It has been more than six months since a tiny crown-shaped novel coronavirus knocked the human kind which resulted in tearing apart of the health system of the world. Its havoc is still continuing and the end of a pandemic is far from sight.
India is a country of paradoxes. It has a dual health care system, public and private both. It is one of the favourite medical tourist destinations in the world. Its healthcare is expected to grow to Rs 8.6 trillion by 2022. The contributory factor for this growth may be increased life expectancy, better standard of living, large population and awareness of health. Even then the other side is very unfortunate. There is a great shortage of laboratory facilities and paramedical staff. As it is now there is a shortage of 6 lakh doctors and India will take another 7-8years to have a doctor-patient ratio as recommended by WHO. But pandemic data is true only when allopathic doctors are counted. Inclusion of doctors of alternative medicine brings the number high.
The real problem is a great disparity between rural and urban health care as 60% of the hospitals and 80% of the doctors are concentrated in urban areas while more than 70% of Indians still live in villages. The variable landscape makes many areas difficult to commute and a high population density ratio is a big hurdle in social distancing. It is not possible to provide healthcare on a personal level to each and every patient in this time of crisis. All this rejuvenated telemedicine once a difficult sell.
EVOLUTION OF TELE-MEDICINE
The era of telecommunication began with the discovery of telephone by Alexander Grahm Bell in 1876. About 48 years later Hogo Gersback’s imagination took a shape of illustration and was published on the cover of April issue of the magazine Radio News in 1924. The illustration showed a man talking to a doctor on the other end with the help of a microphone and television. This was the time when TV was not in the vogue and radio has just started to pick up the momentum in the USA. Telegraph which requires special technology and training was used in the transfer of medical information mostly in military situations. It was well used in the US civil war. The telephone brought a huge transformation in the medical field as people were able to talk to their physicians.
In the early part of 1900, many experiments were done to transfer data related to stethoscope and devices. In 1906 Eithoven transmitted ECG data through telephone lines. In 1940s Pennsylvania radiology images were sent 24 miles between two townships via telephone lines. It was 1959 when the first interactive audiovisual was made between the clinicians of the University of Nebraska and students of the campus. Later in 1964, the University was linked to the state hospital to provide medical care. It was 1960 when telemedicine got a real boost. NASA along with Lockheed Corporation and US Indian Health Services pumped money in project Space Technology Applied to Rural Papago Advanced Health Care. This paved the way for new researches and advancement in the field of technology.
INDIA AND TELE-MEDICINE
The formal beginning of telemedicine in India began in 2001. Indian Research Space Organisation(ISRO) partnered with Apollo Hospital in Chennai and linked it to Apollo Rural Hospital Aragonda village in Andhra Pradesh. Thereafter many projects were taken up by the central government. Some of them are India Integrated Disease Surveillance (IDSP), National Cancer Network (ONCONET), National Rural Telemedicine Network, National Medical College Network and Digital Medical Library Network.
COVID19, TELEMEDICINE, INDIA
COVID 19 has posed multiple problems. A large number of people are being infected daily. India also has a huge burden of non-COVID patients suffering from communicable and non-communicable diseases. A focused approach to treat COVID patients has disrupted the health services to non-COVID patients. Cancer patients, diabetics, heart patients, hypertensive, child& maternal care, immunization, patients with chest diseases, pregnancy all have been hit very hard. These uncared patients are adding extra load to an already overstretched system. The morbidity and mortality in these patients are on the rise from January to May 2020 about 25 lakhs non-COVID patients died. If we let the things to continue as it is there might be a sit Congo like the situation where more people died of malaria than Ebola after the epidemic subsided.
The existing situation and the timely release of government guidelines regarding telemedicine have worked as a booster for it. The guidelines allow Registered Medical Practitioners to use all channels of communications like audio, video and text as modes of communication and have permitted to write prescriptions online. It is a welcome step as we have reported that two doctors were penalized by the Bombay High Court in 2018 for prescribing medicine over the telephone. The guidelines forbid remote surgery through telemedicine and teleconsultation from a doctor stationed outside India. It is mandatory for practitioners to maintain patients reports, records, documents, diagnostic data and images.
The prevailing situation and government guidelines have boosted the scope of telemedicine in the field. There has been an immense surge in teleconsultation. Às per the report of the Indian Express (30th June 2020) there has been a rise of 500% in healthcare teleconsultations in India and 80% of them were first time users from 1st March to 31st May 2020. During this period around 5 crores, Indians have accessed healthcare through this emerging medium. There is a growth of 600% in ENT, 300% in Dermatology, 200% in psychiatry, 250% in gynaecology, 200% in pediatric and 200% in COVID’19 related cases and it continues to grow at the rate of 100% per week. There are various startups in the telemedicine market like Healthplix, Docon, Practo and many more are yet to come. The telemedicine market in India is expected to touch $5.4 Billion by 2021.
The reason for the surge in telemedicine is a rapidly increasing the number of COVID patients and lack of adequate infrastructure that includes less number of beds, doctors and paramedical staff. It is practically impossible to consult each patient physically and provide them with beds. Telemedicine with its advanced form is proving its worth. The cove patients can be screened in the comfort of their home and patients with mild and moderate illnesses, which can be managed at home, are advised to stay at home, thus discouraging unnecessary crowding. The data of the patients who are advised to be admitted is provided to the hospital beforehand in order to allow time for the hospital to prepare for the patients.
Teleconsultation has also helped non-COVID patients to seek consultation without waiting and without the fear of getting infected. By downloading the application, the patients can select the doctor of their choice at their convenience. This helps them stay away from travelling, traffic congestion and overcrowding. According to a recent study, in rural areas of India, a patient has to travel approximately 7kms to access a healthcare centre. Connecting primary centres and healthcare centres to district hospitals or/and state hospitals may facilitate specialized services to the rural population.
India, that already has a shortage of doctors, must protect its COVID warriors. Till now over 100 doctors have passed away in fighting COVID.COVID specific ward and ICU require multidisciplinary approaches. If one person examines( by rotation) and transfers the data to other staff sitting in other rooms, can minimize the risk of infection. Doctors who are in quarantine, experiencing mild symptoms can treat patients through telemedicine.
Earlier telemedicine was mostly used for post-acute settled patients. However, now it is emerging as a proactive tool. By connecting devices or transferring data from one remote location to another, one can access treatment guidance and serious patients can be managed properly. The concept of eICU is evolving fast.
Everyday new information is being obtained regarding COVID, it is imperative that this information is quickly dispersed to healthcare professionals. Telemedicine can play an effective role in doing so. It can facilitate training for any staff and can simultaneously upgrade the knowledge of doctors stationed at different locations.
Most of the telemedicine systems are integrated with electronic health record facility. It automatically stores the patient’s reports, medical record and other important data. This further reduces the chances of error. EHRS helps in providing correct, up to date information of the patients. This enables providers to manage patients well by diagnosing correctly and reducing medicinal error.
Artificial intelligence-led telemedicine is no longer confined to research labs. It is strolling in the real world too. AI-led software can filter data and identify medical problems quicker than human.
AI-led telemedicine may reduce the need for face to face interaction between patients and doctors. AI by collecting and analyzing data can make a diagnosis before the catastrophe sets in.
How mainstreaming telemedicine could help contain the epidemic, can be well learnt from the Shandong province of China, with a population of >100million. As COVID’19 knocked the doors of Shandong, the provincial government and the health committee responded quickly and utilized the platforms including telemedicine in a massive way and found telemedicine playing a commendable role in the containment of the virus.
Young doctors who cannot afford to set up their own clinic due to lack of money may give consultation to their patients through telemedicine by sitting at home. It only requires a laptop/mobile and an app. Telemedicine is a handy tool in brushing up the skills of doctors.
Installation of the telemedicine system is an expensive affair, though there are many areas where telemedicine is of immense use it can never be a substitute of face to face interaction between doctor and patient. The psychological aspect of the patient-doctor relationship, which develops due to physical interaction cannot be overemphasized.
As of 2020, there are 718.74million active internet users in India, that is a little above 50% of the Indian population. In download speed, Indian ranks 74th out of 207 countries. According to the speed test global index in February 2020, in average fixed broadband speed, India ranks 69/176 countries. The poor net connectivity and interrupted power supply are one of the major hurdles. Then there is an issue of language also. To make telemedicine a viable and effective mode the software should incorporate local languages. There are many doctors and patients who are not comfortable with technology.
This inertia can be overcome by training and awareness programme. Due to poor video quality, there is the possibility of making an error in diagnosing a picture shown to the doctor. One more area where telemedicine is not of much help is laboratory investigations and diagnostic images. There are many areas like data privacy, insurance reimbursement and medicolegal aspects which demand clearer guidelines.
Telemedicine is still in an evolving phase but its future widespread adoption is a certainty. It is not a replacement of on-site clinical examination but an effective tool for doctors to use for patients who do not need physical examination and testing.