedicine package. The second is an on foot telemedicine assistance for small populations of less than 1000 or so, or also for people who are unable to visit the clinic because of physical disabilities or because they're better than or many other reasons they may not be able to come. So one might ask how did we manage this, all that is required are these two small bags a backpack and a small bag which will carry all these equipments, the total weight of which is not more than four pages comfortable to carry and and you can just go to the houses and initiate a teleconcertation here is an example of a teleconcertation that has been initiated. So it can be used both for rural as well as urban population, and services could be charged for generating revenue for trained healthcare workers having one business model is we could give it to healthcare workers train them, and they can become the agents of this program connecting to the telemedicine consultation also will be a livelihood for them. It can improve health access for elderly and veteran patients. Then we have another program called the mobile kiosk setup which can actually come into a small suitcase and you can just go ahead and set it up wherever it's required like it's very useful in surveillance program or in programs to create awareness but also it can be used for creating consultations, but it can be it is most likely to be used in small villages of populations of less than 5000, where you are unable to establish a brick and mortar clinic. So somebody can go assemble this and have it in their community centers where people can be screened for chronic conditions and also provide facilitated facilitated assisted telemedicine services. The next one is this I am on wheels. This can be used in sparsely distributed small population of less than 5000 individuals here physical space will not be required because this vehicle would be customized to perform like a brick and mortar telemedicine clinic. And these are useful and hard to reach areas. It again can perform both screening as well as management of patients. Now this is the concept with which we developed I'm going to give a practical example of the community reach and impact of the program that we have done. So apart from the telemedicine program itself, we also organize specialist scams health promotion visit so that the community actually the health of the community improves so we do health promotion visit. There are two step consultations and assistance services, educational webinars weekly community improvement live sessions and collaborations with different institutions to extend our services. So essentially what we are attempting to do is to bridge the gap between the community technology and digital health care to train personnel, provide continuity of care and longitudinal health data through use of inbuilt electronic health to create an innovative model for health service delivery that enhances sustainability accessibility and accountability of care. It also would reduce indirect healthcare costs related to travel and loss of daily wages, provide valuable data that can inform the development of suitable healthcare models prevent complications through improved awareness early detection treatment. So we are improving the quality of care and in our modules for primary care physicians we emphasize the importance of looking for example, when we did a survey around 10 years back, only 7% of the doctors were annually screening patients for neuropathy or retinopathy but once you give them a structured package that screening level improves and it actually reduces the complications. So the health technology that we're using helps to address cost. There is a tremendous quality control over there. It's interoperable. It's scalable which we're shown. There is an enhanced user experience it addresses the contextual needs and get us to the issues. In addition, it is environmentally friendly. In fact, one of the recommendations to prevent climate change or to mitigate climate change and reduce air pollution is the use of telemedicine. Because in countries like India it's not only the patient who comes to the clinic the footfall is very high because at least two relatives accompany the patients. And second they have to use some form of transport to each the hospital. So all that can be avoided if we can have a hybrid model where people really require to visit the clinic or the hospital make the visits and others are provided to get through telemedicine and this was featured in in COP26. This is one of the technologies and PHF had four of the technology which included the drones to deliver drugs and to collect blood samples and get it analyzed in different cases and the point of care device and others. So let me do some practical examples now. We are conducting telemedicine programs in three clinics one in the northern part of Tamil Nadu in its capital Chennai and in the southern part of Tamil Nadu in a place called Pasuvankanai which is in the far south of Tamil Nadu. So three clinics have been established and these are some of the glimpses of the clinic where you can see people working on the point of care device then teleconceptation which is ongoing and consultation with the local doctor here. The second thing is the WHO was very impressed with when we presented the data on the telemedicine in Chennai so they said we should demonstrate that it works in a government setting the previous one was with CSR funding a charity program but they wanted to see whether we can work with the government systems to So we spoke to the government of Karnataka and South India and they have agreed we have signed an MOU and we start the program next month. These are our partners which includes the WHO and several others we are adding new investigations for example the Irvind Ikea system program is a leader in ophthalmology care and it has been featured as one of the sustainable models of healthcare and so we are working with them in terms of providing Ikea. So what does mean the impact so far. So in the last eight or nine months we have provided almost 5,640 consultations of which 3,750 were general consultation and around 1,800 900 specialist consultation and ECG was actually rationed and taken so it's somewhat lower and these are the lab tests that were conducted. So in terms of the specialist conduct distribution, a large majority were general medicine followed by pediatrics and gynecology but currently we are focusing on four major specialities that is general medicine, pediatrics, psychiatry and dermatology. We also provided 80 plus doorstep assistance for people who are unable to come to the clinic and at least 18 patients of these 80 were treated of their conditions. We to create awareness and interest in the community we have conducted specialist clinics. So we conducted a total of 19 camps of various diseases and treated around 1200 patients or so. We make home visits for health promotion. So each month was a specific disease entity to spread awareness in the community for example the importance of salt reduction or alcohol use for hypertension as an example physical activity for diabetes and so on and so forth maintaining hygiene water sanitation and hygiene. These kind of promotional activities were conducted in this community so the community becomes healthier as a whole. So this is the summary of the whole program in Chennai and we touched 14,000 plus lives including home visits and the people we have interacted with and we identified new NCDs in around 600 of these people and were referred to the consultations. Another newly detected hypertension was 250 patients with high DMRs identified to this number and were provided advice with regard to how to reduce that so it is a composite activity of everything that is required for the completing the continuum of care. So what's the patient feedback, I mean that's the most important consumers I won't take too much of time on this, but these were the five domains in which we asked using a Likert scale and we surveyed 139 patients. On a scale of zero to five, we were somewhere a little higher than four for all these domains that we looked at. So in terms of satisfaction again there was overall satisfaction with the healthcare services of the clinic, satisfaction with the healthcare delivery model and likelihood of recommending clinic for diagnosis and treatment to others was almost at the level of four. So there was good satisfaction for this program. Finally, what is the way forward. We need to indulge in large scale capacity building initiatives for health workers in providing assisted telemedicine, we need to pilot different modes of assisted telehealth delivery, improve quality of care through integration with additional digital health technologies, adapt and expand these to other countries with similar health system difficulties and embedded research to evaluate and improve existing technologies. When we look at this whole program that I presented on the surface it looks like we are just trying to improve access to healthcare through bridge personally using telemedicine, but there are several other features that are embedded in this which are under the surface. Then you generate a lot of electronic health record data, which can provide real time patients entered records for secondary data analysis. Second, there is a large number of well trained staff nurses paramedical staff and digital technologies to carry out complex data collection and they can be used in research of this program and in surveillance. There is a community outreach arm with an opportunity to conduct population level surveys and studies. There's infrastructure to evaluate and scale up digital technologies platform to test interoperability acceptance and appropriateness of the health technologies. We can use this for digital disease surveillance and for capacity building so we can use this for building capacity of students and research staff to embedded research projects. I wanted to say and thank you very much for having me and listening to this presentation a bit of monologue here. Thank you. Thank you so much. Fantastic work that you're doing and I'm in awe really of all the amazing things. That's related even the the status cop. I had no idea that that existed and it could be used in in telehealth. It's quite amazing. I'll start with the questions and then we can see if others have questions. Interesting understanding what you found as the major barriers to implementing this across India and whether there were contextual factors that made it more difficult in particular areas or other types of barriers. I think in terms of barriers, if you think there are multiple number one, I think in a philosophical sense, this is a total disruption of the health care of the patient doctor patient relationship which was compromised on the touch and the feel and that is not there. So that's one which people are unable to fathom. The second is there are competing telemedicine programs, the government itself has got a program called he said you need but many of them are basically in terms of remotely connecting patient to the doctor, but many of the features here are not there. So, initially people are saying that no no we have done this on scale so why do we need another platform. Now, now it has been accepted in Karnataka when he spoke to the government, they have agreed that this is a good program and they're willing to implement. So the biggest challenges people worry that such kind of programs like ours is creating a parallel system and not integrating but the ultimate aims to integrate with the larger system and use it. So anyways, we are largely focused on government health care we are not focused on the private health care and so that's another area where we should work on because 70% of the care in India is with the private providers and therefore I think there's a huge market potential over there. There are a lot of achieving problems about the equipments and in fact, it took me took us a lot of time to get the health workers to use the stethoscope because they were quite, they found that it was a little different from the conventional scope they found it daunting they were not using it. And we, yeah, but it took some time so it takes time it takes perseverance it takes training and it takes advocacy and it also also they get feedback from patients and patients were fascinated that they were getting something very different. So again, you give them the touch that they're required. Very interesting. I have a question here from Roger Ram, who asks, what are the impacts of this ncd management program implementation. Right. Yes. I can. I can add to that because there was also something that I was interested in. I can add to that because there was also something that I was wondering about. Do you have any sort of cost effectiveness evaluation or is that plans. And can you talk a little bit about the impact. This is a very short term evaluation that we have done cost effectiveness is a larger evaluation. So we will have to do the impact evaluation in terms of how the ncd care has been the obviously we cannot do any hard outcomes it will be only process outcomes. Like how many visits they made are they taking their drugs regularly are they getting their drugs and what's I mean we can of course get blood pressure but it's a pre post design you just sometimes you know when you measure blood pressure multiple times or blood glucose multiple times there is a regression to the mean and it may appear that it is reducing but the fact is it's important for us to look at some of the process outcomes which actually would translate into real benefit and those include the the time saved for the patient the daily the wages that they've earned because they didn't go to the hospital it takes a day full day for them to go to a hospital and come back all those kind of intangibles you'll have to measure of course cost effectiveness is one of those which is very important which we are looking at maybe take one more year also amazing and just touching on that I think it would be interesting to so you had some sort of patient feedback via a survey maybe interviewing some patients and doing a qualitative kind of analysis of their responses would be interesting because I'm guessing there might be very interesting aspects there on facilitators barriers things they enjoyed or things that could be improved I think you hit the nail on the end the current thinking is code design we didn't really do the code design component but as we scale it up and as we move along to different territories we are embarking on code design plans where we involve patients in the design because they are the consumers ultimately and they know what the pain points are and they would help us in terms of modifying and rectifying any mistakes that are on the way. Great. We have a question here from Anna Louisa and she says congratulations on such an amazing program of work. I was wondering if you have performed or are willing to any evaluation on safety of remote care. Yes I think we should do it because as a as an epidemiologist and a person who has been active in clinical trials I'm always very of you know the pre-post design showing that things improve. So I think it's you need a you need some kind of a trial maybe a cluster RCT or a delayed intervention step-by-step design trial or so in terms of showing but given that it's becoming so popular and getting well established maybe little difficult to do but we could look at communities before introduction of telemedicine after introduction some kind of thing like that. We require to innovatively think in terms of the evaluation. Great. Any other questions Keith. Yeah, thank you. I'm always impressed. I think this is the third time I've seen this presentation and learn each time I view it. I think just a comment where I am most impressed with maybe we'd like to hear a little bit more with the leveraging of the community health worker. And the reason behind my question and there are some other programs that use this but one of the concerns was, and I think it's healthy entrepreneurs for example in Africa leverages community health workers but they're not funded as volunteer. And those community health workers are expected to come up with the what can be financially burdening the cost of the equipment to engage. So add in that along with assigning them fairly significant health responsibilities on a pro bono or for free basis. So I wonder the you mentioned the salaries. Can you expand a little bit about the economic model because that's where a lot of these programs really struggle right to sustainability and funding. So I'd like to hear a little more on that because that's very impressive. So a few points that I want to make is that the programs cannot be sustained on a voluntary mode. That's number one because we are actually focusing too much on the innate goodness of people to contribute to the success of this program. So in India also there is this voluntary program but they are paid like there's something called the accredited social health activists for the Arshas who are women from the local community who are between 18 to 24 years and will provide assistance to anti-natal care and delivery. So it started well intentioned it worked very well they were getting a kind of stipend not a full salary and for and also getting incentives for hospital deliveries. So the incentives for the hospital deliveries were very high so the focus largely became getting the patients they forgot about the importance of anti-natal care so one needs to be very careful in terms of how to incentivize these patients. They incentivize these individuals but I think the way to go is to use the existing health workers and like there are many health workers who have become redundant because in India we have several vertical programs. We had a program for control of guinea worms. We had a program for control of epilepsy. We have the polio immunization program. Many of these diseases they get conquered. These people become redundant to the system. So they can be retrained and repurposed and used for this program because they're already employed. The second is in the national program of India for noncommunicable diseases it's called cardiovascular cancer and diabetes prevention program. There is an extra personal who was sanctioned by the government of India and it works in a partnership model with the state governments and the central government and that extra person can be used for these kind of activities. But we have to be very careful that these health workers are not overburdened because there's a tendency to use them for all kinds of programs. So there has to be that multi-sectoral dialogue even within the health ministry. I'm not talking about beyond the ministry of health but even within that there has to be a dialogue with the workers, with the physicians and with the administrators in terms of how to optimally use these individuals. In terms of Africa itself, I think we can create a business model where for every service they provided there's a small amount of incentive which would be provided from the profits that are earned if you're providing it on a private basis. We can skill these people and give a franchisee model so that they earn money as well as treat patients. So you can think of other means, I mean there may be other ways we should talk to the management guys to see if there are other mechanisms. Do you ever foresee a blending of private offerings that could stoke revenues or a revenue share with public based? Is that a model at all that would work? People have been talking about the public-private partnership model. It requires refinement because the private sector thinks that the government or the public sector should provide the infrastructure and they make the profit. So I don't think that model would work. So we require to refine. It's a long process because inherent in the DNA of private sector is to make profit. Inherent in the public sector though return is to provide service is inefficiency. So I think we need to overcome the inefficiency of the public sector and the profit motives in the private sector. So related to that, I'm curious about where the funding came from for the work that you presented and when you think about scaling it up, what is the plan for funding it? Right. The first branch of funding came to us from an insurance company because they had this corporate social responsibility program or the CSR program as it's popularly called. In India, every private concern has to pledge one percent of its profit towards social services and it's called corporate social responsibility. So they had some funds and they asked us whether they would do something about NCD care and that's when Arun and I had a discussion and we came up with a plan of creating the Stehli Medicine program and of course Dr. Dave Jindal is here who's worked actively on the ML program and we paid all these technologies. We did this very rapidly within a matter of two months or so. In fact, the first approach to us was last November and by February we had everything up and running. The clinic started in February and so within four months we had the discussion with them about the funding. We employed people, we actually rebuilt that building in terms of organizing so it was an amazing job by Arun and Group and we rolled it out. So that was the first level of funding. The second question is about scale up. The scale up has to happen only with the help of the government or with large private sector organizations. So we are advocating with the government in terms of looking at how to scale up across the country. So we need a little bit more data to provide them with the robust evidence that it works. Second is we're also looking at large grants like we recently applied to this NIHR center grant, which aims to, with the aim of using telemedicine for multi-mobility as a thing. So once you have the evidence, once you start doing such big projects, I think people will gravitate towards this kind of the system. There will be resistance, but we will have to work on that resistance. That's great. And just one more question for me and then I'll see if anyone else has questions. I was wondering what was the impact of COVID with all of this? Were there any particular challenges or did COVID accelerate the adoption of this program? Actually, the program came up because of COVID. Because of COVID, there was a liberalization. The government realized that patients cannot visit hospitals like before and door to door crowding, et cetera. But the second part of the problem was when actually a huge surge of COVID happened, we had to close down for some time basically because most of the care, most of the people who came were for COVID and not for non-computable disease. So for some time, maybe a week or so, we closed down. But it has actually helped screening, advocacy management and rehabilitation processes of non-computable diseases. And it's a great idea to do it virtually. Like, for example, post-MI rehabilitation, post-TROP rehabilitation, the conventional program entails that the patients visit the clinics for at least once a week for 12 to 13 weeks. Now you can do all the training of these patients virtually. And you have very high quality pictures and videos for them to be trained after the initial visit. So I think the pandemic has actually helped advancing the cause of telemedicine. Great work. Any other questions? Dr. Rohan, one has asked whether we can write to you. You're welcome to write to us. And Arun, can we put the email ID on the chat? I was just going to make a comment, what I'm also impressed with. You mentioned Dr. Prabhakaran, the interoperability. And I can tell you even in developed part of the world, like here in Canada, we think we have a very robust health system and we struggle with this, right? We have the pharmacies, the hospitals and primary care providers all on different systems. And the fact that you've created or have a telemedicine platform that the specialists can see the same information that I'm seeing, the pharmacist can see the same information I'm seeing, the nurse, the healthcare worker. I think really that that's a critical point. And I'm also just thinking, you know, of how much I do on a day to day basis as a primary care provider. A lot of it is, you know, maybe it sounds hard to say frivolous work, but I'm so caught up in the day to day stuff. It really, you know, do I need to be seeing the patient myself for their blood pressure for their diabetes, some of these non-communicable diseases. And I become the choke point in the system because the patients can't access me because I'm burdened with these other responsibilities to delegate that task into the community really makes so much sense in workflow. Kudos, right? I mean, I think this is disruption that we need. And I'm sure there's there's challenges because there's some of us that maybe hang on to that concept that I'm the doctor, I'm the physician, I know best. It's me that should be doing this and delegating those tasks to be a challenge, but I think it's where it's got to go for sure. It's amazing. Thank you. So I thought in conclusion, in terms of way forward, I forgot to mention one more thing is how do we address the issue of privacy and for that I think we should borrow from the Bitcoin technology, the blockchain technology where it's disaggregated data, which is owned by the patient and the patient actually permits the doctors or is going to use the data to see the data. So I think we need to think out of the box in multiple ways, but ultimately whatever we do, we have to think about the cultural culture, culture sensitivity, the context in which it is being used, the cost and the cost and the equity of the program, the ease of the program and I mean obviously the interoperability is also a major issue. So I think we need to solve this and think from these multiple angles to make this skill of them. Fantastic work. Do you want to close the session, I think we should let Dr Prabhakaram go because he's been so kind and generous with his time and this was a great session. Absolutely, thank you so much and I can see already this is a great warm up for next week. I don't have much to talk about and collaborating with who and the IEEE, this aligns as well. Thank you Dr Prabhakaram, Dr Jose, I see you're on the line as well. We really appreciate it guys, this is wonderful, and we'll be shouting your accolades for times to come yet. Thank you very much. Thank you for having me. Yeah. Thanks. Bye.