This is a guest post by Dr. Aniruddha Malpani:

Everyone agrees that the healthcare industry in the US is a mess. This is a major multi-billion dollar opportunity and India can provide a solution , if we learn how to leverage technology intelligently to make our doctors more productive. Indian doctors are world- class; as is the Indian IT industry. If we marry these cleverly, we can significantly improve patient care all over the world. In the past, we helped to support healthcare in the US and the UK by exporting our doctors ( the "brain-drain"). We can now export our services instead.

Today, the major bottle neck for efficient healthcare delivery in the US are doctors. Doctors are few and far between, and are an expensive resource ( after all, it takes a lot of time and money to train a doctor) . How can we make better use of this scarce resource ?

Today, unfortunately, most of their time and energy is spent on paperwork (“documentation” ); and talking to insurance and HMO clerks for authorization. This creates a lose-lose situation. Doctors are unhappy and frustrated; and patients are angry because they perceive their doctors as being uncaring and rushed ; and are frustrated over the long waits for appointments. For example, it can take an infertile patient over 3 months to see a consultant in the UK today !

The solution I'd like to propose is the use of technology to leverage a doctor’s productivity. ( This would not apply for emergency situations, but for medical care for cold “elective” problems, such as fever, diarrhea, and chronic illnesses such as arthritis and asthma, which constitute about 90% of all medical care episodes.)

We need to change the model of the consultation – the entry point into the healthcare system. At present, a consultation is inefficient and time-consuming. Traditionally, this has been “ face to face “, but this is an archaic model. It’s time for a makeover ! After all, communication technology has changed everything else – why not this too ? Businessmen conduct conferences and meetings efficiently online – why can’t doctors and patients ?

We need to replace the consultation with a better alternative ! I agree this may cause a certain degree of discomfort , because the visit to the doctor is still the “holy cow” of medicine, because medicine is based on “doctor patient contact “. However, is this really needed ? Isn’t there a better alternative ?

Telephone diagnosis is now routine for many specialties , and has been proven to be safe and effective. This confirms that options to the traditional real world consultation are viable alternatives we need to actively explore.

I am going to offer my solution based on my personal experience. As an infertility specialist, I am a resource in scare supply. It takes me about 60 min to do a consultation, and I can manage to do about 4 consultations a day . I am in private practice, and have a wait list of 2 weeks. It also takes the patient a total of 3 hours of their time ( to commute to the clinic and to wait for their turn) to come for a consultation. How can we make this more efficient ?

What do I do in a consult ? Primarily, like most specialists, I take a history; review the records; and then formulate a treatment plan. I don’t need to do a physical examination for the vast majority of patients. ( Many studies have shown that over 80% of medical diagnoses can be made based on the history !)

I have therefore designed a structured questionnaire on our website, which anyone anywhere in the world can fill up online and email to me . I can review it and reply by email and it takes me an average of about 5 minutes to reply to each query. I know what the key points on the form are; so that I can quickly look for these; and then guide them accordingly. Most problems are ones I have encountered before ( after all, I am an expert !); and most questions are ones I have answered before, which means I can reply much more efficiently

This is actually a better model than a face to face consultation ! In fact, a personal consultation may not be the most effective or efficient way of providing the doctor with medical information ! I know this may be iconoclastic, but patients are often confused, disorganized, or embarrassed. By subjecting them to the discipline of filling up a structured form when they have the time to do so , they can provide the key bits of information the doctor needs much more intelligently !

I can also provide reasons for my recommendations , and additional references if needed. Patients are much less stressed out ( studies have shown patients forget half of what their doctor tells them during a consultation) when they email me, which means they remember and retain a lot more of what I tell them, because it’s all in writing. Moreover, this can be an iterative process, because they can ask more pointed queries , which I can reply to.

It’s much easier for me too, because I can reply in my pajamas; and for complex problems, I can refer to my medial journals ! I can also “refer “ patients to online information resources, so they become better informed about their problems.

It’s also much easier for my patients because they can ask me queries at their convenience; and they have a written record of what their options are . Patients can also think about their queries; discuss their options with family members; organize their medical records; and structure their thoughts. I now “see” 25 patients in the virtual world ! I find these patients are much better informed and have more realistic expectations, which makes treating them in the real world much easier. This model would work well for all chronic illnesses, such as diabetes , arthritis, hypertension.

One of the limitations of this model is that no personal physical examination is possible, but this is not essential for solving problems in many specialties today. Not only can a history provide a lot of useful information; the record of the primary doctor’s physical examination notes; as well as the results of imaging studies can be very valuable, which often means that a personal physical examination is not even required in the first place.

Medical experts in world class hospitals have been providing second opinions to patients from halfway across the world ( without examining or seeing them) for many years. Doctors are also used to providing useful medical advise on the telephone. Why can’t we use these models to improve the doctor’s efficiency ?

US doctors have become so petrified by the possibility of being sued anytime they write anything down, that they have got paralysed into inactivity ! They can no longer think of innovative ways of providing medical care, because they are so worried about possible medicolegal liabilities . There’s no reason why Indian doctors should allow this irrational and misplaced fear to immobilize them ! We need to capitalise on this opportunity !

We can use this model intelligently and “extend” it using physician extenders. Using a “ learned intermediary” ( who could be a nurse , community social worker , family member or caregiver) can help to extend the utility of this model. Maybe a “targeted “ physical exam can be done by a trained physician assistant or nurse, who can make house calls and video conference with the doctor ? This could also be done by “expert patients” or peers, for example. I agree that the “human touch” is important; and that an online consultation can be impersonal, but this is no reason to throw out the baby with the bath water.

Doctors have a lot of expertise –we need to tap this intelligently. Many attempts were made in the past which attempted to use “artificial intelligence” to help the doctor to make the right diagnosis. Most of these failed, because I feel their goal was misplaced. Rather than try to use technology to replace human expertise, it would make more sense to use it so that to multiply its efficiency. Amazon’s Mechanical Turk was developed to help solve specific internal data processing problems that required human judgment and intelligence.

It's a clever marriage of information technology and human intelligence. India has lots of medical intelligence, and we can leverage this...

The key would be structured questionnaires designed for each specialty which the patient would need to fill up. The concept could easily be extended to allow family doctors to seek a medical opinion from specialists.

Every specialist need a core of critical information on the patient, based on which he formulates a treatment plan using his expertise and experience. While it may not be possible to capture his experience, reasoning skills or experience, by providing him with the core information he needs efficiently, his expertise can be used much more productively !

This business model would allow expert doctors ( even those who have retired and are no longer in active practice ) to generate more revenue; and also allow patients easier access to medical expertise inexpensively ( because they would no longer be compelled by geographic constraints to going to expensive doctors in the US; or to wait for months and months on a NHS waiting list). This may even galvanize doctors in the US to reduce their expenses; and force them to become more efficient and patient-responsive ! The benefits for insurance companies are also enormous, because these consultant doctors would provide objective evidence based advise, with no vested interests ( since they are not going to be actually treating the patient).

WSJ digs deeper into Buffett's life and work:

Mr. Buffett has relied on gut instinct for decades to run Berkshire Hathaway Inc. Watch him at work inside his $136 billion investment behemoth, and what you see resembles no other modern financial titan. He spends most of his day alone in an office with no computer. He makes swift investment decisions, steers clear of meetings and advisers, eschews set procedures and doesn't require frequent reports from managers. Occasionally he picks up the phone, calls his broker and trades $100 million or more of stock.
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Mr. Buffett deliberately keeps the outside world at bay, believing it is the best way for him to remain "rational" as an investor. If he is interested in investing in a company, he studies the financials himself. "I've created a good environment," he says. "All I have to do is think and not be influenced by others."
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He says he knows an attractive acquisition candidate when he sees it. "If I don't know it in five to 10 minutes," Mr. Buffett says, "then I'm not going to know it in 10 weeks."

[via India Stock Blog] Stephen Roach writes:

Lacking in saving and investment — and the infrastructure and industrial capacity that such flows would support — India has had no choice but to turn to services as the sustenance of economic growth and development. Consequently, unlike China’s deliberate focus on manufacturing, India’s services bias has emerged partly by default — hence the “accidental” aspect of this strategy noted above. The good news for India, however, is that its services-based approach has played to many of its greatest strengths — especially in the new IT-enabled service sector. Drawing heavily on its deep and high-quality stock of human capital, IT competence, and English-language skills, companies such as TCS, Infosys, Wipro, and now Genpact are all leading-edge players in the integrated systems solutions business — setting the pace in one of the world’s fasting growing and most dynamic industries. In terms of it absolute size, India’s IT-enabled service sector is small — accounting for only 5% of the overall Indian GDP growth in 2003, according to Chetan Ahya, our India economist. But this sector is on a pace to double its growth contribution over the next five years — underscoring the increasingly powerful potential of India’s “new services.”

Garr Reynolds has a fascinating comparison.

WSJ writes:

A novel plan to develop a $100 laptop computer for distribution to millions of schoolchildren in developing countries has caught the interest of governments and the attention of computer-industry heavyweights.
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Although no contracts with governments have been signed, Mr. Negroponte says current plans call for producing five to ten million units beginning in late 2006 or early 2007, with tens of millions more a year later. Five companies -- Google Inc., Advanced Micro Devices Inc., Red Hat Inc., News Corp. and Brightstar Corp. -- have each provided $2 million to fund a nonprofit organization called One Laptop Per Child that was set up to oversee the project. Mr. Negroponte says five companies are bidding to make the laptop, although he declined to name them.

Mr. Negroponte remains eager to place the laptop in the hands of 100 to 150 million students. He says he has learned in educational projects in Cambodia and other developing countries that computers spur children to learn and explore outside the boundaries of a classroom, and share their discoveries with their families. "I do not think of them only in classrooms, but part of an integrated and seamless experience for kids and their families," he says.

Barron's writes:

The disappointing performance of tech's biggest names reflects a trend that's been in place for several years. Still scarred by the late 'Nineties bubble, corporate technology buyers have continued to focus on making better use of the stuff they already have. What growth there is has concentrated on security, outsourcing key functions to consulting firms in order to cut staff, and meeting the demands of Sarbanes-Oxley and other new disclosure requirements. Meanwhile, consumers have gone on a home-equity-financed electronics shopping spree, snapping up DVD players, flat-screen televisions, digital camcorders, MP3 players, camera phones, laptop computers and other Asian-made gadgets. In fact, the Semiconductor Industry Association reports that more than half of the world's chip supply now ends up in consumer electronic gear, shifting the historic balance away from corporate computing and networking hardware.

But 2006 could be the year when everything flips back. The macro backdrop is good for tech spending, but there will be a shift, which has already begun, from the consumer to businesses," asserts Mark Zandi, chief economist at West Chester, Pa.-based Economy.com. "The baton has been handed off." Zandi says real investment in information-processing hardware and software this year will check in at 10%, with similar growth likely for next year. Michael Mahoney, portfolio manager at EGM Capital in San Francisco, agrees that business capital spending has started to pick up -- and asserts that the recovery is yet to be fully reflected in stock prices. In fact, Mahoney contends that if you simply bought shares in four tech giants -- IBM, Cisco, Intel and Microsoft -- your return for the next 12 months could reach 25%.

For those wanting more on Google's possible gameplan, John Battelle's “The Search” is just an appetiser. The real meal comes in the form of an e-book by Stephen E. Arnold entitled “The Google Legacy: How Google's Internet Search is Transforming Application Software.” The e-book, at $180, is not cheap. But it provides excellent insights into the technology platform that Google has built and how it is likely to be used in the future to deliver a wide range of virtual applications.

Here is an excerpt from the introduction on Arnold's site:

What kind of company is Google? The world mostly knows this high-flying, publicly traded West Coast company as the upstart that revolutionised search.
Wrong, says Stephen Arnold in this new ebook: Google is much more. New, radical and overlooked, Google is this era's transformational computing platform and could be about to unseat Microsoft from its throne.

Google is not just about search: search is merely one application you can load on its processor. Although Google has been releasing a series of separate application programs, the company is starting to assemble the mosaic pieces into a bigger picture. Its future will be about leveraging its innovative hardware/software infrastructure. In so doing, just as Microsoft replaced IBM, Google promises to replace Microsoft as Network Computing comes of age.
Written for business readers, especially senior executives of mid to large-sized, knowledge-based corporations, The Google Legacy places Google under a microscope, dissects Google's technology, evaluates its potential and determines that Google's future lies beyond search. Three appendices provide lists of Google patents, publishers who have indicated some type of relationship with Google, and universities working with Google-information that, according to the author, Google has sought to keep under wraps.

Dig deeper into Google, dig into its software and engineering patents and you’ll find a roadmap for its future, says an author and online systems specialist, who believes the patents also spell bad news for Microsoft if the tech world moves to a new Google-dominated network paradigm.

“Google really doesn’t hide things,” said Stephen E. Arnold, who has written a book on his one-year odyssey studying the search firm. “Bill Gates is basically in the same spot he had IBM in. IBM was challenged by Microsoft and IBM didn’t understand Microsoft’s business model. It’s history repeating itself.”

Arnold, author of “The Google Legacy”, said in an interview, that it appears that Microsoft doesn’t understand Google in much the same way that IBM didn’t understand Microsoft 20 years ago. “It will be the Googleplex from 2004 to 2020 – a network paradigm,” said Arnold. “It will be enabled by Google’s approach to innovation.”
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“These patents suggest that Google is looking beyond search, possibly targeting such companies as Microsoft, as Google tries to become the leading info tech company of the 21st Century,” he said.

Tomorrow: Capitalism at the Crossroads