Filling the GAPS

Even given its present relevance, telemedicine is not new for the country. The word became a household term soon after the outbreak of COVID-19 pandemic that necessitated complete lockdown as a preventive measure to stop the transmission of a highly infectious and deadly virus.

As the first two phases of the complete lockdown — March 24 to April 14 and April 15 to May 3 — meant that people were not allowed to venture out of their houses barring emergencies, the wheels of telemedicine started rolling and people in need started learning the ins and outs of the digital platform to access medical services.

The Union Health Ministry has previously as well taken initiatives to propagate this 'digital doctor' model. Since the health departments of the states had always faced the heat of the common public over shortage of quality doctors at most of the primary healthcare centres, districts hospitals or even at state-level premier healthcare institutions, the telemedicine concept was introduced in India too after seeing much success of this concept in several other countries.

It is a disturbing fact that India doesn't even have one doctor for every 1,000 people, which is a must as per the recommendations of the World Health Organisation (WHO). The country's doctor-population ratio is only 0.62:1,000, which is very grim.

The other surprising fact is that a large number of population that accounts to above 70 per cent of the 130 crore population lives in the rural areas and more than 75 per cent of the doctors' practice in the urban areas, which means people living in rural pockets are bound to visit cities for better treatment.

As travelling from villages to cities is always a costly affair for poor patients, so in most of the cases, it has been found that patients fall prey to quacks operating in remote villages and avoid visiting specialist doctors. Therefore, a large section of the population receives insufficient health care resulting in an addition to the disease burden.

Considering the micro issues such as deprived education and shortage of medical professionals in rural areas, the Government propelled the telemedicine model to bridge this widening gap.

Recently, Prime Minister Narendra Modi had also stressed on popularising the benefits of telemedicine. "The nation must engage in discussions on how to apply the 'Make in India' initiative in the health sector, use information technology-related tools to create healthier societies, and popularise 'new models' of telemedicine," the PM had said at the 25th Foundation Day celebration of the Rajiv Gandhi University of Health Sciences (RGUHS).

Hailing the efforts of the Government, Bihar cadre IAS officer Dr Jitendra Gupta said, "With technology advancement and its gradual increase in access by common man even in far-flung areas, telemedicine is a vital feature of medicine in future." However, the medical graduate IAS officer said that telemedicine can never be a substitute for doctors in rural areas.

"The access of telemedicine among people living in rural areas has increased manifold but it can never be a substitute for doctors in rural areas. But yes, it will definitely help as many health issues in rural areas can be well addressed by telemedicine. We have Android phones and internet connection in the villages today, so we must make maximum utilisation of it," said Gupta, who was a practising doctor at Delhi's LNJP Hospital prior to clearing the coveted civil services examinations in 2013.

Commenting on the future prospects of telemedicine, Dr Chandrika Kambam, the Director of HCG Cancer Hospital, Bengaluru said that the telemedicine is here to stay regardless of COVID-19.

"Unlike a communicable and non-communicable disease, people with cancer seek care from places that are away from their hometowns especially those who are from tier 2 and 3 cities, they travel to metros for high-end services," Kambam said.

"Earlier, once treatment was done, patients used to keep in touch with their physicians, over phone, emails etc and the outbreak of COVID-19 pandemic has only catalysed this process and helped to streamline this method to a great extent," she added.

The COVID-19 pandemic has given this unstructured process a structure and timely guidelines from the Government have helped to alleviate apprehensions and answered doubts in our minds about safety and legal issues, Kambam said, adding that we have to learn to live with this (COVID-19) disease for at least the next few more months.

It's all due to COVID-19 that telemedicine services have been used extensively by the Union Health Ministry to train doctors in different states regarding the management of the Coronavirus spread. Senior critical care specialists from Delhi AIIMS guided doctors manning intensive care units in COVID hospitals in different states to reduce COVID-19 case fatality rate in the country. The team of specialist doctors provided guidance on effective clinical management of COVID-19 patients in the ICUs of different state hospitals through teleconsultation. The teleconsultation was provided to about 61 hospitals which have a bed capacity ranging from 500-1,000 on twice a week basis.

The Health Ministry has also issued detailed guidelines on telemedicine which were aimed at giving practical advice to doctors so that all services and models of care used by doctors and health workers are encouraged to consider the use of telemedicine as a part of normal practice.

"Disasters and pandemics pose unique challenges to providing health care. Though telemedicine will not solve them all, it is well suited for scenarios in which medical practitioners can evaluate and manage patients," the guidelines stated.

"A telemedicine visit can be conducted without exposing staff to viruses/infections in the times of such outbreaks. Telemedicine practice can prevent the transmission of infectious diseases reducing the risks to both health care workers and patients," it further added.

Even given all these plus points, the use of telemedicine has several challenges too as there is no framework available in the country regarding any medico-legal issues arising out of the use of telemedicine systems. So, there is a need to initiate debate and develop a minimal framework.

Also, the confidentiality of medical data of a patient is at great risk. Though hospitals assure patients of total security of their personal data, risks such as hacking, virus attack, etc., are beyond their control.

The different challenges associated with the implementation of telemedicine systems can be categorised under technical, managerial, ethical, legal and financial aspects, which need to be addressed systematically for establishing a successful telemedicine network.

"The poor connectivity issue is one of the major challenges associated with the telemedicine sector as sometimes the voice of patients is not properly audible to doctors and similarly the doctors' voice is not audible to patients. It's due to such networking issues that penetration of telemedicine is low," Dr Chandrika said, adding that telemedicine cannot be considered a complete solution as yet.

On patients' confidence, she said, "There would be a promise confidentially if patients use prescribed telemedicine portals, which is not happening as most of the patients prefer talking to doctors directly over the phone."

Notably, to ensure safe data transmission during telemedicine practices, the Union Health Ministry has developed a set of Electronic Health Records (EHR) standards in 2013 and a revised version of the same in 2016.

The future prospects for the use of telemedicine in the Indian context are bright. According to a McKinsey report, India could save up to USD 10 billion in 2025 if telemedicine replaced 30 per cent to 40 per cent of in-person outpatient consultations and there is digitisation in the overall healthcare industry.

In an attempt to combine the available public health data and provide easy access, the Union Health Ministry has taken up projects like the Integrated Disease Surveillance Project, National Cancer Network, National Rural Telemedicine Network, National Medical College Network and the Digital Medical Library Network.

As a constituent of the e-health wing of the National Health Portal (NHP), National Digital Health Authority of India (NDHAI)/National e-health Authority (NeHA) is being set up with a vision of achieving high-quality health services for all citizens through the cost-effective and secure use of ICTs in health and health-related fields.

Telemedicine practices in India have also extended to the fields of traditional medicine such as setting up of the National Rural AYUSH Telemedicine Network which is aimed at promoting the benefit of traditional methods of healing to a larger population through telemedicine. Setting up of standardised telemedicine practice guidelines by the Department of Information Technology and setting up of a National Telemedicine Task Force by the Health Ministry, in 2005, were some of the other positive steps by the Centre in this regard.

Internationally, projects like the Pan-African e-network Project and the SAARC (South Asian Association for Regional Cooperation) Telemedicine Network Projects have also been taken up as an initiative of the External Affairs Ministry, strategically placing Indian telemedicine in the global scenario.

Some of the successful examples of telemedicine include mammography services at Sir Ganga Ram Hospital, Delhi, oncology at the regional cancer centre, Trivandrum, surgical services at Sanjay Gandhi Postgraduate Institute of Medical Sciences, School of Telemedicine and Biomedical Informatics, Narayana Health, Apollo Telemedicine Enterprises, Asia Heart Foundation, Escorts Heart Institute, Amrita Institute of Medical Sciences, Aravind Eye Hospitals and RxDx Whitefield, Bangalore.

"On average, RxDx is conducting around 3,000 tele-consults per month globally. Over 70 plus COVID-19 patients are under active remote monitoring," said Dr Sunita Maheshwari, a senior consultant pediatric cardiologist at RxDx.

Though it would too early to predict the promising future of telemedicine even during the post-COVID-19 time, at present, the industry reports suggest that India's telemedicine market is growing immensely and is impacting the international economy in terms of growth rate, revenue, sale, market share and size. However, obstacles remain to such a vision with access to remote areas not only presenting a number of challenges for the service providers, but also for the families who are accessing these services.