India’s Villages Need Doctors. This Startup Takes Cardiologists to Them

"They say if the patient can get out the door of his home at the first sign of a heart attack and come to the hospital within two hours, they can save his heart. That’s a promise hospitals give," says Manick Rajendran, co-founder of iMMi Life.

The problem is that by the time most heart attack patients step out of their homes, they’ve already waited too long since the onset of the first symptom. The average person doesn’t leave for the hospital until 300 minutes after experiencing the first symptom. The roughly 60-120 minute time window is also known as the Golden Hour, because if treated during this time, the heart doesn’t suffer possibly irreversible damage or muscle death.

"Either the patient dies or goes home in a suboptimal manner, where he is going to be a heart patient forever," says Manick. He goes on to say that there are less than 5,000 cardiologists in India, meaning that even if the patient makes it to a hospital, the nearest cardiologist may be in a hospital further away, possibly outside the city.

Photo credit: El Payo

iMMi Life is an initiative to provide access to cardiologists and promote good health habits among the underserved population of India, providing cost-effective and accessible options fot health and encouraging patients to go to hospitals at the first sign of heart trouble.

"We realized that even though cardiologists are of most use in a hospital, they have a wealth of knowledge and competency that they can use when they’re not in the hospital," says Manick. For example, a cardiologist can analyze an electrocardiogram (ECG), a reading of the electrical activity of a patient’s heart, anywhere. That led to Manick and co-founder Ranga Sriraman to develop an app that takes ECGs to cardiologists all over the world for quick interpretation. An ECG reading can inform doctors of a possible impending heart attack, allowing the patient more time to get treatment. It only takes about 30 seconds for a cardiologist to read the ECG and make a determination.

"In the event of an emergency [related] to the heart," says Manick, "an ECG is the simplest piece of information a cardiologist can look at to make an assessment of what’s happening."

Give your heart a break

"We [err] on the side of caution […] Clinically, if two feel it’s a heart attack, we will take it into consideration," says Manick.

Cardiologists who are registered in the iMMi network get a notification when an ECG is available for examination, which they can read at their leisure. If they’re unavailable, someone else picks up the reading, but cardiologists get paid per reading. If the consensus is "no," then the service is free for the patient, which promotes a culture of early detection and pre-hospital stabilization. If the patient’s reading gains a "yes" consensus, then he or she pays a fee that’s less than half the fee for the same service in the hospital.

"It’s much like a Skype model," says Manick. "The one time that you are going to call me on a landline, your local carrier will charge you US$0.02 per minute, which is still cheaper than the US$0.18 [a US carrier] would have charged." Manick says, noting that about one out of the four readings gains a positive consensus.

While the cardiologists read the ECG without knowing any information such as age or location of the patient that could cause a bias to their reading, the app does make sure that one of the cardiologists reading the ECG is local to the patient. If the patient’s reading gains a clinical majority "yes," then the patient is automatically referred to the local cardiologist, helping him or her gain a patient case.

"[Cardiologists] don’t need to waste their time on bogies or false positives [with iMMi Life]," says Manick. "They can get real positives that have been looked at by their peers."

The business of health

Manick Rajendran, co-founder and CEO

iMMi Life’s genesis sprang in part from Manick’s tenure as a hospital CEO in India. Back then, he realized that even in the cities, which have the best health infrastructure in the country, people were coming in and dying because they either waited too long to get treatment or the hospital lacked a cardiologist and had to make up for it by doing time-consuming tests.

"Sometimes someone wouldn’t come in [to the hospital] because they thought it would cost a lot of money, when in fact […] it costs much, much less to do the initial screening," says Manick. "An initial screening is all a general physician needs before he progresses to the next action in the clinical pathway."

iMMi Life was officially launched in mid-August of this year after about three and a half years of design. The founders hope that the model can be extended to other developing countries.

"Heart attacks can be diagnosed quickly [and] cost-effectively," says Ranga.

One of the challenges is convincing patients in India that heart problems are not just a rich man’s disease and that treatment is much easier if started early on. Another problem lies in convincing smaller hospitals that they can use iMMi Life rather than referring patients to larger hospitals due to fear of liability costs.

Even though the app allows for a diagnosis to happen outside of a hospital, it’s far from having a presence that’s as wide as telemedicine services such as WebMD. Because of the measures it takes to protect patient privacy and because iMMi Life is available only to cardiologists and general physicians, who supervise the information sent from each patient, iMMi Life keeps risk of wrong information to a minimum.

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