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Telemedicine in times of COVID 19, virtually perfect but will it win public trust? 

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Practical experiences with telemedicine so far have been impressive, but for its long-term sustainability, the industry will need to build trust among patients and ensure data privacy

AcinthaWillam James (name changed), aged 64 is highly diabetic with multiple health conditions including rheumatoid arthritis. She falls squarely into the category of people-at-risk during the COVID-19 pandemic. When Mumbai issued a lockdown, she was completely baffled. “I didn’t know what to do. My appointments were cancelled. I was worried and scared. My doctors work for a big hospital in Mumbai which is right now treating COVID-19 patients. Initially, I was unable to get any information from the hospital on when the services will resume and I can meet my doctors. My kids live in Canada and I live with my grand-daughter, here in Mumbai so I was really very scared of my situation. I usually have episodes of hypoglycaemia sometimes which my doctor used to help me manage it. I really need to talk to him and meet him”, James anxiously speaks.

Luckily, James’ doctor is tech-savvy and is well equipped to attend to her using telehealth technologies. So, James was able to talk to him via a mobile phone. Now for James, this was her first experience with telemedicine and it turned out to be a good one. “My grandmother was happy to see her doctor. She stopped panicking and her doctor made her feel better. It was obvious that he was comfortable using this technology, but apparently he was trying it for the first time. I was much impressed with his sense of understanding her problem and he helped her to calm down. She now speaks to him every 15 days and I must confess he saved the day for me by offering this wonderful solution,” acknowledges Sarah, James’ grand-daughter.

Acintha and Sarah and hundreds of patients like Acintha have found telemedicine to be a blessing in disguise. Similarly, for some healthcare providers as well, telemedicine has served as a panacea in these times of crisis.  Also, telemedicine services providers in India have seen the number of consultations more than double in recent times. Many experts believe although the segment is in its nascent stages, it could be vital in India’s fight against coronavirus.

Government efforts to enable digital health in times of COVID

With similar sentiments and in view of the fact that there is a need to regulate the utilisation of telemedicine, the Niti Aayog introduced the telemedicine guidelines. According to the draft copy of the guidelines, the government is committed to providing equal access to quality care to all and digital health is a critical enabler for the overall transformation of the health system. Hence, the government believes that mainstreaming telemedicine in health systems will minimise inequity and barriers to access. “India’s digital health policy advocates the use of digital tools for improving the efficiency and outcomes of the healthcare system and lays significant focus on the use of telemedicine services, especially in the health and wellness centres at the grassroots level wherein a midlevel provider/health worker can connect the patients to the doctors through technology platforms in providing timely and best possible care,” the report mentions. Further on, the document elaborates on the purpose of these guidelines.

“These guidelines will provide information on various aspects of telemedicine including information on technology platforms and tools available to medical practitioners and how to integrate these technologies to provide healthcare delivery. It also spells out how technology and transmission of voice, data, images and information should be used in conjunction with other clinical standards, protocols, policies and procedures for the provision of care. Where clinically appropriate, telemedicine is a safe, effective and valuable modality to support patient care. Like any other technology, the technology used for telemedicine services can be abused. It has some risks, drawbacks and limitations, which can be mitigated through appropriate training, enforcement of standards, protocols and guidelines. These guidelines, therefore, should be used in conjunction with other national clinical standards, protocols, policies and procedures,” the Niti Aayog document mentioned.

Industry initiatives and efforts

While the government has supported the use of telemedicine to combat COVID-19, the industry too has chipped in to propel its success. Sharing insights on the same, Dr Pramod Kohli, Dean — Medical education and Medicolegal consultant, Nayati Medicity, Mathura, says, “Tele-health is the option of medical practice which has already set in and it is bound to grow. There is no option except to adopt it (as a supplement to the conventional mode) by hospitals/doctors and the public. As far as the MCI/Niti Aayog guidelines on telehealth are concerned, they appear to be exhaustive and well made. As things move forward, we may have further improvements by way of amendments as and when required.”

Similarly, Dr H S Chhabra, Chief Coordinator and Editor, ElearnSCI.org and Principal Investigator of ISCoS Database Project (IDAP), reveals, “Our telerehabilitation services were started in December 2015, teleconsultations in February 2017 and telenursing in December 2019. So far, we have had 2000, 815 and 22 clients in telerehabilitation, teleconsultations and telenursing, respectively. Frankly, the real thrust to teleconsultations has come only after the ongoing SARS-CoV-2 pandemic. We have had the following feedback from our clients so far that can be of great value to consultants.”

Dr Chhabra further lists down the recommendations:

* Save costs on transportation and no need to bring their parents/patients

* Less time in the waiting room, real-time access of records

* Online transaction saves time on registration and billing counter

* Availability of cash receipt and complete transparency on financial activity

* Keep patients out of the hospital to avoid unnecessary exposure

* Home delivery of medicines from our pharmacy as prescription is available

He further goes on, “Since March 2020, when GoI came up with the telemedicine practice guidelines, it has immensely expanded in India. It has undertaken a new way for doctor consultations, especially amidst COVID19. This rapid growth presents telemedicine as the next frontier in healthcare. Patient data is useful in many ways and one of them is AI (artificial intelligence) and decision support system. In future, this will help in identifying issues related to medical health and also act as a medium to provide decision support to a number of doctors. This could significantly reduce the mortalities and morbidities in patients. Furthermore, through IOT (internet of things) perspective medical emergencies like asthma attack, heart failure, diabetes, etc. can be monitored via connected devices. However, a lot needs to be done before reaching this goal. Telemedicine is also the roadmap for improved medical care in rural areas. Referral network of telemedicine would be a great resource in this regard. We at ISIC have developed a Tele-health Centre of Learning where we are trying to reach the masses, especially in rural India. Though this is in a nascent stage but holds a lot of potential. NITI Aayog states that the National Health Stack is a virtual digital platform for healthcare in the country. NHS study aims to have digital health records for all citizens by 2022 to make telemedicine and E-Health easy.”

Adding to this, Dr Raja Indana, Lead- Doctors team, MFine shares his experience. “Doctors and hospitals are now seeing telemedicine as an enabler. For example, the stethoscope when invented changed and enabled doctors to examine patients much better. Similarly, telemedicine is a tool that can change the landscape of healthcare delivery in future. More advances and automation can happen in triaging cases and standardise treatment protocols. Long-term health problems can be monitored and managed remotely with which we can improve medication compliance and outcomes. The care is slowly moving to the point of need (patient’s home). Moreover,  like a physical OPD, telemedicine will become a part of the doctor’s digital OPD. Patients will also see the ease of consultation and/or follow up. This will become mainstream for primary consultations and follow-ups,” he emphatically says.

Vikram Thaploo, CEO, Apollo TeleHealth also shares insights from the various state government projects Apollo TeleHealth is involved in. Apollo TeleHealth’s managed Urban Primary Healthcare Centres in Andhra Pradesh — this service emerged as the frontline warrior against COVID-19 as community screening began. As part of this project, Apollo TeleHealth’s 183 Urban Primary Healthcare Centres (UPHCs) in the urban municipalities across nine districts are aggressively working with the state governments supporting both grass-roots level efforts as well as providing IT-enabled services. He speaks about the significance of such services in the COVID-19 war. ‘Under the aegis of the State Health Department, the UPHCs are responsible for recognising and tracking suspected COVID-19 cases in allocated areas. The DMHO office allocates details of suspected cases, mostly international travellers, to the UPHCs. We screen them at their homes and ensure that their families are quarantined. The patients are monitored on a daily basis by our UPHC doctors with support from ANMs, ward and ASHA workers. Select UPHC centres have also started community-level screening to assess the extent of community transmission. Swab collection is done for all possible suspects and the samples are sent to government-authorised labs by primary healthcare workers. We also conduct surveys to trace out cases of high-grade fever, ”he informed.

Elaborating on the key learnings from their recent telehealth project, Thaploo describes, “Digital healthcare and telehealth services were thrust to the forefront during the crisis. We learned that if the operational workflow is well-defined, the roles are clearly assigned and proper guidelines and protocols are followed, telehealth has the potential to bridge the gap in healthcare delivery. By scaling up such a model, we can get closer to achieving universal healthcare. We can also expect digitisation to redefine several other facets of healthcare. Increased usage of digital tools such as medical kiosks and face recognition systems will allow people to walk in and discuss their health parameters with a medial chatbot anywhere. Already, some hospitals have installed such kiosks at their entrances to check the health conditions of visitors before allowing them in. Increased adoption of thermal screening systems at airports, railways stations, etc. is also expected to become common. The COVID-19 pandemic has also hastened the adoption of AI-backed digital monitoring systems in hospitals to monitor parameters like temperature, heart rate, oxygen saturation in patients. Such digitally automated monitoring systems are also likely to become the norm. The current crisis is going to propel healthcare in a direction that is going to be “contactless” in many ways. Automated screening kiosks, facial recognition technology, and unmanned reception facilities are just some of the elements of this futuristic design. Social distancing guidelines are here to stay and communities and healthcare organisations will need to change their daily functions to adapt to the new normal.” Check out the interview Vikram Thaploo on the details of the project (https://www.expresshealthcare.in/interviews/telemedicine-during-covid-19-a-nationwide-pilot-in-a-real-time-situation/421050/)

Time to fix the technical and data privacy problems…

Just as the government and healthcare providers seem gung ho about telemedicine and its potential to serve better in future, there are some teething problems that need to be fixed. Not every patient will be positively influenced by the telemedicine service. There would be some common worries, scepticism, language barriers and more that need to be addressed. Chipping in, Dr Kohli goes on, “Doctors and hospitals had apprehensions mostly on technical support (software, etc.), protocols and legal issues. Things are getting clearer day by day. The practical problems being faced from the public is that firstly, they don’t want to pay for this mode of consultation and secondly, they don’t get full satisfaction. There is potential for other problems related to incomplete consults, cancellations and refunds, besides disputes related to confidentiality and privacy issues.”

Dr Indana adds, “There needs to be accreditation from a certified body that monitors the quality standards. With India being a country of multiple languages, it becomes difficult. Solving the language problem can help expand the telemedicine reach.”

“Teleconsultation is not merely a consultation/talking over phones. Our medical system is not equipped with teaching individuals/doctors the means to do teleconsultation. A lot of medical ‘signs’ need to be demonstrated differently. In western countries, teleconsult is a common means to communicate/examine. Hence, the residents/trainees get acclimatised to the system. One of the greatest challenges that we face is the limited capability of the doctors to do teleconsultations in India. Furthermore, there is little confidence amongst the patients about this modality of treatment. However, with the introduction of Ayushman Bharat Scheme, the Indian government has come up with ICT (Information and Communication Technology) focusing on the development of health sector in the country. This scheme includes tele-health development ideology for long-distance medical care to make a safe, effective, efficient, patient-centred and timely health management environment. Thus, there is a huge scope that a number of patients shall benefit from teleconsultation. What we require is a structured programme to teach our doctors about the modalities/means to do such consultations. In a developing country like India, there is a lot of room for development. With the communication industry evolving at such a rapid pace, telemedicine sector is bound to develop too. Organisational challenges to adoption of telemedicine include cost, reimbursement, legal liability, privacy confidentiality, security of data, effectiveness, old equipment, efficiency, workflow, rural setting, profit status, organisation size, teaching status and implementation models.  The challenges for patients include extremes of age, level of education, eHealth or computer literacy, bandwidth, unawareness, high expectations of users, apathy, no phone, socioeconomic status, gender and preference for a personal meeting.  Challenges for staff and programmers include technically-challenged staff, resistance to change, licensing, perception of impersonal care, information overload, interoperability, poor design and language barrier. If we were to summarise, the main challenges would be technically challenged staff, resistance to change, cost, reimbursement, age of patient and level of education of the patient. The non-availability of high-speed bandwidth in rural settings is also one of the main challenges. The main challenges are technology-specific and could be overcome through training, change management techniques and alternating delivery of telemedicine and personal patient-to-provider interaction. The real potential continues to be hampered by quick-fix technological ‘solutions,’ rather than a genuine investment in evaluative research and development,” asserts Dr Chhabra.

Tackling the medico-legal aspects…

Fixing technical glitches is one thing, but providers will also have to consider the medico-legal aspects, which, if not tackled appropriately, may destroy the entire purpose of driving telemedicine. Dr Chhabra gives a clear picture. “The area of teleconsultation was ‘grey’ before the guidelines came. The government has tried to make it into a ‘black and white’ format. It has also opened the doors to first teleconsultations of patients and not just follow-ups or second opinions. This has led to a number of institutes/hospitals to incorporate this modality in their setup. It is also imperative to know that legal implications are associated with anything dealing with ‘heath’. All the technology platforms (for e.g. mobile apps, websites, etc.) that provide telemedicine services to consumers have to ensure that the practitioners on their platform are duly registered with the relevant medical councils. The platforms are required to carry out their due diligence before listing them on their platform. Moreover, the platforms must provide the name, qualification and registration number, contact details of every RMP listed on their platform, along with a proper mechanism to address any queries or grievances of the consumers,” he highlights.

Furthermore, he informs that artificial intelligence and machine learning-based platforms cannot counsel or prescribe any medicine to any patient. “Such technologies can only be used to aid and support the RMP, but the final advice and prescription must be made by the RMP. Any breach of data privacy is also a matter of great concern. Any non-compliance may result in the platform being blacklisted by the Board of Governors, MCI,” he warns.

Thaploo also comprehends with what these experts point out but seems more positive due to the government’s efforts to streamline telemedicine services. “Initially, patients were sceptical of accepting diagnoses without touch-and-feel consultations. This was compounded by the fact that there were no standard practising guidelines until the recent gazette notification. The pervasive cultural bias is slowly being broken down as patients across the country are learning first hand that teleconsultations are just as effective for a majority of OPD cases, and in many instances, quicker and more efficient. With greater patient satisfaction, we will be able to affect cultural change and foster a greater degree of acceptance.”

Indeed, as Thaploo indicates that things will shape up better as doctors and patients both get savvy with technology. However, the fact remains that for telemedicine to thrive in future too, a culture change is needed. For a long time, physical examinations have been the bedrock of how doctors and nurses assess patients. Physical contact has been at the heart of how doctors and patients communicate. Will that change so easily? Will practicality take precedence over emotions and traditional practices?

Well, I am convinced. I rather choose to be practical. In a recent interaction with a scientific journal, infection control experts from Boston had pointed out that for ages, hospitals have been notorious petri dishes for deadly bugs and this pandemic has brought that risk into a spotlight. Now, this is something which is constantly haunting experts in India too. In times to come, we may see an increased rate of HAIs in India. Therefore, telemedicine can be instrumental in reducing that risk.

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